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Hospitals with more diverse and uninsured patients more likely to provide delayed fracture care
Regardless of individual patient-level characteristics such as race, ethnicity, or insurance status, these patients were more likely to miss the recommended 24-hour benchmark for surgery.
“Institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix,” write study author Ida Leah Gitajn, MD, an orthopedic trauma surgeon at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues.
“While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias,” the authors wrote.
The study was published online in JAMA Network Open.
Site performance varied
Racial inequalities in health care utilization and outcomes have been documented in many medical specialties, including orthopedic trauma, the study authors write. However, previous studies evaluating racial disparities in fracture care have been limited to patient-level associations rather than hospital-level factors.
The investigators conducted a secondary analysis of prospectively collected multicenter data for 2,565 patients with hip and femur fractures enrolled in two randomized trials at 23 sites in the United States and Canada. The researchers assessed whether disparities in meeting 24-hour time-to-surgery benchmarks exist at the patient level or at the institutional level, evaluating the association of race, ethnicity, and insurance status.
The cohort study used data from the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), which enrolled patients from 2018-2021 and followed them for 1 year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in the analysis, which was conducted from April to September of this year.
The cohort included 2,565 patients with an average age of about 65 years. About 82% of patients were White, 13.4% were Black, 3.2% were Asian, and 1.1% were classified as another race or ethnicity. Among the study population, 32.5% of participants were employed, and 92.2% had health insurance. Nearly 40% had a femur fracture with an average injury severity score of 10.4.
Overall, 596 patients (23.2%) didn’t meet the 24-hour time-to-operating-room benchmark. Patients who didn’t meet the 24-hour surgical window were more likely to be older, women, and have a femur fracture. They were less likely to be employed.
The 23 sites had variability in meeting the 24-hour benchmark, race and ethnicity distribution, and population-based health insurance. Institutions met benchmarks at frequencies ranging from 45.2% (for 196 of 433 procedures) to 97.4% (37 of 38 procedures). Minority race and ethnicity distribution ranged from 0% (in 99 procedures) to 58.2% (in 53 of 91 procedures). The proportion of uninsured patients ranged from 0% (in 64 procedures) to 34.2% (in 13 of 38 procedures).
At the patient level, there was no association between missing the 24-hour benchmark and race or ethnicity, and there was no independent association between hospital population racial composition and surgical delay. In an analysis that controlled for patient-level characteristics, there was no association between missing the 24-hour benchmark and patient-level insurance status.
There was an independent association, however, between the hospital population insurance coverage and hospital population racial composition as an interaction term, suggesting a moderating effect (P = .03), the study authors write.
At low rates of uninsured patients, the probability of missing the 24-hour benchmark was 12.5%-14.6% when racial composition varied from 0%-50% minority patients. In contrast, at higher rates of uninsured patients, the risk of missing the 24-hour window was higher among more diverse populations. For instance, at 30% uninsured, the risk of missing the benchmark was 0.5% when the racial composition was low and 17.6% at 50% minority patients.
Additional studies are needed to understand the findings and how health system programs or structures play a role, the authors write. For instance, well-funded health systems that care for a higher proportion of insured patients likely have quality improvement programs and other support structures, such as operating room access, that ensure appropriate time-to-surgery benchmarks for time-sensitive fractures, they say.
Addressing inequalities
Troy Amen, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery, New York, said, “Despite these disparities being reported and well documented in recent years, unfortunately, not enough has been done to address them or understand their fundamental root causes.”
Dr. Amen, who wasn’t involved with this study, has researched racial and ethnic disparities in hip fracture surgery care across the United States. He and his colleagues found disparities in delayed time-to-surgery, particularly for Black patients.
“We live in a country and society where we want and strive for equality of care for patients regardless of race, ethnicity, gender, sexual orientation, or background,” he said. “We have a moral imperative to address these disparities as health care providers, not only among ourselves, but also in conjunction with lawmakers, hospital administrators, and health policy specialists.”
Uma Srikumaran, MD, an associate professor of orthopedic surgery at Johns Hopkins University, Baltimore, wasn’t involved with this study but has researched racial disparities in the timing of radiographic assessment and surgical treatment of hip fractures.
“Though we understand that racial disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them,” Dr. Srikumaran told this news organization.
Dr. Srikumaran and colleagues have found that Black patients had longer wait times for evaluation and surgery than White patients.
“We all want to get to the solutions, but those can be difficult to execute without an intricate understanding of the problem,” he said. “We should encourage this type of research all throughout health care in general but also very locally, as solutions are not likely to be one-size-fits-all.”
Dr. Srikumaran pointed to the need to measure the problem in specific pathologies, populations, geographies, hospital types, and other factors.
“Studying the trends of this issue will help us determine whether our national or local initiatives are making a difference and which interventions are most effective for a particular hospital, geographic location, or particular pathology,” he said. “Accordingly, if a particular hospital or health system isn’t looking at differences in the delivery of care by race, they are missing an opportunity to ensure equity and raise overall quality.”
The study was supported by funding from the Patient Centered Outcomes Research Institute. Dr. Gitajn reported receiving personal fees for consulting and teaching work from Stryker outside the submitted work. Dr. Amen and Dr. Srikumaran reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Regardless of individual patient-level characteristics such as race, ethnicity, or insurance status, these patients were more likely to miss the recommended 24-hour benchmark for surgery.
“Institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix,” write study author Ida Leah Gitajn, MD, an orthopedic trauma surgeon at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues.
“While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias,” the authors wrote.
The study was published online in JAMA Network Open.
Site performance varied
Racial inequalities in health care utilization and outcomes have been documented in many medical specialties, including orthopedic trauma, the study authors write. However, previous studies evaluating racial disparities in fracture care have been limited to patient-level associations rather than hospital-level factors.
The investigators conducted a secondary analysis of prospectively collected multicenter data for 2,565 patients with hip and femur fractures enrolled in two randomized trials at 23 sites in the United States and Canada. The researchers assessed whether disparities in meeting 24-hour time-to-surgery benchmarks exist at the patient level or at the institutional level, evaluating the association of race, ethnicity, and insurance status.
The cohort study used data from the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), which enrolled patients from 2018-2021 and followed them for 1 year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in the analysis, which was conducted from April to September of this year.
The cohort included 2,565 patients with an average age of about 65 years. About 82% of patients were White, 13.4% were Black, 3.2% were Asian, and 1.1% were classified as another race or ethnicity. Among the study population, 32.5% of participants were employed, and 92.2% had health insurance. Nearly 40% had a femur fracture with an average injury severity score of 10.4.
Overall, 596 patients (23.2%) didn’t meet the 24-hour time-to-operating-room benchmark. Patients who didn’t meet the 24-hour surgical window were more likely to be older, women, and have a femur fracture. They were less likely to be employed.
The 23 sites had variability in meeting the 24-hour benchmark, race and ethnicity distribution, and population-based health insurance. Institutions met benchmarks at frequencies ranging from 45.2% (for 196 of 433 procedures) to 97.4% (37 of 38 procedures). Minority race and ethnicity distribution ranged from 0% (in 99 procedures) to 58.2% (in 53 of 91 procedures). The proportion of uninsured patients ranged from 0% (in 64 procedures) to 34.2% (in 13 of 38 procedures).
At the patient level, there was no association between missing the 24-hour benchmark and race or ethnicity, and there was no independent association between hospital population racial composition and surgical delay. In an analysis that controlled for patient-level characteristics, there was no association between missing the 24-hour benchmark and patient-level insurance status.
There was an independent association, however, between the hospital population insurance coverage and hospital population racial composition as an interaction term, suggesting a moderating effect (P = .03), the study authors write.
At low rates of uninsured patients, the probability of missing the 24-hour benchmark was 12.5%-14.6% when racial composition varied from 0%-50% minority patients. In contrast, at higher rates of uninsured patients, the risk of missing the 24-hour window was higher among more diverse populations. For instance, at 30% uninsured, the risk of missing the benchmark was 0.5% when the racial composition was low and 17.6% at 50% minority patients.
Additional studies are needed to understand the findings and how health system programs or structures play a role, the authors write. For instance, well-funded health systems that care for a higher proportion of insured patients likely have quality improvement programs and other support structures, such as operating room access, that ensure appropriate time-to-surgery benchmarks for time-sensitive fractures, they say.
Addressing inequalities
Troy Amen, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery, New York, said, “Despite these disparities being reported and well documented in recent years, unfortunately, not enough has been done to address them or understand their fundamental root causes.”
Dr. Amen, who wasn’t involved with this study, has researched racial and ethnic disparities in hip fracture surgery care across the United States. He and his colleagues found disparities in delayed time-to-surgery, particularly for Black patients.
“We live in a country and society where we want and strive for equality of care for patients regardless of race, ethnicity, gender, sexual orientation, or background,” he said. “We have a moral imperative to address these disparities as health care providers, not only among ourselves, but also in conjunction with lawmakers, hospital administrators, and health policy specialists.”
Uma Srikumaran, MD, an associate professor of orthopedic surgery at Johns Hopkins University, Baltimore, wasn’t involved with this study but has researched racial disparities in the timing of radiographic assessment and surgical treatment of hip fractures.
“Though we understand that racial disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them,” Dr. Srikumaran told this news organization.
Dr. Srikumaran and colleagues have found that Black patients had longer wait times for evaluation and surgery than White patients.
“We all want to get to the solutions, but those can be difficult to execute without an intricate understanding of the problem,” he said. “We should encourage this type of research all throughout health care in general but also very locally, as solutions are not likely to be one-size-fits-all.”
Dr. Srikumaran pointed to the need to measure the problem in specific pathologies, populations, geographies, hospital types, and other factors.
“Studying the trends of this issue will help us determine whether our national or local initiatives are making a difference and which interventions are most effective for a particular hospital, geographic location, or particular pathology,” he said. “Accordingly, if a particular hospital or health system isn’t looking at differences in the delivery of care by race, they are missing an opportunity to ensure equity and raise overall quality.”
The study was supported by funding from the Patient Centered Outcomes Research Institute. Dr. Gitajn reported receiving personal fees for consulting and teaching work from Stryker outside the submitted work. Dr. Amen and Dr. Srikumaran reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Regardless of individual patient-level characteristics such as race, ethnicity, or insurance status, these patients were more likely to miss the recommended 24-hour benchmark for surgery.
“Institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix,” write study author Ida Leah Gitajn, MD, an orthopedic trauma surgeon at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues.
“While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias,” the authors wrote.
The study was published online in JAMA Network Open.
Site performance varied
Racial inequalities in health care utilization and outcomes have been documented in many medical specialties, including orthopedic trauma, the study authors write. However, previous studies evaluating racial disparities in fracture care have been limited to patient-level associations rather than hospital-level factors.
The investigators conducted a secondary analysis of prospectively collected multicenter data for 2,565 patients with hip and femur fractures enrolled in two randomized trials at 23 sites in the United States and Canada. The researchers assessed whether disparities in meeting 24-hour time-to-surgery benchmarks exist at the patient level or at the institutional level, evaluating the association of race, ethnicity, and insurance status.
The cohort study used data from the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), which enrolled patients from 2018-2021 and followed them for 1 year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in the analysis, which was conducted from April to September of this year.
The cohort included 2,565 patients with an average age of about 65 years. About 82% of patients were White, 13.4% were Black, 3.2% were Asian, and 1.1% were classified as another race or ethnicity. Among the study population, 32.5% of participants were employed, and 92.2% had health insurance. Nearly 40% had a femur fracture with an average injury severity score of 10.4.
Overall, 596 patients (23.2%) didn’t meet the 24-hour time-to-operating-room benchmark. Patients who didn’t meet the 24-hour surgical window were more likely to be older, women, and have a femur fracture. They were less likely to be employed.
The 23 sites had variability in meeting the 24-hour benchmark, race and ethnicity distribution, and population-based health insurance. Institutions met benchmarks at frequencies ranging from 45.2% (for 196 of 433 procedures) to 97.4% (37 of 38 procedures). Minority race and ethnicity distribution ranged from 0% (in 99 procedures) to 58.2% (in 53 of 91 procedures). The proportion of uninsured patients ranged from 0% (in 64 procedures) to 34.2% (in 13 of 38 procedures).
At the patient level, there was no association between missing the 24-hour benchmark and race or ethnicity, and there was no independent association between hospital population racial composition and surgical delay. In an analysis that controlled for patient-level characteristics, there was no association between missing the 24-hour benchmark and patient-level insurance status.
There was an independent association, however, between the hospital population insurance coverage and hospital population racial composition as an interaction term, suggesting a moderating effect (P = .03), the study authors write.
At low rates of uninsured patients, the probability of missing the 24-hour benchmark was 12.5%-14.6% when racial composition varied from 0%-50% minority patients. In contrast, at higher rates of uninsured patients, the risk of missing the 24-hour window was higher among more diverse populations. For instance, at 30% uninsured, the risk of missing the benchmark was 0.5% when the racial composition was low and 17.6% at 50% minority patients.
Additional studies are needed to understand the findings and how health system programs or structures play a role, the authors write. For instance, well-funded health systems that care for a higher proportion of insured patients likely have quality improvement programs and other support structures, such as operating room access, that ensure appropriate time-to-surgery benchmarks for time-sensitive fractures, they say.
Addressing inequalities
Troy Amen, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery, New York, said, “Despite these disparities being reported and well documented in recent years, unfortunately, not enough has been done to address them or understand their fundamental root causes.”
Dr. Amen, who wasn’t involved with this study, has researched racial and ethnic disparities in hip fracture surgery care across the United States. He and his colleagues found disparities in delayed time-to-surgery, particularly for Black patients.
“We live in a country and society where we want and strive for equality of care for patients regardless of race, ethnicity, gender, sexual orientation, or background,” he said. “We have a moral imperative to address these disparities as health care providers, not only among ourselves, but also in conjunction with lawmakers, hospital administrators, and health policy specialists.”
Uma Srikumaran, MD, an associate professor of orthopedic surgery at Johns Hopkins University, Baltimore, wasn’t involved with this study but has researched racial disparities in the timing of radiographic assessment and surgical treatment of hip fractures.
“Though we understand that racial disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them,” Dr. Srikumaran told this news organization.
Dr. Srikumaran and colleagues have found that Black patients had longer wait times for evaluation and surgery than White patients.
“We all want to get to the solutions, but those can be difficult to execute without an intricate understanding of the problem,” he said. “We should encourage this type of research all throughout health care in general but also very locally, as solutions are not likely to be one-size-fits-all.”
Dr. Srikumaran pointed to the need to measure the problem in specific pathologies, populations, geographies, hospital types, and other factors.
“Studying the trends of this issue will help us determine whether our national or local initiatives are making a difference and which interventions are most effective for a particular hospital, geographic location, or particular pathology,” he said. “Accordingly, if a particular hospital or health system isn’t looking at differences in the delivery of care by race, they are missing an opportunity to ensure equity and raise overall quality.”
The study was supported by funding from the Patient Centered Outcomes Research Institute. Dr. Gitajn reported receiving personal fees for consulting and teaching work from Stryker outside the submitted work. Dr. Amen and Dr. Srikumaran reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
A single pediatric CT scan raises brain cancer risk
Children and young adults who are exposed to a single CT scan of the head or neck before age 22 years are at significantly increased risk of developing a brain tumor, particularly glioma, after at least 5 years, according to results of the large EPI-CT study.
“Translation of our risk estimates to the clinical setting indicates that per 10,000 children who received one head CT examination, about one radiation-induced brain cancer is expected during the 5-15 years following the CT examination,” noted lead author Michael Hauptmann, PhD, from the Institute of Biostatistics and Registry Research, Brandenburg Medical School, Neuruppin, Germany, and coauthors.
“Next to the clinical benefit of most CT scans, there is a small risk of cancer from the radiation exposure,” Dr. Hauptmann told this news organization.
“So, CT examinations should only be used when necessary, and if they are used, the lowest achievable dose should be applied,” he said.
The study was published online in The Lancet Oncology.
“This is a thoughtful and well-conducted study by an outstanding multinational team of scientists that adds further weight to the growing body of evidence that has found exposure to CT scanning increases a child’s risk of developing brain cancer,” commented Rebecca Bindman-Smith, MD, from the University of California, San Francisco, who was not involved in the research.
“The results are real, and important,” she told this news organization, adding that “the authors were conservative in their assumptions, and performed a very large number of sensitivity analyses ... to check that the results were robust to a large range of assumptions – and the results changed relatively little.”
“I do not think there is enough awareness [about this risk],” Dr. Hauptmann said. “There is evidence that a nonnegligible number of CTs is unjustified according to guidelines, and there is evidence that doses vary substantially for the same CT between institutions in the same or different countries.”
Indeed, particularly in the United States, “we perform many CT scans in children and even more so in adults that are simply unnecessary,” agreed Dr. Bindman-Smith, who is professor of epidemiology and biostatistics at the University of California, San Francisco. “It is important for patients and providers to understand that nothing we do in medicine is risk free, including CT scanning. If a CT is necessary, the benefit almost certainly outweighs the risk. But if [not], then it should not be obtained. Both patients and providers must make thoroughly considered decisions before asking for or agreeing to a CT.”
She also pointed out that while this study evaluated the risk only for brain cancer, children who undergo head CTs are also at increased risk for leukemia.
Dose/response relationship
The study included 658,752 individuals from nine European countries and 276 hospitals. Each patient had received at least one CT scan between 1977 and 2014 before they turned 22 years of age. Eligibility requirements included their being alive at least 5 years after the first scan and that they had not previously been diagnosed with cancer or benign brain tumor.
The radiation dose absorbed to the brain and 33 other organs and tissues was estimated for each participant using a dose reconstruction model that included historical information on CT machine settings, questionnaire data, and Digital Imaging and Communication in Medicine header metadata. “Mean brain dose per head or neck CT examination increased from 1984 until about 1991, following the introduction of multislice CT scanners at which point thereafter the mean dose decreased and then stabilized around 2010,” note the authors.
During a median follow-up of 5.6 years (starting 5 years after the first scan), 165 brain cancers occurred, including 121 (73%) gliomas, as well as a variety of other morphologic changes.
The mean cumulative brain dose, which lagged by 5 years, was 47.4 mGy overall and 76.0 mGy among people with brain cancer.
“We observed a significant positive association between the cumulative number of head or neck CT examinations and the risk of all brain cancers combined (P < .0001), and of gliomas separately (P = .0002),” the team reports, adding that, for a brain dose of 38 mGy, which was the average dose per head or neck CT in 2012-2014, the relative risk of developing brain cancer was 1.5, compared with not undergoing a CT scan, and the excess absolute risk per 100,000 person-years was 1.1.
These findings “can be used to give the patients and their parents important information on the risks of CT examination to balance against the known benefits,” noted Nobuyuki Hamada, PhD, from the Central Research Institute of Electric Power Industry, Tokyo, and Lydia B. Zablotska, MD, PhD, from the University of California, San Francisco, writing in a linked commentary.
“In recent years, rates of CT use have been steady or declined, and various efforts (for instance, in terms of diagnostic reference levels) have been made to justify and optimize CT examinations. Such continued efforts, along with extended epidemiological investigations, would be needed to minimize the risk of brain cancer after pediatric CT examination,” they add.
Keeping dose to a minimum
The study’s finding of a dose-response relationship underscores the importance of keeping doses to a minimum, Dr. Bindman-Smith commented. “I do not believe we are doing this nearly enough,” she added.
“In the UCSF International CT Dose Registry, where we have collected CT scans from 165 hospitals on many millions of patients, we found that the average brain dose for a head CT in a 1-year-old is 42 mGy but that this dose varies tremendously, where some children receive a dose of 100 mGy.
“So, a second message is that not only should CT scans be justified and used judiciously, but also they should be optimized, meaning using the lowest dose possible. I personally think there should be regulatory oversight to ensure that patients receive the absolutely lowest doses possible,” she added. “My team at UCSF has written quality measures endorsed by the National Quality Forum as a start for setting explicit standards for how CT should be performed in order to ensure the cancer risks are as low as possible.”
The study was funded through the Belgian Cancer Registry; La Ligue contre le Cancer, L’Institut National du Cancer, France; the Ministry of Health, Labour and Welfare of Japan; the German Federal Ministry of Education and Research; Worldwide Cancer Research; the Dutch Cancer Society; the Research Council of Norway; Consejo de Seguridad Nuclear, Generalitat deCatalunya, Spain; the U.S. National Cancer Institute; the U.K. National Institute for Health Research; and Public Health England. Dr. Hauptmann has disclosed no relevant financial relationships. Other investigators’ relevant financial relationships are listed in the original article. Dr. Hamada and Dr. Zablotska disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Children and young adults who are exposed to a single CT scan of the head or neck before age 22 years are at significantly increased risk of developing a brain tumor, particularly glioma, after at least 5 years, according to results of the large EPI-CT study.
“Translation of our risk estimates to the clinical setting indicates that per 10,000 children who received one head CT examination, about one radiation-induced brain cancer is expected during the 5-15 years following the CT examination,” noted lead author Michael Hauptmann, PhD, from the Institute of Biostatistics and Registry Research, Brandenburg Medical School, Neuruppin, Germany, and coauthors.
“Next to the clinical benefit of most CT scans, there is a small risk of cancer from the radiation exposure,” Dr. Hauptmann told this news organization.
“So, CT examinations should only be used when necessary, and if they are used, the lowest achievable dose should be applied,” he said.
The study was published online in The Lancet Oncology.
“This is a thoughtful and well-conducted study by an outstanding multinational team of scientists that adds further weight to the growing body of evidence that has found exposure to CT scanning increases a child’s risk of developing brain cancer,” commented Rebecca Bindman-Smith, MD, from the University of California, San Francisco, who was not involved in the research.
“The results are real, and important,” she told this news organization, adding that “the authors were conservative in their assumptions, and performed a very large number of sensitivity analyses ... to check that the results were robust to a large range of assumptions – and the results changed relatively little.”
“I do not think there is enough awareness [about this risk],” Dr. Hauptmann said. “There is evidence that a nonnegligible number of CTs is unjustified according to guidelines, and there is evidence that doses vary substantially for the same CT between institutions in the same or different countries.”
Indeed, particularly in the United States, “we perform many CT scans in children and even more so in adults that are simply unnecessary,” agreed Dr. Bindman-Smith, who is professor of epidemiology and biostatistics at the University of California, San Francisco. “It is important for patients and providers to understand that nothing we do in medicine is risk free, including CT scanning. If a CT is necessary, the benefit almost certainly outweighs the risk. But if [not], then it should not be obtained. Both patients and providers must make thoroughly considered decisions before asking for or agreeing to a CT.”
She also pointed out that while this study evaluated the risk only for brain cancer, children who undergo head CTs are also at increased risk for leukemia.
Dose/response relationship
The study included 658,752 individuals from nine European countries and 276 hospitals. Each patient had received at least one CT scan between 1977 and 2014 before they turned 22 years of age. Eligibility requirements included their being alive at least 5 years after the first scan and that they had not previously been diagnosed with cancer or benign brain tumor.
The radiation dose absorbed to the brain and 33 other organs and tissues was estimated for each participant using a dose reconstruction model that included historical information on CT machine settings, questionnaire data, and Digital Imaging and Communication in Medicine header metadata. “Mean brain dose per head or neck CT examination increased from 1984 until about 1991, following the introduction of multislice CT scanners at which point thereafter the mean dose decreased and then stabilized around 2010,” note the authors.
During a median follow-up of 5.6 years (starting 5 years after the first scan), 165 brain cancers occurred, including 121 (73%) gliomas, as well as a variety of other morphologic changes.
The mean cumulative brain dose, which lagged by 5 years, was 47.4 mGy overall and 76.0 mGy among people with brain cancer.
“We observed a significant positive association between the cumulative number of head or neck CT examinations and the risk of all brain cancers combined (P < .0001), and of gliomas separately (P = .0002),” the team reports, adding that, for a brain dose of 38 mGy, which was the average dose per head or neck CT in 2012-2014, the relative risk of developing brain cancer was 1.5, compared with not undergoing a CT scan, and the excess absolute risk per 100,000 person-years was 1.1.
These findings “can be used to give the patients and their parents important information on the risks of CT examination to balance against the known benefits,” noted Nobuyuki Hamada, PhD, from the Central Research Institute of Electric Power Industry, Tokyo, and Lydia B. Zablotska, MD, PhD, from the University of California, San Francisco, writing in a linked commentary.
“In recent years, rates of CT use have been steady or declined, and various efforts (for instance, in terms of diagnostic reference levels) have been made to justify and optimize CT examinations. Such continued efforts, along with extended epidemiological investigations, would be needed to minimize the risk of brain cancer after pediatric CT examination,” they add.
Keeping dose to a minimum
The study’s finding of a dose-response relationship underscores the importance of keeping doses to a minimum, Dr. Bindman-Smith commented. “I do not believe we are doing this nearly enough,” she added.
“In the UCSF International CT Dose Registry, where we have collected CT scans from 165 hospitals on many millions of patients, we found that the average brain dose for a head CT in a 1-year-old is 42 mGy but that this dose varies tremendously, where some children receive a dose of 100 mGy.
“So, a second message is that not only should CT scans be justified and used judiciously, but also they should be optimized, meaning using the lowest dose possible. I personally think there should be regulatory oversight to ensure that patients receive the absolutely lowest doses possible,” she added. “My team at UCSF has written quality measures endorsed by the National Quality Forum as a start for setting explicit standards for how CT should be performed in order to ensure the cancer risks are as low as possible.”
The study was funded through the Belgian Cancer Registry; La Ligue contre le Cancer, L’Institut National du Cancer, France; the Ministry of Health, Labour and Welfare of Japan; the German Federal Ministry of Education and Research; Worldwide Cancer Research; the Dutch Cancer Society; the Research Council of Norway; Consejo de Seguridad Nuclear, Generalitat deCatalunya, Spain; the U.S. National Cancer Institute; the U.K. National Institute for Health Research; and Public Health England. Dr. Hauptmann has disclosed no relevant financial relationships. Other investigators’ relevant financial relationships are listed in the original article. Dr. Hamada and Dr. Zablotska disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Children and young adults who are exposed to a single CT scan of the head or neck before age 22 years are at significantly increased risk of developing a brain tumor, particularly glioma, after at least 5 years, according to results of the large EPI-CT study.
“Translation of our risk estimates to the clinical setting indicates that per 10,000 children who received one head CT examination, about one radiation-induced brain cancer is expected during the 5-15 years following the CT examination,” noted lead author Michael Hauptmann, PhD, from the Institute of Biostatistics and Registry Research, Brandenburg Medical School, Neuruppin, Germany, and coauthors.
“Next to the clinical benefit of most CT scans, there is a small risk of cancer from the radiation exposure,” Dr. Hauptmann told this news organization.
“So, CT examinations should only be used when necessary, and if they are used, the lowest achievable dose should be applied,” he said.
The study was published online in The Lancet Oncology.
“This is a thoughtful and well-conducted study by an outstanding multinational team of scientists that adds further weight to the growing body of evidence that has found exposure to CT scanning increases a child’s risk of developing brain cancer,” commented Rebecca Bindman-Smith, MD, from the University of California, San Francisco, who was not involved in the research.
“The results are real, and important,” she told this news organization, adding that “the authors were conservative in their assumptions, and performed a very large number of sensitivity analyses ... to check that the results were robust to a large range of assumptions – and the results changed relatively little.”
“I do not think there is enough awareness [about this risk],” Dr. Hauptmann said. “There is evidence that a nonnegligible number of CTs is unjustified according to guidelines, and there is evidence that doses vary substantially for the same CT between institutions in the same or different countries.”
Indeed, particularly in the United States, “we perform many CT scans in children and even more so in adults that are simply unnecessary,” agreed Dr. Bindman-Smith, who is professor of epidemiology and biostatistics at the University of California, San Francisco. “It is important for patients and providers to understand that nothing we do in medicine is risk free, including CT scanning. If a CT is necessary, the benefit almost certainly outweighs the risk. But if [not], then it should not be obtained. Both patients and providers must make thoroughly considered decisions before asking for or agreeing to a CT.”
She also pointed out that while this study evaluated the risk only for brain cancer, children who undergo head CTs are also at increased risk for leukemia.
Dose/response relationship
The study included 658,752 individuals from nine European countries and 276 hospitals. Each patient had received at least one CT scan between 1977 and 2014 before they turned 22 years of age. Eligibility requirements included their being alive at least 5 years after the first scan and that they had not previously been diagnosed with cancer or benign brain tumor.
The radiation dose absorbed to the brain and 33 other organs and tissues was estimated for each participant using a dose reconstruction model that included historical information on CT machine settings, questionnaire data, and Digital Imaging and Communication in Medicine header metadata. “Mean brain dose per head or neck CT examination increased from 1984 until about 1991, following the introduction of multislice CT scanners at which point thereafter the mean dose decreased and then stabilized around 2010,” note the authors.
During a median follow-up of 5.6 years (starting 5 years after the first scan), 165 brain cancers occurred, including 121 (73%) gliomas, as well as a variety of other morphologic changes.
The mean cumulative brain dose, which lagged by 5 years, was 47.4 mGy overall and 76.0 mGy among people with brain cancer.
“We observed a significant positive association between the cumulative number of head or neck CT examinations and the risk of all brain cancers combined (P < .0001), and of gliomas separately (P = .0002),” the team reports, adding that, for a brain dose of 38 mGy, which was the average dose per head or neck CT in 2012-2014, the relative risk of developing brain cancer was 1.5, compared with not undergoing a CT scan, and the excess absolute risk per 100,000 person-years was 1.1.
These findings “can be used to give the patients and their parents important information on the risks of CT examination to balance against the known benefits,” noted Nobuyuki Hamada, PhD, from the Central Research Institute of Electric Power Industry, Tokyo, and Lydia B. Zablotska, MD, PhD, from the University of California, San Francisco, writing in a linked commentary.
“In recent years, rates of CT use have been steady or declined, and various efforts (for instance, in terms of diagnostic reference levels) have been made to justify and optimize CT examinations. Such continued efforts, along with extended epidemiological investigations, would be needed to minimize the risk of brain cancer after pediatric CT examination,” they add.
Keeping dose to a minimum
The study’s finding of a dose-response relationship underscores the importance of keeping doses to a minimum, Dr. Bindman-Smith commented. “I do not believe we are doing this nearly enough,” she added.
“In the UCSF International CT Dose Registry, where we have collected CT scans from 165 hospitals on many millions of patients, we found that the average brain dose for a head CT in a 1-year-old is 42 mGy but that this dose varies tremendously, where some children receive a dose of 100 mGy.
“So, a second message is that not only should CT scans be justified and used judiciously, but also they should be optimized, meaning using the lowest dose possible. I personally think there should be regulatory oversight to ensure that patients receive the absolutely lowest doses possible,” she added. “My team at UCSF has written quality measures endorsed by the National Quality Forum as a start for setting explicit standards for how CT should be performed in order to ensure the cancer risks are as low as possible.”
The study was funded through the Belgian Cancer Registry; La Ligue contre le Cancer, L’Institut National du Cancer, France; the Ministry of Health, Labour and Welfare of Japan; the German Federal Ministry of Education and Research; Worldwide Cancer Research; the Dutch Cancer Society; the Research Council of Norway; Consejo de Seguridad Nuclear, Generalitat deCatalunya, Spain; the U.S. National Cancer Institute; the U.K. National Institute for Health Research; and Public Health England. Dr. Hauptmann has disclosed no relevant financial relationships. Other investigators’ relevant financial relationships are listed in the original article. Dr. Hamada and Dr. Zablotska disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE LANCET ONCOLOGY
Screen time may help concussion recovery
research shows.
Now a study suggests that getting back on TikTok and Snapchat may help, too.
After surveying 700 patients ages 8-16 following an injury, researchers for the Pediatric Emergency Research Canada A-CAP study team found that
A “moderate” amount was between 2 and 7 hours per day on various screens. “That includes their phones, computers, and televisions,” says lead author Molly Cairncross, PhD, of Simon Fraser University, Vancouver.
People in the study who reported either less or more screen time than that in the 7-10 days after injury also reported more symptoms, such as headaches and fatigue, during the first month. After that month, all the participants reported similar symptoms, regardless of their early screen use – suggesting that screen time makes little difference long term in pediatric concussion recovery.
The findings differ from a 2021 study by researchers at the University of Massachusetts, Boston, that found screen time slowed recovery. Why the clashing results? “I think what it comes down to are differences in study design,” says Dr. Cairncross. While the earlier study measured screen use in the first 48 hours, and recovery over 10 days, “we focused on screen time use over the first 7-10 days, and tracked recovery over 6 months,” she says.
“Taken together, the studies suggest a need to find balance – not too little and not too much time on screens for kids and teens following a concussion,” Dr. Cairncross says.
Ultimately, the findings support moderation rather than blanket restrictions on screen time as the best way to manage pediatric concussion, especially after the first 48 hours.
“It’s actually unsurprising,” says Sarah Brittain, MS, a speech-language pathologist and founder of Colorado Brain Recovery in Wheat Ridge, who was not involved in the study. “An early return to both cognitive and physical activity in a controlled fashion is really important. Sitting in a dark room and resting is not the answer and has been disproven in the literature.”
Old advice involved lying in a quiet, dark room for days, but recent evidence reveals that such “cocoon therapy” may actually prolong symptoms.
“With time, we have found this can negatively impact quality of life and depression scores, especially in teenagers,” says Katherine Labiner, MD, a child neurologist at Pediatrix Child Neurology Consultants of Austin, Tex., who was not involved in the study.
So, how might screens help? Dr. Labiner, Ms. Brittain, and Dr. Cairncross all point to the importance of connection – not the Internet kind, but the social kind. Children and teens use smartphones and computers to stay connected with peers, so banning screen time could have a negative impact on mental health by leading to loneliness, separation, and lack of social support.
“Depression can prolong the course of recovery,” says Ms. Brittain.
It’s worth noting that screen time could trigger visual symptoms in some patients, she says. “If someone feels worse within 2 minutes of being on a screen, that’s a good indicator that screens aren’t working for them,” Ms. Brittain says. “If being on a screen makes them dizzy or wiped out, or the words on the screen look like they’re moving when they’re not, that means it’s time to back off.”
She advises parents to watch for behavior changes like increased crankiness, impatience, and/or fatigue, which could mean that the child has returned to screen time – or any activity – too soon and should scale back until symptoms subside.
“The most important thing to stress with concussion is full recovery before complete return to activity,” Dr. Labiner says.
A version of this article first appeared on Medscape.com.
research shows.
Now a study suggests that getting back on TikTok and Snapchat may help, too.
After surveying 700 patients ages 8-16 following an injury, researchers for the Pediatric Emergency Research Canada A-CAP study team found that
A “moderate” amount was between 2 and 7 hours per day on various screens. “That includes their phones, computers, and televisions,” says lead author Molly Cairncross, PhD, of Simon Fraser University, Vancouver.
People in the study who reported either less or more screen time than that in the 7-10 days after injury also reported more symptoms, such as headaches and fatigue, during the first month. After that month, all the participants reported similar symptoms, regardless of their early screen use – suggesting that screen time makes little difference long term in pediatric concussion recovery.
The findings differ from a 2021 study by researchers at the University of Massachusetts, Boston, that found screen time slowed recovery. Why the clashing results? “I think what it comes down to are differences in study design,” says Dr. Cairncross. While the earlier study measured screen use in the first 48 hours, and recovery over 10 days, “we focused on screen time use over the first 7-10 days, and tracked recovery over 6 months,” she says.
“Taken together, the studies suggest a need to find balance – not too little and not too much time on screens for kids and teens following a concussion,” Dr. Cairncross says.
Ultimately, the findings support moderation rather than blanket restrictions on screen time as the best way to manage pediatric concussion, especially after the first 48 hours.
“It’s actually unsurprising,” says Sarah Brittain, MS, a speech-language pathologist and founder of Colorado Brain Recovery in Wheat Ridge, who was not involved in the study. “An early return to both cognitive and physical activity in a controlled fashion is really important. Sitting in a dark room and resting is not the answer and has been disproven in the literature.”
Old advice involved lying in a quiet, dark room for days, but recent evidence reveals that such “cocoon therapy” may actually prolong symptoms.
“With time, we have found this can negatively impact quality of life and depression scores, especially in teenagers,” says Katherine Labiner, MD, a child neurologist at Pediatrix Child Neurology Consultants of Austin, Tex., who was not involved in the study.
So, how might screens help? Dr. Labiner, Ms. Brittain, and Dr. Cairncross all point to the importance of connection – not the Internet kind, but the social kind. Children and teens use smartphones and computers to stay connected with peers, so banning screen time could have a negative impact on mental health by leading to loneliness, separation, and lack of social support.
“Depression can prolong the course of recovery,” says Ms. Brittain.
It’s worth noting that screen time could trigger visual symptoms in some patients, she says. “If someone feels worse within 2 minutes of being on a screen, that’s a good indicator that screens aren’t working for them,” Ms. Brittain says. “If being on a screen makes them dizzy or wiped out, or the words on the screen look like they’re moving when they’re not, that means it’s time to back off.”
She advises parents to watch for behavior changes like increased crankiness, impatience, and/or fatigue, which could mean that the child has returned to screen time – or any activity – too soon and should scale back until symptoms subside.
“The most important thing to stress with concussion is full recovery before complete return to activity,” Dr. Labiner says.
A version of this article first appeared on Medscape.com.
research shows.
Now a study suggests that getting back on TikTok and Snapchat may help, too.
After surveying 700 patients ages 8-16 following an injury, researchers for the Pediatric Emergency Research Canada A-CAP study team found that
A “moderate” amount was between 2 and 7 hours per day on various screens. “That includes their phones, computers, and televisions,” says lead author Molly Cairncross, PhD, of Simon Fraser University, Vancouver.
People in the study who reported either less or more screen time than that in the 7-10 days after injury also reported more symptoms, such as headaches and fatigue, during the first month. After that month, all the participants reported similar symptoms, regardless of their early screen use – suggesting that screen time makes little difference long term in pediatric concussion recovery.
The findings differ from a 2021 study by researchers at the University of Massachusetts, Boston, that found screen time slowed recovery. Why the clashing results? “I think what it comes down to are differences in study design,” says Dr. Cairncross. While the earlier study measured screen use in the first 48 hours, and recovery over 10 days, “we focused on screen time use over the first 7-10 days, and tracked recovery over 6 months,” she says.
“Taken together, the studies suggest a need to find balance – not too little and not too much time on screens for kids and teens following a concussion,” Dr. Cairncross says.
Ultimately, the findings support moderation rather than blanket restrictions on screen time as the best way to manage pediatric concussion, especially after the first 48 hours.
“It’s actually unsurprising,” says Sarah Brittain, MS, a speech-language pathologist and founder of Colorado Brain Recovery in Wheat Ridge, who was not involved in the study. “An early return to both cognitive and physical activity in a controlled fashion is really important. Sitting in a dark room and resting is not the answer and has been disproven in the literature.”
Old advice involved lying in a quiet, dark room for days, but recent evidence reveals that such “cocoon therapy” may actually prolong symptoms.
“With time, we have found this can negatively impact quality of life and depression scores, especially in teenagers,” says Katherine Labiner, MD, a child neurologist at Pediatrix Child Neurology Consultants of Austin, Tex., who was not involved in the study.
So, how might screens help? Dr. Labiner, Ms. Brittain, and Dr. Cairncross all point to the importance of connection – not the Internet kind, but the social kind. Children and teens use smartphones and computers to stay connected with peers, so banning screen time could have a negative impact on mental health by leading to loneliness, separation, and lack of social support.
“Depression can prolong the course of recovery,” says Ms. Brittain.
It’s worth noting that screen time could trigger visual symptoms in some patients, she says. “If someone feels worse within 2 minutes of being on a screen, that’s a good indicator that screens aren’t working for them,” Ms. Brittain says. “If being on a screen makes them dizzy or wiped out, or the words on the screen look like they’re moving when they’re not, that means it’s time to back off.”
She advises parents to watch for behavior changes like increased crankiness, impatience, and/or fatigue, which could mean that the child has returned to screen time – or any activity – too soon and should scale back until symptoms subside.
“The most important thing to stress with concussion is full recovery before complete return to activity,” Dr. Labiner says.
A version of this article first appeared on Medscape.com.
FROM PEDIATRICS
Patient harm, not malpractice, top of mind for emergency medicine physicians
according to a study published in JAMA Network Open.
The cross-sectional study was conducted by researchers from Soroka University Medical Center, Israel; the University of Massachusetts, Worcester; Beth Israel Deaconess Medical Center; Harvard Medical School, Boston; and the University of Massachusetts, Amherst.
Online survey responses were collected from 1,222 emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals throughout Massachusetts from January to September 2020.
Participants were asked to rank their level of agreement – from “strongly disagree” to “strongly agree” – with two statements: “In my day-to-day practice, I am fearful of making a mistake which results in [1] harm to the patient” (fear of harm) and [2] “being sued” (fear of suit).
The average age of the participants was about 44 years; 54.2% were men, 45.1% were women, and 0.7% were of other gender. Approximately 70% of responses were from MDs or DOs, and the remainder were from nurse practitioners and physician assistants. Participants had between 5 and 19 years of experience (median, 10 years).
The study found that the mean score was greater with regard to fear of harm than to fear of suit, regardless of clinician type, experience, or sex and whether the survey was completed before or after the start of the COVID-19 pandemic. There was no significant difference in mean scores regarding fear of suit before the pandemic and after it.
“Our data show a significantly greater fear of harming a patient than a fear of a malpractice suit,” Linda Isbell, PhD, professor of psychology at the University of Massachusetts, Amherst, who is one of the study’s authors, told this news organization. “There is a genuine concern and fear of harming patients and a desire to provide the best care for the patient’s well-being.”
In general, fear-of-harm and fear-of-suit scores decreased as providers gained experience. Those with less than 5 years of experience reported the highest levels of both.
“Although our data do not specifically provide reasons why age may impact [fear] levels, it is possible that with more practice experience ... providers have a better sense of the likelihood of patient harm and malpractice and how to manage such outcomes should they happen,” says Dr. Isbell. She noted that a longitudinal study is necessary to confirm this hypothesis.
One exception was female APCs, whose fear-of-harm scores remained relatively steady across all experience levels. Among male APCs, fear of causing patient harm decreased among those with 5-14 years of experience but increased slightly at 14-44 years of experience.
While previous research typically focused on fear of malpractice as a significant driver of defensive medicine, such as testing excessively, this study examined providers’ fear of harming patients because of a medical error.
The findings suggest “that fear of harm should be considered with, and may be more consequential than, fear of suit in medical decision-making,” the authors note.
“[F]ear can motivate people to engage in more careful and thorough information processing, which can drive behaviors in systematic ways,” says Dr. Isbell. “It is possible that one’s fear of harming a patient is triggering a high level of vigilance, reflected in the practice of defensive medicine across different types of patients – some of whom may be better off with less testing and referrals.”
Rade B. Vukmir, MD, JD, FACEP, an emergency medicine physician and spokesman for the American College of Emergency Physicians, says defensive medicine is common in the specialty and that it occurs 20%-40% of the time.
“Early in practice, the proverbial worst sin is missing a diagnosis, so that’s where the overtesting mentality comes from,” he says. In addition, “there are cities where you can’t drive a mile without seeing a half dozen legal advertisements. That imposes a cost burden on the system, [adding] roughly 20% to the cost of overall care.”
Emergency medicine providers attempt to minimize testing, but between their role as “America’s safety net” and the difficult circumstances they often face when treating patients, it takes a while to strike a balance, Dr. Vukmir acknowledges.
“There’s a training correlation, which showed up [in this study]; as people got further advanced in training, they felt more comfortable and felt the need to do it less,” says Dr. Vukmir.
The study was funded by a grant from the Agency for Healthcare Research and Quality. Dr. Isbell reports no conflicts of interest. Dr. Vukmir has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to a study published in JAMA Network Open.
The cross-sectional study was conducted by researchers from Soroka University Medical Center, Israel; the University of Massachusetts, Worcester; Beth Israel Deaconess Medical Center; Harvard Medical School, Boston; and the University of Massachusetts, Amherst.
Online survey responses were collected from 1,222 emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals throughout Massachusetts from January to September 2020.
Participants were asked to rank their level of agreement – from “strongly disagree” to “strongly agree” – with two statements: “In my day-to-day practice, I am fearful of making a mistake which results in [1] harm to the patient” (fear of harm) and [2] “being sued” (fear of suit).
The average age of the participants was about 44 years; 54.2% were men, 45.1% were women, and 0.7% were of other gender. Approximately 70% of responses were from MDs or DOs, and the remainder were from nurse practitioners and physician assistants. Participants had between 5 and 19 years of experience (median, 10 years).
The study found that the mean score was greater with regard to fear of harm than to fear of suit, regardless of clinician type, experience, or sex and whether the survey was completed before or after the start of the COVID-19 pandemic. There was no significant difference in mean scores regarding fear of suit before the pandemic and after it.
“Our data show a significantly greater fear of harming a patient than a fear of a malpractice suit,” Linda Isbell, PhD, professor of psychology at the University of Massachusetts, Amherst, who is one of the study’s authors, told this news organization. “There is a genuine concern and fear of harming patients and a desire to provide the best care for the patient’s well-being.”
In general, fear-of-harm and fear-of-suit scores decreased as providers gained experience. Those with less than 5 years of experience reported the highest levels of both.
“Although our data do not specifically provide reasons why age may impact [fear] levels, it is possible that with more practice experience ... providers have a better sense of the likelihood of patient harm and malpractice and how to manage such outcomes should they happen,” says Dr. Isbell. She noted that a longitudinal study is necessary to confirm this hypothesis.
One exception was female APCs, whose fear-of-harm scores remained relatively steady across all experience levels. Among male APCs, fear of causing patient harm decreased among those with 5-14 years of experience but increased slightly at 14-44 years of experience.
While previous research typically focused on fear of malpractice as a significant driver of defensive medicine, such as testing excessively, this study examined providers’ fear of harming patients because of a medical error.
The findings suggest “that fear of harm should be considered with, and may be more consequential than, fear of suit in medical decision-making,” the authors note.
“[F]ear can motivate people to engage in more careful and thorough information processing, which can drive behaviors in systematic ways,” says Dr. Isbell. “It is possible that one’s fear of harming a patient is triggering a high level of vigilance, reflected in the practice of defensive medicine across different types of patients – some of whom may be better off with less testing and referrals.”
Rade B. Vukmir, MD, JD, FACEP, an emergency medicine physician and spokesman for the American College of Emergency Physicians, says defensive medicine is common in the specialty and that it occurs 20%-40% of the time.
“Early in practice, the proverbial worst sin is missing a diagnosis, so that’s where the overtesting mentality comes from,” he says. In addition, “there are cities where you can’t drive a mile without seeing a half dozen legal advertisements. That imposes a cost burden on the system, [adding] roughly 20% to the cost of overall care.”
Emergency medicine providers attempt to minimize testing, but between their role as “America’s safety net” and the difficult circumstances they often face when treating patients, it takes a while to strike a balance, Dr. Vukmir acknowledges.
“There’s a training correlation, which showed up [in this study]; as people got further advanced in training, they felt more comfortable and felt the need to do it less,” says Dr. Vukmir.
The study was funded by a grant from the Agency for Healthcare Research and Quality. Dr. Isbell reports no conflicts of interest. Dr. Vukmir has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to a study published in JAMA Network Open.
The cross-sectional study was conducted by researchers from Soroka University Medical Center, Israel; the University of Massachusetts, Worcester; Beth Israel Deaconess Medical Center; Harvard Medical School, Boston; and the University of Massachusetts, Amherst.
Online survey responses were collected from 1,222 emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals throughout Massachusetts from January to September 2020.
Participants were asked to rank their level of agreement – from “strongly disagree” to “strongly agree” – with two statements: “In my day-to-day practice, I am fearful of making a mistake which results in [1] harm to the patient” (fear of harm) and [2] “being sued” (fear of suit).
The average age of the participants was about 44 years; 54.2% were men, 45.1% were women, and 0.7% were of other gender. Approximately 70% of responses were from MDs or DOs, and the remainder were from nurse practitioners and physician assistants. Participants had between 5 and 19 years of experience (median, 10 years).
The study found that the mean score was greater with regard to fear of harm than to fear of suit, regardless of clinician type, experience, or sex and whether the survey was completed before or after the start of the COVID-19 pandemic. There was no significant difference in mean scores regarding fear of suit before the pandemic and after it.
“Our data show a significantly greater fear of harming a patient than a fear of a malpractice suit,” Linda Isbell, PhD, professor of psychology at the University of Massachusetts, Amherst, who is one of the study’s authors, told this news organization. “There is a genuine concern and fear of harming patients and a desire to provide the best care for the patient’s well-being.”
In general, fear-of-harm and fear-of-suit scores decreased as providers gained experience. Those with less than 5 years of experience reported the highest levels of both.
“Although our data do not specifically provide reasons why age may impact [fear] levels, it is possible that with more practice experience ... providers have a better sense of the likelihood of patient harm and malpractice and how to manage such outcomes should they happen,” says Dr. Isbell. She noted that a longitudinal study is necessary to confirm this hypothesis.
One exception was female APCs, whose fear-of-harm scores remained relatively steady across all experience levels. Among male APCs, fear of causing patient harm decreased among those with 5-14 years of experience but increased slightly at 14-44 years of experience.
While previous research typically focused on fear of malpractice as a significant driver of defensive medicine, such as testing excessively, this study examined providers’ fear of harming patients because of a medical error.
The findings suggest “that fear of harm should be considered with, and may be more consequential than, fear of suit in medical decision-making,” the authors note.
“[F]ear can motivate people to engage in more careful and thorough information processing, which can drive behaviors in systematic ways,” says Dr. Isbell. “It is possible that one’s fear of harming a patient is triggering a high level of vigilance, reflected in the practice of defensive medicine across different types of patients – some of whom may be better off with less testing and referrals.”
Rade B. Vukmir, MD, JD, FACEP, an emergency medicine physician and spokesman for the American College of Emergency Physicians, says defensive medicine is common in the specialty and that it occurs 20%-40% of the time.
“Early in practice, the proverbial worst sin is missing a diagnosis, so that’s where the overtesting mentality comes from,” he says. In addition, “there are cities where you can’t drive a mile without seeing a half dozen legal advertisements. That imposes a cost burden on the system, [adding] roughly 20% to the cost of overall care.”
Emergency medicine providers attempt to minimize testing, but between their role as “America’s safety net” and the difficult circumstances they often face when treating patients, it takes a while to strike a balance, Dr. Vukmir acknowledges.
“There’s a training correlation, which showed up [in this study]; as people got further advanced in training, they felt more comfortable and felt the need to do it less,” says Dr. Vukmir.
The study was funded by a grant from the Agency for Healthcare Research and Quality. Dr. Isbell reports no conflicts of interest. Dr. Vukmir has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Is opioid abuse leading to pediatric head trauma?
As a physician in the heart of the opioid epidemic, Pavirthra R. Ellison, MD, has watched for years as her patients have lost parents to overdoses. More than 1,400 adults in West Virginia, where she practices, died of opioid abuse in 2021 alone, government statistics show.
The grim toll made Ellison wonder: What was happening to children in the state? The answer, according to a new study, is not reassuring.
Ellison and her colleagues have found a troubling link between a surge in critical head and neck injuries among youth in West Virginia and a spike in positive tests for opioids and benzodiazepines among children who arrive at emergency departments in the state. They don’t think the pattern is a coincidence.
“What we found was really kind of scary,” said Dr. Ellison, a professor of anesthesiology and pediatrics at West Virginia University, Morgantown. “Children in this region often get exposure to these drugs early on.”
A region in crisis
According to a 2020 report from the Department of Health & Human Services, about 9.9 million Americans abused prescription opioids in 2018. That same year, almost 47,000 died following an overdose of the painkillers. In 2017, Appalachian counties experienced a death rate from opioid overdoses that was 72% higher than that of the rest of the country.
Dr. Ellison and associates who presented their findings recently at the 2022 annual meeting of the American Society of Anesthesiologists, examined rates of pediatric trauma injuries, injury severity, and results of drug screenings throughout West Virginia between 2009 and 2019.
The study included 4,538 children and adolescents younger than 18 years who had been treated for head and neck trauma. The youth were divided into two groups: 3,356 who were treated from 2009 to 2016, and 1,182 who were treated between 2017 and 2019.
The incidence of critical head injuries increased from 3.7% in the period 2009-2016 to 7.2% in the period 2017-2019 (P = .007). The incidence of serious neck injuries increased from 12.2% to 27.1% (P = .007) during that period, according to the researchers. The number of days that these patients spent on ventilators more than doubled, from 3.1 to 6.3 (P < .001), they reported.
At the same time, the rate of positive urine drug tests rose sharply, from 0.8% to 1.8% (P < .001) for benzodiazepines and from 1% to 4.9% for opioids (P < .001).
Drug testing of children hospitalized for trauma rose more than threefold, from 6.9% to 23.2% (P < .001). Dr. Ellison’s group was unable to match positive drug screens with patients who came in with injuries.
Dr. Ellison said her research “warrants further evaluation of current policies and protocols targeting substance use in children and adolescents.” To that end, her team is planning to conduct a prospective study in mid 2023 to further illuminate the trends.
“I hope early next year we can put together a group of physicians, pediatric general surgeons, neurosurgeons, and anesthesiologists,” she said. “I want to look at what we can do to reduce the severity of injury.”
She also wants to reach the population that these findings directly affect.
“The next step that we are currently working on is community awareness of the issue,” Dr. Ellison said. “Our trauma institute is partnering with middle school and high school kids to create material to raise awareness.”
Rural Appalachia faces several other endemic problems that affect the health and well-being of children and families, including limited access to health care, poverty, and minimal community support, according to Dr. Ellison. Children and teens in the region who live with parents who abuse opioids are more likely to experience family conflict, mental health challenges, legal troubles, and negative health effects, including physical trauma.
A call to action
Toufic Jildeh, MD, assistant professor of orthopedics, Michigan State University Health Care, East Lansing, who has studied ways to reduce opioid use among surgery patients, called the new findings “alarming.”
After reviewing the study, Dr. Jildeh said that in his opinion, the results support standardized drug testing of children, particularly in the context of severe trauma.
Bruce Bassi, MD, an addiction psychiatrist and owner of TelepsychHealth, a private, online psychiatric practice, agreed. “The main take-home message is that drug screening should be the standard of care for pediatric patients in this region, because it changes the management of those individuals,” Dr. Bassi said.
But identifying these patients is just the first step. “We should continue to educate and raise awareness, not only in the health care system,” Dr. Bassi said. “We also need to let parents know that the possibility of children obtaining access to medications is high.”
The study was independently supported. Dr. Ellison and Dr. Jildeh reported no relevant financial relationships. Dr. Bassi owns a private psychiatry practice called Telepsychhealth but has no other relevant financial relationships.
A version of this article first appeared on Medscape.com.
As a physician in the heart of the opioid epidemic, Pavirthra R. Ellison, MD, has watched for years as her patients have lost parents to overdoses. More than 1,400 adults in West Virginia, where she practices, died of opioid abuse in 2021 alone, government statistics show.
The grim toll made Ellison wonder: What was happening to children in the state? The answer, according to a new study, is not reassuring.
Ellison and her colleagues have found a troubling link between a surge in critical head and neck injuries among youth in West Virginia and a spike in positive tests for opioids and benzodiazepines among children who arrive at emergency departments in the state. They don’t think the pattern is a coincidence.
“What we found was really kind of scary,” said Dr. Ellison, a professor of anesthesiology and pediatrics at West Virginia University, Morgantown. “Children in this region often get exposure to these drugs early on.”
A region in crisis
According to a 2020 report from the Department of Health & Human Services, about 9.9 million Americans abused prescription opioids in 2018. That same year, almost 47,000 died following an overdose of the painkillers. In 2017, Appalachian counties experienced a death rate from opioid overdoses that was 72% higher than that of the rest of the country.
Dr. Ellison and associates who presented their findings recently at the 2022 annual meeting of the American Society of Anesthesiologists, examined rates of pediatric trauma injuries, injury severity, and results of drug screenings throughout West Virginia between 2009 and 2019.
The study included 4,538 children and adolescents younger than 18 years who had been treated for head and neck trauma. The youth were divided into two groups: 3,356 who were treated from 2009 to 2016, and 1,182 who were treated between 2017 and 2019.
The incidence of critical head injuries increased from 3.7% in the period 2009-2016 to 7.2% in the period 2017-2019 (P = .007). The incidence of serious neck injuries increased from 12.2% to 27.1% (P = .007) during that period, according to the researchers. The number of days that these patients spent on ventilators more than doubled, from 3.1 to 6.3 (P < .001), they reported.
At the same time, the rate of positive urine drug tests rose sharply, from 0.8% to 1.8% (P < .001) for benzodiazepines and from 1% to 4.9% for opioids (P < .001).
Drug testing of children hospitalized for trauma rose more than threefold, from 6.9% to 23.2% (P < .001). Dr. Ellison’s group was unable to match positive drug screens with patients who came in with injuries.
Dr. Ellison said her research “warrants further evaluation of current policies and protocols targeting substance use in children and adolescents.” To that end, her team is planning to conduct a prospective study in mid 2023 to further illuminate the trends.
“I hope early next year we can put together a group of physicians, pediatric general surgeons, neurosurgeons, and anesthesiologists,” she said. “I want to look at what we can do to reduce the severity of injury.”
She also wants to reach the population that these findings directly affect.
“The next step that we are currently working on is community awareness of the issue,” Dr. Ellison said. “Our trauma institute is partnering with middle school and high school kids to create material to raise awareness.”
Rural Appalachia faces several other endemic problems that affect the health and well-being of children and families, including limited access to health care, poverty, and minimal community support, according to Dr. Ellison. Children and teens in the region who live with parents who abuse opioids are more likely to experience family conflict, mental health challenges, legal troubles, and negative health effects, including physical trauma.
A call to action
Toufic Jildeh, MD, assistant professor of orthopedics, Michigan State University Health Care, East Lansing, who has studied ways to reduce opioid use among surgery patients, called the new findings “alarming.”
After reviewing the study, Dr. Jildeh said that in his opinion, the results support standardized drug testing of children, particularly in the context of severe trauma.
Bruce Bassi, MD, an addiction psychiatrist and owner of TelepsychHealth, a private, online psychiatric practice, agreed. “The main take-home message is that drug screening should be the standard of care for pediatric patients in this region, because it changes the management of those individuals,” Dr. Bassi said.
But identifying these patients is just the first step. “We should continue to educate and raise awareness, not only in the health care system,” Dr. Bassi said. “We also need to let parents know that the possibility of children obtaining access to medications is high.”
The study was independently supported. Dr. Ellison and Dr. Jildeh reported no relevant financial relationships. Dr. Bassi owns a private psychiatry practice called Telepsychhealth but has no other relevant financial relationships.
A version of this article first appeared on Medscape.com.
As a physician in the heart of the opioid epidemic, Pavirthra R. Ellison, MD, has watched for years as her patients have lost parents to overdoses. More than 1,400 adults in West Virginia, where she practices, died of opioid abuse in 2021 alone, government statistics show.
The grim toll made Ellison wonder: What was happening to children in the state? The answer, according to a new study, is not reassuring.
Ellison and her colleagues have found a troubling link between a surge in critical head and neck injuries among youth in West Virginia and a spike in positive tests for opioids and benzodiazepines among children who arrive at emergency departments in the state. They don’t think the pattern is a coincidence.
“What we found was really kind of scary,” said Dr. Ellison, a professor of anesthesiology and pediatrics at West Virginia University, Morgantown. “Children in this region often get exposure to these drugs early on.”
A region in crisis
According to a 2020 report from the Department of Health & Human Services, about 9.9 million Americans abused prescription opioids in 2018. That same year, almost 47,000 died following an overdose of the painkillers. In 2017, Appalachian counties experienced a death rate from opioid overdoses that was 72% higher than that of the rest of the country.
Dr. Ellison and associates who presented their findings recently at the 2022 annual meeting of the American Society of Anesthesiologists, examined rates of pediatric trauma injuries, injury severity, and results of drug screenings throughout West Virginia between 2009 and 2019.
The study included 4,538 children and adolescents younger than 18 years who had been treated for head and neck trauma. The youth were divided into two groups: 3,356 who were treated from 2009 to 2016, and 1,182 who were treated between 2017 and 2019.
The incidence of critical head injuries increased from 3.7% in the period 2009-2016 to 7.2% in the period 2017-2019 (P = .007). The incidence of serious neck injuries increased from 12.2% to 27.1% (P = .007) during that period, according to the researchers. The number of days that these patients spent on ventilators more than doubled, from 3.1 to 6.3 (P < .001), they reported.
At the same time, the rate of positive urine drug tests rose sharply, from 0.8% to 1.8% (P < .001) for benzodiazepines and from 1% to 4.9% for opioids (P < .001).
Drug testing of children hospitalized for trauma rose more than threefold, from 6.9% to 23.2% (P < .001). Dr. Ellison’s group was unable to match positive drug screens with patients who came in with injuries.
Dr. Ellison said her research “warrants further evaluation of current policies and protocols targeting substance use in children and adolescents.” To that end, her team is planning to conduct a prospective study in mid 2023 to further illuminate the trends.
“I hope early next year we can put together a group of physicians, pediatric general surgeons, neurosurgeons, and anesthesiologists,” she said. “I want to look at what we can do to reduce the severity of injury.”
She also wants to reach the population that these findings directly affect.
“The next step that we are currently working on is community awareness of the issue,” Dr. Ellison said. “Our trauma institute is partnering with middle school and high school kids to create material to raise awareness.”
Rural Appalachia faces several other endemic problems that affect the health and well-being of children and families, including limited access to health care, poverty, and minimal community support, according to Dr. Ellison. Children and teens in the region who live with parents who abuse opioids are more likely to experience family conflict, mental health challenges, legal troubles, and negative health effects, including physical trauma.
A call to action
Toufic Jildeh, MD, assistant professor of orthopedics, Michigan State University Health Care, East Lansing, who has studied ways to reduce opioid use among surgery patients, called the new findings “alarming.”
After reviewing the study, Dr. Jildeh said that in his opinion, the results support standardized drug testing of children, particularly in the context of severe trauma.
Bruce Bassi, MD, an addiction psychiatrist and owner of TelepsychHealth, a private, online psychiatric practice, agreed. “The main take-home message is that drug screening should be the standard of care for pediatric patients in this region, because it changes the management of those individuals,” Dr. Bassi said.
But identifying these patients is just the first step. “We should continue to educate and raise awareness, not only in the health care system,” Dr. Bassi said. “We also need to let parents know that the possibility of children obtaining access to medications is high.”
The study was independently supported. Dr. Ellison and Dr. Jildeh reported no relevant financial relationships. Dr. Bassi owns a private psychiatry practice called Telepsychhealth but has no other relevant financial relationships.
A version of this article first appeared on Medscape.com.
New CDC guidance on prescribing opioids for pain
The 2022 Clinical Practice Guideline provides guidance on determining whether to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use.
“Patients with pain should receive compassionate, safe, and effective pain care. We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life,” Christopher M. Jones, PharmD, DrPH, acting director for the CDC’s National Center for Injury Prevention and Control, said in a news release.
How to taper safely
The last guideline on the topic was released by CDC in 2016. Since then, new evidence has emerged regarding the benefits and risks of prescription opioids for acute and chronic pain, comparisons with nonopioid pain treatments, dosing strategies, opioid dose-dependent effects, risk mitigation strategies, and opioid tapering and discontinuation, the CDC says.
A “critical” addition to the 2022 guideline is advice on tapering opioids, Dr. Jones said during a press briefing.
“Practical tips on how to taper in an individualized patient-centered manner have been added to help clinicians if the decision is made to taper opioids, and the guideline explicitly advises against abrupt discontinuation or rapid dose reductions of opioids,” Dr. Jones said.
“That is based on lessons learned over the last several years as well as new science about how we approach tapering and the real harms that can result when patients are abruptly discontinued or rapidly tapered,” he added.
The updated guideline was published online Nov. 3 in the Morbidity and Mortality Weekly Report.
Key recommendations in the 100-page document include the following:
- In determining whether or not to initiate opioids, nonopioid therapies are at least as effective as opioids for many common types of acute pain. Use of nondrug and nonopioid drug therapies should be maximized as appropriate, and opioid therapy should only be considered for acute pain if it is anticipated that benefits outweigh risks to the patient.
- Before starting opioid therapy, providers should discuss with patients the realistic benefits and known risks of opioid therapy.
- Before starting ongoing opioid therapy for patients with subacute pain lasting 1 to 3 months or chronic pain lasting more than 3 months, providers should work with patients to establish treatment goals for pain and function, and consideration should be given as to how opioid therapy will be discontinued if benefits do not outweigh risks.
- Once opioids are started, the lowest effective dose of immediate-release opioids should be prescribed for no longer than needed for the expected duration of pain severe enough to require opioids.
- Within 1 to 4 weeks of starting opioid therapy for subacute or chronic pain, providers should work with patients to evaluate and carefully weigh benefits and risks of continuing opioid therapy; care should be exercised when increasing, continuing, or reducing opioid dosage.
- Before starting and periodically during ongoing opioid therapy, providers should evaluate risk for opioid-related harms and should work with patients to incorporate relevant strategies to mitigate risk, including offering naloxone and reviewing potential interactions with any other prescribed medications or substance used.
- Abrupt discontinuation of opioids should be avoided, especially for patients receiving high doses.
- For treating patients with opioid use disorder, treatment with evidence-based medications should be provided, or arrangements for such treatment should be made.
Dr. Jones emphasized that the guideline is “voluntary and meant to guide shared decision-making between a clinician and patient. It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, governmental entities.”
He also noted that the “current state of the overdose crisis, which is very much driven by illicit synthetic opioids, is not the aim of this guideline.
“The release of this guideline is really about advancing pain care and improving the lives of patients living with pain,” he said.
“We know that at least 1 in 5 people in the country have chronic pain. It’s one of the most common reasons why people present to their health care provider, and the goal here is to advance pain care, function, and quality of life for that patient population, while also reducing misuse, diversion, and consequences of prescription opioid misuse,” Dr. Jones added.
A version of this article first appeared on Medscape.com.
The 2022 Clinical Practice Guideline provides guidance on determining whether to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use.
“Patients with pain should receive compassionate, safe, and effective pain care. We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life,” Christopher M. Jones, PharmD, DrPH, acting director for the CDC’s National Center for Injury Prevention and Control, said in a news release.
How to taper safely
The last guideline on the topic was released by CDC in 2016. Since then, new evidence has emerged regarding the benefits and risks of prescription opioids for acute and chronic pain, comparisons with nonopioid pain treatments, dosing strategies, opioid dose-dependent effects, risk mitigation strategies, and opioid tapering and discontinuation, the CDC says.
A “critical” addition to the 2022 guideline is advice on tapering opioids, Dr. Jones said during a press briefing.
“Practical tips on how to taper in an individualized patient-centered manner have been added to help clinicians if the decision is made to taper opioids, and the guideline explicitly advises against abrupt discontinuation or rapid dose reductions of opioids,” Dr. Jones said.
“That is based on lessons learned over the last several years as well as new science about how we approach tapering and the real harms that can result when patients are abruptly discontinued or rapidly tapered,” he added.
The updated guideline was published online Nov. 3 in the Morbidity and Mortality Weekly Report.
Key recommendations in the 100-page document include the following:
- In determining whether or not to initiate opioids, nonopioid therapies are at least as effective as opioids for many common types of acute pain. Use of nondrug and nonopioid drug therapies should be maximized as appropriate, and opioid therapy should only be considered for acute pain if it is anticipated that benefits outweigh risks to the patient.
- Before starting opioid therapy, providers should discuss with patients the realistic benefits and known risks of opioid therapy.
- Before starting ongoing opioid therapy for patients with subacute pain lasting 1 to 3 months or chronic pain lasting more than 3 months, providers should work with patients to establish treatment goals for pain and function, and consideration should be given as to how opioid therapy will be discontinued if benefits do not outweigh risks.
- Once opioids are started, the lowest effective dose of immediate-release opioids should be prescribed for no longer than needed for the expected duration of pain severe enough to require opioids.
- Within 1 to 4 weeks of starting opioid therapy for subacute or chronic pain, providers should work with patients to evaluate and carefully weigh benefits and risks of continuing opioid therapy; care should be exercised when increasing, continuing, or reducing opioid dosage.
- Before starting and periodically during ongoing opioid therapy, providers should evaluate risk for opioid-related harms and should work with patients to incorporate relevant strategies to mitigate risk, including offering naloxone and reviewing potential interactions with any other prescribed medications or substance used.
- Abrupt discontinuation of opioids should be avoided, especially for patients receiving high doses.
- For treating patients with opioid use disorder, treatment with evidence-based medications should be provided, or arrangements for such treatment should be made.
Dr. Jones emphasized that the guideline is “voluntary and meant to guide shared decision-making between a clinician and patient. It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, governmental entities.”
He also noted that the “current state of the overdose crisis, which is very much driven by illicit synthetic opioids, is not the aim of this guideline.
“The release of this guideline is really about advancing pain care and improving the lives of patients living with pain,” he said.
“We know that at least 1 in 5 people in the country have chronic pain. It’s one of the most common reasons why people present to their health care provider, and the goal here is to advance pain care, function, and quality of life for that patient population, while also reducing misuse, diversion, and consequences of prescription opioid misuse,” Dr. Jones added.
A version of this article first appeared on Medscape.com.
The 2022 Clinical Practice Guideline provides guidance on determining whether to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use.
“Patients with pain should receive compassionate, safe, and effective pain care. We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life,” Christopher M. Jones, PharmD, DrPH, acting director for the CDC’s National Center for Injury Prevention and Control, said in a news release.
How to taper safely
The last guideline on the topic was released by CDC in 2016. Since then, new evidence has emerged regarding the benefits and risks of prescription opioids for acute and chronic pain, comparisons with nonopioid pain treatments, dosing strategies, opioid dose-dependent effects, risk mitigation strategies, and opioid tapering and discontinuation, the CDC says.
A “critical” addition to the 2022 guideline is advice on tapering opioids, Dr. Jones said during a press briefing.
“Practical tips on how to taper in an individualized patient-centered manner have been added to help clinicians if the decision is made to taper opioids, and the guideline explicitly advises against abrupt discontinuation or rapid dose reductions of opioids,” Dr. Jones said.
“That is based on lessons learned over the last several years as well as new science about how we approach tapering and the real harms that can result when patients are abruptly discontinued or rapidly tapered,” he added.
The updated guideline was published online Nov. 3 in the Morbidity and Mortality Weekly Report.
Key recommendations in the 100-page document include the following:
- In determining whether or not to initiate opioids, nonopioid therapies are at least as effective as opioids for many common types of acute pain. Use of nondrug and nonopioid drug therapies should be maximized as appropriate, and opioid therapy should only be considered for acute pain if it is anticipated that benefits outweigh risks to the patient.
- Before starting opioid therapy, providers should discuss with patients the realistic benefits and known risks of opioid therapy.
- Before starting ongoing opioid therapy for patients with subacute pain lasting 1 to 3 months or chronic pain lasting more than 3 months, providers should work with patients to establish treatment goals for pain and function, and consideration should be given as to how opioid therapy will be discontinued if benefits do not outweigh risks.
- Once opioids are started, the lowest effective dose of immediate-release opioids should be prescribed for no longer than needed for the expected duration of pain severe enough to require opioids.
- Within 1 to 4 weeks of starting opioid therapy for subacute or chronic pain, providers should work with patients to evaluate and carefully weigh benefits and risks of continuing opioid therapy; care should be exercised when increasing, continuing, or reducing opioid dosage.
- Before starting and periodically during ongoing opioid therapy, providers should evaluate risk for opioid-related harms and should work with patients to incorporate relevant strategies to mitigate risk, including offering naloxone and reviewing potential interactions with any other prescribed medications or substance used.
- Abrupt discontinuation of opioids should be avoided, especially for patients receiving high doses.
- For treating patients with opioid use disorder, treatment with evidence-based medications should be provided, or arrangements for such treatment should be made.
Dr. Jones emphasized that the guideline is “voluntary and meant to guide shared decision-making between a clinician and patient. It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, governmental entities.”
He also noted that the “current state of the overdose crisis, which is very much driven by illicit synthetic opioids, is not the aim of this guideline.
“The release of this guideline is really about advancing pain care and improving the lives of patients living with pain,” he said.
“We know that at least 1 in 5 people in the country have chronic pain. It’s one of the most common reasons why people present to their health care provider, and the goal here is to advance pain care, function, and quality of life for that patient population, while also reducing misuse, diversion, and consequences of prescription opioid misuse,” Dr. Jones added.
A version of this article first appeared on Medscape.com.
Pediatricians urged to check for vision problems after concussion
Pediatricians should consider screening children suspected of having a concussion for resulting vision problems that are often overlooked, according to the American Academy of Pediatrics.
Christina Master, MD, a pediatrician and sports medicine specialist at the Children’s Hospital of Philadelphia, said many doctors don’t think of vision problems when examining children who’ve experienced a head injury. But the issues are common and can significantly affect a child’s performance in school and sports, and disrupt daily life.
Dr. Master led a team of sports medicine and vision specialists who wrote an AAP policy statement on vision and concussion. She summarized the new recommendations during a plenary session Oct. 9 at the American Academy of Pediatrics National Conference.
Dr. Master told this news organization that the vast majority of the estimated 1.4 million U.S. children and adolescents who have concussions annually are treated in pediatricians’ offices.
Up to 40% of young patients experience symptoms such as blurred vision, light sensitivity, and double vision following a concussion, the panel said. In addition, children with vision problems are more likely to have prolonged recoveries and delays in returning to school than children who have concussions but don’t have similar eyesight issues.
Concussions affect neurologic pathways of the visual system and disturb basic functions such as the ability of the eyes to change focus from a distant object to a near one.
Dr. Master said most pediatricians do not routinely check for vision problems following a concussion, and children themselves may not recognize that they have vision deficits “unless you ask them very specifically.”
In addition to asking children about their vision, the policy statement recommends pediatricians conduct a thorough exam to assess ocular alignment, the ability to track a moving object, and the ability to maintain focus on an image while moving.
Dr. Master said that an assessment of vision and balance, which is described in an accompanying clinical report, lasts about 5 minutes and is easy for pediatricians to learn.
Managing vision problems
Pediatricians can guide parents in talking to their child’s school about accommodations such as extra time on classroom tasks, creating materials with enlarged fonts, and using preprinted or audio notes, the statement said.
At school, vision deficits can interfere with reading by causing children to skip words, lose their place, become fatigued, or lose interest, according to the statement.
Children can also take breaks from visual stressors such as bright lights and screens, and use prescription glasses temporarily to correct blurred vision, the panel noted.
Although most children will recover from a concussion on their own within 4 weeks, up to one-third will have persistent symptoms and may benefit from seeing a specialist who can provide treatment such as rehabilitative exercises. While evidence suggests that referring some children to specialty care within a week of a concussion improves outcomes, the signs of who would benefit are not always clear, according to the panel.
Specialties such as sports medicine, neurology, physiatry, otorhinolaryngology, and occupational therapy may provide care for prolonged symptoms, Dr. Master said.
The panel noted that more study is needed on treatment options such as rehabilitation exercises, which have been shown to help with balance and dizziness.
Dr. Master said the panel did not recommend that pediatricians provide a home exercise program to treat concussion, as she does in her practice, explaining that “it’s not clear that it’s necessary for all kids.”
One author of the policy statement, Ankoor Shah, MD, PhD, reported an intellectual property relationship with Rebion involving a patent application for a pediatric vision screener. Others, including Dr. Master, reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Pediatricians should consider screening children suspected of having a concussion for resulting vision problems that are often overlooked, according to the American Academy of Pediatrics.
Christina Master, MD, a pediatrician and sports medicine specialist at the Children’s Hospital of Philadelphia, said many doctors don’t think of vision problems when examining children who’ve experienced a head injury. But the issues are common and can significantly affect a child’s performance in school and sports, and disrupt daily life.
Dr. Master led a team of sports medicine and vision specialists who wrote an AAP policy statement on vision and concussion. She summarized the new recommendations during a plenary session Oct. 9 at the American Academy of Pediatrics National Conference.
Dr. Master told this news organization that the vast majority of the estimated 1.4 million U.S. children and adolescents who have concussions annually are treated in pediatricians’ offices.
Up to 40% of young patients experience symptoms such as blurred vision, light sensitivity, and double vision following a concussion, the panel said. In addition, children with vision problems are more likely to have prolonged recoveries and delays in returning to school than children who have concussions but don’t have similar eyesight issues.
Concussions affect neurologic pathways of the visual system and disturb basic functions such as the ability of the eyes to change focus from a distant object to a near one.
Dr. Master said most pediatricians do not routinely check for vision problems following a concussion, and children themselves may not recognize that they have vision deficits “unless you ask them very specifically.”
In addition to asking children about their vision, the policy statement recommends pediatricians conduct a thorough exam to assess ocular alignment, the ability to track a moving object, and the ability to maintain focus on an image while moving.
Dr. Master said that an assessment of vision and balance, which is described in an accompanying clinical report, lasts about 5 minutes and is easy for pediatricians to learn.
Managing vision problems
Pediatricians can guide parents in talking to their child’s school about accommodations such as extra time on classroom tasks, creating materials with enlarged fonts, and using preprinted or audio notes, the statement said.
At school, vision deficits can interfere with reading by causing children to skip words, lose their place, become fatigued, or lose interest, according to the statement.
Children can also take breaks from visual stressors such as bright lights and screens, and use prescription glasses temporarily to correct blurred vision, the panel noted.
Although most children will recover from a concussion on their own within 4 weeks, up to one-third will have persistent symptoms and may benefit from seeing a specialist who can provide treatment such as rehabilitative exercises. While evidence suggests that referring some children to specialty care within a week of a concussion improves outcomes, the signs of who would benefit are not always clear, according to the panel.
Specialties such as sports medicine, neurology, physiatry, otorhinolaryngology, and occupational therapy may provide care for prolonged symptoms, Dr. Master said.
The panel noted that more study is needed on treatment options such as rehabilitation exercises, which have been shown to help with balance and dizziness.
Dr. Master said the panel did not recommend that pediatricians provide a home exercise program to treat concussion, as she does in her practice, explaining that “it’s not clear that it’s necessary for all kids.”
One author of the policy statement, Ankoor Shah, MD, PhD, reported an intellectual property relationship with Rebion involving a patent application for a pediatric vision screener. Others, including Dr. Master, reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Pediatricians should consider screening children suspected of having a concussion for resulting vision problems that are often overlooked, according to the American Academy of Pediatrics.
Christina Master, MD, a pediatrician and sports medicine specialist at the Children’s Hospital of Philadelphia, said many doctors don’t think of vision problems when examining children who’ve experienced a head injury. But the issues are common and can significantly affect a child’s performance in school and sports, and disrupt daily life.
Dr. Master led a team of sports medicine and vision specialists who wrote an AAP policy statement on vision and concussion. She summarized the new recommendations during a plenary session Oct. 9 at the American Academy of Pediatrics National Conference.
Dr. Master told this news organization that the vast majority of the estimated 1.4 million U.S. children and adolescents who have concussions annually are treated in pediatricians’ offices.
Up to 40% of young patients experience symptoms such as blurred vision, light sensitivity, and double vision following a concussion, the panel said. In addition, children with vision problems are more likely to have prolonged recoveries and delays in returning to school than children who have concussions but don’t have similar eyesight issues.
Concussions affect neurologic pathways of the visual system and disturb basic functions such as the ability of the eyes to change focus from a distant object to a near one.
Dr. Master said most pediatricians do not routinely check for vision problems following a concussion, and children themselves may not recognize that they have vision deficits “unless you ask them very specifically.”
In addition to asking children about their vision, the policy statement recommends pediatricians conduct a thorough exam to assess ocular alignment, the ability to track a moving object, and the ability to maintain focus on an image while moving.
Dr. Master said that an assessment of vision and balance, which is described in an accompanying clinical report, lasts about 5 minutes and is easy for pediatricians to learn.
Managing vision problems
Pediatricians can guide parents in talking to their child’s school about accommodations such as extra time on classroom tasks, creating materials with enlarged fonts, and using preprinted or audio notes, the statement said.
At school, vision deficits can interfere with reading by causing children to skip words, lose their place, become fatigued, or lose interest, according to the statement.
Children can also take breaks from visual stressors such as bright lights and screens, and use prescription glasses temporarily to correct blurred vision, the panel noted.
Although most children will recover from a concussion on their own within 4 weeks, up to one-third will have persistent symptoms and may benefit from seeing a specialist who can provide treatment such as rehabilitative exercises. While evidence suggests that referring some children to specialty care within a week of a concussion improves outcomes, the signs of who would benefit are not always clear, according to the panel.
Specialties such as sports medicine, neurology, physiatry, otorhinolaryngology, and occupational therapy may provide care for prolonged symptoms, Dr. Master said.
The panel noted that more study is needed on treatment options such as rehabilitation exercises, which have been shown to help with balance and dizziness.
Dr. Master said the panel did not recommend that pediatricians provide a home exercise program to treat concussion, as she does in her practice, explaining that “it’s not clear that it’s necessary for all kids.”
One author of the policy statement, Ankoor Shah, MD, PhD, reported an intellectual property relationship with Rebion involving a patent application for a pediatric vision screener. Others, including Dr. Master, reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM AAP 2022
Opioids leading cause of poisoning deaths in young children
ANAHEIM, CALIF. – Opioids are the most common cause of fatal poisonings in young children, and their contribution to children’s deaths has been increasing, according to research presented at the American Academy of Pediatrics National Conference.
The study found that the proportion of deaths in U.S. children linked to opioids has doubled since the mid-2000s, tracking the course of the epidemic in adults in this country.
“What is striking about our study is how the opioid epidemic has not spared our nation’s infants or young children,” Christopher Gaw, MD, MA, a pediatric emergency medicine fellow physician at Children’s Hospital of Philadelphia, said in an interview. “There is important work being done to reduce unnecessary opioid prescribing, drug diversion, and treatment of substance use disorders. These efforts – though not directly related to children – also help protect them, since they can reduce the chance of exposure to opioids in the home.”
Dr. Gaw and his colleagues analyzed data in Child Death Reviews from 40 states that participate in the National Fatality Review Case Reporting System, focusing on children aged 5 years and younger who died from a poisoning between 2005 and 2018. During that time, 731 child poisoning deaths were reported to the system – of which nearly half (47%) involved opioids as the poisoning agent – up from 24% in 2005. More than 4 in 10 deaths (42%) involved children under age 1.
Most of the deaths (61%) occurred in the child’s home, and in even more cases (71%) the child was being supervised when the poisoning occurred, most often by a parent (58.5%). The others supervising children were usually a grandparent (11%) or another relative (5.5%). The child was in view of the supervising individual in 28.5% of the deaths. A child protective services case was opened in 13% of the cases.
“Supervising a child is hard. Kids are constantly exploring and moving,” Dr. Gaw said. “A child may find a dropped medication on the floor that a caregiver doesn’t see, or a child may get into a bag or a purse when a caregiver is looking the other way. Poisonings can happen in a split second.”
Expecting caregivers to be able to watch kids every moment and always be within arm’s reach to prevent an accident is unrealistic, Dr. Gaw said, so families should focus on preparedness.
“Young children can’t tell the difference between a deadly substance versus a substance that is harmless or would only cause some harm. The best way to protect children is to prevent the poisoning from happening in the first place,” Dr. Gaw said. ”
It is recommended that caregivers keep the Poison Control Center’s national 24/7 hotline in their phones: (800) 222-1222.
Two-thirds of the cases Dr. Gaw examined did not involve a call to a poison control center, but most did involve a call to 911.
“My guess is that caregivers likely called 911 instead of poison control because the child was likely critically ill or deceased when found,” Dr. Gaw said, noting that his group did not have access to descriptive information about 911 calls. “If a child is critically ill and a caregiver called poison control first, they would be referred to 911.”
If a child looks healthy but has just swallowed something dangerous or deadly, Dr. Gaw said poison control can guide the family to getting prompt medical attention that could be lifesaving.
“We don’t expect the public to know what substances are harmless, harmful, or deadly,” he said. “People should always call poison control if there is any concern, even if the child looks well.”
Some poison control centers are working to increase the ways people can reach them, including through texting, apps, or online chat, he added.
Gary A. Smith, MD, DrPH, president of the nonprofit Child Injury Prevention Alliance in Columbus, Ohio, and director of the Center for Injury Research and Policy at Nationwide Children’s Hospital, said the high level of supervision in these cases was not surprising.
”We have shown that most children are being directly supervised at the moment of injury for baby walker–related injuries, firework-related injuries, and other types of injuries that we have studied,” Dr. Smith said in an interview. “Injuries happen quickly and generally do not give a parent or caregiver time to react.”
“This dispels the myth that parental supervision is the key to injury prevention,” Dr. Smith said. “Although supervision helps, it is not adequate. These injuries occur to children of good and caring parents. The message for pediatricians is that we must create safe environments for children and design hazards out of existence to effectively prevent poisoning and other injuries.”
That preventive approach has been used for infectious disease and other public health problems, he added.
“Prescription opioids must be kept in their original containers with children-resistant closures and be stored up, away, and out of sight of children, preferably in a locked location,” Dr. Smith said. “If adults use illicit opioids or any other illicit substances – which are commonly laced with fentanyl – they should not use or store them in the home where children can access them.”
Over-the-counter pain, cold, and allergy medications were the second most common cause of death, occurring in 15% of cases.
“There has been a lot of work over the years among health care providers to counsel families on the proper dosing and use of medications such as Tylenol, Motrin, and Benadryl,” Dr. Gaw said. “There has also been a push to educate families that using antihistamines, such as Benadryl, to sedate their children can be dangerous and, depending on the dose, potentially deadly.”
Another 14% of cases were an unspecified illicit drug, and 10% were an unspecified over-the-counter or prescription medication. Carbon monoxide poisoning made up 6% of cases, and the remaining substances included amphetamines, antidepressants, cocaine, and alcohol.
Over half the deaths in 1-year-olds (61%) and children aged 2-5 (54%) were due to opioid poisoning, as were a third of deaths in infants (34%). Most of the poisonings involving amphetamines (81%), cocaine (84%), and alcohol (61.5%) occurred in infants under age 1.
Dr. Smith said that harm-reduction strategies, such as having naloxone on hand and using fentanyl test strips, can reduce the likelihood of death from illicit drugs.
Reducing stigma can save lives
“Referring parents to services for individuals who use drugs is key,” Dr. Smith said. “Treating this as a public health problem without stigmatizing the behavior is something that pediatricians and other health care professionals must remember.” As a resource for other pediatricians, Dr. Gaw noted that CHOP’s poison control center medical director Kevin Osterhoudt, MD produced a 25-minute podcast that covers common causes of poisonings, use of naloxone in children, and prevention tips.
“Naloxone is an effective antidote to opioid poisonings,” Dr. Gaw said. “We often think of using it in adults, but this is also a lifesaving medication for children poisoned by opioids. Educating people on recognizing the signs and symptoms of opioid poisoning and helping them feel empowered to use naloxone is something the public health world is working on.”
Dr. Gaw and Dr. Smith had no relevant disclosures. No external funding was noted for the study.
ANAHEIM, CALIF. – Opioids are the most common cause of fatal poisonings in young children, and their contribution to children’s deaths has been increasing, according to research presented at the American Academy of Pediatrics National Conference.
The study found that the proportion of deaths in U.S. children linked to opioids has doubled since the mid-2000s, tracking the course of the epidemic in adults in this country.
“What is striking about our study is how the opioid epidemic has not spared our nation’s infants or young children,” Christopher Gaw, MD, MA, a pediatric emergency medicine fellow physician at Children’s Hospital of Philadelphia, said in an interview. “There is important work being done to reduce unnecessary opioid prescribing, drug diversion, and treatment of substance use disorders. These efforts – though not directly related to children – also help protect them, since they can reduce the chance of exposure to opioids in the home.”
Dr. Gaw and his colleagues analyzed data in Child Death Reviews from 40 states that participate in the National Fatality Review Case Reporting System, focusing on children aged 5 years and younger who died from a poisoning between 2005 and 2018. During that time, 731 child poisoning deaths were reported to the system – of which nearly half (47%) involved opioids as the poisoning agent – up from 24% in 2005. More than 4 in 10 deaths (42%) involved children under age 1.
Most of the deaths (61%) occurred in the child’s home, and in even more cases (71%) the child was being supervised when the poisoning occurred, most often by a parent (58.5%). The others supervising children were usually a grandparent (11%) or another relative (5.5%). The child was in view of the supervising individual in 28.5% of the deaths. A child protective services case was opened in 13% of the cases.
“Supervising a child is hard. Kids are constantly exploring and moving,” Dr. Gaw said. “A child may find a dropped medication on the floor that a caregiver doesn’t see, or a child may get into a bag or a purse when a caregiver is looking the other way. Poisonings can happen in a split second.”
Expecting caregivers to be able to watch kids every moment and always be within arm’s reach to prevent an accident is unrealistic, Dr. Gaw said, so families should focus on preparedness.
“Young children can’t tell the difference between a deadly substance versus a substance that is harmless or would only cause some harm. The best way to protect children is to prevent the poisoning from happening in the first place,” Dr. Gaw said. ”
It is recommended that caregivers keep the Poison Control Center’s national 24/7 hotline in their phones: (800) 222-1222.
Two-thirds of the cases Dr. Gaw examined did not involve a call to a poison control center, but most did involve a call to 911.
“My guess is that caregivers likely called 911 instead of poison control because the child was likely critically ill or deceased when found,” Dr. Gaw said, noting that his group did not have access to descriptive information about 911 calls. “If a child is critically ill and a caregiver called poison control first, they would be referred to 911.”
If a child looks healthy but has just swallowed something dangerous or deadly, Dr. Gaw said poison control can guide the family to getting prompt medical attention that could be lifesaving.
“We don’t expect the public to know what substances are harmless, harmful, or deadly,” he said. “People should always call poison control if there is any concern, even if the child looks well.”
Some poison control centers are working to increase the ways people can reach them, including through texting, apps, or online chat, he added.
Gary A. Smith, MD, DrPH, president of the nonprofit Child Injury Prevention Alliance in Columbus, Ohio, and director of the Center for Injury Research and Policy at Nationwide Children’s Hospital, said the high level of supervision in these cases was not surprising.
”We have shown that most children are being directly supervised at the moment of injury for baby walker–related injuries, firework-related injuries, and other types of injuries that we have studied,” Dr. Smith said in an interview. “Injuries happen quickly and generally do not give a parent or caregiver time to react.”
“This dispels the myth that parental supervision is the key to injury prevention,” Dr. Smith said. “Although supervision helps, it is not adequate. These injuries occur to children of good and caring parents. The message for pediatricians is that we must create safe environments for children and design hazards out of existence to effectively prevent poisoning and other injuries.”
That preventive approach has been used for infectious disease and other public health problems, he added.
“Prescription opioids must be kept in their original containers with children-resistant closures and be stored up, away, and out of sight of children, preferably in a locked location,” Dr. Smith said. “If adults use illicit opioids or any other illicit substances – which are commonly laced with fentanyl – they should not use or store them in the home where children can access them.”
Over-the-counter pain, cold, and allergy medications were the second most common cause of death, occurring in 15% of cases.
“There has been a lot of work over the years among health care providers to counsel families on the proper dosing and use of medications such as Tylenol, Motrin, and Benadryl,” Dr. Gaw said. “There has also been a push to educate families that using antihistamines, such as Benadryl, to sedate their children can be dangerous and, depending on the dose, potentially deadly.”
Another 14% of cases were an unspecified illicit drug, and 10% were an unspecified over-the-counter or prescription medication. Carbon monoxide poisoning made up 6% of cases, and the remaining substances included amphetamines, antidepressants, cocaine, and alcohol.
Over half the deaths in 1-year-olds (61%) and children aged 2-5 (54%) were due to opioid poisoning, as were a third of deaths in infants (34%). Most of the poisonings involving amphetamines (81%), cocaine (84%), and alcohol (61.5%) occurred in infants under age 1.
Dr. Smith said that harm-reduction strategies, such as having naloxone on hand and using fentanyl test strips, can reduce the likelihood of death from illicit drugs.
Reducing stigma can save lives
“Referring parents to services for individuals who use drugs is key,” Dr. Smith said. “Treating this as a public health problem without stigmatizing the behavior is something that pediatricians and other health care professionals must remember.” As a resource for other pediatricians, Dr. Gaw noted that CHOP’s poison control center medical director Kevin Osterhoudt, MD produced a 25-minute podcast that covers common causes of poisonings, use of naloxone in children, and prevention tips.
“Naloxone is an effective antidote to opioid poisonings,” Dr. Gaw said. “We often think of using it in adults, but this is also a lifesaving medication for children poisoned by opioids. Educating people on recognizing the signs and symptoms of opioid poisoning and helping them feel empowered to use naloxone is something the public health world is working on.”
Dr. Gaw and Dr. Smith had no relevant disclosures. No external funding was noted for the study.
ANAHEIM, CALIF. – Opioids are the most common cause of fatal poisonings in young children, and their contribution to children’s deaths has been increasing, according to research presented at the American Academy of Pediatrics National Conference.
The study found that the proportion of deaths in U.S. children linked to opioids has doubled since the mid-2000s, tracking the course of the epidemic in adults in this country.
“What is striking about our study is how the opioid epidemic has not spared our nation’s infants or young children,” Christopher Gaw, MD, MA, a pediatric emergency medicine fellow physician at Children’s Hospital of Philadelphia, said in an interview. “There is important work being done to reduce unnecessary opioid prescribing, drug diversion, and treatment of substance use disorders. These efforts – though not directly related to children – also help protect them, since they can reduce the chance of exposure to opioids in the home.”
Dr. Gaw and his colleagues analyzed data in Child Death Reviews from 40 states that participate in the National Fatality Review Case Reporting System, focusing on children aged 5 years and younger who died from a poisoning between 2005 and 2018. During that time, 731 child poisoning deaths were reported to the system – of which nearly half (47%) involved opioids as the poisoning agent – up from 24% in 2005. More than 4 in 10 deaths (42%) involved children under age 1.
Most of the deaths (61%) occurred in the child’s home, and in even more cases (71%) the child was being supervised when the poisoning occurred, most often by a parent (58.5%). The others supervising children were usually a grandparent (11%) or another relative (5.5%). The child was in view of the supervising individual in 28.5% of the deaths. A child protective services case was opened in 13% of the cases.
“Supervising a child is hard. Kids are constantly exploring and moving,” Dr. Gaw said. “A child may find a dropped medication on the floor that a caregiver doesn’t see, or a child may get into a bag or a purse when a caregiver is looking the other way. Poisonings can happen in a split second.”
Expecting caregivers to be able to watch kids every moment and always be within arm’s reach to prevent an accident is unrealistic, Dr. Gaw said, so families should focus on preparedness.
“Young children can’t tell the difference between a deadly substance versus a substance that is harmless or would only cause some harm. The best way to protect children is to prevent the poisoning from happening in the first place,” Dr. Gaw said. ”
It is recommended that caregivers keep the Poison Control Center’s national 24/7 hotline in their phones: (800) 222-1222.
Two-thirds of the cases Dr. Gaw examined did not involve a call to a poison control center, but most did involve a call to 911.
“My guess is that caregivers likely called 911 instead of poison control because the child was likely critically ill or deceased when found,” Dr. Gaw said, noting that his group did not have access to descriptive information about 911 calls. “If a child is critically ill and a caregiver called poison control first, they would be referred to 911.”
If a child looks healthy but has just swallowed something dangerous or deadly, Dr. Gaw said poison control can guide the family to getting prompt medical attention that could be lifesaving.
“We don’t expect the public to know what substances are harmless, harmful, or deadly,” he said. “People should always call poison control if there is any concern, even if the child looks well.”
Some poison control centers are working to increase the ways people can reach them, including through texting, apps, or online chat, he added.
Gary A. Smith, MD, DrPH, president of the nonprofit Child Injury Prevention Alliance in Columbus, Ohio, and director of the Center for Injury Research and Policy at Nationwide Children’s Hospital, said the high level of supervision in these cases was not surprising.
”We have shown that most children are being directly supervised at the moment of injury for baby walker–related injuries, firework-related injuries, and other types of injuries that we have studied,” Dr. Smith said in an interview. “Injuries happen quickly and generally do not give a parent or caregiver time to react.”
“This dispels the myth that parental supervision is the key to injury prevention,” Dr. Smith said. “Although supervision helps, it is not adequate. These injuries occur to children of good and caring parents. The message for pediatricians is that we must create safe environments for children and design hazards out of existence to effectively prevent poisoning and other injuries.”
That preventive approach has been used for infectious disease and other public health problems, he added.
“Prescription opioids must be kept in their original containers with children-resistant closures and be stored up, away, and out of sight of children, preferably in a locked location,” Dr. Smith said. “If adults use illicit opioids or any other illicit substances – which are commonly laced with fentanyl – they should not use or store them in the home where children can access them.”
Over-the-counter pain, cold, and allergy medications were the second most common cause of death, occurring in 15% of cases.
“There has been a lot of work over the years among health care providers to counsel families on the proper dosing and use of medications such as Tylenol, Motrin, and Benadryl,” Dr. Gaw said. “There has also been a push to educate families that using antihistamines, such as Benadryl, to sedate their children can be dangerous and, depending on the dose, potentially deadly.”
Another 14% of cases were an unspecified illicit drug, and 10% were an unspecified over-the-counter or prescription medication. Carbon monoxide poisoning made up 6% of cases, and the remaining substances included amphetamines, antidepressants, cocaine, and alcohol.
Over half the deaths in 1-year-olds (61%) and children aged 2-5 (54%) were due to opioid poisoning, as were a third of deaths in infants (34%). Most of the poisonings involving amphetamines (81%), cocaine (84%), and alcohol (61.5%) occurred in infants under age 1.
Dr. Smith said that harm-reduction strategies, such as having naloxone on hand and using fentanyl test strips, can reduce the likelihood of death from illicit drugs.
Reducing stigma can save lives
“Referring parents to services for individuals who use drugs is key,” Dr. Smith said. “Treating this as a public health problem without stigmatizing the behavior is something that pediatricians and other health care professionals must remember.” As a resource for other pediatricians, Dr. Gaw noted that CHOP’s poison control center medical director Kevin Osterhoudt, MD produced a 25-minute podcast that covers common causes of poisonings, use of naloxone in children, and prevention tips.
“Naloxone is an effective antidote to opioid poisonings,” Dr. Gaw said. “We often think of using it in adults, but this is also a lifesaving medication for children poisoned by opioids. Educating people on recognizing the signs and symptoms of opioid poisoning and helping them feel empowered to use naloxone is something the public health world is working on.”
Dr. Gaw and Dr. Smith had no relevant disclosures. No external funding was noted for the study.
AT AAP 2022
Youth killed by guns in U.S. equals classroom a day
according to the American Academy of Pediatrics.
Preventing firearm-related injuries and deaths in children and youth “demands a public safety approach like regulation of motor vehicles,” the group said.
The organization on Oct. 8 released an updated policy statement and technical report about gun violence and children at its 2022 annual meeting in Anaheim, Calif. The reports were published in the journal Pediatrics, and the authors plan to discuss them during the conference.
“Each day, 28 U.S. children and teens – the equivalent of a high school classroom – die from gun violence, making it the No. 1 killer of youth through age 24,” the AAP said in a statement about the reports. “The national death rate is significantly higher than all other high-income countries combined, largely due to an alarming increase in suicides and homicides that do not make national headlines.”
Firearms have become the leading cause of death among children in the United States.
In 2020, guns caused 10,197 deaths of Americans younger than 24, according to the Society for Adolescent Health and Medicine.
In 2015, more than 7,200 American youth were killed by firearms. That same year in 28 other high-income countries – which combined would have had a population twice that of the United States – just 685 youth were killed by firearms, according to the AAP.
Separately at the AAP conference, physicians are presenting new research about gun violence and children. And on Oct. 10, a pediatrician who was at Uvalde Memorial Hospital in Texas after the deadly school shooting in May is scheduled to address attendees. The doctor, Roy Guerrero, MD, testified on Capitol Hill to advocate for gun control after the shooting at Robb Elementary School, which killed 19 children and two adults.
“This is not a simple problem, and it cannot be fixed with a simple solution,” Lois K. Lee, MD, MPH, said in the AAP news release. Dr. Lee chairs the AAP Council on Injury, Violence, and Poison Prevention that wrote the new reports. “Pediatricians as a start can offer families guidance and education on more safely storing guns. AAP also calls for supporting legislation that, much like the common-sense requirements for obtaining a driver’s license, would improve gun ownership safety.”
Many deaths occur at home
The rate of homicide from firearms in U.S. youth, especially those aged 15-24 years, increased by 14% during the past decade, and the rate of suicide from firearms increased by 39%, according to the AAP.
Homicides account for 58% of youth firearm deaths, whereas suicides account for 37%. Another 2% of youth firearm deaths are unintentional, and 1% result from law enforcement actions, the group said.
Among children 12 years old and younger, about 85% of firearm deaths occur at home. Teen firearm deaths are about as likely to occur at home (39%) as on the street or sidewalk (38%), according to research based on 2014 data.
“School shootings represent a relatively new phenomenon over the last half-century, and the United States has the highest rate of school shootings in the world,” the AAP technical report noted. Between 1966 and 2008, according to the group, 44 such shootings occurred in the United States, or an average of about one per year. Fast forward a few years and the violence became dramatically worse: Between 2013 and 2015, officials counted 154 school shootings – or about one per week.
Still, school shootings are responsible for less than 1% of all firearm deaths among children 17 years or younger in the United States. While school shootings “receive a tremendous amount of attention,” the report stated, other child firearm deaths may be less likely to make national headlines.
“Many firearm tragedies escape public attention because they occur in a home, sometimes in a child’s own home or at a friend’s house, or their neighbor’s or grandparent’s residence,” Eric W. Fleegler, MD, MPH, Boston Children’s Hospital, a co-author of the new reports, said in a statement from AAP. “Research tells us that families tend to underestimate how children will behave when they encounter a gun and miscalculate the risks. Suicide risks are also a huge concern, especially in families where teens are struggling with their mental health.”
AAP-recommended actions include:
- Mental health screenings and safe gun storage education provided by clinicians as part of routine patient visits
- Increased funding for violence intervention programs in hospital and community settings
- Regulation of firearms like other consumer products, with national requirements that address training, licensing, insurance coverage, registration of individuals purchasing firearms, and safe storage
- The use of technology that allows only authorized users to pull the trigger
- Universal background checks that use federal databases and information from local police before all gun purchases
- Extreme risk protection order laws, or “red flag laws,” that prohibit individuals at risk for harming themselves or others from purchasing or owning a firearm
- More funding for firearm injury and prevention research.
A noticeable increase in the ED
Irma Ugalde, MD, associate professor and director of pediatric emergency medicine research at McGovern Medical School at UTHealth Houston, noticed that firearm-related injuries in children at her hospital were more common during the COVID-19 pandemic, even as pediatric emergency department visits decreased overall.
She and her colleagues studied the trends and reported their findings at the AAP meeting.
“We saw a drop in pediatric admissions overall,” Dr. Ugalde said in a statement about the study. “But what was really noticeable was that trauma was still very prevalent – in fact probably more so – and we were seeing more firearm injuries.”
The researchers found that firearm injuries in children rose from 88 cases in 2019 to 118 in 2020. The number of incidents remained elevated in 2021, with 115 cases.
In addition, the researchers found an initial increase in injuries occurring at home where the shooter was a known family member or friend, and in cases involving firearms that were not properly stored.
By comparison, pediatric ED visits overall decreased by 34.2% from 2019 to 2020, and by 11.8% from 2019 to 2021.
The increase in firearm injuries coincided with an increase in gun sales in the United States, the researchers noted.
“National and statewide initiatives to mitigate the risk of firearm-related injury and death are necessary,” Dr. Ugalde’s group said. “We recommend that health care workers remain vigilant about screening for potential risk factors and safe storage of firearms.”
Accidental injuries
Daniel D. Guzman, MD, with Cook Children’s Health Care Center, Fort Worth, Tex., conducted a study focused on unintentional firearm injuries in children. Dr. Guzman’s group analyzed data from 204 patients younger than age 19 seen at Cook Children’s from January 2015 to June 2021.
Dr. Guzman and his colleagues examined outcomes for injuries caused by powder guns – shotguns, rifles, and handguns – and air-power guns that shoot BBs and pellets.
The researchers found that 29% of the unintentional firearm injuries occurred with powder guns and 71% with air-power weapons, often BB guns.
“It is important that all firearms, powdered and air-powered, be stored safely in a lock box or safe,” Dr. Guzman said in a statement. To that end, Cook Children’s has developed a program called Aim for Safety to teach children and parents about the dangers of unsupervised play with BB guns and pellet guns, as well as the importance of storing all firearms unloaded and in a locked safe.
A version of this article first appeared on Medscape.com.
according to the American Academy of Pediatrics.
Preventing firearm-related injuries and deaths in children and youth “demands a public safety approach like regulation of motor vehicles,” the group said.
The organization on Oct. 8 released an updated policy statement and technical report about gun violence and children at its 2022 annual meeting in Anaheim, Calif. The reports were published in the journal Pediatrics, and the authors plan to discuss them during the conference.
“Each day, 28 U.S. children and teens – the equivalent of a high school classroom – die from gun violence, making it the No. 1 killer of youth through age 24,” the AAP said in a statement about the reports. “The national death rate is significantly higher than all other high-income countries combined, largely due to an alarming increase in suicides and homicides that do not make national headlines.”
Firearms have become the leading cause of death among children in the United States.
In 2020, guns caused 10,197 deaths of Americans younger than 24, according to the Society for Adolescent Health and Medicine.
In 2015, more than 7,200 American youth were killed by firearms. That same year in 28 other high-income countries – which combined would have had a population twice that of the United States – just 685 youth were killed by firearms, according to the AAP.
Separately at the AAP conference, physicians are presenting new research about gun violence and children. And on Oct. 10, a pediatrician who was at Uvalde Memorial Hospital in Texas after the deadly school shooting in May is scheduled to address attendees. The doctor, Roy Guerrero, MD, testified on Capitol Hill to advocate for gun control after the shooting at Robb Elementary School, which killed 19 children and two adults.
“This is not a simple problem, and it cannot be fixed with a simple solution,” Lois K. Lee, MD, MPH, said in the AAP news release. Dr. Lee chairs the AAP Council on Injury, Violence, and Poison Prevention that wrote the new reports. “Pediatricians as a start can offer families guidance and education on more safely storing guns. AAP also calls for supporting legislation that, much like the common-sense requirements for obtaining a driver’s license, would improve gun ownership safety.”
Many deaths occur at home
The rate of homicide from firearms in U.S. youth, especially those aged 15-24 years, increased by 14% during the past decade, and the rate of suicide from firearms increased by 39%, according to the AAP.
Homicides account for 58% of youth firearm deaths, whereas suicides account for 37%. Another 2% of youth firearm deaths are unintentional, and 1% result from law enforcement actions, the group said.
Among children 12 years old and younger, about 85% of firearm deaths occur at home. Teen firearm deaths are about as likely to occur at home (39%) as on the street or sidewalk (38%), according to research based on 2014 data.
“School shootings represent a relatively new phenomenon over the last half-century, and the United States has the highest rate of school shootings in the world,” the AAP technical report noted. Between 1966 and 2008, according to the group, 44 such shootings occurred in the United States, or an average of about one per year. Fast forward a few years and the violence became dramatically worse: Between 2013 and 2015, officials counted 154 school shootings – or about one per week.
Still, school shootings are responsible for less than 1% of all firearm deaths among children 17 years or younger in the United States. While school shootings “receive a tremendous amount of attention,” the report stated, other child firearm deaths may be less likely to make national headlines.
“Many firearm tragedies escape public attention because they occur in a home, sometimes in a child’s own home or at a friend’s house, or their neighbor’s or grandparent’s residence,” Eric W. Fleegler, MD, MPH, Boston Children’s Hospital, a co-author of the new reports, said in a statement from AAP. “Research tells us that families tend to underestimate how children will behave when they encounter a gun and miscalculate the risks. Suicide risks are also a huge concern, especially in families where teens are struggling with their mental health.”
AAP-recommended actions include:
- Mental health screenings and safe gun storage education provided by clinicians as part of routine patient visits
- Increased funding for violence intervention programs in hospital and community settings
- Regulation of firearms like other consumer products, with national requirements that address training, licensing, insurance coverage, registration of individuals purchasing firearms, and safe storage
- The use of technology that allows only authorized users to pull the trigger
- Universal background checks that use federal databases and information from local police before all gun purchases
- Extreme risk protection order laws, or “red flag laws,” that prohibit individuals at risk for harming themselves or others from purchasing or owning a firearm
- More funding for firearm injury and prevention research.
A noticeable increase in the ED
Irma Ugalde, MD, associate professor and director of pediatric emergency medicine research at McGovern Medical School at UTHealth Houston, noticed that firearm-related injuries in children at her hospital were more common during the COVID-19 pandemic, even as pediatric emergency department visits decreased overall.
She and her colleagues studied the trends and reported their findings at the AAP meeting.
“We saw a drop in pediatric admissions overall,” Dr. Ugalde said in a statement about the study. “But what was really noticeable was that trauma was still very prevalent – in fact probably more so – and we were seeing more firearm injuries.”
The researchers found that firearm injuries in children rose from 88 cases in 2019 to 118 in 2020. The number of incidents remained elevated in 2021, with 115 cases.
In addition, the researchers found an initial increase in injuries occurring at home where the shooter was a known family member or friend, and in cases involving firearms that were not properly stored.
By comparison, pediatric ED visits overall decreased by 34.2% from 2019 to 2020, and by 11.8% from 2019 to 2021.
The increase in firearm injuries coincided with an increase in gun sales in the United States, the researchers noted.
“National and statewide initiatives to mitigate the risk of firearm-related injury and death are necessary,” Dr. Ugalde’s group said. “We recommend that health care workers remain vigilant about screening for potential risk factors and safe storage of firearms.”
Accidental injuries
Daniel D. Guzman, MD, with Cook Children’s Health Care Center, Fort Worth, Tex., conducted a study focused on unintentional firearm injuries in children. Dr. Guzman’s group analyzed data from 204 patients younger than age 19 seen at Cook Children’s from January 2015 to June 2021.
Dr. Guzman and his colleagues examined outcomes for injuries caused by powder guns – shotguns, rifles, and handguns – and air-power guns that shoot BBs and pellets.
The researchers found that 29% of the unintentional firearm injuries occurred with powder guns and 71% with air-power weapons, often BB guns.
“It is important that all firearms, powdered and air-powered, be stored safely in a lock box or safe,” Dr. Guzman said in a statement. To that end, Cook Children’s has developed a program called Aim for Safety to teach children and parents about the dangers of unsupervised play with BB guns and pellet guns, as well as the importance of storing all firearms unloaded and in a locked safe.
A version of this article first appeared on Medscape.com.
according to the American Academy of Pediatrics.
Preventing firearm-related injuries and deaths in children and youth “demands a public safety approach like regulation of motor vehicles,” the group said.
The organization on Oct. 8 released an updated policy statement and technical report about gun violence and children at its 2022 annual meeting in Anaheim, Calif. The reports were published in the journal Pediatrics, and the authors plan to discuss them during the conference.
“Each day, 28 U.S. children and teens – the equivalent of a high school classroom – die from gun violence, making it the No. 1 killer of youth through age 24,” the AAP said in a statement about the reports. “The national death rate is significantly higher than all other high-income countries combined, largely due to an alarming increase in suicides and homicides that do not make national headlines.”
Firearms have become the leading cause of death among children in the United States.
In 2020, guns caused 10,197 deaths of Americans younger than 24, according to the Society for Adolescent Health and Medicine.
In 2015, more than 7,200 American youth were killed by firearms. That same year in 28 other high-income countries – which combined would have had a population twice that of the United States – just 685 youth were killed by firearms, according to the AAP.
Separately at the AAP conference, physicians are presenting new research about gun violence and children. And on Oct. 10, a pediatrician who was at Uvalde Memorial Hospital in Texas after the deadly school shooting in May is scheduled to address attendees. The doctor, Roy Guerrero, MD, testified on Capitol Hill to advocate for gun control after the shooting at Robb Elementary School, which killed 19 children and two adults.
“This is not a simple problem, and it cannot be fixed with a simple solution,” Lois K. Lee, MD, MPH, said in the AAP news release. Dr. Lee chairs the AAP Council on Injury, Violence, and Poison Prevention that wrote the new reports. “Pediatricians as a start can offer families guidance and education on more safely storing guns. AAP also calls for supporting legislation that, much like the common-sense requirements for obtaining a driver’s license, would improve gun ownership safety.”
Many deaths occur at home
The rate of homicide from firearms in U.S. youth, especially those aged 15-24 years, increased by 14% during the past decade, and the rate of suicide from firearms increased by 39%, according to the AAP.
Homicides account for 58% of youth firearm deaths, whereas suicides account for 37%. Another 2% of youth firearm deaths are unintentional, and 1% result from law enforcement actions, the group said.
Among children 12 years old and younger, about 85% of firearm deaths occur at home. Teen firearm deaths are about as likely to occur at home (39%) as on the street or sidewalk (38%), according to research based on 2014 data.
“School shootings represent a relatively new phenomenon over the last half-century, and the United States has the highest rate of school shootings in the world,” the AAP technical report noted. Between 1966 and 2008, according to the group, 44 such shootings occurred in the United States, or an average of about one per year. Fast forward a few years and the violence became dramatically worse: Between 2013 and 2015, officials counted 154 school shootings – or about one per week.
Still, school shootings are responsible for less than 1% of all firearm deaths among children 17 years or younger in the United States. While school shootings “receive a tremendous amount of attention,” the report stated, other child firearm deaths may be less likely to make national headlines.
“Many firearm tragedies escape public attention because they occur in a home, sometimes in a child’s own home or at a friend’s house, or their neighbor’s or grandparent’s residence,” Eric W. Fleegler, MD, MPH, Boston Children’s Hospital, a co-author of the new reports, said in a statement from AAP. “Research tells us that families tend to underestimate how children will behave when they encounter a gun and miscalculate the risks. Suicide risks are also a huge concern, especially in families where teens are struggling with their mental health.”
AAP-recommended actions include:
- Mental health screenings and safe gun storage education provided by clinicians as part of routine patient visits
- Increased funding for violence intervention programs in hospital and community settings
- Regulation of firearms like other consumer products, with national requirements that address training, licensing, insurance coverage, registration of individuals purchasing firearms, and safe storage
- The use of technology that allows only authorized users to pull the trigger
- Universal background checks that use federal databases and information from local police before all gun purchases
- Extreme risk protection order laws, or “red flag laws,” that prohibit individuals at risk for harming themselves or others from purchasing or owning a firearm
- More funding for firearm injury and prevention research.
A noticeable increase in the ED
Irma Ugalde, MD, associate professor and director of pediatric emergency medicine research at McGovern Medical School at UTHealth Houston, noticed that firearm-related injuries in children at her hospital were more common during the COVID-19 pandemic, even as pediatric emergency department visits decreased overall.
She and her colleagues studied the trends and reported their findings at the AAP meeting.
“We saw a drop in pediatric admissions overall,” Dr. Ugalde said in a statement about the study. “But what was really noticeable was that trauma was still very prevalent – in fact probably more so – and we were seeing more firearm injuries.”
The researchers found that firearm injuries in children rose from 88 cases in 2019 to 118 in 2020. The number of incidents remained elevated in 2021, with 115 cases.
In addition, the researchers found an initial increase in injuries occurring at home where the shooter was a known family member or friend, and in cases involving firearms that were not properly stored.
By comparison, pediatric ED visits overall decreased by 34.2% from 2019 to 2020, and by 11.8% from 2019 to 2021.
The increase in firearm injuries coincided with an increase in gun sales in the United States, the researchers noted.
“National and statewide initiatives to mitigate the risk of firearm-related injury and death are necessary,” Dr. Ugalde’s group said. “We recommend that health care workers remain vigilant about screening for potential risk factors and safe storage of firearms.”
Accidental injuries
Daniel D. Guzman, MD, with Cook Children’s Health Care Center, Fort Worth, Tex., conducted a study focused on unintentional firearm injuries in children. Dr. Guzman’s group analyzed data from 204 patients younger than age 19 seen at Cook Children’s from January 2015 to June 2021.
Dr. Guzman and his colleagues examined outcomes for injuries caused by powder guns – shotguns, rifles, and handguns – and air-power guns that shoot BBs and pellets.
The researchers found that 29% of the unintentional firearm injuries occurred with powder guns and 71% with air-power weapons, often BB guns.
“It is important that all firearms, powdered and air-powered, be stored safely in a lock box or safe,” Dr. Guzman said in a statement. To that end, Cook Children’s has developed a program called Aim for Safety to teach children and parents about the dangers of unsupervised play with BB guns and pellet guns, as well as the importance of storing all firearms unloaded and in a locked safe.
A version of this article first appeared on Medscape.com.
FROM PEDIATRICS
Experts debate infant chiropractic care on TikTok
Several chiropractors in the United States are posting TikTok videos of themselves working with newborns, babies, and toddlers, often promoting treatments that aren’t backed by science, according to The Washington Post.
The videos include various devices and treatments, such as vibrating handheld massagers, spinal adjustments, and body movements, which are meant to address colic, constipation, reflux, musculoskeletal problems, and even trauma that babies experience during childbirth.
Chiropractors say the treatments are safe and gentle for babies and are unlike the more strenuous movements associated with adult chiropractic care. However, some doctors have said the videos are concerning because babies have softer bones and looser joints.
“Ultimately, there is no way you’re going to get an improvement in a newborn from a manipulation,” Sean Tabaie, MD, an orthopedic surgeon at Children’s National Hospital, Washington, told the newspaper.
Dr. Tabaie said his colleagues are shocked when he sends them Instagram or TikTok videos of chiropractic clinics treating infants.
“The only thing that you might possibly cause is harm,” he said.
Generally, chiropractors are licensed health professionals who use stretching, pressure, and joint manipulation on the spine to treat patients. Although chiropractic care is typically seen as an “alternative therapy,” some data in adults suggest that chiropractic treatments can help some conditions, such as low back pain.
“To my knowledge, there is little to no evidence that chiropractic care changes the natural history of any disease or condition,” Anthony Stans, MD, a pediatric orthopedic surgeon at Mayo Clinic Children’s Center, Rochester, Minn., told the newspaper. Stans said he would caution parents and recommend against chiropractic treatment for babies.
For some parents, the treatments and TikTok videos seem appealing because they promise relief for problems that traditional medicine can’t always address, especially colic, the newspaper reported. Colic, which features intense and prolonged crying in an otherwise healthy baby, tends to resolve over time without treatment.
Recent studies have attempted to study chiropractic care in infants. In a 2021 study, researchers in Denmark conducted a randomized controlled trial with 186 babies to test light pressure treatments. Although excessive crying was reduced by half an hour in the group that received treatment, the findings weren’t statistically significant in the end.
In a new study, researchers in Spain conducted a randomized trial with 58 babies to test “light touch manual therapy.” The babies who received treatment appeared to cry significantly less, but the parents weren’t “blinded” and were aware of the study’s treatment conditions, which can bias the results.
However, it can be challenging to “get that level of evidence” to support manual therapies such as chiropractic care, Joy Weydert, MD, director of pediatric integrative medicine at the University of Arizona, Tucson, told the newspaper. Certain treatments could help reduce the discomfort of colic or reflux, which can be difficult to measures in infants, she said.
The American Academy of Pediatrics told The Post that it doesn’t have an “official policy” on chiropractic care for infants or toddlers. At the same time, a 2017 report released by the organization concluded that “high-quality evidence” is lacking for spinal manipulation in children.
The American Chiropractic Association said chiropractic treatments are safe and effective for children, yet more research is needed to prove they work.
“We still haven’t been able to demonstrate in the research the effectiveness that we’ve seen clinically,” Jennifer Brocker, president of the group’s Council on Chiropractic Pediatrics, told the newspaper.
“We can’t really say for sure what’s happening,” she said. “It’s sort of like a black box. But what we do know is that, clinically, what we’re doing is effective because we see a change in the symptoms of the child.”
A version of this article first appeared on WebMD.com.
Several chiropractors in the United States are posting TikTok videos of themselves working with newborns, babies, and toddlers, often promoting treatments that aren’t backed by science, according to The Washington Post.
The videos include various devices and treatments, such as vibrating handheld massagers, spinal adjustments, and body movements, which are meant to address colic, constipation, reflux, musculoskeletal problems, and even trauma that babies experience during childbirth.
Chiropractors say the treatments are safe and gentle for babies and are unlike the more strenuous movements associated with adult chiropractic care. However, some doctors have said the videos are concerning because babies have softer bones and looser joints.
“Ultimately, there is no way you’re going to get an improvement in a newborn from a manipulation,” Sean Tabaie, MD, an orthopedic surgeon at Children’s National Hospital, Washington, told the newspaper.
Dr. Tabaie said his colleagues are shocked when he sends them Instagram or TikTok videos of chiropractic clinics treating infants.
“The only thing that you might possibly cause is harm,” he said.
Generally, chiropractors are licensed health professionals who use stretching, pressure, and joint manipulation on the spine to treat patients. Although chiropractic care is typically seen as an “alternative therapy,” some data in adults suggest that chiropractic treatments can help some conditions, such as low back pain.
“To my knowledge, there is little to no evidence that chiropractic care changes the natural history of any disease or condition,” Anthony Stans, MD, a pediatric orthopedic surgeon at Mayo Clinic Children’s Center, Rochester, Minn., told the newspaper. Stans said he would caution parents and recommend against chiropractic treatment for babies.
For some parents, the treatments and TikTok videos seem appealing because they promise relief for problems that traditional medicine can’t always address, especially colic, the newspaper reported. Colic, which features intense and prolonged crying in an otherwise healthy baby, tends to resolve over time without treatment.
Recent studies have attempted to study chiropractic care in infants. In a 2021 study, researchers in Denmark conducted a randomized controlled trial with 186 babies to test light pressure treatments. Although excessive crying was reduced by half an hour in the group that received treatment, the findings weren’t statistically significant in the end.
In a new study, researchers in Spain conducted a randomized trial with 58 babies to test “light touch manual therapy.” The babies who received treatment appeared to cry significantly less, but the parents weren’t “blinded” and were aware of the study’s treatment conditions, which can bias the results.
However, it can be challenging to “get that level of evidence” to support manual therapies such as chiropractic care, Joy Weydert, MD, director of pediatric integrative medicine at the University of Arizona, Tucson, told the newspaper. Certain treatments could help reduce the discomfort of colic or reflux, which can be difficult to measures in infants, she said.
The American Academy of Pediatrics told The Post that it doesn’t have an “official policy” on chiropractic care for infants or toddlers. At the same time, a 2017 report released by the organization concluded that “high-quality evidence” is lacking for spinal manipulation in children.
The American Chiropractic Association said chiropractic treatments are safe and effective for children, yet more research is needed to prove they work.
“We still haven’t been able to demonstrate in the research the effectiveness that we’ve seen clinically,” Jennifer Brocker, president of the group’s Council on Chiropractic Pediatrics, told the newspaper.
“We can’t really say for sure what’s happening,” she said. “It’s sort of like a black box. But what we do know is that, clinically, what we’re doing is effective because we see a change in the symptoms of the child.”
A version of this article first appeared on WebMD.com.
Several chiropractors in the United States are posting TikTok videos of themselves working with newborns, babies, and toddlers, often promoting treatments that aren’t backed by science, according to The Washington Post.
The videos include various devices and treatments, such as vibrating handheld massagers, spinal adjustments, and body movements, which are meant to address colic, constipation, reflux, musculoskeletal problems, and even trauma that babies experience during childbirth.
Chiropractors say the treatments are safe and gentle for babies and are unlike the more strenuous movements associated with adult chiropractic care. However, some doctors have said the videos are concerning because babies have softer bones and looser joints.
“Ultimately, there is no way you’re going to get an improvement in a newborn from a manipulation,” Sean Tabaie, MD, an orthopedic surgeon at Children’s National Hospital, Washington, told the newspaper.
Dr. Tabaie said his colleagues are shocked when he sends them Instagram or TikTok videos of chiropractic clinics treating infants.
“The only thing that you might possibly cause is harm,” he said.
Generally, chiropractors are licensed health professionals who use stretching, pressure, and joint manipulation on the spine to treat patients. Although chiropractic care is typically seen as an “alternative therapy,” some data in adults suggest that chiropractic treatments can help some conditions, such as low back pain.
“To my knowledge, there is little to no evidence that chiropractic care changes the natural history of any disease or condition,” Anthony Stans, MD, a pediatric orthopedic surgeon at Mayo Clinic Children’s Center, Rochester, Minn., told the newspaper. Stans said he would caution parents and recommend against chiropractic treatment for babies.
For some parents, the treatments and TikTok videos seem appealing because they promise relief for problems that traditional medicine can’t always address, especially colic, the newspaper reported. Colic, which features intense and prolonged crying in an otherwise healthy baby, tends to resolve over time without treatment.
Recent studies have attempted to study chiropractic care in infants. In a 2021 study, researchers in Denmark conducted a randomized controlled trial with 186 babies to test light pressure treatments. Although excessive crying was reduced by half an hour in the group that received treatment, the findings weren’t statistically significant in the end.
In a new study, researchers in Spain conducted a randomized trial with 58 babies to test “light touch manual therapy.” The babies who received treatment appeared to cry significantly less, but the parents weren’t “blinded” and were aware of the study’s treatment conditions, which can bias the results.
However, it can be challenging to “get that level of evidence” to support manual therapies such as chiropractic care, Joy Weydert, MD, director of pediatric integrative medicine at the University of Arizona, Tucson, told the newspaper. Certain treatments could help reduce the discomfort of colic or reflux, which can be difficult to measures in infants, she said.
The American Academy of Pediatrics told The Post that it doesn’t have an “official policy” on chiropractic care for infants or toddlers. At the same time, a 2017 report released by the organization concluded that “high-quality evidence” is lacking for spinal manipulation in children.
The American Chiropractic Association said chiropractic treatments are safe and effective for children, yet more research is needed to prove they work.
“We still haven’t been able to demonstrate in the research the effectiveness that we’ve seen clinically,” Jennifer Brocker, president of the group’s Council on Chiropractic Pediatrics, told the newspaper.
“We can’t really say for sure what’s happening,” she said. “It’s sort of like a black box. But what we do know is that, clinically, what we’re doing is effective because we see a change in the symptoms of the child.”
A version of this article first appeared on WebMD.com.