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Tackling screen time from birth
In this day and age, a new question should make its way to the top of the list for new parents and their pediatricians: How will the family approach the issue of household technology use – for their children as well as themselves?
Even the most vigilant among them will find much available guidance conflicting – and a good deal of it may feel oblivious to their day-to-day realities. This is especially true now, as many families face the daunting demands of pandemic parenting – juggling full-time jobs with childcare and distance learning.
While the American Academy of Pediatrics still specifies daily time limits by age (difficult for many families to achieve even in “normal” times), pediatricians and other child development experts now recognize that a host of factors should inform decisions about healthy screen use. There’s no one “magic number” for acceptable daily use, as not all screen time is the same (particularly during the pandemic) – and different children will experience the effects of technology usage differently.
The quality of content the child engages with; the degree of parental involvement; and the individual cognitive and behavioral considerations of a child are just some of the factors that should be considered. Given the complexities, it’s unfortunate that many parents will not have discussed screen use with their pediatrician or even their partner before their child first reaches for that glowing screen – and certainly not before they are using technology to multitask work, social connections, and day-to-day child rearing. Screen habits form early for both children and families.
An early well-visit priority
Pediatricians have an important role to play in helping families develop a more purposeful approach to household technology by providing them with trusted, evidence-based information on screens and the potential impact on children’s development. This is not information parents should receive when a child is 2 or 3 years of age. By then, toddlers are often already avid tablet users and parents may have come to rely on technology as a parenting aid.
Parents also need to know that, from birth, they can influence their child’s brain and communication development through undistracted time for talking, reading, singing, and interacting with their baby. Though the way children develop speech and language skills has not changed, the level of distraction posed by technology has grown immensely. It is much more difficult for parents to notice a baby’s subtle communication attempts – a coo or a smile, for instance, and respond accordingly – with a smartphone in hand. Rather than admonish parents for overusing their devices, we can focus them on what supports healthy child development instead.
By talking to parents earlier, pediatricians can help prevent premature or excessive exposure to technology – as well as encourage parents to dedicate “unplugged” times of day with their baby, such as during feeding time or before bedtime. By accenting the positive – educating parents about how they can encourage development and growth, how they can bond with their baby, and how they can establish a loving and nurturing relationship – pediatricians can motivate them towards simple steps that limit technology’s disruption of daily developmental opportunities. They can also help them lay a solid foundation for healthy screen time habits in the long term for their family.
The critical period for speech and language development is early
The impact of screen use on a child’s communication development is a significant concern. The critical time window for the development of speech, language, and social skills is between birth and 3 years. What happens then is the precursor for later reading and writing skills that are key to academic and vocational success.
A meta-analysis published in JAMA Pediatrics in July 2020 found that greater quantity of screen use was associated with poorer language skills – while screen-use onset at later ages was also associated with stronger child language skills. A November 2019 JAMA Pediatrics study using brain imaging in pre–school age children found an association between increased screen-based media use, compared with the AAP guidelines, and lower integrity of white matter tracts supporting language and emergent literacy skills. That study also used several language and literacy tests, finding that children with higher screen exposure had poorer expressive language and worse language processing speed. A 2017 study of 900 children between 18 and 24 months found that every 30-minute increase in daily screen time was linked to a 49% increased risk of expressive speech delay. And on the parental side, numerous studies have documented decreased verbal and nonverbal interactions initiated by parents when they are using a device.
Be tech wise with baby
AAP offers many resources in its Media and Children Communication Toolkit that serve as helpful starting points for conversations, including its family media use plan templates. However, more resources tailored to parents of newborns and very young children are needed.
One new option recently developed by the American Speech-Language-Hearing Association (ASHA) and the Children’s Screen Time Action Network is Be Tech Wise With Baby! Aimed at prospective and new parents, this simple handout, available for free in English and Spanish, is an easy takeaway from early well-child visits that pediatricians and pediatric nurses can distribute.
Pediatricians have a vital role to play championing healthy, balanced screen time use for children and adults – starting from baby’s first moments of life. By guiding new parents towards simple steps, such as carving out tech-free times of day and delaying introduction of screens, they can positively influence the screen-time habits of the next generation of connected kids.
Mark Bertin, MD, is a developmental pediatrician and author of numerous parenting books, including “How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids” and “Mindful Parenting for ADHD.” Diane Paul, PhD, CCC-SLP, is the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association (ASHA) and author of numerous books, including “Talking on the Go: Everyday Activities to Enhance Speech and Language Development.” Email them at [email protected].
In this day and age, a new question should make its way to the top of the list for new parents and their pediatricians: How will the family approach the issue of household technology use – for their children as well as themselves?
Even the most vigilant among them will find much available guidance conflicting – and a good deal of it may feel oblivious to their day-to-day realities. This is especially true now, as many families face the daunting demands of pandemic parenting – juggling full-time jobs with childcare and distance learning.
While the American Academy of Pediatrics still specifies daily time limits by age (difficult for many families to achieve even in “normal” times), pediatricians and other child development experts now recognize that a host of factors should inform decisions about healthy screen use. There’s no one “magic number” for acceptable daily use, as not all screen time is the same (particularly during the pandemic) – and different children will experience the effects of technology usage differently.
The quality of content the child engages with; the degree of parental involvement; and the individual cognitive and behavioral considerations of a child are just some of the factors that should be considered. Given the complexities, it’s unfortunate that many parents will not have discussed screen use with their pediatrician or even their partner before their child first reaches for that glowing screen – and certainly not before they are using technology to multitask work, social connections, and day-to-day child rearing. Screen habits form early for both children and families.
An early well-visit priority
Pediatricians have an important role to play in helping families develop a more purposeful approach to household technology by providing them with trusted, evidence-based information on screens and the potential impact on children’s development. This is not information parents should receive when a child is 2 or 3 years of age. By then, toddlers are often already avid tablet users and parents may have come to rely on technology as a parenting aid.
Parents also need to know that, from birth, they can influence their child’s brain and communication development through undistracted time for talking, reading, singing, and interacting with their baby. Though the way children develop speech and language skills has not changed, the level of distraction posed by technology has grown immensely. It is much more difficult for parents to notice a baby’s subtle communication attempts – a coo or a smile, for instance, and respond accordingly – with a smartphone in hand. Rather than admonish parents for overusing their devices, we can focus them on what supports healthy child development instead.
By talking to parents earlier, pediatricians can help prevent premature or excessive exposure to technology – as well as encourage parents to dedicate “unplugged” times of day with their baby, such as during feeding time or before bedtime. By accenting the positive – educating parents about how they can encourage development and growth, how they can bond with their baby, and how they can establish a loving and nurturing relationship – pediatricians can motivate them towards simple steps that limit technology’s disruption of daily developmental opportunities. They can also help them lay a solid foundation for healthy screen time habits in the long term for their family.
The critical period for speech and language development is early
The impact of screen use on a child’s communication development is a significant concern. The critical time window for the development of speech, language, and social skills is between birth and 3 years. What happens then is the precursor for later reading and writing skills that are key to academic and vocational success.
A meta-analysis published in JAMA Pediatrics in July 2020 found that greater quantity of screen use was associated with poorer language skills – while screen-use onset at later ages was also associated with stronger child language skills. A November 2019 JAMA Pediatrics study using brain imaging in pre–school age children found an association between increased screen-based media use, compared with the AAP guidelines, and lower integrity of white matter tracts supporting language and emergent literacy skills. That study also used several language and literacy tests, finding that children with higher screen exposure had poorer expressive language and worse language processing speed. A 2017 study of 900 children between 18 and 24 months found that every 30-minute increase in daily screen time was linked to a 49% increased risk of expressive speech delay. And on the parental side, numerous studies have documented decreased verbal and nonverbal interactions initiated by parents when they are using a device.
Be tech wise with baby
AAP offers many resources in its Media and Children Communication Toolkit that serve as helpful starting points for conversations, including its family media use plan templates. However, more resources tailored to parents of newborns and very young children are needed.
One new option recently developed by the American Speech-Language-Hearing Association (ASHA) and the Children’s Screen Time Action Network is Be Tech Wise With Baby! Aimed at prospective and new parents, this simple handout, available for free in English and Spanish, is an easy takeaway from early well-child visits that pediatricians and pediatric nurses can distribute.
Pediatricians have a vital role to play championing healthy, balanced screen time use for children and adults – starting from baby’s first moments of life. By guiding new parents towards simple steps, such as carving out tech-free times of day and delaying introduction of screens, they can positively influence the screen-time habits of the next generation of connected kids.
Mark Bertin, MD, is a developmental pediatrician and author of numerous parenting books, including “How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids” and “Mindful Parenting for ADHD.” Diane Paul, PhD, CCC-SLP, is the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association (ASHA) and author of numerous books, including “Talking on the Go: Everyday Activities to Enhance Speech and Language Development.” Email them at [email protected].
In this day and age, a new question should make its way to the top of the list for new parents and their pediatricians: How will the family approach the issue of household technology use – for their children as well as themselves?
Even the most vigilant among them will find much available guidance conflicting – and a good deal of it may feel oblivious to their day-to-day realities. This is especially true now, as many families face the daunting demands of pandemic parenting – juggling full-time jobs with childcare and distance learning.
While the American Academy of Pediatrics still specifies daily time limits by age (difficult for many families to achieve even in “normal” times), pediatricians and other child development experts now recognize that a host of factors should inform decisions about healthy screen use. There’s no one “magic number” for acceptable daily use, as not all screen time is the same (particularly during the pandemic) – and different children will experience the effects of technology usage differently.
The quality of content the child engages with; the degree of parental involvement; and the individual cognitive and behavioral considerations of a child are just some of the factors that should be considered. Given the complexities, it’s unfortunate that many parents will not have discussed screen use with their pediatrician or even their partner before their child first reaches for that glowing screen – and certainly not before they are using technology to multitask work, social connections, and day-to-day child rearing. Screen habits form early for both children and families.
An early well-visit priority
Pediatricians have an important role to play in helping families develop a more purposeful approach to household technology by providing them with trusted, evidence-based information on screens and the potential impact on children’s development. This is not information parents should receive when a child is 2 or 3 years of age. By then, toddlers are often already avid tablet users and parents may have come to rely on technology as a parenting aid.
Parents also need to know that, from birth, they can influence their child’s brain and communication development through undistracted time for talking, reading, singing, and interacting with their baby. Though the way children develop speech and language skills has not changed, the level of distraction posed by technology has grown immensely. It is much more difficult for parents to notice a baby’s subtle communication attempts – a coo or a smile, for instance, and respond accordingly – with a smartphone in hand. Rather than admonish parents for overusing their devices, we can focus them on what supports healthy child development instead.
By talking to parents earlier, pediatricians can help prevent premature or excessive exposure to technology – as well as encourage parents to dedicate “unplugged” times of day with their baby, such as during feeding time or before bedtime. By accenting the positive – educating parents about how they can encourage development and growth, how they can bond with their baby, and how they can establish a loving and nurturing relationship – pediatricians can motivate them towards simple steps that limit technology’s disruption of daily developmental opportunities. They can also help them lay a solid foundation for healthy screen time habits in the long term for their family.
The critical period for speech and language development is early
The impact of screen use on a child’s communication development is a significant concern. The critical time window for the development of speech, language, and social skills is between birth and 3 years. What happens then is the precursor for later reading and writing skills that are key to academic and vocational success.
A meta-analysis published in JAMA Pediatrics in July 2020 found that greater quantity of screen use was associated with poorer language skills – while screen-use onset at later ages was also associated with stronger child language skills. A November 2019 JAMA Pediatrics study using brain imaging in pre–school age children found an association between increased screen-based media use, compared with the AAP guidelines, and lower integrity of white matter tracts supporting language and emergent literacy skills. That study also used several language and literacy tests, finding that children with higher screen exposure had poorer expressive language and worse language processing speed. A 2017 study of 900 children between 18 and 24 months found that every 30-minute increase in daily screen time was linked to a 49% increased risk of expressive speech delay. And on the parental side, numerous studies have documented decreased verbal and nonverbal interactions initiated by parents when they are using a device.
Be tech wise with baby
AAP offers many resources in its Media and Children Communication Toolkit that serve as helpful starting points for conversations, including its family media use plan templates. However, more resources tailored to parents of newborns and very young children are needed.
One new option recently developed by the American Speech-Language-Hearing Association (ASHA) and the Children’s Screen Time Action Network is Be Tech Wise With Baby! Aimed at prospective and new parents, this simple handout, available for free in English and Spanish, is an easy takeaway from early well-child visits that pediatricians and pediatric nurses can distribute.
Pediatricians have a vital role to play championing healthy, balanced screen time use for children and adults – starting from baby’s first moments of life. By guiding new parents towards simple steps, such as carving out tech-free times of day and delaying introduction of screens, they can positively influence the screen-time habits of the next generation of connected kids.
Mark Bertin, MD, is a developmental pediatrician and author of numerous parenting books, including “How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids” and “Mindful Parenting for ADHD.” Diane Paul, PhD, CCC-SLP, is the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association (ASHA) and author of numerous books, including “Talking on the Go: Everyday Activities to Enhance Speech and Language Development.” Email them at [email protected].
The top pediatric articles of 2019
Updates in pediatric hospital medicine
The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.3 We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.
STUDY 1
Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.
Background
Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
Study overview and results
The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV1. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
Limitations
Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV1, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
Important findings and implications
While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
STUDY 2
Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.
Background
Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
Study overview and results
The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.4 They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
Limitations
These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
Important findings and implications
This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.
STUDY 3
Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.
Background
Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
Study overview and results
The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
Limitations
Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
Important findings and implications
Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
STUDY 4
Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.
Background
Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
Study overview and results
The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
Limitations
The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
Important findings and implications
Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
STUDY 5
McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.
Background
Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.
Study overview and results
In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
Limitations
This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
Important findings and implications
An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.
References
1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.
2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.
3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.
4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.
Updates in pediatric hospital medicine
Updates in pediatric hospital medicine
The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.3 We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.
STUDY 1
Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.
Background
Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
Study overview and results
The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV1. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
Limitations
Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV1, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
Important findings and implications
While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
STUDY 2
Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.
Background
Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
Study overview and results
The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.4 They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
Limitations
These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
Important findings and implications
This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.
STUDY 3
Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.
Background
Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
Study overview and results
The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
Limitations
Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
Important findings and implications
Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
STUDY 4
Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.
Background
Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
Study overview and results
The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
Limitations
The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
Important findings and implications
Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
STUDY 5
McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.
Background
Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.
Study overview and results
In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
Limitations
This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
Important findings and implications
An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.
References
1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.
2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.
3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.
4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.
The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.3 We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.
STUDY 1
Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.
Background
Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
Study overview and results
The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV1. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
Limitations
Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV1, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
Important findings and implications
While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
STUDY 2
Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.
Background
Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
Study overview and results
The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.4 They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
Limitations
These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
Important findings and implications
This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.
STUDY 3
Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.
Background
Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
Study overview and results
The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
Limitations
Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
Important findings and implications
Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
STUDY 4
Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.
Background
Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
Study overview and results
The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
Limitations
The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
Important findings and implications
Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
STUDY 5
McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.
Background
Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.
Study overview and results
In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
Limitations
This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
Important findings and implications
An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.
References
1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.
2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.
3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.
4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.
Gender surgical outcomes differ following puberty suppression
Puberty suppression (PS) not only successfully reduces the physical development of sex characteristics, giving transgender youth the opportunity to qualify “for different gender-affirming surgical techniques, it also gives adolescents the time needed to explore their gender identity prior to beginning irreversible cross-sex hormone (CSH) treatment,” Tim C. van de Grift, MD, PhD, of the Vrije Universiteit Medical Center, Amsterdam, and colleagues reported in a retrospective single-center cohort study published in Pediatrics.
Dr. van de Grift and his colleagues evaluated the development of sex characteristics in 184 (61%) transgender men and 116 (39%) transgender women aged an average of 23 years at follow-up; a total of 50 men and 50 women served as controls within the total patient pool. The patients, identified from local registries, were adolescents at the time who had applied for gender-affirming medical interventions between 2006 and 2013.
In order to be included in the analysis, patients were required to 1) have a confirmed gender dysphoria diagnosis, 2) be at least 18 years of age at the point of data collection, 3) be less than 18 years of age when PS was initiated, 4) have initiated and continued PS treatment, and 5) not be lost to follow-up.
Clinical controls were identified by random sample using hospital records. Unlike patients in the PS cohort, the controls received CSH instead of PS, but they otherwise applied for gender-affirming surgery during the same years and met all other non-PS inclusion criteria.
PS offers more favorable, less invasive outcomes for transgender men than women
The researchers found no statistically significant impact of PS on height, weight, and body mass index preoperatively in either transgender men or women.
In transgender men, breast development differed the most, with the least development in the Tanner 2/3 puberty scale group, intermediate development in Tanner 4/5 patients, and the most development in controls who did not have PS. As a result, fewer mastectomies were required after PS, and those that were performed were less invasive, compared with controls. Dr. van de Grift and colleagues noted that these findings were in line with surgical guidelines that advise which mastectomy technique is appropriate based on breast size, elasticity, and ptosis grade. They cautioned that, while PS improves the odds of not needing a mastectomy, it is not a guaranteed outcome.
In transgender women, PS had a significant effect on penile development, which was less in Tanner 2/3 patients, compared with the other groups and less in Tanner 4/5 patients, compared with controls. As the researchers explained, penile length is key to vaginoplasty surgery since the penile skin is what is used to create the vaginal lining. For patients lacking sufficient skin, an alternative vaginoplasty technique using intestinal tissue or full-thickness graft is necessary. In this group, surgical options depended upon the onset of PS. In the control group, standard penile-inversion vaginoplasty was more probable, but it was less so in the Tanner 4/5 patients and only infrequently probable in Tanner 2/3 patients. Most transgender women who started PS in Tanner 2/3 underwent intestinal vaginoplasty.
Before PS is initiated much dialog and planning is warranted
“Clinicians should counsel transgender youth and their parents in making informed decisions when starting PS. Counseling consists of informing about the possible surgical consequences when puberty is suppressed and that these techniques may not be available in general transgender care facilities,” advised Dr. van de Grift and his colleagues. Specifically, when pediatricians prescribe PS, they need to be cognizant of the consequences down the line regarding the demand for “technically complex gender-affirming surgery,” performed by, for example, plastic surgeons, who will need to be “skilled in minimally invasive mastectomy techniques and more extensive vaginoplasty approaches.” Therefore, it is key for referring physicians to be sensitive to the need for early referral to specialized care in order to maximize positive outcomes, they added.
The study was limited by the sample size of some subgroups. Only two-thirds of eligible candidates were included in the sample size because follow-up data were not available for the remaining patients. Future studies should include multicenter standardized prospective data collection that provides patient-reported outcomes to enhance the perspective of the clinical findings, the researchers observed.
In a separate interview with Pediatric News, M. Brett Cooper, MD, of the department of pediatrics at University of Texas, Dallas, and an adolescent medicine physician at Children’s Medical Center in Dallas, noted that “Initiation of puberty suppression can be lifesaving for many gender-diverse youth, preventing the development of secondary sex characteristics. However, this can have effects later if these youth choose to pursue gender-affirming surgeries. This study is important for helping to frame the conversation for youth and their parents when doing consent to start puberty-blocking medications, as well as around optimal timing for each individual.”
Dr. Cooper is a paid MDedge consultant for the LGBTQ Youth Consult in Pediatric News. He had no other disclosures to report.
SOURCE: van de Grift T et al. Pediatrics. 2020;146(5):e20193653.
Puberty suppression (PS) not only successfully reduces the physical development of sex characteristics, giving transgender youth the opportunity to qualify “for different gender-affirming surgical techniques, it also gives adolescents the time needed to explore their gender identity prior to beginning irreversible cross-sex hormone (CSH) treatment,” Tim C. van de Grift, MD, PhD, of the Vrije Universiteit Medical Center, Amsterdam, and colleagues reported in a retrospective single-center cohort study published in Pediatrics.
Dr. van de Grift and his colleagues evaluated the development of sex characteristics in 184 (61%) transgender men and 116 (39%) transgender women aged an average of 23 years at follow-up; a total of 50 men and 50 women served as controls within the total patient pool. The patients, identified from local registries, were adolescents at the time who had applied for gender-affirming medical interventions between 2006 and 2013.
In order to be included in the analysis, patients were required to 1) have a confirmed gender dysphoria diagnosis, 2) be at least 18 years of age at the point of data collection, 3) be less than 18 years of age when PS was initiated, 4) have initiated and continued PS treatment, and 5) not be lost to follow-up.
Clinical controls were identified by random sample using hospital records. Unlike patients in the PS cohort, the controls received CSH instead of PS, but they otherwise applied for gender-affirming surgery during the same years and met all other non-PS inclusion criteria.
PS offers more favorable, less invasive outcomes for transgender men than women
The researchers found no statistically significant impact of PS on height, weight, and body mass index preoperatively in either transgender men or women.
In transgender men, breast development differed the most, with the least development in the Tanner 2/3 puberty scale group, intermediate development in Tanner 4/5 patients, and the most development in controls who did not have PS. As a result, fewer mastectomies were required after PS, and those that were performed were less invasive, compared with controls. Dr. van de Grift and colleagues noted that these findings were in line with surgical guidelines that advise which mastectomy technique is appropriate based on breast size, elasticity, and ptosis grade. They cautioned that, while PS improves the odds of not needing a mastectomy, it is not a guaranteed outcome.
In transgender women, PS had a significant effect on penile development, which was less in Tanner 2/3 patients, compared with the other groups and less in Tanner 4/5 patients, compared with controls. As the researchers explained, penile length is key to vaginoplasty surgery since the penile skin is what is used to create the vaginal lining. For patients lacking sufficient skin, an alternative vaginoplasty technique using intestinal tissue or full-thickness graft is necessary. In this group, surgical options depended upon the onset of PS. In the control group, standard penile-inversion vaginoplasty was more probable, but it was less so in the Tanner 4/5 patients and only infrequently probable in Tanner 2/3 patients. Most transgender women who started PS in Tanner 2/3 underwent intestinal vaginoplasty.
Before PS is initiated much dialog and planning is warranted
“Clinicians should counsel transgender youth and their parents in making informed decisions when starting PS. Counseling consists of informing about the possible surgical consequences when puberty is suppressed and that these techniques may not be available in general transgender care facilities,” advised Dr. van de Grift and his colleagues. Specifically, when pediatricians prescribe PS, they need to be cognizant of the consequences down the line regarding the demand for “technically complex gender-affirming surgery,” performed by, for example, plastic surgeons, who will need to be “skilled in minimally invasive mastectomy techniques and more extensive vaginoplasty approaches.” Therefore, it is key for referring physicians to be sensitive to the need for early referral to specialized care in order to maximize positive outcomes, they added.
The study was limited by the sample size of some subgroups. Only two-thirds of eligible candidates were included in the sample size because follow-up data were not available for the remaining patients. Future studies should include multicenter standardized prospective data collection that provides patient-reported outcomes to enhance the perspective of the clinical findings, the researchers observed.
In a separate interview with Pediatric News, M. Brett Cooper, MD, of the department of pediatrics at University of Texas, Dallas, and an adolescent medicine physician at Children’s Medical Center in Dallas, noted that “Initiation of puberty suppression can be lifesaving for many gender-diverse youth, preventing the development of secondary sex characteristics. However, this can have effects later if these youth choose to pursue gender-affirming surgeries. This study is important for helping to frame the conversation for youth and their parents when doing consent to start puberty-blocking medications, as well as around optimal timing for each individual.”
Dr. Cooper is a paid MDedge consultant for the LGBTQ Youth Consult in Pediatric News. He had no other disclosures to report.
SOURCE: van de Grift T et al. Pediatrics. 2020;146(5):e20193653.
Puberty suppression (PS) not only successfully reduces the physical development of sex characteristics, giving transgender youth the opportunity to qualify “for different gender-affirming surgical techniques, it also gives adolescents the time needed to explore their gender identity prior to beginning irreversible cross-sex hormone (CSH) treatment,” Tim C. van de Grift, MD, PhD, of the Vrije Universiteit Medical Center, Amsterdam, and colleagues reported in a retrospective single-center cohort study published in Pediatrics.
Dr. van de Grift and his colleagues evaluated the development of sex characteristics in 184 (61%) transgender men and 116 (39%) transgender women aged an average of 23 years at follow-up; a total of 50 men and 50 women served as controls within the total patient pool. The patients, identified from local registries, were adolescents at the time who had applied for gender-affirming medical interventions between 2006 and 2013.
In order to be included in the analysis, patients were required to 1) have a confirmed gender dysphoria diagnosis, 2) be at least 18 years of age at the point of data collection, 3) be less than 18 years of age when PS was initiated, 4) have initiated and continued PS treatment, and 5) not be lost to follow-up.
Clinical controls were identified by random sample using hospital records. Unlike patients in the PS cohort, the controls received CSH instead of PS, but they otherwise applied for gender-affirming surgery during the same years and met all other non-PS inclusion criteria.
PS offers more favorable, less invasive outcomes for transgender men than women
The researchers found no statistically significant impact of PS on height, weight, and body mass index preoperatively in either transgender men or women.
In transgender men, breast development differed the most, with the least development in the Tanner 2/3 puberty scale group, intermediate development in Tanner 4/5 patients, and the most development in controls who did not have PS. As a result, fewer mastectomies were required after PS, and those that were performed were less invasive, compared with controls. Dr. van de Grift and colleagues noted that these findings were in line with surgical guidelines that advise which mastectomy technique is appropriate based on breast size, elasticity, and ptosis grade. They cautioned that, while PS improves the odds of not needing a mastectomy, it is not a guaranteed outcome.
In transgender women, PS had a significant effect on penile development, which was less in Tanner 2/3 patients, compared with the other groups and less in Tanner 4/5 patients, compared with controls. As the researchers explained, penile length is key to vaginoplasty surgery since the penile skin is what is used to create the vaginal lining. For patients lacking sufficient skin, an alternative vaginoplasty technique using intestinal tissue or full-thickness graft is necessary. In this group, surgical options depended upon the onset of PS. In the control group, standard penile-inversion vaginoplasty was more probable, but it was less so in the Tanner 4/5 patients and only infrequently probable in Tanner 2/3 patients. Most transgender women who started PS in Tanner 2/3 underwent intestinal vaginoplasty.
Before PS is initiated much dialog and planning is warranted
“Clinicians should counsel transgender youth and their parents in making informed decisions when starting PS. Counseling consists of informing about the possible surgical consequences when puberty is suppressed and that these techniques may not be available in general transgender care facilities,” advised Dr. van de Grift and his colleagues. Specifically, when pediatricians prescribe PS, they need to be cognizant of the consequences down the line regarding the demand for “technically complex gender-affirming surgery,” performed by, for example, plastic surgeons, who will need to be “skilled in minimally invasive mastectomy techniques and more extensive vaginoplasty approaches.” Therefore, it is key for referring physicians to be sensitive to the need for early referral to specialized care in order to maximize positive outcomes, they added.
The study was limited by the sample size of some subgroups. Only two-thirds of eligible candidates were included in the sample size because follow-up data were not available for the remaining patients. Future studies should include multicenter standardized prospective data collection that provides patient-reported outcomes to enhance the perspective of the clinical findings, the researchers observed.
In a separate interview with Pediatric News, M. Brett Cooper, MD, of the department of pediatrics at University of Texas, Dallas, and an adolescent medicine physician at Children’s Medical Center in Dallas, noted that “Initiation of puberty suppression can be lifesaving for many gender-diverse youth, preventing the development of secondary sex characteristics. However, this can have effects later if these youth choose to pursue gender-affirming surgeries. This study is important for helping to frame the conversation for youth and their parents when doing consent to start puberty-blocking medications, as well as around optimal timing for each individual.”
Dr. Cooper is a paid MDedge consultant for the LGBTQ Youth Consult in Pediatric News. He had no other disclosures to report.
SOURCE: van de Grift T et al. Pediatrics. 2020;146(5):e20193653.
FROM PEDIATRICS
Flattening the hierarchy
What fellows can learn about leadership from aircraft crews
Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.
For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.
Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.
The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.
I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”1 The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.
The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.
The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.
To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.2 This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.
Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.
I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.
As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.
Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.
References
1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec. https://hbr.org/2019/12/what-aircraft-crews-know-about-managing-high-pressure-situations
2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.
3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.
4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.
5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.
6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.
7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.
What fellows can learn about leadership from aircraft crews
What fellows can learn about leadership from aircraft crews
Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.
For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.
Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.
The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.
I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”1 The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.
The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.
The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.
To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.2 This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.
Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.
I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.
As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.
Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.
References
1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec. https://hbr.org/2019/12/what-aircraft-crews-know-about-managing-high-pressure-situations
2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.
3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.
4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.
5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.
6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.
7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.
Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.
For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.
Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.
The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.
I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”1 The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.
The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.
The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.
To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.2 This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.
Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.
I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.
As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.
Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.
References
1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec. https://hbr.org/2019/12/what-aircraft-crews-know-about-managing-high-pressure-situations
2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.
3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.
4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.
5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.
6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.
7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.
Antibiotic prescribing: How to manage patient pressures
Inappropriate antibiotic prescribing in the face of growing microbial resistance is a global public health problem, and a major cause is perceived patient pressure.
At the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year, Tanya Stivers, PhD, professor of sociology at the University of California, Los Angeles, presented some of her team’s work studying patterns of clinical prescription.
It is widely appreciated that inappropriate prescribing is a common problem that the medical community seems powerless to stop, particularly in primary care. Already, clinicians are running out of effective antibiotics to treat a range of serious infections. Dr. Stivers began by saying that this problem isn’t caused by a lack of understanding about disease causation and microbial resistance or patients overtly demanding antibiotics, which occurs in less than 2% of cases. Instead, the cause appears to lie in doctor-patient interactions during consultations.
In pediatric practice, physicians have previously been found to prescribe antibiotics for a clinically diagnosed respiratory viral infection in 62% of cases when they perceive that this diagnosis was expected by parents, compared with 7% in the absence of such perception. Similarly, associated ear infections were diagnosed three times more often, and sinus infections seven times more often, leading to increased prescribing.
In adult practice, Dr. Stivers reported that patients can exert subtle pressure to prescribe through:
- Priming. Patients help their physician to see the problem as relatively severe (e.g., a sore throat that “feels like a knife”).
- Nudging. Patients redirect physicians back to a bacterial problem (e.g., “I’ve tried all these medicines, and nothing worked”). Nudging was found to occur in 41% of encounters.
- Resisting. Patients contest diagnosis or treatment in 40% of consultations (e.g., “there was pus yesterday”).
Priming or nudging resulted in antibiotic prescribing in 60% of patients without signs of a bacterial infection, compared with 30% where this was not a feature (P < 0.05).
But how can these pressures be countered? Dr. Stivers offered advice based on her original data from 570 video recordings of pediatric encounters. The current findings come from an analysis of 68 adult primary care visits for upper respiratory tract infections in Southern California. Inappropriate prescribing was identified in 37%.
When researching the antibiotic prescribing problem, it is helpful to explore a typical primary care consultation. The acute medical visit structure is a stepwise process involving opening, establishing the problem, gathering information, counseling, and then closing the consultation. It is important is to recognize that patients shape prescribing decisions, and effective communication is vital in influencing the outcome. In Dr. Stivers’ experience, priming, nudging, and resisting result in antibiotic prescribing in 60% of cases in whom clinical signs of bacterial illness are absent, compared with 30% where patient pressure is not a feature.
How can we change practice? Global experience suggests that printed material aimed at physicians is only of marginal benefit. By comparison, patient education does work but needs to be repeated, and there’s always a reason why this consultation should be “special.”
Try a 3-prong communication plan
To counteract these pressures, Dr. Stivers recommends a three-prong communication plan to influence the consultation:
- Foreshadowing, where suggesting that the cause of the patient’s symptoms is likely to be viral is introduced early in the consultation. This approach was found to reduce antibiotic prescribing to 33%, compared with 59% without foreshadowing (P < .05). Resistance may also be reduced.
- Affirmative nonantibiotic treatment plans, where specific positive recommendations given early (e.g., “I’m going to put you on some medicine to try to dry that out”) are less likely to be resisted than is vague negative advice at the end of a consultation.
- Persuasion, which involves explaining the diagnosis and nature of a cough and cold, educating about viral and bacterial differences, and presenting the risks of antibiotics. When persuasion is employed, antibiotic prescribing is reduced to 33%, compared with 63% (P < .05) without persuasion. In general, effective foreshadowing and affirmation should avoid the need for persuasion.
Dr. Stivers’ research suggests that these techniques work, but to do so, they should be delivered naturally as part of routine practice. Interestingly, her data showed that physicians rarely foreshadowed, and when they encountered resistance, they adopted persuasion in 53% of cases. By comparison, affirmative recommendations were used in 89% of cases, but their effects were reduced by the physician being vague and nonspecific.
In conclusion, Dr. Stivers said that addressing inappropriate prescribing requires awareness but that is not enough. The challenge is to reconsider health policies and ways of communicating about antibiotics. There is no downside to foreshadowing a likely viral origin, delivering affirmation, or using persuasion. She added, “If we can make even a 5%-10% reduction [in prescribing], wouldn’t it be worth it?”
Questions answered
A question-and-answer session followed Dr. Stivers’ presentation, and points raised included:
- Physicians have a desire to please. Dr. Stivers countered this point by saying that satisfaction is not tied to antibiotic prescription, and that physicians often misjudge what patients want. It’s important to communicate other treatment options because patients often just want “something they can do.”
- Decision fatigue is often a factor. Evidence shows that antibiotic prescription is more frequent toward the end of a shift. Doctors should avoid negotiation because it increases consultation time. Here, foreshadowing early on may help. Setting may also be important – prescription is more frequent in the ED.
- Vaccine-resistant parents often want active treatment. Here, conversations can be challenging. Trying to persuade may be a less successful than giving positive instruction (e.g., “we’ll give you a vaccine today.”) Resistance is likely to be lower.
- Concern was expressed about manipulating patients ahead of a firm diagnosis. Could this lead to missing a serious bacterial infection? Dr. Stivers acknowledged that this was a gamble. She recommended a “neutral” early foreshadowing statement such as “we are seeing a lot of viral infections at the present.”
- Cultural differences can have an effect. In China, for example, the argument between parents and physicians no longer focuses on antibiotics versus nonantibiotics but rather on oral versus intravenous administration.
- Litigation is a factor in prescribing, especially in the United States. Dr. Stivers stated that her proposed approach to prescribing should not interfere with appropriate management. The clinical picture can change, and antibiotics should be prescribed where needed.
- Audits improve prescribing in the short term. These results were based on recorded consultations, and that factor may have influenced management. In unrecorded consultations, inappropriate antibiotic prescription would be higher.
- Increased point-of-care testing can reduce unnecessary prescribing. This has been documented in countries such as Sweden. Evidence from China suggests that many patients will still receive antibiotics even if a bacterial cause is excluded.
When patients dictate treatment, sometimes we must tell them what is best. Dr. Stivers closed her presentation by emphasizing that, “how you say things will matter.”
Louis Bont, MD, PhD, chair of this session and pediatric infectious diseases specialist at the University Medical Center Utrecht (the Netherlands), commented: “Antimicrobial resistance is a global health threat which jeopardizes sustainable health goals. The World Health Organization has declared that antimicrobial resistance is one of the top 10 global public health threats facing humanity. Resistance to ciprofloxacin varies from 8%-93% in Escherichia coli and 4%-80% in Klebsiella pneumoniae. Colistin is the only last-resort treatment for life-threatening infections caused by carbapenem-resistant enterobacteriaceae.”
Dr. Stivers stated that she has nothing to disclose.
Inappropriate antibiotic prescribing in the face of growing microbial resistance is a global public health problem, and a major cause is perceived patient pressure.
At the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year, Tanya Stivers, PhD, professor of sociology at the University of California, Los Angeles, presented some of her team’s work studying patterns of clinical prescription.
It is widely appreciated that inappropriate prescribing is a common problem that the medical community seems powerless to stop, particularly in primary care. Already, clinicians are running out of effective antibiotics to treat a range of serious infections. Dr. Stivers began by saying that this problem isn’t caused by a lack of understanding about disease causation and microbial resistance or patients overtly demanding antibiotics, which occurs in less than 2% of cases. Instead, the cause appears to lie in doctor-patient interactions during consultations.
In pediatric practice, physicians have previously been found to prescribe antibiotics for a clinically diagnosed respiratory viral infection in 62% of cases when they perceive that this diagnosis was expected by parents, compared with 7% in the absence of such perception. Similarly, associated ear infections were diagnosed three times more often, and sinus infections seven times more often, leading to increased prescribing.
In adult practice, Dr. Stivers reported that patients can exert subtle pressure to prescribe through:
- Priming. Patients help their physician to see the problem as relatively severe (e.g., a sore throat that “feels like a knife”).
- Nudging. Patients redirect physicians back to a bacterial problem (e.g., “I’ve tried all these medicines, and nothing worked”). Nudging was found to occur in 41% of encounters.
- Resisting. Patients contest diagnosis or treatment in 40% of consultations (e.g., “there was pus yesterday”).
Priming or nudging resulted in antibiotic prescribing in 60% of patients without signs of a bacterial infection, compared with 30% where this was not a feature (P < 0.05).
But how can these pressures be countered? Dr. Stivers offered advice based on her original data from 570 video recordings of pediatric encounters. The current findings come from an analysis of 68 adult primary care visits for upper respiratory tract infections in Southern California. Inappropriate prescribing was identified in 37%.
When researching the antibiotic prescribing problem, it is helpful to explore a typical primary care consultation. The acute medical visit structure is a stepwise process involving opening, establishing the problem, gathering information, counseling, and then closing the consultation. It is important is to recognize that patients shape prescribing decisions, and effective communication is vital in influencing the outcome. In Dr. Stivers’ experience, priming, nudging, and resisting result in antibiotic prescribing in 60% of cases in whom clinical signs of bacterial illness are absent, compared with 30% where patient pressure is not a feature.
How can we change practice? Global experience suggests that printed material aimed at physicians is only of marginal benefit. By comparison, patient education does work but needs to be repeated, and there’s always a reason why this consultation should be “special.”
Try a 3-prong communication plan
To counteract these pressures, Dr. Stivers recommends a three-prong communication plan to influence the consultation:
- Foreshadowing, where suggesting that the cause of the patient’s symptoms is likely to be viral is introduced early in the consultation. This approach was found to reduce antibiotic prescribing to 33%, compared with 59% without foreshadowing (P < .05). Resistance may also be reduced.
- Affirmative nonantibiotic treatment plans, where specific positive recommendations given early (e.g., “I’m going to put you on some medicine to try to dry that out”) are less likely to be resisted than is vague negative advice at the end of a consultation.
- Persuasion, which involves explaining the diagnosis and nature of a cough and cold, educating about viral and bacterial differences, and presenting the risks of antibiotics. When persuasion is employed, antibiotic prescribing is reduced to 33%, compared with 63% (P < .05) without persuasion. In general, effective foreshadowing and affirmation should avoid the need for persuasion.
Dr. Stivers’ research suggests that these techniques work, but to do so, they should be delivered naturally as part of routine practice. Interestingly, her data showed that physicians rarely foreshadowed, and when they encountered resistance, they adopted persuasion in 53% of cases. By comparison, affirmative recommendations were used in 89% of cases, but their effects were reduced by the physician being vague and nonspecific.
In conclusion, Dr. Stivers said that addressing inappropriate prescribing requires awareness but that is not enough. The challenge is to reconsider health policies and ways of communicating about antibiotics. There is no downside to foreshadowing a likely viral origin, delivering affirmation, or using persuasion. She added, “If we can make even a 5%-10% reduction [in prescribing], wouldn’t it be worth it?”
Questions answered
A question-and-answer session followed Dr. Stivers’ presentation, and points raised included:
- Physicians have a desire to please. Dr. Stivers countered this point by saying that satisfaction is not tied to antibiotic prescription, and that physicians often misjudge what patients want. It’s important to communicate other treatment options because patients often just want “something they can do.”
- Decision fatigue is often a factor. Evidence shows that antibiotic prescription is more frequent toward the end of a shift. Doctors should avoid negotiation because it increases consultation time. Here, foreshadowing early on may help. Setting may also be important – prescription is more frequent in the ED.
- Vaccine-resistant parents often want active treatment. Here, conversations can be challenging. Trying to persuade may be a less successful than giving positive instruction (e.g., “we’ll give you a vaccine today.”) Resistance is likely to be lower.
- Concern was expressed about manipulating patients ahead of a firm diagnosis. Could this lead to missing a serious bacterial infection? Dr. Stivers acknowledged that this was a gamble. She recommended a “neutral” early foreshadowing statement such as “we are seeing a lot of viral infections at the present.”
- Cultural differences can have an effect. In China, for example, the argument between parents and physicians no longer focuses on antibiotics versus nonantibiotics but rather on oral versus intravenous administration.
- Litigation is a factor in prescribing, especially in the United States. Dr. Stivers stated that her proposed approach to prescribing should not interfere with appropriate management. The clinical picture can change, and antibiotics should be prescribed where needed.
- Audits improve prescribing in the short term. These results were based on recorded consultations, and that factor may have influenced management. In unrecorded consultations, inappropriate antibiotic prescription would be higher.
- Increased point-of-care testing can reduce unnecessary prescribing. This has been documented in countries such as Sweden. Evidence from China suggests that many patients will still receive antibiotics even if a bacterial cause is excluded.
When patients dictate treatment, sometimes we must tell them what is best. Dr. Stivers closed her presentation by emphasizing that, “how you say things will matter.”
Louis Bont, MD, PhD, chair of this session and pediatric infectious diseases specialist at the University Medical Center Utrecht (the Netherlands), commented: “Antimicrobial resistance is a global health threat which jeopardizes sustainable health goals. The World Health Organization has declared that antimicrobial resistance is one of the top 10 global public health threats facing humanity. Resistance to ciprofloxacin varies from 8%-93% in Escherichia coli and 4%-80% in Klebsiella pneumoniae. Colistin is the only last-resort treatment for life-threatening infections caused by carbapenem-resistant enterobacteriaceae.”
Dr. Stivers stated that she has nothing to disclose.
Inappropriate antibiotic prescribing in the face of growing microbial resistance is a global public health problem, and a major cause is perceived patient pressure.
At the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year, Tanya Stivers, PhD, professor of sociology at the University of California, Los Angeles, presented some of her team’s work studying patterns of clinical prescription.
It is widely appreciated that inappropriate prescribing is a common problem that the medical community seems powerless to stop, particularly in primary care. Already, clinicians are running out of effective antibiotics to treat a range of serious infections. Dr. Stivers began by saying that this problem isn’t caused by a lack of understanding about disease causation and microbial resistance or patients overtly demanding antibiotics, which occurs in less than 2% of cases. Instead, the cause appears to lie in doctor-patient interactions during consultations.
In pediatric practice, physicians have previously been found to prescribe antibiotics for a clinically diagnosed respiratory viral infection in 62% of cases when they perceive that this diagnosis was expected by parents, compared with 7% in the absence of such perception. Similarly, associated ear infections were diagnosed three times more often, and sinus infections seven times more often, leading to increased prescribing.
In adult practice, Dr. Stivers reported that patients can exert subtle pressure to prescribe through:
- Priming. Patients help their physician to see the problem as relatively severe (e.g., a sore throat that “feels like a knife”).
- Nudging. Patients redirect physicians back to a bacterial problem (e.g., “I’ve tried all these medicines, and nothing worked”). Nudging was found to occur in 41% of encounters.
- Resisting. Patients contest diagnosis or treatment in 40% of consultations (e.g., “there was pus yesterday”).
Priming or nudging resulted in antibiotic prescribing in 60% of patients without signs of a bacterial infection, compared with 30% where this was not a feature (P < 0.05).
But how can these pressures be countered? Dr. Stivers offered advice based on her original data from 570 video recordings of pediatric encounters. The current findings come from an analysis of 68 adult primary care visits for upper respiratory tract infections in Southern California. Inappropriate prescribing was identified in 37%.
When researching the antibiotic prescribing problem, it is helpful to explore a typical primary care consultation. The acute medical visit structure is a stepwise process involving opening, establishing the problem, gathering information, counseling, and then closing the consultation. It is important is to recognize that patients shape prescribing decisions, and effective communication is vital in influencing the outcome. In Dr. Stivers’ experience, priming, nudging, and resisting result in antibiotic prescribing in 60% of cases in whom clinical signs of bacterial illness are absent, compared with 30% where patient pressure is not a feature.
How can we change practice? Global experience suggests that printed material aimed at physicians is only of marginal benefit. By comparison, patient education does work but needs to be repeated, and there’s always a reason why this consultation should be “special.”
Try a 3-prong communication plan
To counteract these pressures, Dr. Stivers recommends a three-prong communication plan to influence the consultation:
- Foreshadowing, where suggesting that the cause of the patient’s symptoms is likely to be viral is introduced early in the consultation. This approach was found to reduce antibiotic prescribing to 33%, compared with 59% without foreshadowing (P < .05). Resistance may also be reduced.
- Affirmative nonantibiotic treatment plans, where specific positive recommendations given early (e.g., “I’m going to put you on some medicine to try to dry that out”) are less likely to be resisted than is vague negative advice at the end of a consultation.
- Persuasion, which involves explaining the diagnosis and nature of a cough and cold, educating about viral and bacterial differences, and presenting the risks of antibiotics. When persuasion is employed, antibiotic prescribing is reduced to 33%, compared with 63% (P < .05) without persuasion. In general, effective foreshadowing and affirmation should avoid the need for persuasion.
Dr. Stivers’ research suggests that these techniques work, but to do so, they should be delivered naturally as part of routine practice. Interestingly, her data showed that physicians rarely foreshadowed, and when they encountered resistance, they adopted persuasion in 53% of cases. By comparison, affirmative recommendations were used in 89% of cases, but their effects were reduced by the physician being vague and nonspecific.
In conclusion, Dr. Stivers said that addressing inappropriate prescribing requires awareness but that is not enough. The challenge is to reconsider health policies and ways of communicating about antibiotics. There is no downside to foreshadowing a likely viral origin, delivering affirmation, or using persuasion. She added, “If we can make even a 5%-10% reduction [in prescribing], wouldn’t it be worth it?”
Questions answered
A question-and-answer session followed Dr. Stivers’ presentation, and points raised included:
- Physicians have a desire to please. Dr. Stivers countered this point by saying that satisfaction is not tied to antibiotic prescription, and that physicians often misjudge what patients want. It’s important to communicate other treatment options because patients often just want “something they can do.”
- Decision fatigue is often a factor. Evidence shows that antibiotic prescription is more frequent toward the end of a shift. Doctors should avoid negotiation because it increases consultation time. Here, foreshadowing early on may help. Setting may also be important – prescription is more frequent in the ED.
- Vaccine-resistant parents often want active treatment. Here, conversations can be challenging. Trying to persuade may be a less successful than giving positive instruction (e.g., “we’ll give you a vaccine today.”) Resistance is likely to be lower.
- Concern was expressed about manipulating patients ahead of a firm diagnosis. Could this lead to missing a serious bacterial infection? Dr. Stivers acknowledged that this was a gamble. She recommended a “neutral” early foreshadowing statement such as “we are seeing a lot of viral infections at the present.”
- Cultural differences can have an effect. In China, for example, the argument between parents and physicians no longer focuses on antibiotics versus nonantibiotics but rather on oral versus intravenous administration.
- Litigation is a factor in prescribing, especially in the United States. Dr. Stivers stated that her proposed approach to prescribing should not interfere with appropriate management. The clinical picture can change, and antibiotics should be prescribed where needed.
- Audits improve prescribing in the short term. These results were based on recorded consultations, and that factor may have influenced management. In unrecorded consultations, inappropriate antibiotic prescription would be higher.
- Increased point-of-care testing can reduce unnecessary prescribing. This has been documented in countries such as Sweden. Evidence from China suggests that many patients will still receive antibiotics even if a bacterial cause is excluded.
When patients dictate treatment, sometimes we must tell them what is best. Dr. Stivers closed her presentation by emphasizing that, “how you say things will matter.”
Louis Bont, MD, PhD, chair of this session and pediatric infectious diseases specialist at the University Medical Center Utrecht (the Netherlands), commented: “Antimicrobial resistance is a global health threat which jeopardizes sustainable health goals. The World Health Organization has declared that antimicrobial resistance is one of the top 10 global public health threats facing humanity. Resistance to ciprofloxacin varies from 8%-93% in Escherichia coli and 4%-80% in Klebsiella pneumoniae. Colistin is the only last-resort treatment for life-threatening infections caused by carbapenem-resistant enterobacteriaceae.”
Dr. Stivers stated that she has nothing to disclose.
FROM ESPID 2020
Hand hygiene in pediatric ICUs: Identifying areas for improvement
A multidisciplinary team seeking to measure compliance with hand hygiene (HH) practices in pediatric ICUs across Europe found compliance was comparable and relatively high among unit doctors and nurses, but not as high in nonunit doctors and nurses.
Ioannis Kopsidas, MD, presented these results from the RANIN-KIDS Network during the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year. RANIN-KIDS (Reducing Antimicrobial Use and Nosocomial Infections in Kids) is a European network with the aim of preventing hospital-associated infections and promoting judicial antimicrobial use in pediatric patients using a common sustainable methodology across Europe.
Infections kill. This is especially the case in pediatric ICUs, where young age and an immunocompromised status make patients particularly vulnerable to infections. Poor HH is a major cause for disease transmission. To reduce the risk, the World Health Organization recommends attention to five moments of hand hygiene and nine steps for hand washing. Various tools are available to improve adherence, but whether these measures are being followed is unclear. The researchers sought to assess the degree of compliance with HH practices in pediatric ICUs and to identify targets for improvement.
Dr. Kopsidas, of the Center of Clinical Epidemiology and Outcomes Research, the National and Kapodistrian University of Athens, and colleagues examined practices in nine pediatric ICUs across six European countries (Estonia, Germany, Greece, Italy, Spain, and Switzerland) by means of prospective observational study. All organizations were part of the RANIN-KIDS network. Over a 6-month period starting in March 2019, observations were conducted in every unit by observers using a data collection tool developed based on WHO guidelines. Training for observers was provided using a self-paced teaching kit comprising PowerPoint and video presentations, followed by the completion of a test observation form after observing staged hand hygiene exercises. Results were then compared with WHO guidance, and irregularities were explained in order to achieve interrater reliability.
Researchers observed 1,715 HH opportunities. Across all pediatric ICUs, the median HH compliance rate was 82% (interquartile range, 72%-95%). Stratified by type of professional, median compliance was comparable among unit doctors (90%) and nurses (87%), but lower for nonunit doctors and nurses (81%) and also for nondoctors and nonnurses (67%). Alcohol-based hand rub was substantially preferred to soap and water, being used in 84% of the observations (IQR, 69%-87%). Cleaning and drying technique was considered appropriate in a median of 93% of observations (IQR, 86%-96%).
Compliance to moment 5 (after touching patient surroundings) was the lowest across hospitals (median 71%), compared with a median 100% for moment 2 (before clean/aseptic procedures) and a median 93% for moment 3 (after body fluid exposure/risk). For moment 1, median compliance was 87% (before touching a patient), and for moment 4, median compliance was 82% (after touching a patient).
Dr. Kopsidas concluded that the overall level of HH compliance among doctors and nurses working in European pediatric ICUs appears to be high, with moment 5 being the most frequently missed opportunity. Nonunit doctors and nurses and other personnel show lower WHO guidelines adherence. He stated that “these results will be used to design tailor-made interventions in participating units with the aim of reducing HAIs [health care–associated infections] and spread of multidrug resistant infections.”
He also said that “unified surveillance in Europe is possible and achievable, and allows for benchmarking among countries, institutions and wards.”
For some units, improving HH is a missed opportunity. The next stop for the RANIN-KIDS network is to look at the effects of interventions on reducing spread.
Dr. Kopsidas had no relevant financial disclosures.
A multidisciplinary team seeking to measure compliance with hand hygiene (HH) practices in pediatric ICUs across Europe found compliance was comparable and relatively high among unit doctors and nurses, but not as high in nonunit doctors and nurses.
Ioannis Kopsidas, MD, presented these results from the RANIN-KIDS Network during the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year. RANIN-KIDS (Reducing Antimicrobial Use and Nosocomial Infections in Kids) is a European network with the aim of preventing hospital-associated infections and promoting judicial antimicrobial use in pediatric patients using a common sustainable methodology across Europe.
Infections kill. This is especially the case in pediatric ICUs, where young age and an immunocompromised status make patients particularly vulnerable to infections. Poor HH is a major cause for disease transmission. To reduce the risk, the World Health Organization recommends attention to five moments of hand hygiene and nine steps for hand washing. Various tools are available to improve adherence, but whether these measures are being followed is unclear. The researchers sought to assess the degree of compliance with HH practices in pediatric ICUs and to identify targets for improvement.
Dr. Kopsidas, of the Center of Clinical Epidemiology and Outcomes Research, the National and Kapodistrian University of Athens, and colleagues examined practices in nine pediatric ICUs across six European countries (Estonia, Germany, Greece, Italy, Spain, and Switzerland) by means of prospective observational study. All organizations were part of the RANIN-KIDS network. Over a 6-month period starting in March 2019, observations were conducted in every unit by observers using a data collection tool developed based on WHO guidelines. Training for observers was provided using a self-paced teaching kit comprising PowerPoint and video presentations, followed by the completion of a test observation form after observing staged hand hygiene exercises. Results were then compared with WHO guidance, and irregularities were explained in order to achieve interrater reliability.
Researchers observed 1,715 HH opportunities. Across all pediatric ICUs, the median HH compliance rate was 82% (interquartile range, 72%-95%). Stratified by type of professional, median compliance was comparable among unit doctors (90%) and nurses (87%), but lower for nonunit doctors and nurses (81%) and also for nondoctors and nonnurses (67%). Alcohol-based hand rub was substantially preferred to soap and water, being used in 84% of the observations (IQR, 69%-87%). Cleaning and drying technique was considered appropriate in a median of 93% of observations (IQR, 86%-96%).
Compliance to moment 5 (after touching patient surroundings) was the lowest across hospitals (median 71%), compared with a median 100% for moment 2 (before clean/aseptic procedures) and a median 93% for moment 3 (after body fluid exposure/risk). For moment 1, median compliance was 87% (before touching a patient), and for moment 4, median compliance was 82% (after touching a patient).
Dr. Kopsidas concluded that the overall level of HH compliance among doctors and nurses working in European pediatric ICUs appears to be high, with moment 5 being the most frequently missed opportunity. Nonunit doctors and nurses and other personnel show lower WHO guidelines adherence. He stated that “these results will be used to design tailor-made interventions in participating units with the aim of reducing HAIs [health care–associated infections] and spread of multidrug resistant infections.”
He also said that “unified surveillance in Europe is possible and achievable, and allows for benchmarking among countries, institutions and wards.”
For some units, improving HH is a missed opportunity. The next stop for the RANIN-KIDS network is to look at the effects of interventions on reducing spread.
Dr. Kopsidas had no relevant financial disclosures.
A multidisciplinary team seeking to measure compliance with hand hygiene (HH) practices in pediatric ICUs across Europe found compliance was comparable and relatively high among unit doctors and nurses, but not as high in nonunit doctors and nurses.
Ioannis Kopsidas, MD, presented these results from the RANIN-KIDS Network during the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year. RANIN-KIDS (Reducing Antimicrobial Use and Nosocomial Infections in Kids) is a European network with the aim of preventing hospital-associated infections and promoting judicial antimicrobial use in pediatric patients using a common sustainable methodology across Europe.
Infections kill. This is especially the case in pediatric ICUs, where young age and an immunocompromised status make patients particularly vulnerable to infections. Poor HH is a major cause for disease transmission. To reduce the risk, the World Health Organization recommends attention to five moments of hand hygiene and nine steps for hand washing. Various tools are available to improve adherence, but whether these measures are being followed is unclear. The researchers sought to assess the degree of compliance with HH practices in pediatric ICUs and to identify targets for improvement.
Dr. Kopsidas, of the Center of Clinical Epidemiology and Outcomes Research, the National and Kapodistrian University of Athens, and colleagues examined practices in nine pediatric ICUs across six European countries (Estonia, Germany, Greece, Italy, Spain, and Switzerland) by means of prospective observational study. All organizations were part of the RANIN-KIDS network. Over a 6-month period starting in March 2019, observations were conducted in every unit by observers using a data collection tool developed based on WHO guidelines. Training for observers was provided using a self-paced teaching kit comprising PowerPoint and video presentations, followed by the completion of a test observation form after observing staged hand hygiene exercises. Results were then compared with WHO guidance, and irregularities were explained in order to achieve interrater reliability.
Researchers observed 1,715 HH opportunities. Across all pediatric ICUs, the median HH compliance rate was 82% (interquartile range, 72%-95%). Stratified by type of professional, median compliance was comparable among unit doctors (90%) and nurses (87%), but lower for nonunit doctors and nurses (81%) and also for nondoctors and nonnurses (67%). Alcohol-based hand rub was substantially preferred to soap and water, being used in 84% of the observations (IQR, 69%-87%). Cleaning and drying technique was considered appropriate in a median of 93% of observations (IQR, 86%-96%).
Compliance to moment 5 (after touching patient surroundings) was the lowest across hospitals (median 71%), compared with a median 100% for moment 2 (before clean/aseptic procedures) and a median 93% for moment 3 (after body fluid exposure/risk). For moment 1, median compliance was 87% (before touching a patient), and for moment 4, median compliance was 82% (after touching a patient).
Dr. Kopsidas concluded that the overall level of HH compliance among doctors and nurses working in European pediatric ICUs appears to be high, with moment 5 being the most frequently missed opportunity. Nonunit doctors and nurses and other personnel show lower WHO guidelines adherence. He stated that “these results will be used to design tailor-made interventions in participating units with the aim of reducing HAIs [health care–associated infections] and spread of multidrug resistant infections.”
He also said that “unified surveillance in Europe is possible and achievable, and allows for benchmarking among countries, institutions and wards.”
For some units, improving HH is a missed opportunity. The next stop for the RANIN-KIDS network is to look at the effects of interventions on reducing spread.
Dr. Kopsidas had no relevant financial disclosures.
FROM ESPID 2020
Nicotine vaping tapers off among teens
Levels of nicotine and marijuana vaping among adolescents remain elevated but did not increase significantly in the past year, data from the annual Monitoring the Future survey show.
The 2020 survey included responses from 11,821 individuals in 112 schools across the United States from Feb. 11, 2020, to March 14, 2020, at which time data collection ended prematurely because of the COVID-19 pandemic.
A key positive finding in this year’s survey was the relatively stable levels of nicotine vaping from 2019 to 2020, following a trend of notably increased use annually since vaping was added to the survey in 2017.
During the years 2017-2019, the percentage of teens who reported vaping nicotine in the past 12 months increased from 7.5% to 16.5% among 8th graders, from 15.8% to 30.7% among 10th graders, and from 18.8% to 35.3% among 12th graders. However, in 2020, the percentages of teens who reported past-year nicotine vaping were relatively steady at 16.6%, 30.7%, and 34.5%, for 8th-, 10th-, and 12th-grade students, respectively. In addition, reports of daily or near-daily nicotine vaping (defined as 20 occasions in the past 30 days) decreased significantly, from 6.8% to 3.6% among 10th graders and from 11.6% to 5.3% among 12th graders.
“The rapid rise of teen nicotine vaping in recent years has been unprecedented and deeply concerning since we know that nicotine is highly addictive and can be delivered at high doses by vaping devices, which may also contain other toxic chemicals that may be harmful when inhaled,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse in a press release accompanying the release of the findings. “It is encouraging to see a leveling off of this trend though the rates still remain very high.”
Reports of past-year marijuana vaping remained similar to 2019 levels after a twofold increase in the past 2 years, according to the survey. In early 2020, 8.1%, 19.1%, and 22.1% of 8th, 10th, and 12th graders reported past-year use. However, daily marijuana vaping decreased by more than half from 2019, to 1.1% among 10th graders and 1.5% among 12th graders.
Past-year use of the JUUL devices specifically also declined among older teens, from 28.7% in 2019 to 20% in 2020 among 10th graders and from 28.4% in 2019 to 22.7% in 2020 among 12th graders.
Other trends this year included the increased past-year use of amphetamines, inhalants, and cough medicines among 8th graders, and relatively low reported use among 12th graders of LSD (3.9%), synthetic cannabinoids (2.4%), cocaine (2.9%), ecstasy (1.8%), methamphetamine (1.4%), and heroin (0.3%).
The findings were published in JAMA Pediatrics.
Early data show progress
“The MTF survey is the most referenced and reliable longitudinal study reporting current use of tobacco, drugs, and alcohol among young people,” said Mark S. Gold, MD, of Washington University, St. Louis, in an interview.
“The new data, collected before data collection stopped prematurely due to the COVID-19 pandemic, suggests that some progress is being made in slowing the increase in substance use among these, the most vulnerable,” he said.
“The best news was that nicotine vaping decreased significantly after its meteoric increase over the past few years,” Dr. Gold emphasized. “Past-year vaping of marijuana remained steady at alarming levels in 2020, with 8.1% of 8th graders, 19.1% of 10th graders, and 22.1% of 12th graders reporting past-year use, following a two-fold increase over the past 2 years.” The use of all forms of marijuana, including smoking and vaping, did not significantly change in any of the three grades for lifetime use, past 12-month use, past 30-day use, and daily use from 2019 to 2020.
“Teen alcohol use has not significantly changed over the past 5 years,” and cigarette smoking in the last 30 days did not significantly change from 2019 to 2020, said Dr. Gold. However, “as with adults, psychostimulant use is increasing. Past year nonmedical use of amphetamines among 8th graders increased, from 3.5% in 2017 to 5.3% in 2020.”
COVID-era limitations
“The data suggest that pre-COVID pandemic vaping, smoking cigarettes, marijuana, and alcohol use had stabilized,” Dr. Gold said. “However, it is very difficult to predict what the COVID era data will show as many young people are at home, on the streets, and unsupervised; while adult substance misuse, substance use disorders, and overdoses are increasing. Drug supplies and access have increased for alcohol, cannabis, vaping, and tobacco as have supply synthetics like methamphetamine and fentanyl.”
In addition, “access to evaluation, intervention, and treatment have been curtailed during the pandemic,” Dr. Gold said. “The loss of peer role models, daily routine, and teacher or other adult supervision and interventions may interact with increasing despair, social isolation, depression, and anxiety in ways that are unknown. “It will not be clear until the next survey if perceived dangerousness has changed in ways that can protect these 8th, 10th, and 12th graders and increase the numbers of never users or current nonusers.”
The Monitoring the Future survey is conducted each year by the University of Michigan’s Institute for Social Research, Ann Arbor, and supported by NIDA, part of the National Institutes of Health. Dr. Gold had no relevant financial conflicts to disclose.
Levels of nicotine and marijuana vaping among adolescents remain elevated but did not increase significantly in the past year, data from the annual Monitoring the Future survey show.
The 2020 survey included responses from 11,821 individuals in 112 schools across the United States from Feb. 11, 2020, to March 14, 2020, at which time data collection ended prematurely because of the COVID-19 pandemic.
A key positive finding in this year’s survey was the relatively stable levels of nicotine vaping from 2019 to 2020, following a trend of notably increased use annually since vaping was added to the survey in 2017.
During the years 2017-2019, the percentage of teens who reported vaping nicotine in the past 12 months increased from 7.5% to 16.5% among 8th graders, from 15.8% to 30.7% among 10th graders, and from 18.8% to 35.3% among 12th graders. However, in 2020, the percentages of teens who reported past-year nicotine vaping were relatively steady at 16.6%, 30.7%, and 34.5%, for 8th-, 10th-, and 12th-grade students, respectively. In addition, reports of daily or near-daily nicotine vaping (defined as 20 occasions in the past 30 days) decreased significantly, from 6.8% to 3.6% among 10th graders and from 11.6% to 5.3% among 12th graders.
“The rapid rise of teen nicotine vaping in recent years has been unprecedented and deeply concerning since we know that nicotine is highly addictive and can be delivered at high doses by vaping devices, which may also contain other toxic chemicals that may be harmful when inhaled,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse in a press release accompanying the release of the findings. “It is encouraging to see a leveling off of this trend though the rates still remain very high.”
Reports of past-year marijuana vaping remained similar to 2019 levels after a twofold increase in the past 2 years, according to the survey. In early 2020, 8.1%, 19.1%, and 22.1% of 8th, 10th, and 12th graders reported past-year use. However, daily marijuana vaping decreased by more than half from 2019, to 1.1% among 10th graders and 1.5% among 12th graders.
Past-year use of the JUUL devices specifically also declined among older teens, from 28.7% in 2019 to 20% in 2020 among 10th graders and from 28.4% in 2019 to 22.7% in 2020 among 12th graders.
Other trends this year included the increased past-year use of amphetamines, inhalants, and cough medicines among 8th graders, and relatively low reported use among 12th graders of LSD (3.9%), synthetic cannabinoids (2.4%), cocaine (2.9%), ecstasy (1.8%), methamphetamine (1.4%), and heroin (0.3%).
The findings were published in JAMA Pediatrics.
Early data show progress
“The MTF survey is the most referenced and reliable longitudinal study reporting current use of tobacco, drugs, and alcohol among young people,” said Mark S. Gold, MD, of Washington University, St. Louis, in an interview.
“The new data, collected before data collection stopped prematurely due to the COVID-19 pandemic, suggests that some progress is being made in slowing the increase in substance use among these, the most vulnerable,” he said.
“The best news was that nicotine vaping decreased significantly after its meteoric increase over the past few years,” Dr. Gold emphasized. “Past-year vaping of marijuana remained steady at alarming levels in 2020, with 8.1% of 8th graders, 19.1% of 10th graders, and 22.1% of 12th graders reporting past-year use, following a two-fold increase over the past 2 years.” The use of all forms of marijuana, including smoking and vaping, did not significantly change in any of the three grades for lifetime use, past 12-month use, past 30-day use, and daily use from 2019 to 2020.
“Teen alcohol use has not significantly changed over the past 5 years,” and cigarette smoking in the last 30 days did not significantly change from 2019 to 2020, said Dr. Gold. However, “as with adults, psychostimulant use is increasing. Past year nonmedical use of amphetamines among 8th graders increased, from 3.5% in 2017 to 5.3% in 2020.”
COVID-era limitations
“The data suggest that pre-COVID pandemic vaping, smoking cigarettes, marijuana, and alcohol use had stabilized,” Dr. Gold said. “However, it is very difficult to predict what the COVID era data will show as many young people are at home, on the streets, and unsupervised; while adult substance misuse, substance use disorders, and overdoses are increasing. Drug supplies and access have increased for alcohol, cannabis, vaping, and tobacco as have supply synthetics like methamphetamine and fentanyl.”
In addition, “access to evaluation, intervention, and treatment have been curtailed during the pandemic,” Dr. Gold said. “The loss of peer role models, daily routine, and teacher or other adult supervision and interventions may interact with increasing despair, social isolation, depression, and anxiety in ways that are unknown. “It will not be clear until the next survey if perceived dangerousness has changed in ways that can protect these 8th, 10th, and 12th graders and increase the numbers of never users or current nonusers.”
The Monitoring the Future survey is conducted each year by the University of Michigan’s Institute for Social Research, Ann Arbor, and supported by NIDA, part of the National Institutes of Health. Dr. Gold had no relevant financial conflicts to disclose.
Levels of nicotine and marijuana vaping among adolescents remain elevated but did not increase significantly in the past year, data from the annual Monitoring the Future survey show.
The 2020 survey included responses from 11,821 individuals in 112 schools across the United States from Feb. 11, 2020, to March 14, 2020, at which time data collection ended prematurely because of the COVID-19 pandemic.
A key positive finding in this year’s survey was the relatively stable levels of nicotine vaping from 2019 to 2020, following a trend of notably increased use annually since vaping was added to the survey in 2017.
During the years 2017-2019, the percentage of teens who reported vaping nicotine in the past 12 months increased from 7.5% to 16.5% among 8th graders, from 15.8% to 30.7% among 10th graders, and from 18.8% to 35.3% among 12th graders. However, in 2020, the percentages of teens who reported past-year nicotine vaping were relatively steady at 16.6%, 30.7%, and 34.5%, for 8th-, 10th-, and 12th-grade students, respectively. In addition, reports of daily or near-daily nicotine vaping (defined as 20 occasions in the past 30 days) decreased significantly, from 6.8% to 3.6% among 10th graders and from 11.6% to 5.3% among 12th graders.
“The rapid rise of teen nicotine vaping in recent years has been unprecedented and deeply concerning since we know that nicotine is highly addictive and can be delivered at high doses by vaping devices, which may also contain other toxic chemicals that may be harmful when inhaled,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse in a press release accompanying the release of the findings. “It is encouraging to see a leveling off of this trend though the rates still remain very high.”
Reports of past-year marijuana vaping remained similar to 2019 levels after a twofold increase in the past 2 years, according to the survey. In early 2020, 8.1%, 19.1%, and 22.1% of 8th, 10th, and 12th graders reported past-year use. However, daily marijuana vaping decreased by more than half from 2019, to 1.1% among 10th graders and 1.5% among 12th graders.
Past-year use of the JUUL devices specifically also declined among older teens, from 28.7% in 2019 to 20% in 2020 among 10th graders and from 28.4% in 2019 to 22.7% in 2020 among 12th graders.
Other trends this year included the increased past-year use of amphetamines, inhalants, and cough medicines among 8th graders, and relatively low reported use among 12th graders of LSD (3.9%), synthetic cannabinoids (2.4%), cocaine (2.9%), ecstasy (1.8%), methamphetamine (1.4%), and heroin (0.3%).
The findings were published in JAMA Pediatrics.
Early data show progress
“The MTF survey is the most referenced and reliable longitudinal study reporting current use of tobacco, drugs, and alcohol among young people,” said Mark S. Gold, MD, of Washington University, St. Louis, in an interview.
“The new data, collected before data collection stopped prematurely due to the COVID-19 pandemic, suggests that some progress is being made in slowing the increase in substance use among these, the most vulnerable,” he said.
“The best news was that nicotine vaping decreased significantly after its meteoric increase over the past few years,” Dr. Gold emphasized. “Past-year vaping of marijuana remained steady at alarming levels in 2020, with 8.1% of 8th graders, 19.1% of 10th graders, and 22.1% of 12th graders reporting past-year use, following a two-fold increase over the past 2 years.” The use of all forms of marijuana, including smoking and vaping, did not significantly change in any of the three grades for lifetime use, past 12-month use, past 30-day use, and daily use from 2019 to 2020.
“Teen alcohol use has not significantly changed over the past 5 years,” and cigarette smoking in the last 30 days did not significantly change from 2019 to 2020, said Dr. Gold. However, “as with adults, psychostimulant use is increasing. Past year nonmedical use of amphetamines among 8th graders increased, from 3.5% in 2017 to 5.3% in 2020.”
COVID-era limitations
“The data suggest that pre-COVID pandemic vaping, smoking cigarettes, marijuana, and alcohol use had stabilized,” Dr. Gold said. “However, it is very difficult to predict what the COVID era data will show as many young people are at home, on the streets, and unsupervised; while adult substance misuse, substance use disorders, and overdoses are increasing. Drug supplies and access have increased for alcohol, cannabis, vaping, and tobacco as have supply synthetics like methamphetamine and fentanyl.”
In addition, “access to evaluation, intervention, and treatment have been curtailed during the pandemic,” Dr. Gold said. “The loss of peer role models, daily routine, and teacher or other adult supervision and interventions may interact with increasing despair, social isolation, depression, and anxiety in ways that are unknown. “It will not be clear until the next survey if perceived dangerousness has changed in ways that can protect these 8th, 10th, and 12th graders and increase the numbers of never users or current nonusers.”
The Monitoring the Future survey is conducted each year by the University of Michigan’s Institute for Social Research, Ann Arbor, and supported by NIDA, part of the National Institutes of Health. Dr. Gold had no relevant financial conflicts to disclose.
Consider C. difficile early in children with cancer with GI symptoms
Children with cancer are at increased risk of potentially life-threatening Clostridioides difficile infections (CDI), and Brianna Murphy, DO, reported at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.
CDI are characterized by diarrhea, fever, and loss of appetite. The clinical features are caused by the release of toxins A and B by this gram-positive bacterium. In pediatric groups, CDI are a leading cause of antibiotic-associated gastric illness. This in turn can lead to a protracted stay in hospital and increases risk of mortality. The rising incidence in the United States over the last 2 decades prompted Dr. Murphy, a pediatric hematology oncology fellow working at the department of pediatric research at the University of Texas MD Anderson Cancer Center, Houston, to investigate further. A search of the literature found limited information regarding CDI and pediatric oncology patients.
Recognized factors for contracting CDI include the presence of other illnesses, a weakened immune system because of drugs or disease, enteral nutrition, usage of medicines such as proton pump inhibitors which decrease gastric acid production, and classically, treatment with broad spectrum antibiotics.
Dr. Murphy’s study included patients aged 1-18 years, all of whom had a cancer diagnosis and a positive stool culture for C. difficile. Presenting symptoms were three or more loose stools per day or acute onset ileus. The study evaluated data for the years 2000-2017 and included 11,366 children; 207 CDI (0.98%) cases were identified among pediatric oncology patients during the study period. This compares with historical data showing an incidence of 0.14% among hospitalized children in general.
Malignancy data were then subdivided into three groups: hematologic, nonneural solid tumors (NNST), and neural tumors. Hematologic malignancies had a CDI prevalence higher than the average for oncologic patients at 5.4%. Inside this group those suffering with acute myeloid leukemia had a rate of 10.5%. In the NNST and neural tumor groups, CDI rates were lower and closer to the overall average.
Dr. Murphy then looked at her patient population in more detail. Poor clinical outcomes (PCOs) were defined as severe, refractory, recurrent, or multiple infections. Severe CDI included features such as toxic megacolon, gastrointestinal perforation, or need for surgical intervention. Refractory CDI were defined as continuation of symptoms beyond 7 days of appropriate therapy, and recurrent CDI were classed as reinfection within 8 weeks of a previous CDI. Ultimately, 51% of patients in this study died. Patients with severe CDI experienced increased mortality (P = .02). There was no difference shown when looking at the type of cancer, age, gender, or patient ethnicity.
Next, Dr. Murphy looked for associations. Hematologic and biochemical testing identified that elevated creatinine was statistically associated with the likelihood of PCOs, compared with leukocytosis and neutropenia, particularly in the NNST group. Treatment modality also was studied. Here radiation therapy was the only treatment shown to increase PCOs in patients with CDI. One-fifth (22%) of radiation therapy recipients experienced multiple CDI, compared with 12% of the total population.
In commenting on her paper, Louis Bent, MD, from the Netherlands raised the issue of deaths in septic patients. What was the origin of the responsible organism, for example from the GI tract or from central lines, and were patients receiving appropriate antibiotic treatment?
Dr. Kelly responded that sepsis was generally believed to occur as a result of infection with mixed bacterial translocation through the bowel wall, notably Escherichia coli. Patients were usually on a cocktail of antibiotics targeting CDI, but also other infections illustrating the serious nature of the situation.
Dr. Murphy had no financial conflicts of interest to declare.
Children with cancer are at increased risk of potentially life-threatening Clostridioides difficile infections (CDI), and Brianna Murphy, DO, reported at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.
CDI are characterized by diarrhea, fever, and loss of appetite. The clinical features are caused by the release of toxins A and B by this gram-positive bacterium. In pediatric groups, CDI are a leading cause of antibiotic-associated gastric illness. This in turn can lead to a protracted stay in hospital and increases risk of mortality. The rising incidence in the United States over the last 2 decades prompted Dr. Murphy, a pediatric hematology oncology fellow working at the department of pediatric research at the University of Texas MD Anderson Cancer Center, Houston, to investigate further. A search of the literature found limited information regarding CDI and pediatric oncology patients.
Recognized factors for contracting CDI include the presence of other illnesses, a weakened immune system because of drugs or disease, enteral nutrition, usage of medicines such as proton pump inhibitors which decrease gastric acid production, and classically, treatment with broad spectrum antibiotics.
Dr. Murphy’s study included patients aged 1-18 years, all of whom had a cancer diagnosis and a positive stool culture for C. difficile. Presenting symptoms were three or more loose stools per day or acute onset ileus. The study evaluated data for the years 2000-2017 and included 11,366 children; 207 CDI (0.98%) cases were identified among pediatric oncology patients during the study period. This compares with historical data showing an incidence of 0.14% among hospitalized children in general.
Malignancy data were then subdivided into three groups: hematologic, nonneural solid tumors (NNST), and neural tumors. Hematologic malignancies had a CDI prevalence higher than the average for oncologic patients at 5.4%. Inside this group those suffering with acute myeloid leukemia had a rate of 10.5%. In the NNST and neural tumor groups, CDI rates were lower and closer to the overall average.
Dr. Murphy then looked at her patient population in more detail. Poor clinical outcomes (PCOs) were defined as severe, refractory, recurrent, or multiple infections. Severe CDI included features such as toxic megacolon, gastrointestinal perforation, or need for surgical intervention. Refractory CDI were defined as continuation of symptoms beyond 7 days of appropriate therapy, and recurrent CDI were classed as reinfection within 8 weeks of a previous CDI. Ultimately, 51% of patients in this study died. Patients with severe CDI experienced increased mortality (P = .02). There was no difference shown when looking at the type of cancer, age, gender, or patient ethnicity.
Next, Dr. Murphy looked for associations. Hematologic and biochemical testing identified that elevated creatinine was statistically associated with the likelihood of PCOs, compared with leukocytosis and neutropenia, particularly in the NNST group. Treatment modality also was studied. Here radiation therapy was the only treatment shown to increase PCOs in patients with CDI. One-fifth (22%) of radiation therapy recipients experienced multiple CDI, compared with 12% of the total population.
In commenting on her paper, Louis Bent, MD, from the Netherlands raised the issue of deaths in septic patients. What was the origin of the responsible organism, for example from the GI tract or from central lines, and were patients receiving appropriate antibiotic treatment?
Dr. Kelly responded that sepsis was generally believed to occur as a result of infection with mixed bacterial translocation through the bowel wall, notably Escherichia coli. Patients were usually on a cocktail of antibiotics targeting CDI, but also other infections illustrating the serious nature of the situation.
Dr. Murphy had no financial conflicts of interest to declare.
Children with cancer are at increased risk of potentially life-threatening Clostridioides difficile infections (CDI), and Brianna Murphy, DO, reported at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.
CDI are characterized by diarrhea, fever, and loss of appetite. The clinical features are caused by the release of toxins A and B by this gram-positive bacterium. In pediatric groups, CDI are a leading cause of antibiotic-associated gastric illness. This in turn can lead to a protracted stay in hospital and increases risk of mortality. The rising incidence in the United States over the last 2 decades prompted Dr. Murphy, a pediatric hematology oncology fellow working at the department of pediatric research at the University of Texas MD Anderson Cancer Center, Houston, to investigate further. A search of the literature found limited information regarding CDI and pediatric oncology patients.
Recognized factors for contracting CDI include the presence of other illnesses, a weakened immune system because of drugs or disease, enteral nutrition, usage of medicines such as proton pump inhibitors which decrease gastric acid production, and classically, treatment with broad spectrum antibiotics.
Dr. Murphy’s study included patients aged 1-18 years, all of whom had a cancer diagnosis and a positive stool culture for C. difficile. Presenting symptoms were three or more loose stools per day or acute onset ileus. The study evaluated data for the years 2000-2017 and included 11,366 children; 207 CDI (0.98%) cases were identified among pediatric oncology patients during the study period. This compares with historical data showing an incidence of 0.14% among hospitalized children in general.
Malignancy data were then subdivided into three groups: hematologic, nonneural solid tumors (NNST), and neural tumors. Hematologic malignancies had a CDI prevalence higher than the average for oncologic patients at 5.4%. Inside this group those suffering with acute myeloid leukemia had a rate of 10.5%. In the NNST and neural tumor groups, CDI rates were lower and closer to the overall average.
Dr. Murphy then looked at her patient population in more detail. Poor clinical outcomes (PCOs) were defined as severe, refractory, recurrent, or multiple infections. Severe CDI included features such as toxic megacolon, gastrointestinal perforation, or need for surgical intervention. Refractory CDI were defined as continuation of symptoms beyond 7 days of appropriate therapy, and recurrent CDI were classed as reinfection within 8 weeks of a previous CDI. Ultimately, 51% of patients in this study died. Patients with severe CDI experienced increased mortality (P = .02). There was no difference shown when looking at the type of cancer, age, gender, or patient ethnicity.
Next, Dr. Murphy looked for associations. Hematologic and biochemical testing identified that elevated creatinine was statistically associated with the likelihood of PCOs, compared with leukocytosis and neutropenia, particularly in the NNST group. Treatment modality also was studied. Here radiation therapy was the only treatment shown to increase PCOs in patients with CDI. One-fifth (22%) of radiation therapy recipients experienced multiple CDI, compared with 12% of the total population.
In commenting on her paper, Louis Bent, MD, from the Netherlands raised the issue of deaths in septic patients. What was the origin of the responsible organism, for example from the GI tract or from central lines, and were patients receiving appropriate antibiotic treatment?
Dr. Kelly responded that sepsis was generally believed to occur as a result of infection with mixed bacterial translocation through the bowel wall, notably Escherichia coli. Patients were usually on a cocktail of antibiotics targeting CDI, but also other infections illustrating the serious nature of the situation.
Dr. Murphy had no financial conflicts of interest to declare.
FROM ESPID 2020
Should we use antibiotics to treat sore throats?
The use of antibiotics to treat a sore throat remains contentious, with guidelines from around the world providing contradictory advice. This topic generated a lively debate at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.
Lauri Ivaska, MD, of the department of pediatrics and adolescent medicine at Turku (Finland) University Hospital, argued for the use of antibiotics, while Borbála Zsigmond, MD, of Heim Pál Children’s Hospital in Budapest, made the case against their use. Interestingly, this debate occurred against the background of a poll conducted before the debate, which found that only 11% of the audience voted in favor of using antibiotics to treat sore throats.
Both speakers began by exploring their approach to the treatment of a recent clinical case involving a 4-year-old girl presenting with sore throat. Dr. Ivaska stressed the difference between a sore throat, pharyngitis, and tonsillitis: the latter two refer to a physical finding, while the former is a subjective symptom.
International guidelines differ on the subject
The debate moved to discussing the international guidelines for treating pharyngitis and tonsillitis. Dr. Zsigmond believes that these are flawed and unhelpful, arguing that they differ depending on what part of the world a physician is practicing in. For example, the 2012 Infectious Diseases Society of America guidelines recommend using best clinical judgment and then backing this up by testing. If testing proves positive for group A Streptococcus pyogenes (GAS), the physician should universally treat. By comparison, the European Society of Clinical Microbiology and Infectious Diseases Sore Throat Guideline Group focuses on severity rather than the cause of the infection. If the case is deemed to be serious, antibiotics can be prescribed without a positive test.
Sore throat is frequently associated with a common cold. In a recent study, more that 80% of students with an acute viral respiratory tract infection had soreness at the beginning of their illness.
Reporting from his own research, Dr. Ivaska argued that viruses can be detected in almost two-thirds of children with pharyngitis using polymerase chain reaction analysis. He thinks antibiotics should be reserved for those 30%-40% of patients with a confirmed GAS infection. The potential role of Fusobacterium necrophorum was raised, but there is no evidence of the benefits of antibiotic treatment in such cases.
There are diagnostic aids for GAS infection
It was suggested that, instead of concentrating on sore throat, the debate should be about whether to use antibiotics to treat GAS infection. But how can the diagnosis be confirmed simply in a clinical setting? Dr. Ivaska recommended adopting diagnostic aids such as Centor, McIsaac, and FeverPAIN, which award scores for several common disease features – the higher the score, the more likely a patient is to be suffering from a GAS infection.
Dr. Zsigmond also likes scoring symptoms but believes they are often inaccurate, especially in young children. She pointed to a report that examined the use of the Centor tool among 441 children attending a pediatric ED. The authors concluded that the Centor criteria were ineffective in predicting a positive GAS culture in throat swabs taken from symptomatic patients.
When are antibiotics warranted?
It is widely accepted that antibiotics should be avoided for viral infections. Returning to the case described at the start of this debate, Dr. Zsigmond calculated that her patient with a 2-day history of sore throat, elevated temperature, pussy tonsils, and enlarged cervical lymph glands but no cough or rhinitis had a FeverPAIN score of 4-5 and a Centor score of 4, meaning that, according to the European guidelines, she should receive antibiotic treatment. However, viral swabs proved positive for adenovirus.
Dr. Ivaska responded with his recent experiences of a similar case, where a 5-year-old boy had a FeverPAIN score of 4-5 and Centor score of 3. Cultures from his throat were GAS positive, illustrating the problem of differentiating between bacterial and viral infections.
But does a GAS-positive pharyngeal culture necessarily mean that antibiotic treatment is indicated? Dr. Ivaska believes it does, citing the importance of preventing serious complications such as rheumatic fever. Dr. Zsigmind countered by pointing out the low levels of acute rheumatic fever in developed nations. In her own country, Hungary, there has not been a case in the last 30 years. Giving antibiotics for historical reasons cannot, in her view, be justified.
Dr. Ivaska responded that perhaps this is because of early treatment in children with sore throats.
Another complication of tonsillitis is quinsy. Dr. Zsigmond cited a study showing that there is no statistically significant evidence demonstrating that antibiotics prevent quinsy. She attributed this to quinsy appearing quickly, typically within 2 days. Delay in seeking help means that the window to treat is often missed. However, should symptoms present early, there is no statistical evidence that prior antibiotic use can prevent quinsy. Also, given the rarity of this condition, prevention would mean excessive use of antibiotics.
Are there other possible benefits of antibiotic treatment in patients with a sore throat? Dr. Ivaska referred to a Cochrane review that found a shortening in duration of throat soreness and fever. Furthermore, compared with placebo, antibiotics reduced the incidence of suppurative complications such as acute otitis media and sinusitis following a sore throat. Other studies have also pointed to the potential benefits of reduced transmission in families where one member with pharyngitis was GAS positive.
As the debate ended, Dr. Zsigmond reported evidence of global antibiotic overprescribing for sore throat ranging from 53% in Europe to 94% in Australia. She also highlighted risks such as altered gut flora, drug resistance, and rashes.
Robin Marlow from the University of Bristol (England), PhD, MBBS, commented that “one of the most enjoyable parts of the ESPID meeting is hearing different viewpoints rationally explained from across the world. As [antibiotic prescription for a sore throat is] a clinical conundrum that faces pediatricians every day, I thought this debate was a really great example of how, despite our different health care systems and ways of working, we are all striving together to improve children’s health using the best evidence available.”
The presenters had no financial conflicts of interest to declare.
The use of antibiotics to treat a sore throat remains contentious, with guidelines from around the world providing contradictory advice. This topic generated a lively debate at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.
Lauri Ivaska, MD, of the department of pediatrics and adolescent medicine at Turku (Finland) University Hospital, argued for the use of antibiotics, while Borbála Zsigmond, MD, of Heim Pál Children’s Hospital in Budapest, made the case against their use. Interestingly, this debate occurred against the background of a poll conducted before the debate, which found that only 11% of the audience voted in favor of using antibiotics to treat sore throats.
Both speakers began by exploring their approach to the treatment of a recent clinical case involving a 4-year-old girl presenting with sore throat. Dr. Ivaska stressed the difference between a sore throat, pharyngitis, and tonsillitis: the latter two refer to a physical finding, while the former is a subjective symptom.
International guidelines differ on the subject
The debate moved to discussing the international guidelines for treating pharyngitis and tonsillitis. Dr. Zsigmond believes that these are flawed and unhelpful, arguing that they differ depending on what part of the world a physician is practicing in. For example, the 2012 Infectious Diseases Society of America guidelines recommend using best clinical judgment and then backing this up by testing. If testing proves positive for group A Streptococcus pyogenes (GAS), the physician should universally treat. By comparison, the European Society of Clinical Microbiology and Infectious Diseases Sore Throat Guideline Group focuses on severity rather than the cause of the infection. If the case is deemed to be serious, antibiotics can be prescribed without a positive test.
Sore throat is frequently associated with a common cold. In a recent study, more that 80% of students with an acute viral respiratory tract infection had soreness at the beginning of their illness.
Reporting from his own research, Dr. Ivaska argued that viruses can be detected in almost two-thirds of children with pharyngitis using polymerase chain reaction analysis. He thinks antibiotics should be reserved for those 30%-40% of patients with a confirmed GAS infection. The potential role of Fusobacterium necrophorum was raised, but there is no evidence of the benefits of antibiotic treatment in such cases.
There are diagnostic aids for GAS infection
It was suggested that, instead of concentrating on sore throat, the debate should be about whether to use antibiotics to treat GAS infection. But how can the diagnosis be confirmed simply in a clinical setting? Dr. Ivaska recommended adopting diagnostic aids such as Centor, McIsaac, and FeverPAIN, which award scores for several common disease features – the higher the score, the more likely a patient is to be suffering from a GAS infection.
Dr. Zsigmond also likes scoring symptoms but believes they are often inaccurate, especially in young children. She pointed to a report that examined the use of the Centor tool among 441 children attending a pediatric ED. The authors concluded that the Centor criteria were ineffective in predicting a positive GAS culture in throat swabs taken from symptomatic patients.
When are antibiotics warranted?
It is widely accepted that antibiotics should be avoided for viral infections. Returning to the case described at the start of this debate, Dr. Zsigmond calculated that her patient with a 2-day history of sore throat, elevated temperature, pussy tonsils, and enlarged cervical lymph glands but no cough or rhinitis had a FeverPAIN score of 4-5 and a Centor score of 4, meaning that, according to the European guidelines, she should receive antibiotic treatment. However, viral swabs proved positive for adenovirus.
Dr. Ivaska responded with his recent experiences of a similar case, where a 5-year-old boy had a FeverPAIN score of 4-5 and Centor score of 3. Cultures from his throat were GAS positive, illustrating the problem of differentiating between bacterial and viral infections.
But does a GAS-positive pharyngeal culture necessarily mean that antibiotic treatment is indicated? Dr. Ivaska believes it does, citing the importance of preventing serious complications such as rheumatic fever. Dr. Zsigmind countered by pointing out the low levels of acute rheumatic fever in developed nations. In her own country, Hungary, there has not been a case in the last 30 years. Giving antibiotics for historical reasons cannot, in her view, be justified.
Dr. Ivaska responded that perhaps this is because of early treatment in children with sore throats.
Another complication of tonsillitis is quinsy. Dr. Zsigmond cited a study showing that there is no statistically significant evidence demonstrating that antibiotics prevent quinsy. She attributed this to quinsy appearing quickly, typically within 2 days. Delay in seeking help means that the window to treat is often missed. However, should symptoms present early, there is no statistical evidence that prior antibiotic use can prevent quinsy. Also, given the rarity of this condition, prevention would mean excessive use of antibiotics.
Are there other possible benefits of antibiotic treatment in patients with a sore throat? Dr. Ivaska referred to a Cochrane review that found a shortening in duration of throat soreness and fever. Furthermore, compared with placebo, antibiotics reduced the incidence of suppurative complications such as acute otitis media and sinusitis following a sore throat. Other studies have also pointed to the potential benefits of reduced transmission in families where one member with pharyngitis was GAS positive.
As the debate ended, Dr. Zsigmond reported evidence of global antibiotic overprescribing for sore throat ranging from 53% in Europe to 94% in Australia. She also highlighted risks such as altered gut flora, drug resistance, and rashes.
Robin Marlow from the University of Bristol (England), PhD, MBBS, commented that “one of the most enjoyable parts of the ESPID meeting is hearing different viewpoints rationally explained from across the world. As [antibiotic prescription for a sore throat is] a clinical conundrum that faces pediatricians every day, I thought this debate was a really great example of how, despite our different health care systems and ways of working, we are all striving together to improve children’s health using the best evidence available.”
The presenters had no financial conflicts of interest to declare.
The use of antibiotics to treat a sore throat remains contentious, with guidelines from around the world providing contradictory advice. This topic generated a lively debate at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.
Lauri Ivaska, MD, of the department of pediatrics and adolescent medicine at Turku (Finland) University Hospital, argued for the use of antibiotics, while Borbála Zsigmond, MD, of Heim Pál Children’s Hospital in Budapest, made the case against their use. Interestingly, this debate occurred against the background of a poll conducted before the debate, which found that only 11% of the audience voted in favor of using antibiotics to treat sore throats.
Both speakers began by exploring their approach to the treatment of a recent clinical case involving a 4-year-old girl presenting with sore throat. Dr. Ivaska stressed the difference between a sore throat, pharyngitis, and tonsillitis: the latter two refer to a physical finding, while the former is a subjective symptom.
International guidelines differ on the subject
The debate moved to discussing the international guidelines for treating pharyngitis and tonsillitis. Dr. Zsigmond believes that these are flawed and unhelpful, arguing that they differ depending on what part of the world a physician is practicing in. For example, the 2012 Infectious Diseases Society of America guidelines recommend using best clinical judgment and then backing this up by testing. If testing proves positive for group A Streptococcus pyogenes (GAS), the physician should universally treat. By comparison, the European Society of Clinical Microbiology and Infectious Diseases Sore Throat Guideline Group focuses on severity rather than the cause of the infection. If the case is deemed to be serious, antibiotics can be prescribed without a positive test.
Sore throat is frequently associated with a common cold. In a recent study, more that 80% of students with an acute viral respiratory tract infection had soreness at the beginning of their illness.
Reporting from his own research, Dr. Ivaska argued that viruses can be detected in almost two-thirds of children with pharyngitis using polymerase chain reaction analysis. He thinks antibiotics should be reserved for those 30%-40% of patients with a confirmed GAS infection. The potential role of Fusobacterium necrophorum was raised, but there is no evidence of the benefits of antibiotic treatment in such cases.
There are diagnostic aids for GAS infection
It was suggested that, instead of concentrating on sore throat, the debate should be about whether to use antibiotics to treat GAS infection. But how can the diagnosis be confirmed simply in a clinical setting? Dr. Ivaska recommended adopting diagnostic aids such as Centor, McIsaac, and FeverPAIN, which award scores for several common disease features – the higher the score, the more likely a patient is to be suffering from a GAS infection.
Dr. Zsigmond also likes scoring symptoms but believes they are often inaccurate, especially in young children. She pointed to a report that examined the use of the Centor tool among 441 children attending a pediatric ED. The authors concluded that the Centor criteria were ineffective in predicting a positive GAS culture in throat swabs taken from symptomatic patients.
When are antibiotics warranted?
It is widely accepted that antibiotics should be avoided for viral infections. Returning to the case described at the start of this debate, Dr. Zsigmond calculated that her patient with a 2-day history of sore throat, elevated temperature, pussy tonsils, and enlarged cervical lymph glands but no cough or rhinitis had a FeverPAIN score of 4-5 and a Centor score of 4, meaning that, according to the European guidelines, she should receive antibiotic treatment. However, viral swabs proved positive for adenovirus.
Dr. Ivaska responded with his recent experiences of a similar case, where a 5-year-old boy had a FeverPAIN score of 4-5 and Centor score of 3. Cultures from his throat were GAS positive, illustrating the problem of differentiating between bacterial and viral infections.
But does a GAS-positive pharyngeal culture necessarily mean that antibiotic treatment is indicated? Dr. Ivaska believes it does, citing the importance of preventing serious complications such as rheumatic fever. Dr. Zsigmind countered by pointing out the low levels of acute rheumatic fever in developed nations. In her own country, Hungary, there has not been a case in the last 30 years. Giving antibiotics for historical reasons cannot, in her view, be justified.
Dr. Ivaska responded that perhaps this is because of early treatment in children with sore throats.
Another complication of tonsillitis is quinsy. Dr. Zsigmond cited a study showing that there is no statistically significant evidence demonstrating that antibiotics prevent quinsy. She attributed this to quinsy appearing quickly, typically within 2 days. Delay in seeking help means that the window to treat is often missed. However, should symptoms present early, there is no statistical evidence that prior antibiotic use can prevent quinsy. Also, given the rarity of this condition, prevention would mean excessive use of antibiotics.
Are there other possible benefits of antibiotic treatment in patients with a sore throat? Dr. Ivaska referred to a Cochrane review that found a shortening in duration of throat soreness and fever. Furthermore, compared with placebo, antibiotics reduced the incidence of suppurative complications such as acute otitis media and sinusitis following a sore throat. Other studies have also pointed to the potential benefits of reduced transmission in families where one member with pharyngitis was GAS positive.
As the debate ended, Dr. Zsigmond reported evidence of global antibiotic overprescribing for sore throat ranging from 53% in Europe to 94% in Australia. She also highlighted risks such as altered gut flora, drug resistance, and rashes.
Robin Marlow from the University of Bristol (England), PhD, MBBS, commented that “one of the most enjoyable parts of the ESPID meeting is hearing different viewpoints rationally explained from across the world. As [antibiotic prescription for a sore throat is] a clinical conundrum that faces pediatricians every day, I thought this debate was a really great example of how, despite our different health care systems and ways of working, we are all striving together to improve children’s health using the best evidence available.”
The presenters had no financial conflicts of interest to declare.
FROM ESPID 2020
Pediatricians want kids to be part of COVID vaccine trials
If clinical trials for COVID-19 vaccines aren’t expanded soon to include children, it’s unlikely that even kids in their teens will be vaccinated in time for the next school year.
The hurdle is that COVID vaccine makers are only in the early stages of testing their products on children. The Pfizer vaccine authorized for use by the Food and Drug Administration on Friday was greenlighted only for people aged 16 years and older. Moderna just started trials for 12- to 17-year-olds for its vaccine, likely to be authorized later this month.
It will take months to approve use of the vaccines for middle- and high school–aged kids, and months more to test them in younger children. But some pediatricians say that concerns about the safety of the front-runner vaccines make the wait worthwhile.
Although most pediatricians believe the eventual vaccination of children will be crucial to subduing the COVID virus, they’re split on how fast to move toward that, says James Campbell, MD, professor of pediatrics at the University of Maryland’s Center for Vaccine Development and Global Health in Baltimore. Dr. Campbell and colleagues said it’s a matter of urgency to get the vaccines tested in kids, while others want to hold off on those trials until millions of adults have been safely vaccinated.
Much of the debate centers on two issues: the degree of harm COVID-19 causes children and the extent to which children are spreading the virus to their friends, teachers, parents and grandparents.
COVID-19’s impact on children represents a tiny fraction of the suffering and death experienced by vulnerable adults. Yet it would qualify as a pretty serious childhood disease, having caused 154 deaths and more than 7,500 hospitalizations as of Dec. 3 among aged people 19 years and younger in the United States. Those numbers rank it as worse than a typical year of influenza, and worse than diseases like mumps or hepatitis B in children before the vaccination era.
Studies thus far show that 1%-2% of children infected with the virus end up requiring intensive care, Stanley Plotkin, MD, professor emeritus of pediatrics at the University of Pennsylvania, Philadelphia told a federal panel. That’s in line with the percentage who become gravely ill as result of infections like Haemophilus influenzae type B, for which doctors have vaccinated children since the 1980s, he pointed out.
Dr. Campbell, who with colleagues has developed a plan for how to run pediatric COVID vaccine trials, pointed out that, “in a universe where COVID mainly affected children the way it’s affecting them now, and we had potential vaccines, people would be clamoring for them.”
The evidence that teens can transmit the disease is pretty clear, and transmission has been documented in children as young as 8. Fear of spread by children has been enough to close schools, and led the American Academy of Pediatrics to demand that children be quickly included in vaccine testing.
“The longer we take to start kids in trials, the longer it will take them to get vaccinated and to break the chains of transmission,” said Yvonne Maldonado, MD, a professor of pediatrics at Stanford (Calif.) University who chairs the AAP’s infectious disease committee. “If you want kids to go back to school and not have the teachers union terrified, you have to make sure they aren’t a risk.”
Other pediatricians worry that early pediatric trials could backfire. Cody Meissner, MD, chief of pediatric infectious diseases at Tufts Medical Center and a member of the FDA’s advisory committee on vaccines, is worried that whatever causes multisystem inflammatory syndrome in children, a rare but frightening COVID-related disorder, might also be triggered, however rarely, by vaccination.
Dr. Meissner abstained from the committee’s vote Thursday that supported, by a 17-4 vote, an emergency authorization of the Pfizer vaccine for people aged 16 years and older.
“I have trouble justifying it for children so unlikely to get the disease,” he said during debate on the measure.
But panel member Ofer Levy, MD, PhD, director of the Precision Vaccines Program at Boston Children’s Hospital, said the 16-years-and-up authorization would speed the vaccine’s testing in and approval for younger children. That is vital for the world’s protection from COVID-19, he said, since in the United States and most places “most vaccines are delivered early in life.”
While vaccines given to tens of thousands of people so far appear to be safe, the lack of understanding of the inflammatory syndrome means that children in any trials should be followed closely, said Emily Erbelding, MD, MPH, director of the division of microbiology and infectious diseases at the National Institute of Allergy and Infectious Diseases.
Under a 2003 law, vaccine companies are required eventually to test all their products on children. By late November, Pfizer had vaccinated approximately 100 children aged 12-15 years, said spokesperson Jerica Pitts.
Moderna has started enrolling 3,000 children aged 12 years and over in another clinical trial, and other companies have similar plans. Assuming the trials show the vaccines are safe and provide a good immune response, future tests could include progressively younger children, moving to, say, 6- to 12-year-olds next, then 2- to 6-year-olds. Eventually, trials could include younger toddlers and infants.
Similar step-down approaches were taken to test vaccines against human papillomavirus (HPV), influenza and other diseases in the past, Dr. Erbelding noted. Such trials are easiest to conduct when researchers know that a measurable immune response, like antibody levels in the blood, translates to effective protection against disease. Armed with such knowledge, they can see whether children were protected without them having to be exposed to the virus. Federal scientists hope to get that data from the Moderna and Pfizer adult vaccine trials, she said.
Vaccine trials geared to tweens or younger children may involve testing half-doses, which, if protective, would require less vaccine and might cause fewer incidents of sore arms and fevers that afflicted many who’ve received the Pfizer and Moderna vaccines, Dr. Campbell said.
But unless additional studies begin quickly, the window for having an FDA-authorized vaccine available before the next school year “will be closed even for our oldest children,” said Evan Anderson, MD, a pediatrics professor at Emory University, Atlanta. “Our younger children are almost certainly going into next school year without a vaccine option available for them.”
In the meantime, teachers are likely to be high on the priority list for vaccination. Protecting school staff could allow more schools to reopen even if most children can’t be vaccinated, Dr. Erbelding said.
Eventually, if the SARS-CoV-2 virus remains in circulation, governments may want to mandate childhood vaccination against the virus to protect them as they grow up and protect society as a whole, Dr. Plotkin said.
In the 1960s, Dr. Plotkin invented the rubella vaccine that has been given to hundreds of millions of children since. Like COVID-19, rubella – or German measles – is not usually a serious illness for children. But congenital rubella syndrome afflicted babies in the womb with blindness, deafness, developmental delays, and autism. Immunizing toddlers, which, in turn, protects their pregnant mothers, has indirectly prevented hundreds of thousands of such cases.
“We don’t want to use children to protect everyone in the community,” said Dr. Campbell. “But when you can protect both children and their community, that’s important.”
And while a coronavirus infection may not be bad for most children, missed school, absent friends, and distanced families have caused them immense suffering, he said.
“It’s a huge burden on a child to have their entire world flipped around,” Dr. Campbell said. “If vaccinating could help to flip it back, we should begin testing to see if that’s possible.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
If clinical trials for COVID-19 vaccines aren’t expanded soon to include children, it’s unlikely that even kids in their teens will be vaccinated in time for the next school year.
The hurdle is that COVID vaccine makers are only in the early stages of testing their products on children. The Pfizer vaccine authorized for use by the Food and Drug Administration on Friday was greenlighted only for people aged 16 years and older. Moderna just started trials for 12- to 17-year-olds for its vaccine, likely to be authorized later this month.
It will take months to approve use of the vaccines for middle- and high school–aged kids, and months more to test them in younger children. But some pediatricians say that concerns about the safety of the front-runner vaccines make the wait worthwhile.
Although most pediatricians believe the eventual vaccination of children will be crucial to subduing the COVID virus, they’re split on how fast to move toward that, says James Campbell, MD, professor of pediatrics at the University of Maryland’s Center for Vaccine Development and Global Health in Baltimore. Dr. Campbell and colleagues said it’s a matter of urgency to get the vaccines tested in kids, while others want to hold off on those trials until millions of adults have been safely vaccinated.
Much of the debate centers on two issues: the degree of harm COVID-19 causes children and the extent to which children are spreading the virus to their friends, teachers, parents and grandparents.
COVID-19’s impact on children represents a tiny fraction of the suffering and death experienced by vulnerable adults. Yet it would qualify as a pretty serious childhood disease, having caused 154 deaths and more than 7,500 hospitalizations as of Dec. 3 among aged people 19 years and younger in the United States. Those numbers rank it as worse than a typical year of influenza, and worse than diseases like mumps or hepatitis B in children before the vaccination era.
Studies thus far show that 1%-2% of children infected with the virus end up requiring intensive care, Stanley Plotkin, MD, professor emeritus of pediatrics at the University of Pennsylvania, Philadelphia told a federal panel. That’s in line with the percentage who become gravely ill as result of infections like Haemophilus influenzae type B, for which doctors have vaccinated children since the 1980s, he pointed out.
Dr. Campbell, who with colleagues has developed a plan for how to run pediatric COVID vaccine trials, pointed out that, “in a universe where COVID mainly affected children the way it’s affecting them now, and we had potential vaccines, people would be clamoring for them.”
The evidence that teens can transmit the disease is pretty clear, and transmission has been documented in children as young as 8. Fear of spread by children has been enough to close schools, and led the American Academy of Pediatrics to demand that children be quickly included in vaccine testing.
“The longer we take to start kids in trials, the longer it will take them to get vaccinated and to break the chains of transmission,” said Yvonne Maldonado, MD, a professor of pediatrics at Stanford (Calif.) University who chairs the AAP’s infectious disease committee. “If you want kids to go back to school and not have the teachers union terrified, you have to make sure they aren’t a risk.”
Other pediatricians worry that early pediatric trials could backfire. Cody Meissner, MD, chief of pediatric infectious diseases at Tufts Medical Center and a member of the FDA’s advisory committee on vaccines, is worried that whatever causes multisystem inflammatory syndrome in children, a rare but frightening COVID-related disorder, might also be triggered, however rarely, by vaccination.
Dr. Meissner abstained from the committee’s vote Thursday that supported, by a 17-4 vote, an emergency authorization of the Pfizer vaccine for people aged 16 years and older.
“I have trouble justifying it for children so unlikely to get the disease,” he said during debate on the measure.
But panel member Ofer Levy, MD, PhD, director of the Precision Vaccines Program at Boston Children’s Hospital, said the 16-years-and-up authorization would speed the vaccine’s testing in and approval for younger children. That is vital for the world’s protection from COVID-19, he said, since in the United States and most places “most vaccines are delivered early in life.”
While vaccines given to tens of thousands of people so far appear to be safe, the lack of understanding of the inflammatory syndrome means that children in any trials should be followed closely, said Emily Erbelding, MD, MPH, director of the division of microbiology and infectious diseases at the National Institute of Allergy and Infectious Diseases.
Under a 2003 law, vaccine companies are required eventually to test all their products on children. By late November, Pfizer had vaccinated approximately 100 children aged 12-15 years, said spokesperson Jerica Pitts.
Moderna has started enrolling 3,000 children aged 12 years and over in another clinical trial, and other companies have similar plans. Assuming the trials show the vaccines are safe and provide a good immune response, future tests could include progressively younger children, moving to, say, 6- to 12-year-olds next, then 2- to 6-year-olds. Eventually, trials could include younger toddlers and infants.
Similar step-down approaches were taken to test vaccines against human papillomavirus (HPV), influenza and other diseases in the past, Dr. Erbelding noted. Such trials are easiest to conduct when researchers know that a measurable immune response, like antibody levels in the blood, translates to effective protection against disease. Armed with such knowledge, they can see whether children were protected without them having to be exposed to the virus. Federal scientists hope to get that data from the Moderna and Pfizer adult vaccine trials, she said.
Vaccine trials geared to tweens or younger children may involve testing half-doses, which, if protective, would require less vaccine and might cause fewer incidents of sore arms and fevers that afflicted many who’ve received the Pfizer and Moderna vaccines, Dr. Campbell said.
But unless additional studies begin quickly, the window for having an FDA-authorized vaccine available before the next school year “will be closed even for our oldest children,” said Evan Anderson, MD, a pediatrics professor at Emory University, Atlanta. “Our younger children are almost certainly going into next school year without a vaccine option available for them.”
In the meantime, teachers are likely to be high on the priority list for vaccination. Protecting school staff could allow more schools to reopen even if most children can’t be vaccinated, Dr. Erbelding said.
Eventually, if the SARS-CoV-2 virus remains in circulation, governments may want to mandate childhood vaccination against the virus to protect them as they grow up and protect society as a whole, Dr. Plotkin said.
In the 1960s, Dr. Plotkin invented the rubella vaccine that has been given to hundreds of millions of children since. Like COVID-19, rubella – or German measles – is not usually a serious illness for children. But congenital rubella syndrome afflicted babies in the womb with blindness, deafness, developmental delays, and autism. Immunizing toddlers, which, in turn, protects their pregnant mothers, has indirectly prevented hundreds of thousands of such cases.
“We don’t want to use children to protect everyone in the community,” said Dr. Campbell. “But when you can protect both children and their community, that’s important.”
And while a coronavirus infection may not be bad for most children, missed school, absent friends, and distanced families have caused them immense suffering, he said.
“It’s a huge burden on a child to have their entire world flipped around,” Dr. Campbell said. “If vaccinating could help to flip it back, we should begin testing to see if that’s possible.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
If clinical trials for COVID-19 vaccines aren’t expanded soon to include children, it’s unlikely that even kids in their teens will be vaccinated in time for the next school year.
The hurdle is that COVID vaccine makers are only in the early stages of testing their products on children. The Pfizer vaccine authorized for use by the Food and Drug Administration on Friday was greenlighted only for people aged 16 years and older. Moderna just started trials for 12- to 17-year-olds for its vaccine, likely to be authorized later this month.
It will take months to approve use of the vaccines for middle- and high school–aged kids, and months more to test them in younger children. But some pediatricians say that concerns about the safety of the front-runner vaccines make the wait worthwhile.
Although most pediatricians believe the eventual vaccination of children will be crucial to subduing the COVID virus, they’re split on how fast to move toward that, says James Campbell, MD, professor of pediatrics at the University of Maryland’s Center for Vaccine Development and Global Health in Baltimore. Dr. Campbell and colleagues said it’s a matter of urgency to get the vaccines tested in kids, while others want to hold off on those trials until millions of adults have been safely vaccinated.
Much of the debate centers on two issues: the degree of harm COVID-19 causes children and the extent to which children are spreading the virus to their friends, teachers, parents and grandparents.
COVID-19’s impact on children represents a tiny fraction of the suffering and death experienced by vulnerable adults. Yet it would qualify as a pretty serious childhood disease, having caused 154 deaths and more than 7,500 hospitalizations as of Dec. 3 among aged people 19 years and younger in the United States. Those numbers rank it as worse than a typical year of influenza, and worse than diseases like mumps or hepatitis B in children before the vaccination era.
Studies thus far show that 1%-2% of children infected with the virus end up requiring intensive care, Stanley Plotkin, MD, professor emeritus of pediatrics at the University of Pennsylvania, Philadelphia told a federal panel. That’s in line with the percentage who become gravely ill as result of infections like Haemophilus influenzae type B, for which doctors have vaccinated children since the 1980s, he pointed out.
Dr. Campbell, who with colleagues has developed a plan for how to run pediatric COVID vaccine trials, pointed out that, “in a universe where COVID mainly affected children the way it’s affecting them now, and we had potential vaccines, people would be clamoring for them.”
The evidence that teens can transmit the disease is pretty clear, and transmission has been documented in children as young as 8. Fear of spread by children has been enough to close schools, and led the American Academy of Pediatrics to demand that children be quickly included in vaccine testing.
“The longer we take to start kids in trials, the longer it will take them to get vaccinated and to break the chains of transmission,” said Yvonne Maldonado, MD, a professor of pediatrics at Stanford (Calif.) University who chairs the AAP’s infectious disease committee. “If you want kids to go back to school and not have the teachers union terrified, you have to make sure they aren’t a risk.”
Other pediatricians worry that early pediatric trials could backfire. Cody Meissner, MD, chief of pediatric infectious diseases at Tufts Medical Center and a member of the FDA’s advisory committee on vaccines, is worried that whatever causes multisystem inflammatory syndrome in children, a rare but frightening COVID-related disorder, might also be triggered, however rarely, by vaccination.
Dr. Meissner abstained from the committee’s vote Thursday that supported, by a 17-4 vote, an emergency authorization of the Pfizer vaccine for people aged 16 years and older.
“I have trouble justifying it for children so unlikely to get the disease,” he said during debate on the measure.
But panel member Ofer Levy, MD, PhD, director of the Precision Vaccines Program at Boston Children’s Hospital, said the 16-years-and-up authorization would speed the vaccine’s testing in and approval for younger children. That is vital for the world’s protection from COVID-19, he said, since in the United States and most places “most vaccines are delivered early in life.”
While vaccines given to tens of thousands of people so far appear to be safe, the lack of understanding of the inflammatory syndrome means that children in any trials should be followed closely, said Emily Erbelding, MD, MPH, director of the division of microbiology and infectious diseases at the National Institute of Allergy and Infectious Diseases.
Under a 2003 law, vaccine companies are required eventually to test all their products on children. By late November, Pfizer had vaccinated approximately 100 children aged 12-15 years, said spokesperson Jerica Pitts.
Moderna has started enrolling 3,000 children aged 12 years and over in another clinical trial, and other companies have similar plans. Assuming the trials show the vaccines are safe and provide a good immune response, future tests could include progressively younger children, moving to, say, 6- to 12-year-olds next, then 2- to 6-year-olds. Eventually, trials could include younger toddlers and infants.
Similar step-down approaches were taken to test vaccines against human papillomavirus (HPV), influenza and other diseases in the past, Dr. Erbelding noted. Such trials are easiest to conduct when researchers know that a measurable immune response, like antibody levels in the blood, translates to effective protection against disease. Armed with such knowledge, they can see whether children were protected without them having to be exposed to the virus. Federal scientists hope to get that data from the Moderna and Pfizer adult vaccine trials, she said.
Vaccine trials geared to tweens or younger children may involve testing half-doses, which, if protective, would require less vaccine and might cause fewer incidents of sore arms and fevers that afflicted many who’ve received the Pfizer and Moderna vaccines, Dr. Campbell said.
But unless additional studies begin quickly, the window for having an FDA-authorized vaccine available before the next school year “will be closed even for our oldest children,” said Evan Anderson, MD, a pediatrics professor at Emory University, Atlanta. “Our younger children are almost certainly going into next school year without a vaccine option available for them.”
In the meantime, teachers are likely to be high on the priority list for vaccination. Protecting school staff could allow more schools to reopen even if most children can’t be vaccinated, Dr. Erbelding said.
Eventually, if the SARS-CoV-2 virus remains in circulation, governments may want to mandate childhood vaccination against the virus to protect them as they grow up and protect society as a whole, Dr. Plotkin said.
In the 1960s, Dr. Plotkin invented the rubella vaccine that has been given to hundreds of millions of children since. Like COVID-19, rubella – or German measles – is not usually a serious illness for children. But congenital rubella syndrome afflicted babies in the womb with blindness, deafness, developmental delays, and autism. Immunizing toddlers, which, in turn, protects their pregnant mothers, has indirectly prevented hundreds of thousands of such cases.
“We don’t want to use children to protect everyone in the community,” said Dr. Campbell. “But when you can protect both children and their community, that’s important.”
And while a coronavirus infection may not be bad for most children, missed school, absent friends, and distanced families have caused them immense suffering, he said.
“It’s a huge burden on a child to have their entire world flipped around,” Dr. Campbell said. “If vaccinating could help to flip it back, we should begin testing to see if that’s possible.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.