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Combined Pediatric Derm-Rheum Clinics Supported by Survey Respondents
TOPLINE:
.
METHODOLOGY:
- Combined pediatric dermatology-rheumatology clinics can improve patient outcomes and experiences, particularly for pediatric autoimmune conditions presenting with both cutaneous and systemic manifestations.
- The researchers surveyed 208 pediatric dermatologists working in combined pediatric dermatology-rheumatology clinics.
- A total of 13 member responses were recorded from three countries: 10 from the United States, two from Mexico, and one from Canada.
TAKEAWAY:
- Perceived benefits of combined clinics were improved patient care through coordinated treatment decisions and timely communication between providers.
- Patient satisfaction was favorable, and patients and families endorsed the combined clinic approach.
- Barriers to clinic establishment included differences in the pace between dermatology and rheumatology clinic flow, the need to generate more relative value units, resistance from colleagues, and limited time.
- Areas that needed improvement included more time for patient visits, dedicated research assistants, new patient referrals, additional patient rooms, resources for research, and patient care infrastructure.
IN PRACTICE:
The insights from this survey “will hopefully inspire further development of these combined clinics,” the authors wrote.
SOURCE:
The investigation, led by Olga S. Cherepakhin, BS, University of Washington, Seattle, Washington, was published in Pediatric Dermatology.
LIMITATIONS:
Limitations included the subjective nature, lack of some information, selection bias, and small number of respondents, and the survey reflected the perspective of the pediatric dermatologists only.
DISCLOSURES:
The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. One author reported full-time employment at Janssen R&D, and the other authors had no disclosures.
A version of this article appeared on Medscape.com.
TOPLINE:
.
METHODOLOGY:
- Combined pediatric dermatology-rheumatology clinics can improve patient outcomes and experiences, particularly for pediatric autoimmune conditions presenting with both cutaneous and systemic manifestations.
- The researchers surveyed 208 pediatric dermatologists working in combined pediatric dermatology-rheumatology clinics.
- A total of 13 member responses were recorded from three countries: 10 from the United States, two from Mexico, and one from Canada.
TAKEAWAY:
- Perceived benefits of combined clinics were improved patient care through coordinated treatment decisions and timely communication between providers.
- Patient satisfaction was favorable, and patients and families endorsed the combined clinic approach.
- Barriers to clinic establishment included differences in the pace between dermatology and rheumatology clinic flow, the need to generate more relative value units, resistance from colleagues, and limited time.
- Areas that needed improvement included more time for patient visits, dedicated research assistants, new patient referrals, additional patient rooms, resources for research, and patient care infrastructure.
IN PRACTICE:
The insights from this survey “will hopefully inspire further development of these combined clinics,” the authors wrote.
SOURCE:
The investigation, led by Olga S. Cherepakhin, BS, University of Washington, Seattle, Washington, was published in Pediatric Dermatology.
LIMITATIONS:
Limitations included the subjective nature, lack of some information, selection bias, and small number of respondents, and the survey reflected the perspective of the pediatric dermatologists only.
DISCLOSURES:
The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. One author reported full-time employment at Janssen R&D, and the other authors had no disclosures.
A version of this article appeared on Medscape.com.
TOPLINE:
.
METHODOLOGY:
- Combined pediatric dermatology-rheumatology clinics can improve patient outcomes and experiences, particularly for pediatric autoimmune conditions presenting with both cutaneous and systemic manifestations.
- The researchers surveyed 208 pediatric dermatologists working in combined pediatric dermatology-rheumatology clinics.
- A total of 13 member responses were recorded from three countries: 10 from the United States, two from Mexico, and one from Canada.
TAKEAWAY:
- Perceived benefits of combined clinics were improved patient care through coordinated treatment decisions and timely communication between providers.
- Patient satisfaction was favorable, and patients and families endorsed the combined clinic approach.
- Barriers to clinic establishment included differences in the pace between dermatology and rheumatology clinic flow, the need to generate more relative value units, resistance from colleagues, and limited time.
- Areas that needed improvement included more time for patient visits, dedicated research assistants, new patient referrals, additional patient rooms, resources for research, and patient care infrastructure.
IN PRACTICE:
The insights from this survey “will hopefully inspire further development of these combined clinics,” the authors wrote.
SOURCE:
The investigation, led by Olga S. Cherepakhin, BS, University of Washington, Seattle, Washington, was published in Pediatric Dermatology.
LIMITATIONS:
Limitations included the subjective nature, lack of some information, selection bias, and small number of respondents, and the survey reflected the perspective of the pediatric dermatologists only.
DISCLOSURES:
The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. One author reported full-time employment at Janssen R&D, and the other authors had no disclosures.
A version of this article appeared on Medscape.com.
How Long Should a Woman Wait Before Becoming Pregnant Again?
How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.
Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians.
In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.
Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.
Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
Interpregnancy Interval and SGA Risk
The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.
According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.
According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.
Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.
“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
Previous and Subsequent Adverse Events
The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.
Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.”
“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.
There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.
The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.
The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.
“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.
This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.
Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians.
In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.
Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.
Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
Interpregnancy Interval and SGA Risk
The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.
According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.
According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.
Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.
“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
Previous and Subsequent Adverse Events
The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.
Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.”
“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.
There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.
The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.
The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.
“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.
This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.
Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians.
In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.
Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.
Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
Interpregnancy Interval and SGA Risk
The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.
According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.
According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.
Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.
“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
Previous and Subsequent Adverse Events
The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.
Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.”
“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.
There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.
The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.
The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.
“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.
This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Discovering the Impact of the Injury Prevention Program on Childhood Safety
TOPLINE:
METHODOLOGY:
- The American Academy of Pediatrics designed TIPP in 1983 to aid pediatricians in preventing unintentional injuries among children. TIPP’s effectiveness in reducing childhood injuries had not been formally evaluated in a randomized trial prior to this study.
- TIPP implementation included developmentally based safety counseling and distribution of age-appropriate safety materials to parents.
- A total of 781 parent-infant dyads participated, with the study population primarily consisting of low-income, Hispanic, and non-Hispanic Black families.
- Parent-reported injuries were tracked at each well-child check from 2 to 24 months, with the study adjusting for baseline child, parent, and household factors.
TAKEAWAY:
- TIPP led to a significant reduction in reported childhood injuries over 2 years with adjusted odds ratios of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.
- The study highlights the need for further research to explore TIPP’s impact on serious injuries and to identify optimal implementation strategies in busy clinical settings.
- IN PRACTICE:
“This program includes a developmentally based safety counseling schedule that guides what materials (safety sheets and an age-appropriate Framingham safety survey) to ask about risk behaviors. For the age group relevant here, there are pediatric patient handouts for parents of children who are aged 0 to 6 months, 6 to 12 months, and 1 to 2 years, and they review safety for falls, motor vehicles, firearms, drowning, poisoning, choking, and burns”, wrote the authors of the study.
SOURCE:
The study was led by Eliana M. Perrin, MD, MPH, Department of Pediatrics, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. It was published online in Pediatrics.
LIMITATIONS:
Further research is necessary to assess TIPP’s effect on serious injuries and to determine effective implementation strategies in various clinical settings.
DISCLOSURES:
The study was supported by grants from the Eunice Kennedy Shriver Institute of Child Health and Development, with supplemental funding from the Centers for Disease Control and Prevention, and the Office of Behavioral and Social Sciences Research.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- The American Academy of Pediatrics designed TIPP in 1983 to aid pediatricians in preventing unintentional injuries among children. TIPP’s effectiveness in reducing childhood injuries had not been formally evaluated in a randomized trial prior to this study.
- TIPP implementation included developmentally based safety counseling and distribution of age-appropriate safety materials to parents.
- A total of 781 parent-infant dyads participated, with the study population primarily consisting of low-income, Hispanic, and non-Hispanic Black families.
- Parent-reported injuries were tracked at each well-child check from 2 to 24 months, with the study adjusting for baseline child, parent, and household factors.
TAKEAWAY:
- TIPP led to a significant reduction in reported childhood injuries over 2 years with adjusted odds ratios of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.
- The study highlights the need for further research to explore TIPP’s impact on serious injuries and to identify optimal implementation strategies in busy clinical settings.
- IN PRACTICE:
“This program includes a developmentally based safety counseling schedule that guides what materials (safety sheets and an age-appropriate Framingham safety survey) to ask about risk behaviors. For the age group relevant here, there are pediatric patient handouts for parents of children who are aged 0 to 6 months, 6 to 12 months, and 1 to 2 years, and they review safety for falls, motor vehicles, firearms, drowning, poisoning, choking, and burns”, wrote the authors of the study.
SOURCE:
The study was led by Eliana M. Perrin, MD, MPH, Department of Pediatrics, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. It was published online in Pediatrics.
LIMITATIONS:
Further research is necessary to assess TIPP’s effect on serious injuries and to determine effective implementation strategies in various clinical settings.
DISCLOSURES:
The study was supported by grants from the Eunice Kennedy Shriver Institute of Child Health and Development, with supplemental funding from the Centers for Disease Control and Prevention, and the Office of Behavioral and Social Sciences Research.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- The American Academy of Pediatrics designed TIPP in 1983 to aid pediatricians in preventing unintentional injuries among children. TIPP’s effectiveness in reducing childhood injuries had not been formally evaluated in a randomized trial prior to this study.
- TIPP implementation included developmentally based safety counseling and distribution of age-appropriate safety materials to parents.
- A total of 781 parent-infant dyads participated, with the study population primarily consisting of low-income, Hispanic, and non-Hispanic Black families.
- Parent-reported injuries were tracked at each well-child check from 2 to 24 months, with the study adjusting for baseline child, parent, and household factors.
TAKEAWAY:
- TIPP led to a significant reduction in reported childhood injuries over 2 years with adjusted odds ratios of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.
- The study highlights the need for further research to explore TIPP’s impact on serious injuries and to identify optimal implementation strategies in busy clinical settings.
- IN PRACTICE:
“This program includes a developmentally based safety counseling schedule that guides what materials (safety sheets and an age-appropriate Framingham safety survey) to ask about risk behaviors. For the age group relevant here, there are pediatric patient handouts for parents of children who are aged 0 to 6 months, 6 to 12 months, and 1 to 2 years, and they review safety for falls, motor vehicles, firearms, drowning, poisoning, choking, and burns”, wrote the authors of the study.
SOURCE:
The study was led by Eliana M. Perrin, MD, MPH, Department of Pediatrics, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. It was published online in Pediatrics.
LIMITATIONS:
Further research is necessary to assess TIPP’s effect on serious injuries and to determine effective implementation strategies in various clinical settings.
DISCLOSURES:
The study was supported by grants from the Eunice Kennedy Shriver Institute of Child Health and Development, with supplemental funding from the Centers for Disease Control and Prevention, and the Office of Behavioral and Social Sciences Research.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Lidocaine Nerve Block Effective for Severe, Refractory Migraine in Children
DENVER — , results of a randomized controlled trial show.
Investigators found children receiving bilateral occipital nerve blocks with 2% lidocaine had significantly greater pain relief than that of peers receiving saline injections.
Cases series have shown a benefit of peripheral nerve blocks (PNBs) — injections of local anesthetics over branches of the occipital or trigeminal nerve — for severe, refractory headache in children.
Although 80% of pediatric headache specialists use PNBs, there is “inconsistent insurance coverage” for this treatment, which had not been tested in a randomized controlled trial in children before now, lead investigator Christina Szperka, MD, with the Pediatric Headache Program, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, told delegates attending the 2024 annual meeting of the American Academy of Neurology.
Significant Results
Investigators enrolled 58 children and adolescents with acute status migrainosus. The mean age was 16 years, and reported gender was female for 44 participants, male for 11 participants, and nonbinary or transgender in 3 participants. Participants had a migraine flare duration of 22 days and had not responded to other treatments.
All participants had topical lidocaine cream applied for 30 minutes as a run-in step and could decline injections if they experienced sufficient benefit from cream alone.
“We used a lidocaine cream lead-in for two reasons. One was to try to see if we could address the issue of high placebo response in pediatric trials in particular, and also to see if we could help with blinding to injection,” said Dr. Szperka.
Topical lidocaine cream led to a small decrease in pain score overall (0.2 point on a 0-10 scale), and all participants proceeded to randomized blinded bilateral greater occipital nerve injection with 2% lidocaine or saline, she reported.
On the primary endpoint — change in pain score at 30 minutes — lidocaine was significantly more effective than saline, achieving a 2.3-point decrease on average (on a 0-10 scale) vs a 1.1-point decrease with saline (P = .01).
A 2-point pain reduction was achieved in 69% of patients in the lidocaine group versus 34% in the saline group.
Three quarters (76%) of patients getting lidocaine reported at least partial relief in severity or location of pain compared with 48% of those getting saline (P = .03). Rates of pain freedom at 30 minutes were 17% and 7%, respectively, and at 24 hours were 14% and 0%, respectively.
The majority of adverse events were mild and fairly equal across groups and included anxiety, worsening headache, injection site pain, dizziness, and numbness (more so with lidocaine). There was one case of anaphylaxis after lidocaine injection.
Quite unexpectedly, said Dr. Szperka, patients rated the saline injection as more painful than the lidocaine injection. “This was not what I expected going in, and I think is relevant for future trials,” she said.
Encouraging Results
Reached for comment, Shaheen Lakhan, MD, a neurologist and researcher based in Miami, said that as a neurologist and pain physician, he sees firsthand the “devastating impact of status migrainosus on children.”
“These debilitating headaches can rob them of precious school days, hindering learning and social interaction,” said Dr. Lakhan. “The constant pain and fear of the next attack can also take a toll on their emotional well-being.”
The impact on families is significant as well, highlighting the need to find more effective treatments, Dr. Lakhan said.
“Traditionally, we’ve relied on case studies to see the benefits of nerve blocks for migraine in younger patients. This is the first randomized controlled trial that shows lidocaine injections can be significantly more effective than a placebo for these unrelenting migraines,” he said.
“It’s important to note that this is a relatively small study, and not without safety concerns, including rare but potentially life-threatening anaphylaxis to lidocaine,” Dr. Lakhan added. “More research is needed, but these findings are encouraging. Lidocaine injections could become a valuable tool for managing treatment-resistant migraines in adolescents and young adults.”
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Szperka is a consultant for AbbVie and Teva; serves on a Data Safety Monitoring Board for Eli Lilly and Upsher-Smith; and is a site principal investigator for AbbVie, Amgen, Biohaven/Pfizer, Teva, and Theranica. Dr. Lakhan had no disclosures.
A version of this article appeared on Medscape.com.
DENVER — , results of a randomized controlled trial show.
Investigators found children receiving bilateral occipital nerve blocks with 2% lidocaine had significantly greater pain relief than that of peers receiving saline injections.
Cases series have shown a benefit of peripheral nerve blocks (PNBs) — injections of local anesthetics over branches of the occipital or trigeminal nerve — for severe, refractory headache in children.
Although 80% of pediatric headache specialists use PNBs, there is “inconsistent insurance coverage” for this treatment, which had not been tested in a randomized controlled trial in children before now, lead investigator Christina Szperka, MD, with the Pediatric Headache Program, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, told delegates attending the 2024 annual meeting of the American Academy of Neurology.
Significant Results
Investigators enrolled 58 children and adolescents with acute status migrainosus. The mean age was 16 years, and reported gender was female for 44 participants, male for 11 participants, and nonbinary or transgender in 3 participants. Participants had a migraine flare duration of 22 days and had not responded to other treatments.
All participants had topical lidocaine cream applied for 30 minutes as a run-in step and could decline injections if they experienced sufficient benefit from cream alone.
“We used a lidocaine cream lead-in for two reasons. One was to try to see if we could address the issue of high placebo response in pediatric trials in particular, and also to see if we could help with blinding to injection,” said Dr. Szperka.
Topical lidocaine cream led to a small decrease in pain score overall (0.2 point on a 0-10 scale), and all participants proceeded to randomized blinded bilateral greater occipital nerve injection with 2% lidocaine or saline, she reported.
On the primary endpoint — change in pain score at 30 minutes — lidocaine was significantly more effective than saline, achieving a 2.3-point decrease on average (on a 0-10 scale) vs a 1.1-point decrease with saline (P = .01).
A 2-point pain reduction was achieved in 69% of patients in the lidocaine group versus 34% in the saline group.
Three quarters (76%) of patients getting lidocaine reported at least partial relief in severity or location of pain compared with 48% of those getting saline (P = .03). Rates of pain freedom at 30 minutes were 17% and 7%, respectively, and at 24 hours were 14% and 0%, respectively.
The majority of adverse events were mild and fairly equal across groups and included anxiety, worsening headache, injection site pain, dizziness, and numbness (more so with lidocaine). There was one case of anaphylaxis after lidocaine injection.
Quite unexpectedly, said Dr. Szperka, patients rated the saline injection as more painful than the lidocaine injection. “This was not what I expected going in, and I think is relevant for future trials,” she said.
Encouraging Results
Reached for comment, Shaheen Lakhan, MD, a neurologist and researcher based in Miami, said that as a neurologist and pain physician, he sees firsthand the “devastating impact of status migrainosus on children.”
“These debilitating headaches can rob them of precious school days, hindering learning and social interaction,” said Dr. Lakhan. “The constant pain and fear of the next attack can also take a toll on their emotional well-being.”
The impact on families is significant as well, highlighting the need to find more effective treatments, Dr. Lakhan said.
“Traditionally, we’ve relied on case studies to see the benefits of nerve blocks for migraine in younger patients. This is the first randomized controlled trial that shows lidocaine injections can be significantly more effective than a placebo for these unrelenting migraines,” he said.
“It’s important to note that this is a relatively small study, and not without safety concerns, including rare but potentially life-threatening anaphylaxis to lidocaine,” Dr. Lakhan added. “More research is needed, but these findings are encouraging. Lidocaine injections could become a valuable tool for managing treatment-resistant migraines in adolescents and young adults.”
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Szperka is a consultant for AbbVie and Teva; serves on a Data Safety Monitoring Board for Eli Lilly and Upsher-Smith; and is a site principal investigator for AbbVie, Amgen, Biohaven/Pfizer, Teva, and Theranica. Dr. Lakhan had no disclosures.
A version of this article appeared on Medscape.com.
DENVER — , results of a randomized controlled trial show.
Investigators found children receiving bilateral occipital nerve blocks with 2% lidocaine had significantly greater pain relief than that of peers receiving saline injections.
Cases series have shown a benefit of peripheral nerve blocks (PNBs) — injections of local anesthetics over branches of the occipital or trigeminal nerve — for severe, refractory headache in children.
Although 80% of pediatric headache specialists use PNBs, there is “inconsistent insurance coverage” for this treatment, which had not been tested in a randomized controlled trial in children before now, lead investigator Christina Szperka, MD, with the Pediatric Headache Program, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, told delegates attending the 2024 annual meeting of the American Academy of Neurology.
Significant Results
Investigators enrolled 58 children and adolescents with acute status migrainosus. The mean age was 16 years, and reported gender was female for 44 participants, male for 11 participants, and nonbinary or transgender in 3 participants. Participants had a migraine flare duration of 22 days and had not responded to other treatments.
All participants had topical lidocaine cream applied for 30 minutes as a run-in step and could decline injections if they experienced sufficient benefit from cream alone.
“We used a lidocaine cream lead-in for two reasons. One was to try to see if we could address the issue of high placebo response in pediatric trials in particular, and also to see if we could help with blinding to injection,” said Dr. Szperka.
Topical lidocaine cream led to a small decrease in pain score overall (0.2 point on a 0-10 scale), and all participants proceeded to randomized blinded bilateral greater occipital nerve injection with 2% lidocaine or saline, she reported.
On the primary endpoint — change in pain score at 30 minutes — lidocaine was significantly more effective than saline, achieving a 2.3-point decrease on average (on a 0-10 scale) vs a 1.1-point decrease with saline (P = .01).
A 2-point pain reduction was achieved in 69% of patients in the lidocaine group versus 34% in the saline group.
Three quarters (76%) of patients getting lidocaine reported at least partial relief in severity or location of pain compared with 48% of those getting saline (P = .03). Rates of pain freedom at 30 minutes were 17% and 7%, respectively, and at 24 hours were 14% and 0%, respectively.
The majority of adverse events were mild and fairly equal across groups and included anxiety, worsening headache, injection site pain, dizziness, and numbness (more so with lidocaine). There was one case of anaphylaxis after lidocaine injection.
Quite unexpectedly, said Dr. Szperka, patients rated the saline injection as more painful than the lidocaine injection. “This was not what I expected going in, and I think is relevant for future trials,” she said.
Encouraging Results
Reached for comment, Shaheen Lakhan, MD, a neurologist and researcher based in Miami, said that as a neurologist and pain physician, he sees firsthand the “devastating impact of status migrainosus on children.”
“These debilitating headaches can rob them of precious school days, hindering learning and social interaction,” said Dr. Lakhan. “The constant pain and fear of the next attack can also take a toll on their emotional well-being.”
The impact on families is significant as well, highlighting the need to find more effective treatments, Dr. Lakhan said.
“Traditionally, we’ve relied on case studies to see the benefits of nerve blocks for migraine in younger patients. This is the first randomized controlled trial that shows lidocaine injections can be significantly more effective than a placebo for these unrelenting migraines,” he said.
“It’s important to note that this is a relatively small study, and not without safety concerns, including rare but potentially life-threatening anaphylaxis to lidocaine,” Dr. Lakhan added. “More research is needed, but these findings are encouraging. Lidocaine injections could become a valuable tool for managing treatment-resistant migraines in adolescents and young adults.”
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Szperka is a consultant for AbbVie and Teva; serves on a Data Safety Monitoring Board for Eli Lilly and Upsher-Smith; and is a site principal investigator for AbbVie, Amgen, Biohaven/Pfizer, Teva, and Theranica. Dr. Lakhan had no disclosures.
A version of this article appeared on Medscape.com.
FROM AAN 2024
What’s ‘Tried and True’ in Atopic Dermatitis? An Expert Reflects
SAN DIEGO — Whether you completed your dermatology residency training 20 years ago or 2 years ago, recent advances in treatments for atopic dermatitis (AD) have likely influenced your “go to” interventions when treating children with AD, according to Lawrence F. Eichenfield, MD.
“There have been many changes in the understanding of AD and recognition of the variable courses of the disease, and the associated allergic and nonallergic comorbidities,” Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego in California, said at the Society for Pediatric Dermatology meeting, held the day before the annual meeting of the American Academy of Dermatology. “With our revolutionary systemic and evolving topical therapies, we are in a new day of pediatric management.”
Drawing from 2023 American Academy of Dermatology guidelines of care on topical treatments of AD and his own clinical experience, he shared his perspective on “what’s tried and true” in care for patients with persistent eczema:
Both bathing and moisturizing leave skin moist. It’s well established that the use of moisturizers/emollients minimizes xerosis and the amount of prescription anti-inflammatory medications, but limited evidence exists to recommend a particular ingredient and formulation, said Dr. Eichenfield, also professor of dermatology and pediatrics at the University of California, San Diego. “Future studies may tell us whether specific moisturizers work better than others, and/or if early interventions may prevent AD, but that remains a big question mark,” he noted. In addition, applications may sometimes “mobilize” topical prescriptive residual absorption and activity.
As for baths, he said, “avoidance of bathing to avoid drying out skin is a practice without evidence basis. Bathing also may have many benefits in active eczema.”
Bleach baths may enhance skin barrier function, reduce itch, and improve eczema, but the practice remains controversial, he continued. Authors of a systematic review and meta-analysis concluded that while bleach baths are effective in reducing the severity of AD, they do not appear to be more effective than water bath alone. Authors of a more recent study found that bleach baths did not normalize dysbiosis, “but that study did not compare outcomes to bathing without bleach,” Dr. Eichenfield noted.“My sense is there is some benefit to regular bathing, especially in children with moderate to severe AD, especially those with colonized or infected eczema.”
He advises clinicians to be aware of other “standard AD interventions” from around the world, including black tea wet dressings and green tea bath therapy.
Topical corticosteroids. These are “tried and true” for their anti-inflammatory properties and rapid response, relatively low cost, and large range of potency, he said. Potential problems include the burden of topical application and the potential for stinging/burning, atrophy, telangiectasias, adrenal axis suppression, and concerns about withdrawal phenomena. “Being a proponent of topical corticosteroids, but explaining reasonable and appropriate use can be challenging,” Dr. Eichenfield said. “Social media has influenced concerns about topical corticosteroids, with steroid addiction and withdrawal being concerns influencing discomfort with therapies.”
Make sure to measure outcomes. The suggested core outcome measure for recording clinical signs in AD clinical trials is the Eczema Area and Severity Index (EASI) score, he said. In clinical practice, Dr. Eichenfield favors body surface area (BSA) and the Validated Global Assessment scale (v-IGA) to measure signs of moderate to severe AD. “Documenting extent of disease makes a big difference in families understanding how severe their child’s disease is and how it is doing over time.” Alternatively, he recommends the Atopic Dermatitis Control Tool (ADCT) or the Recap of Atopic Eczema (RECAP) as tools assessing long-term disease control.
Familiarize yourself with nonsteroidal anti-inflammatory medications for care regimens. Options include topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus; phosphodiesterase 4 (PDE-4) inhibitors such as crisaborole and roflumilast; the aryl-hydrocarbon receptor agonist tapinarof; and topical Janus kinase (JAK) inhibitors such as delgocitinib and ruxolitinib as well as others in development. “There is variable status around the world in terms of whether these nonsteroidal options are approved or not,” Dr. Eichenfield said. “Issues of use include cost, availability, side effects, and concerns about potential absorption. I think there’s an evolution in how much we rely on these instead of topical corticosteroids. They’re more commonly used in maintenance regimens rather than for remission induction.”
Dr. Eichenfield encouraged dermatologists to share information about and experiences with evolving treatment options for AD, “because when the studies are done, they are done as monotherapy. We must translate that into clinical practice and figure out how they fit in. Our exchange of information is critical.”
Dr. Eichenfield disclosed conflicts of interest from many pharmaceutical companies, including those with AD treatments.
SAN DIEGO — Whether you completed your dermatology residency training 20 years ago or 2 years ago, recent advances in treatments for atopic dermatitis (AD) have likely influenced your “go to” interventions when treating children with AD, according to Lawrence F. Eichenfield, MD.
“There have been many changes in the understanding of AD and recognition of the variable courses of the disease, and the associated allergic and nonallergic comorbidities,” Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego in California, said at the Society for Pediatric Dermatology meeting, held the day before the annual meeting of the American Academy of Dermatology. “With our revolutionary systemic and evolving topical therapies, we are in a new day of pediatric management.”
Drawing from 2023 American Academy of Dermatology guidelines of care on topical treatments of AD and his own clinical experience, he shared his perspective on “what’s tried and true” in care for patients with persistent eczema:
Both bathing and moisturizing leave skin moist. It’s well established that the use of moisturizers/emollients minimizes xerosis and the amount of prescription anti-inflammatory medications, but limited evidence exists to recommend a particular ingredient and formulation, said Dr. Eichenfield, also professor of dermatology and pediatrics at the University of California, San Diego. “Future studies may tell us whether specific moisturizers work better than others, and/or if early interventions may prevent AD, but that remains a big question mark,” he noted. In addition, applications may sometimes “mobilize” topical prescriptive residual absorption and activity.
As for baths, he said, “avoidance of bathing to avoid drying out skin is a practice without evidence basis. Bathing also may have many benefits in active eczema.”
Bleach baths may enhance skin barrier function, reduce itch, and improve eczema, but the practice remains controversial, he continued. Authors of a systematic review and meta-analysis concluded that while bleach baths are effective in reducing the severity of AD, they do not appear to be more effective than water bath alone. Authors of a more recent study found that bleach baths did not normalize dysbiosis, “but that study did not compare outcomes to bathing without bleach,” Dr. Eichenfield noted.“My sense is there is some benefit to regular bathing, especially in children with moderate to severe AD, especially those with colonized or infected eczema.”
He advises clinicians to be aware of other “standard AD interventions” from around the world, including black tea wet dressings and green tea bath therapy.
Topical corticosteroids. These are “tried and true” for their anti-inflammatory properties and rapid response, relatively low cost, and large range of potency, he said. Potential problems include the burden of topical application and the potential for stinging/burning, atrophy, telangiectasias, adrenal axis suppression, and concerns about withdrawal phenomena. “Being a proponent of topical corticosteroids, but explaining reasonable and appropriate use can be challenging,” Dr. Eichenfield said. “Social media has influenced concerns about topical corticosteroids, with steroid addiction and withdrawal being concerns influencing discomfort with therapies.”
Make sure to measure outcomes. The suggested core outcome measure for recording clinical signs in AD clinical trials is the Eczema Area and Severity Index (EASI) score, he said. In clinical practice, Dr. Eichenfield favors body surface area (BSA) and the Validated Global Assessment scale (v-IGA) to measure signs of moderate to severe AD. “Documenting extent of disease makes a big difference in families understanding how severe their child’s disease is and how it is doing over time.” Alternatively, he recommends the Atopic Dermatitis Control Tool (ADCT) or the Recap of Atopic Eczema (RECAP) as tools assessing long-term disease control.
Familiarize yourself with nonsteroidal anti-inflammatory medications for care regimens. Options include topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus; phosphodiesterase 4 (PDE-4) inhibitors such as crisaborole and roflumilast; the aryl-hydrocarbon receptor agonist tapinarof; and topical Janus kinase (JAK) inhibitors such as delgocitinib and ruxolitinib as well as others in development. “There is variable status around the world in terms of whether these nonsteroidal options are approved or not,” Dr. Eichenfield said. “Issues of use include cost, availability, side effects, and concerns about potential absorption. I think there’s an evolution in how much we rely on these instead of topical corticosteroids. They’re more commonly used in maintenance regimens rather than for remission induction.”
Dr. Eichenfield encouraged dermatologists to share information about and experiences with evolving treatment options for AD, “because when the studies are done, they are done as monotherapy. We must translate that into clinical practice and figure out how they fit in. Our exchange of information is critical.”
Dr. Eichenfield disclosed conflicts of interest from many pharmaceutical companies, including those with AD treatments.
SAN DIEGO — Whether you completed your dermatology residency training 20 years ago or 2 years ago, recent advances in treatments for atopic dermatitis (AD) have likely influenced your “go to” interventions when treating children with AD, according to Lawrence F. Eichenfield, MD.
“There have been many changes in the understanding of AD and recognition of the variable courses of the disease, and the associated allergic and nonallergic comorbidities,” Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego in California, said at the Society for Pediatric Dermatology meeting, held the day before the annual meeting of the American Academy of Dermatology. “With our revolutionary systemic and evolving topical therapies, we are in a new day of pediatric management.”
Drawing from 2023 American Academy of Dermatology guidelines of care on topical treatments of AD and his own clinical experience, he shared his perspective on “what’s tried and true” in care for patients with persistent eczema:
Both bathing and moisturizing leave skin moist. It’s well established that the use of moisturizers/emollients minimizes xerosis and the amount of prescription anti-inflammatory medications, but limited evidence exists to recommend a particular ingredient and formulation, said Dr. Eichenfield, also professor of dermatology and pediatrics at the University of California, San Diego. “Future studies may tell us whether specific moisturizers work better than others, and/or if early interventions may prevent AD, but that remains a big question mark,” he noted. In addition, applications may sometimes “mobilize” topical prescriptive residual absorption and activity.
As for baths, he said, “avoidance of bathing to avoid drying out skin is a practice without evidence basis. Bathing also may have many benefits in active eczema.”
Bleach baths may enhance skin barrier function, reduce itch, and improve eczema, but the practice remains controversial, he continued. Authors of a systematic review and meta-analysis concluded that while bleach baths are effective in reducing the severity of AD, they do not appear to be more effective than water bath alone. Authors of a more recent study found that bleach baths did not normalize dysbiosis, “but that study did not compare outcomes to bathing without bleach,” Dr. Eichenfield noted.“My sense is there is some benefit to regular bathing, especially in children with moderate to severe AD, especially those with colonized or infected eczema.”
He advises clinicians to be aware of other “standard AD interventions” from around the world, including black tea wet dressings and green tea bath therapy.
Topical corticosteroids. These are “tried and true” for their anti-inflammatory properties and rapid response, relatively low cost, and large range of potency, he said. Potential problems include the burden of topical application and the potential for stinging/burning, atrophy, telangiectasias, adrenal axis suppression, and concerns about withdrawal phenomena. “Being a proponent of topical corticosteroids, but explaining reasonable and appropriate use can be challenging,” Dr. Eichenfield said. “Social media has influenced concerns about topical corticosteroids, with steroid addiction and withdrawal being concerns influencing discomfort with therapies.”
Make sure to measure outcomes. The suggested core outcome measure for recording clinical signs in AD clinical trials is the Eczema Area and Severity Index (EASI) score, he said. In clinical practice, Dr. Eichenfield favors body surface area (BSA) and the Validated Global Assessment scale (v-IGA) to measure signs of moderate to severe AD. “Documenting extent of disease makes a big difference in families understanding how severe their child’s disease is and how it is doing over time.” Alternatively, he recommends the Atopic Dermatitis Control Tool (ADCT) or the Recap of Atopic Eczema (RECAP) as tools assessing long-term disease control.
Familiarize yourself with nonsteroidal anti-inflammatory medications for care regimens. Options include topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus; phosphodiesterase 4 (PDE-4) inhibitors such as crisaborole and roflumilast; the aryl-hydrocarbon receptor agonist tapinarof; and topical Janus kinase (JAK) inhibitors such as delgocitinib and ruxolitinib as well as others in development. “There is variable status around the world in terms of whether these nonsteroidal options are approved or not,” Dr. Eichenfield said. “Issues of use include cost, availability, side effects, and concerns about potential absorption. I think there’s an evolution in how much we rely on these instead of topical corticosteroids. They’re more commonly used in maintenance regimens rather than for remission induction.”
Dr. Eichenfield encouraged dermatologists to share information about and experiences with evolving treatment options for AD, “because when the studies are done, they are done as monotherapy. We must translate that into clinical practice and figure out how they fit in. Our exchange of information is critical.”
Dr. Eichenfield disclosed conflicts of interest from many pharmaceutical companies, including those with AD treatments.
Port-Wine Birthmarks: Shorter Interval Laser Treatments Show Promise in Infants
TOPLINE:
METHODOLOGY:
- Early intervention of PWB in infants can significantly improve outcomes, and some studies suggest shorter intervals between laser treatments may be more effective. While laser treatment with PDL is the gold standard, the optimal treatment interval has not been determined.
- Researchers evaluated the records of 10 infants with PWB who received weekly PDL treatments from 2022 to 2023 at a single center. Treatment was initiated when the infants were 6 months old or younger, with the median age at the first treatment being 4 weeks. Of the 10 infants, eight had Fitzpatrick skin types I-III and two had skin type IV.
- Two dermatologists assessed photographs taken before and after laser treatment, and the primary outcome was the percentage improvement of PWB.
TAKEAWAY:
- Of the 10 patients, six achieved near-total (76%-95%) clearance, and one achieved total (96%-100%) clearance of PWB at a mean of 2 months after the first treatment.
- Marked improvement (51%-75%) in PWB was observed in the remaining three patients, who achieved near-total clearance with additional treatments.
- The median duration of treatment was 2 months (range, 0.2-5.1), and a median of eight treatments (range, 2-20) were needed to achieve near total or total clearance.
- No adverse events were reported, including pigmentary changes, scarring, burns, erosions, or infections.
IN PRACTICE:
The outcomes in the case series, the authors concluded, “are compelling and warrant attention and further investigation into the possibility that this novel and decreased treatment interval of 1 week ... is associated with potential improvement in outcomes and shorter overall treatment duration.”
SOURCE:
This study was led by Shirin Bajaj, MD, of the Laser & Skin Surgery Center of New York, where the infants were treated, and was published online on April 17, 2024, in JAMA Dermatology.
LIMITATIONS:
A small sample size and the lack of a comparison arm limited the ability to draw any conclusions or make treatment recommendations based on the results.
DISCLOSURES:
The authors disclosed no conflicts of interest.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Early intervention of PWB in infants can significantly improve outcomes, and some studies suggest shorter intervals between laser treatments may be more effective. While laser treatment with PDL is the gold standard, the optimal treatment interval has not been determined.
- Researchers evaluated the records of 10 infants with PWB who received weekly PDL treatments from 2022 to 2023 at a single center. Treatment was initiated when the infants were 6 months old or younger, with the median age at the first treatment being 4 weeks. Of the 10 infants, eight had Fitzpatrick skin types I-III and two had skin type IV.
- Two dermatologists assessed photographs taken before and after laser treatment, and the primary outcome was the percentage improvement of PWB.
TAKEAWAY:
- Of the 10 patients, six achieved near-total (76%-95%) clearance, and one achieved total (96%-100%) clearance of PWB at a mean of 2 months after the first treatment.
- Marked improvement (51%-75%) in PWB was observed in the remaining three patients, who achieved near-total clearance with additional treatments.
- The median duration of treatment was 2 months (range, 0.2-5.1), and a median of eight treatments (range, 2-20) were needed to achieve near total or total clearance.
- No adverse events were reported, including pigmentary changes, scarring, burns, erosions, or infections.
IN PRACTICE:
The outcomes in the case series, the authors concluded, “are compelling and warrant attention and further investigation into the possibility that this novel and decreased treatment interval of 1 week ... is associated with potential improvement in outcomes and shorter overall treatment duration.”
SOURCE:
This study was led by Shirin Bajaj, MD, of the Laser & Skin Surgery Center of New York, where the infants were treated, and was published online on April 17, 2024, in JAMA Dermatology.
LIMITATIONS:
A small sample size and the lack of a comparison arm limited the ability to draw any conclusions or make treatment recommendations based on the results.
DISCLOSURES:
The authors disclosed no conflicts of interest.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Early intervention of PWB in infants can significantly improve outcomes, and some studies suggest shorter intervals between laser treatments may be more effective. While laser treatment with PDL is the gold standard, the optimal treatment interval has not been determined.
- Researchers evaluated the records of 10 infants with PWB who received weekly PDL treatments from 2022 to 2023 at a single center. Treatment was initiated when the infants were 6 months old or younger, with the median age at the first treatment being 4 weeks. Of the 10 infants, eight had Fitzpatrick skin types I-III and two had skin type IV.
- Two dermatologists assessed photographs taken before and after laser treatment, and the primary outcome was the percentage improvement of PWB.
TAKEAWAY:
- Of the 10 patients, six achieved near-total (76%-95%) clearance, and one achieved total (96%-100%) clearance of PWB at a mean of 2 months after the first treatment.
- Marked improvement (51%-75%) in PWB was observed in the remaining three patients, who achieved near-total clearance with additional treatments.
- The median duration of treatment was 2 months (range, 0.2-5.1), and a median of eight treatments (range, 2-20) were needed to achieve near total or total clearance.
- No adverse events were reported, including pigmentary changes, scarring, burns, erosions, or infections.
IN PRACTICE:
The outcomes in the case series, the authors concluded, “are compelling and warrant attention and further investigation into the possibility that this novel and decreased treatment interval of 1 week ... is associated with potential improvement in outcomes and shorter overall treatment duration.”
SOURCE:
This study was led by Shirin Bajaj, MD, of the Laser & Skin Surgery Center of New York, where the infants were treated, and was published online on April 17, 2024, in JAMA Dermatology.
LIMITATIONS:
A small sample size and the lack of a comparison arm limited the ability to draw any conclusions or make treatment recommendations based on the results.
DISCLOSURES:
The authors disclosed no conflicts of interest.
A version of this article appeared on Medscape.com.
IV Ketamine Promising for Severe Refractory Headache in Children
DENVER — , new research suggests. In a retrospective chart review, IV ketamine led to in a 50% reduction in pain at discharge, with “nearly two-thirds” of patients having no recurrence within 30 days, noted lead investigator Scott Rosenthal, MD, from the University of Colorado Anschutz Medical Campus, Aurora.
Dr. Rosenthal reported the findings at the 2024 annual meeting of the American Academy of Neurology.
Statistically Significant Pain Relief
“IV ketamine has shown benefit in nonheadache chronic pain syndromes and refractory mood disorders. Patients with refractory status migraines are often left with ongoing pain and dysfunction after failing typical interventions,” Dr. Rosenthal said.
“Ketamine has emerged as a potential treatment option in this population. However, there’s very little research on the efficacy and tolerability of it in general as well as the pediatric population,” he noted.
Dr. Rosenthal and colleagues took a look back at patients admitted to Children’s Hospital Colorado between 2019 and 2022 for treatment of severe refractory headache who were treated with continuous IV ketamine.
They analyzed 68 encounters of 41 unique patients aged 5-21 years (median age 16 years; 85% girls). Chronic migraine without aura made up 79% of cases.
On presentation, most patients had an exacerbation or ongoing worsening of pain for about 10 days, and all but two were taking a preventive medication. Nearly 70% had a comorbid psychiatric diagnosis such as anxiety or depression, and 60% had a comorbid chronic pain diagnosis separate from their headache diagnosis.
The primary outcome was percent pain reduction at discharge and headache recurrence within 72 hours, with headache recurrence defined as receipt of neurology care via phone, clinic, or hospital encounter.
Patients received IV ketamine at a median dose of 0.25 mg/kg/hr for a median of 3 days.
Overall, the treatment was “safe and well tolerated,” Dr. Rosenthal said.
There were no serious adverse events and no cardiac side effects; 7% (five out of 68) stopped treatment due to side effects. The most common side effects were dizziness (23%), nausea (16%), blurred vision (12%), hallucinations (19%), cognitive fog (7%), vomiting (6%) and dysphoria (4%), worsening headache (4%), and paresthesia and cramping (1.5%).
‘Exciting Starting Point’
At baseline, pain scores were 8 (on a scale of 0-10) and progressively fell (improved) during treatment. Pain scores were 6 on day 1 and were 5 on day 2, with a slight rebound to 5 at discharge, although the pain reduction at discharge (vs baseline) remained statistically significant (P < .001).
“The median percent pain reduction after 3 days of ketamine was about 40%,” Dr. Rosenthal said.
He noted that on the first day of treatment, 16% of patients responded to treatment (with a > 50% reduction in their initial pain); this doubled to 33% on day 2 and increased to 44% at discharge.
In terms of recurrence, 38% had a recurrence within 1 month, “meaning two thirds did not,” Dr. Rosenthal noted. Median time to recurrence was 7 days. There were no recurrences within 72 hours.
The researchers also tried to tease out which patients might respond best to ketamine.
“Surprisingly,” there wasn’t a strong effect of most demographic variables such as age, sex, gender identity, chronic pain, psychiatric comorbidities, duration of headache, or prior interventions, Dr. Rosenthal noted.
“Interestingly,” he said, patients who were on two or more preventive medications had a 50% reduction in their pain at discharge compared with a 33% reduction in patients taking one or no preventive medication. It’s possible that more preventative medications may “prime” a patient’s response to ketamine, Dr. Rosenthal said.
She added that future randomized studies are needed to further assess IV ketamine for refractory headache in children, but these results are “an exciting starting point.”
‘Still an Unknown’
Seniha Nur Ozudogru, MD, assistant professor of clinical neurology at Penn Medicine in Philadelphia, echoed the need for further study.
The role of IV ketamine in refractory pediatric headache is “still an unknown,” said Dr. Ozudogru, who was not involved in the study.
She noted that currently, there is “no standard protocol for ketamine infusion, even for adults. Every institution has their own protocols, which makes it difficult.”
Dr. Ozudogru also wonders how “doable” in-hospital IV infusions over 3 days may be for children.
“Especially for chronic migraine patients, it can be really tricky to manage expectations in that even if they don’t respond and the headache doesn’t go away, they still may have to be discharged. That requires a specific approach and discussion with the patients,” Dr. Ozudogru said.
Intranasal ketamine is another potential option, she said, with a recent study suggesting that intranasal ketamine is an effective treatment for children hospitalized with refractory migraine.
“However, there is some concern about the potential of addiction and the side effects of hallucinations and what the main protocol will be, so this not a standard treatment and has to be studied further,” she said.
The study had no specific funding. Dr. Rosenthal and Dr. Ozudogru have no relevant disclosures.
A version of this article appeared on Medscape.com.
DENVER — , new research suggests. In a retrospective chart review, IV ketamine led to in a 50% reduction in pain at discharge, with “nearly two-thirds” of patients having no recurrence within 30 days, noted lead investigator Scott Rosenthal, MD, from the University of Colorado Anschutz Medical Campus, Aurora.
Dr. Rosenthal reported the findings at the 2024 annual meeting of the American Academy of Neurology.
Statistically Significant Pain Relief
“IV ketamine has shown benefit in nonheadache chronic pain syndromes and refractory mood disorders. Patients with refractory status migraines are often left with ongoing pain and dysfunction after failing typical interventions,” Dr. Rosenthal said.
“Ketamine has emerged as a potential treatment option in this population. However, there’s very little research on the efficacy and tolerability of it in general as well as the pediatric population,” he noted.
Dr. Rosenthal and colleagues took a look back at patients admitted to Children’s Hospital Colorado between 2019 and 2022 for treatment of severe refractory headache who were treated with continuous IV ketamine.
They analyzed 68 encounters of 41 unique patients aged 5-21 years (median age 16 years; 85% girls). Chronic migraine without aura made up 79% of cases.
On presentation, most patients had an exacerbation or ongoing worsening of pain for about 10 days, and all but two were taking a preventive medication. Nearly 70% had a comorbid psychiatric diagnosis such as anxiety or depression, and 60% had a comorbid chronic pain diagnosis separate from their headache diagnosis.
The primary outcome was percent pain reduction at discharge and headache recurrence within 72 hours, with headache recurrence defined as receipt of neurology care via phone, clinic, or hospital encounter.
Patients received IV ketamine at a median dose of 0.25 mg/kg/hr for a median of 3 days.
Overall, the treatment was “safe and well tolerated,” Dr. Rosenthal said.
There were no serious adverse events and no cardiac side effects; 7% (five out of 68) stopped treatment due to side effects. The most common side effects were dizziness (23%), nausea (16%), blurred vision (12%), hallucinations (19%), cognitive fog (7%), vomiting (6%) and dysphoria (4%), worsening headache (4%), and paresthesia and cramping (1.5%).
‘Exciting Starting Point’
At baseline, pain scores were 8 (on a scale of 0-10) and progressively fell (improved) during treatment. Pain scores were 6 on day 1 and were 5 on day 2, with a slight rebound to 5 at discharge, although the pain reduction at discharge (vs baseline) remained statistically significant (P < .001).
“The median percent pain reduction after 3 days of ketamine was about 40%,” Dr. Rosenthal said.
He noted that on the first day of treatment, 16% of patients responded to treatment (with a > 50% reduction in their initial pain); this doubled to 33% on day 2 and increased to 44% at discharge.
In terms of recurrence, 38% had a recurrence within 1 month, “meaning two thirds did not,” Dr. Rosenthal noted. Median time to recurrence was 7 days. There were no recurrences within 72 hours.
The researchers also tried to tease out which patients might respond best to ketamine.
“Surprisingly,” there wasn’t a strong effect of most demographic variables such as age, sex, gender identity, chronic pain, psychiatric comorbidities, duration of headache, or prior interventions, Dr. Rosenthal noted.
“Interestingly,” he said, patients who were on two or more preventive medications had a 50% reduction in their pain at discharge compared with a 33% reduction in patients taking one or no preventive medication. It’s possible that more preventative medications may “prime” a patient’s response to ketamine, Dr. Rosenthal said.
She added that future randomized studies are needed to further assess IV ketamine for refractory headache in children, but these results are “an exciting starting point.”
‘Still an Unknown’
Seniha Nur Ozudogru, MD, assistant professor of clinical neurology at Penn Medicine in Philadelphia, echoed the need for further study.
The role of IV ketamine in refractory pediatric headache is “still an unknown,” said Dr. Ozudogru, who was not involved in the study.
She noted that currently, there is “no standard protocol for ketamine infusion, even for adults. Every institution has their own protocols, which makes it difficult.”
Dr. Ozudogru also wonders how “doable” in-hospital IV infusions over 3 days may be for children.
“Especially for chronic migraine patients, it can be really tricky to manage expectations in that even if they don’t respond and the headache doesn’t go away, they still may have to be discharged. That requires a specific approach and discussion with the patients,” Dr. Ozudogru said.
Intranasal ketamine is another potential option, she said, with a recent study suggesting that intranasal ketamine is an effective treatment for children hospitalized with refractory migraine.
“However, there is some concern about the potential of addiction and the side effects of hallucinations and what the main protocol will be, so this not a standard treatment and has to be studied further,” she said.
The study had no specific funding. Dr. Rosenthal and Dr. Ozudogru have no relevant disclosures.
A version of this article appeared on Medscape.com.
DENVER — , new research suggests. In a retrospective chart review, IV ketamine led to in a 50% reduction in pain at discharge, with “nearly two-thirds” of patients having no recurrence within 30 days, noted lead investigator Scott Rosenthal, MD, from the University of Colorado Anschutz Medical Campus, Aurora.
Dr. Rosenthal reported the findings at the 2024 annual meeting of the American Academy of Neurology.
Statistically Significant Pain Relief
“IV ketamine has shown benefit in nonheadache chronic pain syndromes and refractory mood disorders. Patients with refractory status migraines are often left with ongoing pain and dysfunction after failing typical interventions,” Dr. Rosenthal said.
“Ketamine has emerged as a potential treatment option in this population. However, there’s very little research on the efficacy and tolerability of it in general as well as the pediatric population,” he noted.
Dr. Rosenthal and colleagues took a look back at patients admitted to Children’s Hospital Colorado between 2019 and 2022 for treatment of severe refractory headache who were treated with continuous IV ketamine.
They analyzed 68 encounters of 41 unique patients aged 5-21 years (median age 16 years; 85% girls). Chronic migraine without aura made up 79% of cases.
On presentation, most patients had an exacerbation or ongoing worsening of pain for about 10 days, and all but two were taking a preventive medication. Nearly 70% had a comorbid psychiatric diagnosis such as anxiety or depression, and 60% had a comorbid chronic pain diagnosis separate from their headache diagnosis.
The primary outcome was percent pain reduction at discharge and headache recurrence within 72 hours, with headache recurrence defined as receipt of neurology care via phone, clinic, or hospital encounter.
Patients received IV ketamine at a median dose of 0.25 mg/kg/hr for a median of 3 days.
Overall, the treatment was “safe and well tolerated,” Dr. Rosenthal said.
There were no serious adverse events and no cardiac side effects; 7% (five out of 68) stopped treatment due to side effects. The most common side effects were dizziness (23%), nausea (16%), blurred vision (12%), hallucinations (19%), cognitive fog (7%), vomiting (6%) and dysphoria (4%), worsening headache (4%), and paresthesia and cramping (1.5%).
‘Exciting Starting Point’
At baseline, pain scores were 8 (on a scale of 0-10) and progressively fell (improved) during treatment. Pain scores were 6 on day 1 and were 5 on day 2, with a slight rebound to 5 at discharge, although the pain reduction at discharge (vs baseline) remained statistically significant (P < .001).
“The median percent pain reduction after 3 days of ketamine was about 40%,” Dr. Rosenthal said.
He noted that on the first day of treatment, 16% of patients responded to treatment (with a > 50% reduction in their initial pain); this doubled to 33% on day 2 and increased to 44% at discharge.
In terms of recurrence, 38% had a recurrence within 1 month, “meaning two thirds did not,” Dr. Rosenthal noted. Median time to recurrence was 7 days. There were no recurrences within 72 hours.
The researchers also tried to tease out which patients might respond best to ketamine.
“Surprisingly,” there wasn’t a strong effect of most demographic variables such as age, sex, gender identity, chronic pain, psychiatric comorbidities, duration of headache, or prior interventions, Dr. Rosenthal noted.
“Interestingly,” he said, patients who were on two or more preventive medications had a 50% reduction in their pain at discharge compared with a 33% reduction in patients taking one or no preventive medication. It’s possible that more preventative medications may “prime” a patient’s response to ketamine, Dr. Rosenthal said.
She added that future randomized studies are needed to further assess IV ketamine for refractory headache in children, but these results are “an exciting starting point.”
‘Still an Unknown’
Seniha Nur Ozudogru, MD, assistant professor of clinical neurology at Penn Medicine in Philadelphia, echoed the need for further study.
The role of IV ketamine in refractory pediatric headache is “still an unknown,” said Dr. Ozudogru, who was not involved in the study.
She noted that currently, there is “no standard protocol for ketamine infusion, even for adults. Every institution has their own protocols, which makes it difficult.”
Dr. Ozudogru also wonders how “doable” in-hospital IV infusions over 3 days may be for children.
“Especially for chronic migraine patients, it can be really tricky to manage expectations in that even if they don’t respond and the headache doesn’t go away, they still may have to be discharged. That requires a specific approach and discussion with the patients,” Dr. Ozudogru said.
Intranasal ketamine is another potential option, she said, with a recent study suggesting that intranasal ketamine is an effective treatment for children hospitalized with refractory migraine.
“However, there is some concern about the potential of addiction and the side effects of hallucinations and what the main protocol will be, so this not a standard treatment and has to be studied further,” she said.
The study had no specific funding. Dr. Rosenthal and Dr. Ozudogru have no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM AAN 2024
Too Little Sleep Raises Health Risks for Teens With T1D
TOPLINE:
METHODOLOGY:
- Sleep is recognized as an important factor in diabetes assessment and treatment by the 2023 American Diabetes Association’s Standards of Medical Care in Diabetes, but it is unclear whether sleep may improve health outcomes across the lifespan in patients with T1D.
- This secondary analysis of the BCQR-T1D crossover trial investigated the link between sleep and cardiometabolic health in 42 adults (age, 19-60 years) and 42 adolescents (age, 12-18 years) with T1D.
- Participants had T1D duration greater than 9 months and received bromocriptine quick-release (BCQR) therapy or placebo for 4 weeks and then switched between the treatments in a separate 4-week period.
- They underwent laboratory testing and anthropometric measurements. Also, continuous glucose monitoring data were collected for a week during each treatment phase along with an accompanying insulin dosing diary.
- Participants were required to wear an actigraphy monitor on the wrist of their nondominant hand for 7 days during each treatment phase to estimate sleep duration.
TAKEAWAY:
- Most adolescents (62%) and adults (74%) with T1D reported less than 7 hours of sleep at baseline.
- Participants with insufficient sleep versus those without insufficient sleep (< 7 vs > 7 hours) had a larger waist circumference and higher mean body mass index, systolic blood pressure, and pulse pressure, as well as lower estimated insulin sensitivity and brachial artery distensibility (P < .05 for all).
- When stratified by age, only adolescents with T1D with insufficient sleep had significant differences in most health outcomes by sleep duration status, except that adults with less than 7 hours of sleep had higher pulse pressure than those with more than 7 hours of sleep.
- Compared with placebo, BCQR slightly improved sleeping parameters in adolescents by delaying their time of waking up and prolonging their time in bed.
IN PRACTICE:
“Sleep may be an important and novel target for improving health in individuals with T1D, particularly when initiated in adolescence or early in diabetes,” the authors wrote.
SOURCE:
Stacey L. Simon, PhD, and Janet K. Snell-Bergeon, PhD, University of Colorado Anschutz Medical Campus, Aurora, led this study, which was published online in Diabetes, Obesity and Metabolism.
LIMITATIONS:
The study lacked polysomnography or melatonin assessment to quantify circadian rhythms and subjective sleep quality ratings. It also had no objective measurement of the timing of the daily pills of BCQR, which, when taken in the morning, are hypothesized to reset the circadian rhythm for hypothalamic dopamine and serotonin. The recommended sleep duration of 8 hours for adolescents was not used as the cutoff value due to too few participants who qualified. Also, this study›s findings may be affected by the fact that participants were recruited throughout the year, while adolescents show different sleeping patterns during the academic year compared with school breaks.
DISCLOSURES:
This work was supported by a JDRF grant. Two authors declared receiving equipment, honoraria for lectures, and support for conference travel, which were all unrelated to this study.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Sleep is recognized as an important factor in diabetes assessment and treatment by the 2023 American Diabetes Association’s Standards of Medical Care in Diabetes, but it is unclear whether sleep may improve health outcomes across the lifespan in patients with T1D.
- This secondary analysis of the BCQR-T1D crossover trial investigated the link between sleep and cardiometabolic health in 42 adults (age, 19-60 years) and 42 adolescents (age, 12-18 years) with T1D.
- Participants had T1D duration greater than 9 months and received bromocriptine quick-release (BCQR) therapy or placebo for 4 weeks and then switched between the treatments in a separate 4-week period.
- They underwent laboratory testing and anthropometric measurements. Also, continuous glucose monitoring data were collected for a week during each treatment phase along with an accompanying insulin dosing diary.
- Participants were required to wear an actigraphy monitor on the wrist of their nondominant hand for 7 days during each treatment phase to estimate sleep duration.
TAKEAWAY:
- Most adolescents (62%) and adults (74%) with T1D reported less than 7 hours of sleep at baseline.
- Participants with insufficient sleep versus those without insufficient sleep (< 7 vs > 7 hours) had a larger waist circumference and higher mean body mass index, systolic blood pressure, and pulse pressure, as well as lower estimated insulin sensitivity and brachial artery distensibility (P < .05 for all).
- When stratified by age, only adolescents with T1D with insufficient sleep had significant differences in most health outcomes by sleep duration status, except that adults with less than 7 hours of sleep had higher pulse pressure than those with more than 7 hours of sleep.
- Compared with placebo, BCQR slightly improved sleeping parameters in adolescents by delaying their time of waking up and prolonging their time in bed.
IN PRACTICE:
“Sleep may be an important and novel target for improving health in individuals with T1D, particularly when initiated in adolescence or early in diabetes,” the authors wrote.
SOURCE:
Stacey L. Simon, PhD, and Janet K. Snell-Bergeon, PhD, University of Colorado Anschutz Medical Campus, Aurora, led this study, which was published online in Diabetes, Obesity and Metabolism.
LIMITATIONS:
The study lacked polysomnography or melatonin assessment to quantify circadian rhythms and subjective sleep quality ratings. It also had no objective measurement of the timing of the daily pills of BCQR, which, when taken in the morning, are hypothesized to reset the circadian rhythm for hypothalamic dopamine and serotonin. The recommended sleep duration of 8 hours for adolescents was not used as the cutoff value due to too few participants who qualified. Also, this study›s findings may be affected by the fact that participants were recruited throughout the year, while adolescents show different sleeping patterns during the academic year compared with school breaks.
DISCLOSURES:
This work was supported by a JDRF grant. Two authors declared receiving equipment, honoraria for lectures, and support for conference travel, which were all unrelated to this study.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Sleep is recognized as an important factor in diabetes assessment and treatment by the 2023 American Diabetes Association’s Standards of Medical Care in Diabetes, but it is unclear whether sleep may improve health outcomes across the lifespan in patients with T1D.
- This secondary analysis of the BCQR-T1D crossover trial investigated the link between sleep and cardiometabolic health in 42 adults (age, 19-60 years) and 42 adolescents (age, 12-18 years) with T1D.
- Participants had T1D duration greater than 9 months and received bromocriptine quick-release (BCQR) therapy or placebo for 4 weeks and then switched between the treatments in a separate 4-week period.
- They underwent laboratory testing and anthropometric measurements. Also, continuous glucose monitoring data were collected for a week during each treatment phase along with an accompanying insulin dosing diary.
- Participants were required to wear an actigraphy monitor on the wrist of their nondominant hand for 7 days during each treatment phase to estimate sleep duration.
TAKEAWAY:
- Most adolescents (62%) and adults (74%) with T1D reported less than 7 hours of sleep at baseline.
- Participants with insufficient sleep versus those without insufficient sleep (< 7 vs > 7 hours) had a larger waist circumference and higher mean body mass index, systolic blood pressure, and pulse pressure, as well as lower estimated insulin sensitivity and brachial artery distensibility (P < .05 for all).
- When stratified by age, only adolescents with T1D with insufficient sleep had significant differences in most health outcomes by sleep duration status, except that adults with less than 7 hours of sleep had higher pulse pressure than those with more than 7 hours of sleep.
- Compared with placebo, BCQR slightly improved sleeping parameters in adolescents by delaying their time of waking up and prolonging their time in bed.
IN PRACTICE:
“Sleep may be an important and novel target for improving health in individuals with T1D, particularly when initiated in adolescence or early in diabetes,” the authors wrote.
SOURCE:
Stacey L. Simon, PhD, and Janet K. Snell-Bergeon, PhD, University of Colorado Anschutz Medical Campus, Aurora, led this study, which was published online in Diabetes, Obesity and Metabolism.
LIMITATIONS:
The study lacked polysomnography or melatonin assessment to quantify circadian rhythms and subjective sleep quality ratings. It also had no objective measurement of the timing of the daily pills of BCQR, which, when taken in the morning, are hypothesized to reset the circadian rhythm for hypothalamic dopamine and serotonin. The recommended sleep duration of 8 hours for adolescents was not used as the cutoff value due to too few participants who qualified. Also, this study›s findings may be affected by the fact that participants were recruited throughout the year, while adolescents show different sleeping patterns during the academic year compared with school breaks.
DISCLOSURES:
This work was supported by a JDRF grant. Two authors declared receiving equipment, honoraria for lectures, and support for conference travel, which were all unrelated to this study.
A version of this article appeared on Medscape.com.
Most Targeted Cancer Drugs Lack Substantial Clinical Benefit
TOPLINE:
METHODOLOGY:
- The strength and quality of evidence supporting genome-targeted cancer drug approvals vary. A big reason is the growing number of cancer drug approvals based on surrogate endpoints, such as disease-free and progression-free survival, instead of clinical endpoints, such as overall survival or quality of life. The US Food and Drug Administration (FDA) has also approved genome-targeted cancer drugs based on phase 1 or single-arm trials.
- Given these less rigorous considerations for approval, “the validity and value of the targets and surrogate measures underlying FDA genome-targeted cancer drug approvals are uncertain,” the researchers explained.
- In the current analysis, researchers assessed the validity of the molecular targets as well as the clinical benefits of genome-targeted cancer drugs approved in the United States from 2015 to 2022 based on results from pivotal trials.
- The researchers evaluated the strength of evidence supporting molecular targetability using the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT) and the clinical benefit using the ESMO–Magnitude of Clinical Benefit Scale (ESMO-MCBS).
- The authors defined a substantial clinical benefit as an A or B grade for curative intent and a 4 or 5 for noncurative intent. High-benefit genomic-based cancer treatments were defined as those associated with a substantial clinical benefit (ESMO-MCBS) and that qualified as ESCAT category level I-A (a clinical benefit based on prospective randomized data) or I-B (prospective nonrandomized data).
TAKEAWAY:
- The analyses focused on 50 molecular-targeted cancer drugs covering 84 indications. Of which, 45 indications (54%) were approved based on phase 1 or 2 pivotal trials, 45 (54%) were supported by single-arm pivotal trials and the remaining 39 (46%) by randomized trial, and 48 (57%) were approved based on subgroup analyses.
- Among the 84 indications, more than half (55%) of the pivotal trials supporting approval used overall response rate as a primary endpoint, 31% used progression-free survival, and 6% used disease-free survival. Only seven indications (8%) were supported by pivotal trials demonstrating an improvement in overall survival.
- Among the 84 trials, 24 (29%) met the ESMO-MCBS threshold for substantial clinical benefit.
- Overall, when combining all ratings, only 24 of the 84 indications (29%) were considered high-benefit genomic-based cancer treatments.
IN PRACTICE:
“We applied the ESMO-MCBS and ESCAT value frameworks to identify therapies and molecular targets providing high clinical value that should be widely available to patients” and “found that drug indications supported by these characteristics represent a minority of cancer drug approvals in recent years,” the authors said. Using these value frameworks could help payers, governments, and individual patients “prioritize the availability of high-value molecular-targeted therapies.”
SOURCE:
The study, with first author Ariadna Tibau, MD, PhD, Brigham and Women’s Hospital and Harvard Medical School, Boston, was published online in JAMA Oncology.
LIMITATIONS:
The study evaluated only trials that supported regulatory approval and did not include outcomes of postapproval clinical studies, which could lead to changes in ESMO-MCBS grades and ESCAT levels of evidence over time.
DISCLOSURES:
The study was funded by the Kaiser Permanente Institute for Health Policy, Arnold Ventures, and the Commonwealth Fund. The authors had no relevant disclosures.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- The strength and quality of evidence supporting genome-targeted cancer drug approvals vary. A big reason is the growing number of cancer drug approvals based on surrogate endpoints, such as disease-free and progression-free survival, instead of clinical endpoints, such as overall survival or quality of life. The US Food and Drug Administration (FDA) has also approved genome-targeted cancer drugs based on phase 1 or single-arm trials.
- Given these less rigorous considerations for approval, “the validity and value of the targets and surrogate measures underlying FDA genome-targeted cancer drug approvals are uncertain,” the researchers explained.
- In the current analysis, researchers assessed the validity of the molecular targets as well as the clinical benefits of genome-targeted cancer drugs approved in the United States from 2015 to 2022 based on results from pivotal trials.
- The researchers evaluated the strength of evidence supporting molecular targetability using the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT) and the clinical benefit using the ESMO–Magnitude of Clinical Benefit Scale (ESMO-MCBS).
- The authors defined a substantial clinical benefit as an A or B grade for curative intent and a 4 or 5 for noncurative intent. High-benefit genomic-based cancer treatments were defined as those associated with a substantial clinical benefit (ESMO-MCBS) and that qualified as ESCAT category level I-A (a clinical benefit based on prospective randomized data) or I-B (prospective nonrandomized data).
TAKEAWAY:
- The analyses focused on 50 molecular-targeted cancer drugs covering 84 indications. Of which, 45 indications (54%) were approved based on phase 1 or 2 pivotal trials, 45 (54%) were supported by single-arm pivotal trials and the remaining 39 (46%) by randomized trial, and 48 (57%) were approved based on subgroup analyses.
- Among the 84 indications, more than half (55%) of the pivotal trials supporting approval used overall response rate as a primary endpoint, 31% used progression-free survival, and 6% used disease-free survival. Only seven indications (8%) were supported by pivotal trials demonstrating an improvement in overall survival.
- Among the 84 trials, 24 (29%) met the ESMO-MCBS threshold for substantial clinical benefit.
- Overall, when combining all ratings, only 24 of the 84 indications (29%) were considered high-benefit genomic-based cancer treatments.
IN PRACTICE:
“We applied the ESMO-MCBS and ESCAT value frameworks to identify therapies and molecular targets providing high clinical value that should be widely available to patients” and “found that drug indications supported by these characteristics represent a minority of cancer drug approvals in recent years,” the authors said. Using these value frameworks could help payers, governments, and individual patients “prioritize the availability of high-value molecular-targeted therapies.”
SOURCE:
The study, with first author Ariadna Tibau, MD, PhD, Brigham and Women’s Hospital and Harvard Medical School, Boston, was published online in JAMA Oncology.
LIMITATIONS:
The study evaluated only trials that supported regulatory approval and did not include outcomes of postapproval clinical studies, which could lead to changes in ESMO-MCBS grades and ESCAT levels of evidence over time.
DISCLOSURES:
The study was funded by the Kaiser Permanente Institute for Health Policy, Arnold Ventures, and the Commonwealth Fund. The authors had no relevant disclosures.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- The strength and quality of evidence supporting genome-targeted cancer drug approvals vary. A big reason is the growing number of cancer drug approvals based on surrogate endpoints, such as disease-free and progression-free survival, instead of clinical endpoints, such as overall survival or quality of life. The US Food and Drug Administration (FDA) has also approved genome-targeted cancer drugs based on phase 1 or single-arm trials.
- Given these less rigorous considerations for approval, “the validity and value of the targets and surrogate measures underlying FDA genome-targeted cancer drug approvals are uncertain,” the researchers explained.
- In the current analysis, researchers assessed the validity of the molecular targets as well as the clinical benefits of genome-targeted cancer drugs approved in the United States from 2015 to 2022 based on results from pivotal trials.
- The researchers evaluated the strength of evidence supporting molecular targetability using the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT) and the clinical benefit using the ESMO–Magnitude of Clinical Benefit Scale (ESMO-MCBS).
- The authors defined a substantial clinical benefit as an A or B grade for curative intent and a 4 or 5 for noncurative intent. High-benefit genomic-based cancer treatments were defined as those associated with a substantial clinical benefit (ESMO-MCBS) and that qualified as ESCAT category level I-A (a clinical benefit based on prospective randomized data) or I-B (prospective nonrandomized data).
TAKEAWAY:
- The analyses focused on 50 molecular-targeted cancer drugs covering 84 indications. Of which, 45 indications (54%) were approved based on phase 1 or 2 pivotal trials, 45 (54%) were supported by single-arm pivotal trials and the remaining 39 (46%) by randomized trial, and 48 (57%) were approved based on subgroup analyses.
- Among the 84 indications, more than half (55%) of the pivotal trials supporting approval used overall response rate as a primary endpoint, 31% used progression-free survival, and 6% used disease-free survival. Only seven indications (8%) were supported by pivotal trials demonstrating an improvement in overall survival.
- Among the 84 trials, 24 (29%) met the ESMO-MCBS threshold for substantial clinical benefit.
- Overall, when combining all ratings, only 24 of the 84 indications (29%) were considered high-benefit genomic-based cancer treatments.
IN PRACTICE:
“We applied the ESMO-MCBS and ESCAT value frameworks to identify therapies and molecular targets providing high clinical value that should be widely available to patients” and “found that drug indications supported by these characteristics represent a minority of cancer drug approvals in recent years,” the authors said. Using these value frameworks could help payers, governments, and individual patients “prioritize the availability of high-value molecular-targeted therapies.”
SOURCE:
The study, with first author Ariadna Tibau, MD, PhD, Brigham and Women’s Hospital and Harvard Medical School, Boston, was published online in JAMA Oncology.
LIMITATIONS:
The study evaluated only trials that supported regulatory approval and did not include outcomes of postapproval clinical studies, which could lead to changes in ESMO-MCBS grades and ESCAT levels of evidence over time.
DISCLOSURES:
The study was funded by the Kaiser Permanente Institute for Health Policy, Arnold Ventures, and the Commonwealth Fund. The authors had no relevant disclosures.
A version of this article appeared on Medscape.com.
Is Picky Eating a Problem?
Is picky eating a problem? Well, yes and no. We have all had parents come to us with concerns about their child’s picky eating. At this point in history, we may feel grateful not to be facing another of the myriad of our child patients who are seriously overweight. So, should we just tell parents to not worry about it?
About 18% of young children are picky eaters; 7% of older children, even adolescents, are still picky eaters. The lack of variety eaten can limit growth and nutrition — in particular iron, and vitamins A and C — and limit them socially at older ages because people think they’re weird because they don’t eat typical foods. The crying, tantrums, gagging, even vomiting at the sight of certain foods that may be part of picky eating is hard on families and may make them all less welcome as guests/friends. We know that if eating issues are not addressed early, they tend to persist. For example, the fruit variety eaten is actually higher at 27 months than it is at 60 months without intervention. The fruit variety eaten at 2 years of age actually predicts what the child will eat when they’re 6-8 years old. About 40% of irregular eaters at age 5 are still irregular eaters at age 14.
Practical Advice for Dealing With Picky Eating
There are some things you may not know about this common condition that could change your approach. Infants in the first year of life will naturally turn away from the bottle or breast when sated. But babies need to learn to eat solids, and it is actually stressful. Pushing food out is their first response. If progressively more textured foods are not provided between 6 and 10 months of age, the baby may struggle with accepting solids subsequently. Babies around 8 months want to grab everything, including the spoon, and want to feed themselves. If parents push the spoon and thwart participation, refusal to be fed — the so-called Battle of the Spoon, the most common reason for stalled weight gain at this age — may ensue. Instead, caregivers need to give the baby his/her own spoon to hold, and allow finger feeding, no matter how messy! The parent’s job is to provide healthy food in reasonable amounts, and the child’s job is to eat what they want of it.
But, often suddenly, typically around 21 months, children may become picky. What happened? This is an age of perceiving differences and developing a strong sense of autonomy. Foods recently eaten without protest may now be dramatically rejected. Whole food categories or textures (think slimy) may be refused, especially vegetables and meat. Food cut in their preferred shape, their favorite brand, or delivered in the same cup may be demanded with alternatives refused. Foods that touch together on the plate or are covered with sauce may cause a tantrum. Some of this pickiness may reflect sensitive or intense temperament. Some food preferences are cultural (borscht?), or familial (no fruit), but others are nearly universal because of the heightened sensitivity of taste at this age (spinach, for example, as it contains oxalic acid).
Young children refusing foods can have their autonomy honored by providing only healthy foods on a low table to eat as they please without commentary, but continue seating them with family for meals, allowing exit (no return) from that meal if they choose. The desire to be social and removal of pressure results in eating regular meals within a week in most cases.
Any of these new reactions may persist for years. In most cases, picky eaters get adequate nutrition and grow fine without any intervention. Removing the power struggle or parental discord is generally more important than getting the child to accept a few more foods. Keep in mind that children may have picky eating because mealtime interactions are aversive or in order to get attention or a special menu — both reinforcers to avoid.
But there are some ways food selectivity can be reduced. Modeling eating a variety of foods can make a difference but is best done without comment (seen as pressure). Seeing heroes or peers eat the food that might otherwise be undesired by a picky eater (recall Popeye, who ate his spinach), is based on this. Having a peer come over who will eat that specific food (Mikey likes it!) can be very helpful.
There are other practices that can improve picky eating and are good general feeding advice. Maintaining three meals and three snacks, always at the table with adult company, can reduce grazing on perhaps tasty and filling foods or drinks (milk being the worst) that replace the drive for eating less desired foods once seated. Providing the child a multivitamin can help parents avoid showing panic or pressure when working to increase food variety. All the foods prepared for the family should be put on the plate to increase exposure, along with at least one item the child is known to eat. Family meals have many benefits (eg, language development), and it has been shown that children who sit at a meal for 20-30 minutes eat significantly more undesired fruits and vegetables than those seated for less time. Boredom helps with exploration!
Sometimes a new brand or new way of preparing a food that they currently won’t eat, or sprinkling a new food on a currently accepted food (eg, chocolate on a fruit) will encourage eating it. Adding a food similar to one they are already eating may help.
It is wise to avoid supplements, however. While nutritionally sound and supportive of growth, supplements are usually calorie dense, and they remove the drive to eat at meals, as well as not providing the variety of components needed to reduce selectivity.
Advice for Severe Cases
If picky eating is severe or growth is impaired, and the eating pattern does not respond to these adjustments and parent counseling, more may be needed. One of the main things known to increase the variety eaten is repeated tasting. Looks are not enough. A proven method includes giving praise and sticker rewards for eating a little piece of the same undesired vegetable/food presented to them each day for at least 14 days in a row. This method may expand the range of foods eaten as well as the range of those liked. Even a microscopic amount, the size of a grain of rice of an undesired food, if ingested regularly and repeatedly, will increase acceptance!
A feeding program for serious problems with food selectivity at Penn State has the child given A) a pea-sized amount of an undesired food and B) a bite-sized amount of an accepted food. The child is required to eat A in order to get B, plus a small drink. This is done repeatedly for about 10 minutes. If the child does not eat anything, they don’t get anything more until the next meal. An alternative to this is insisting on one bite per meal or one bite per day of an undesired food. One can also mix in, in increasing amounts, an undesired liquid into a desired liquid. While families travel far for this special program when selectivity is extreme, the “praise and sticker” method has been shown effective done at home.
In extreme cases of food selectivity or refusal, we need to consider medical problems as a potential cause, especially if choking, gagging, or vomiting occur or if there is poor weight gain or complications such as rash, abdominal pain, or diarrhea. An episode of food poisoning or an allergic reaction (anaphylaxis can present as diarrhea) can trigger onset of a lifelong aversion to that food. Omitting foods that have sickened a person is reasonable. Gastroesophageal reflux and eosinophilic esophagitis, oral-motor incoordination and choking, dental caries, tracheo-esophageal fistulas with aspiration, constipation, sensory issues, and sometimes lactose intolerance all may cause food refusal through the conditioned responses to the discomfort. Children with autism often have a combination of these factors producing severe food selectivity for which the above methods can be helpful.
Parents everywhere take feeding their children as one of their highest priorities. Along with empathy for their concern, understanding potential contributing factors and some practical prevention and intervention steps for picky eating can help you partner on what can be a long journey. On a positive note, you can reassure parents that studies also show that picky eaters are less likely to go on to be overweight!
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].
Is picky eating a problem? Well, yes and no. We have all had parents come to us with concerns about their child’s picky eating. At this point in history, we may feel grateful not to be facing another of the myriad of our child patients who are seriously overweight. So, should we just tell parents to not worry about it?
About 18% of young children are picky eaters; 7% of older children, even adolescents, are still picky eaters. The lack of variety eaten can limit growth and nutrition — in particular iron, and vitamins A and C — and limit them socially at older ages because people think they’re weird because they don’t eat typical foods. The crying, tantrums, gagging, even vomiting at the sight of certain foods that may be part of picky eating is hard on families and may make them all less welcome as guests/friends. We know that if eating issues are not addressed early, they tend to persist. For example, the fruit variety eaten is actually higher at 27 months than it is at 60 months without intervention. The fruit variety eaten at 2 years of age actually predicts what the child will eat when they’re 6-8 years old. About 40% of irregular eaters at age 5 are still irregular eaters at age 14.
Practical Advice for Dealing With Picky Eating
There are some things you may not know about this common condition that could change your approach. Infants in the first year of life will naturally turn away from the bottle or breast when sated. But babies need to learn to eat solids, and it is actually stressful. Pushing food out is their first response. If progressively more textured foods are not provided between 6 and 10 months of age, the baby may struggle with accepting solids subsequently. Babies around 8 months want to grab everything, including the spoon, and want to feed themselves. If parents push the spoon and thwart participation, refusal to be fed — the so-called Battle of the Spoon, the most common reason for stalled weight gain at this age — may ensue. Instead, caregivers need to give the baby his/her own spoon to hold, and allow finger feeding, no matter how messy! The parent’s job is to provide healthy food in reasonable amounts, and the child’s job is to eat what they want of it.
But, often suddenly, typically around 21 months, children may become picky. What happened? This is an age of perceiving differences and developing a strong sense of autonomy. Foods recently eaten without protest may now be dramatically rejected. Whole food categories or textures (think slimy) may be refused, especially vegetables and meat. Food cut in their preferred shape, their favorite brand, or delivered in the same cup may be demanded with alternatives refused. Foods that touch together on the plate or are covered with sauce may cause a tantrum. Some of this pickiness may reflect sensitive or intense temperament. Some food preferences are cultural (borscht?), or familial (no fruit), but others are nearly universal because of the heightened sensitivity of taste at this age (spinach, for example, as it contains oxalic acid).
Young children refusing foods can have their autonomy honored by providing only healthy foods on a low table to eat as they please without commentary, but continue seating them with family for meals, allowing exit (no return) from that meal if they choose. The desire to be social and removal of pressure results in eating regular meals within a week in most cases.
Any of these new reactions may persist for years. In most cases, picky eaters get adequate nutrition and grow fine without any intervention. Removing the power struggle or parental discord is generally more important than getting the child to accept a few more foods. Keep in mind that children may have picky eating because mealtime interactions are aversive or in order to get attention or a special menu — both reinforcers to avoid.
But there are some ways food selectivity can be reduced. Modeling eating a variety of foods can make a difference but is best done without comment (seen as pressure). Seeing heroes or peers eat the food that might otherwise be undesired by a picky eater (recall Popeye, who ate his spinach), is based on this. Having a peer come over who will eat that specific food (Mikey likes it!) can be very helpful.
There are other practices that can improve picky eating and are good general feeding advice. Maintaining three meals and three snacks, always at the table with adult company, can reduce grazing on perhaps tasty and filling foods or drinks (milk being the worst) that replace the drive for eating less desired foods once seated. Providing the child a multivitamin can help parents avoid showing panic or pressure when working to increase food variety. All the foods prepared for the family should be put on the plate to increase exposure, along with at least one item the child is known to eat. Family meals have many benefits (eg, language development), and it has been shown that children who sit at a meal for 20-30 minutes eat significantly more undesired fruits and vegetables than those seated for less time. Boredom helps with exploration!
Sometimes a new brand or new way of preparing a food that they currently won’t eat, or sprinkling a new food on a currently accepted food (eg, chocolate on a fruit) will encourage eating it. Adding a food similar to one they are already eating may help.
It is wise to avoid supplements, however. While nutritionally sound and supportive of growth, supplements are usually calorie dense, and they remove the drive to eat at meals, as well as not providing the variety of components needed to reduce selectivity.
Advice for Severe Cases
If picky eating is severe or growth is impaired, and the eating pattern does not respond to these adjustments and parent counseling, more may be needed. One of the main things known to increase the variety eaten is repeated tasting. Looks are not enough. A proven method includes giving praise and sticker rewards for eating a little piece of the same undesired vegetable/food presented to them each day for at least 14 days in a row. This method may expand the range of foods eaten as well as the range of those liked. Even a microscopic amount, the size of a grain of rice of an undesired food, if ingested regularly and repeatedly, will increase acceptance!
A feeding program for serious problems with food selectivity at Penn State has the child given A) a pea-sized amount of an undesired food and B) a bite-sized amount of an accepted food. The child is required to eat A in order to get B, plus a small drink. This is done repeatedly for about 10 minutes. If the child does not eat anything, they don’t get anything more until the next meal. An alternative to this is insisting on one bite per meal or one bite per day of an undesired food. One can also mix in, in increasing amounts, an undesired liquid into a desired liquid. While families travel far for this special program when selectivity is extreme, the “praise and sticker” method has been shown effective done at home.
In extreme cases of food selectivity or refusal, we need to consider medical problems as a potential cause, especially if choking, gagging, or vomiting occur or if there is poor weight gain or complications such as rash, abdominal pain, or diarrhea. An episode of food poisoning or an allergic reaction (anaphylaxis can present as diarrhea) can trigger onset of a lifelong aversion to that food. Omitting foods that have sickened a person is reasonable. Gastroesophageal reflux and eosinophilic esophagitis, oral-motor incoordination and choking, dental caries, tracheo-esophageal fistulas with aspiration, constipation, sensory issues, and sometimes lactose intolerance all may cause food refusal through the conditioned responses to the discomfort. Children with autism often have a combination of these factors producing severe food selectivity for which the above methods can be helpful.
Parents everywhere take feeding their children as one of their highest priorities. Along with empathy for their concern, understanding potential contributing factors and some practical prevention and intervention steps for picky eating can help you partner on what can be a long journey. On a positive note, you can reassure parents that studies also show that picky eaters are less likely to go on to be overweight!
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].
Is picky eating a problem? Well, yes and no. We have all had parents come to us with concerns about their child’s picky eating. At this point in history, we may feel grateful not to be facing another of the myriad of our child patients who are seriously overweight. So, should we just tell parents to not worry about it?
About 18% of young children are picky eaters; 7% of older children, even adolescents, are still picky eaters. The lack of variety eaten can limit growth and nutrition — in particular iron, and vitamins A and C — and limit them socially at older ages because people think they’re weird because they don’t eat typical foods. The crying, tantrums, gagging, even vomiting at the sight of certain foods that may be part of picky eating is hard on families and may make them all less welcome as guests/friends. We know that if eating issues are not addressed early, they tend to persist. For example, the fruit variety eaten is actually higher at 27 months than it is at 60 months without intervention. The fruit variety eaten at 2 years of age actually predicts what the child will eat when they’re 6-8 years old. About 40% of irregular eaters at age 5 are still irregular eaters at age 14.
Practical Advice for Dealing With Picky Eating
There are some things you may not know about this common condition that could change your approach. Infants in the first year of life will naturally turn away from the bottle or breast when sated. But babies need to learn to eat solids, and it is actually stressful. Pushing food out is their first response. If progressively more textured foods are not provided between 6 and 10 months of age, the baby may struggle with accepting solids subsequently. Babies around 8 months want to grab everything, including the spoon, and want to feed themselves. If parents push the spoon and thwart participation, refusal to be fed — the so-called Battle of the Spoon, the most common reason for stalled weight gain at this age — may ensue. Instead, caregivers need to give the baby his/her own spoon to hold, and allow finger feeding, no matter how messy! The parent’s job is to provide healthy food in reasonable amounts, and the child’s job is to eat what they want of it.
But, often suddenly, typically around 21 months, children may become picky. What happened? This is an age of perceiving differences and developing a strong sense of autonomy. Foods recently eaten without protest may now be dramatically rejected. Whole food categories or textures (think slimy) may be refused, especially vegetables and meat. Food cut in their preferred shape, their favorite brand, or delivered in the same cup may be demanded with alternatives refused. Foods that touch together on the plate or are covered with sauce may cause a tantrum. Some of this pickiness may reflect sensitive or intense temperament. Some food preferences are cultural (borscht?), or familial (no fruit), but others are nearly universal because of the heightened sensitivity of taste at this age (spinach, for example, as it contains oxalic acid).
Young children refusing foods can have their autonomy honored by providing only healthy foods on a low table to eat as they please without commentary, but continue seating them with family for meals, allowing exit (no return) from that meal if they choose. The desire to be social and removal of pressure results in eating regular meals within a week in most cases.
Any of these new reactions may persist for years. In most cases, picky eaters get adequate nutrition and grow fine without any intervention. Removing the power struggle or parental discord is generally more important than getting the child to accept a few more foods. Keep in mind that children may have picky eating because mealtime interactions are aversive or in order to get attention or a special menu — both reinforcers to avoid.
But there are some ways food selectivity can be reduced. Modeling eating a variety of foods can make a difference but is best done without comment (seen as pressure). Seeing heroes or peers eat the food that might otherwise be undesired by a picky eater (recall Popeye, who ate his spinach), is based on this. Having a peer come over who will eat that specific food (Mikey likes it!) can be very helpful.
There are other practices that can improve picky eating and are good general feeding advice. Maintaining three meals and three snacks, always at the table with adult company, can reduce grazing on perhaps tasty and filling foods or drinks (milk being the worst) that replace the drive for eating less desired foods once seated. Providing the child a multivitamin can help parents avoid showing panic or pressure when working to increase food variety. All the foods prepared for the family should be put on the plate to increase exposure, along with at least one item the child is known to eat. Family meals have many benefits (eg, language development), and it has been shown that children who sit at a meal for 20-30 minutes eat significantly more undesired fruits and vegetables than those seated for less time. Boredom helps with exploration!
Sometimes a new brand or new way of preparing a food that they currently won’t eat, or sprinkling a new food on a currently accepted food (eg, chocolate on a fruit) will encourage eating it. Adding a food similar to one they are already eating may help.
It is wise to avoid supplements, however. While nutritionally sound and supportive of growth, supplements are usually calorie dense, and they remove the drive to eat at meals, as well as not providing the variety of components needed to reduce selectivity.
Advice for Severe Cases
If picky eating is severe or growth is impaired, and the eating pattern does not respond to these adjustments and parent counseling, more may be needed. One of the main things known to increase the variety eaten is repeated tasting. Looks are not enough. A proven method includes giving praise and sticker rewards for eating a little piece of the same undesired vegetable/food presented to them each day for at least 14 days in a row. This method may expand the range of foods eaten as well as the range of those liked. Even a microscopic amount, the size of a grain of rice of an undesired food, if ingested regularly and repeatedly, will increase acceptance!
A feeding program for serious problems with food selectivity at Penn State has the child given A) a pea-sized amount of an undesired food and B) a bite-sized amount of an accepted food. The child is required to eat A in order to get B, plus a small drink. This is done repeatedly for about 10 minutes. If the child does not eat anything, they don’t get anything more until the next meal. An alternative to this is insisting on one bite per meal or one bite per day of an undesired food. One can also mix in, in increasing amounts, an undesired liquid into a desired liquid. While families travel far for this special program when selectivity is extreme, the “praise and sticker” method has been shown effective done at home.
In extreme cases of food selectivity or refusal, we need to consider medical problems as a potential cause, especially if choking, gagging, or vomiting occur or if there is poor weight gain or complications such as rash, abdominal pain, or diarrhea. An episode of food poisoning or an allergic reaction (anaphylaxis can present as diarrhea) can trigger onset of a lifelong aversion to that food. Omitting foods that have sickened a person is reasonable. Gastroesophageal reflux and eosinophilic esophagitis, oral-motor incoordination and choking, dental caries, tracheo-esophageal fistulas with aspiration, constipation, sensory issues, and sometimes lactose intolerance all may cause food refusal through the conditioned responses to the discomfort. Children with autism often have a combination of these factors producing severe food selectivity for which the above methods can be helpful.
Parents everywhere take feeding their children as one of their highest priorities. Along with empathy for their concern, understanding potential contributing factors and some practical prevention and intervention steps for picky eating can help you partner on what can be a long journey. On a positive note, you can reassure parents that studies also show that picky eaters are less likely to go on to be overweight!
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].