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Infant deaths from birth defects decline, but some disparities widen
according to the Centers for Disease Control and Prevention.
The total rate of IMBD dropped from 12.2 cases per 10,000 live births in 2003 to 11 cases per 10,000 in 2017, with decreases occurring “across the categories of maternal race/ethnicity, infant sex, and infant age at death,” Lynn M. Almli, PhD, of the CDC’s National Center on Birth Defects and Developmental Disabilities and associates wrote in the Morbidity and Mortality Weekly Report.
Rates were down for infants of white non-Hispanic, black non-Hispanic, and Hispanic mothers, but disparities among races/ethnicities persisted or even increased. The IMBD rate for infants born to Hispanic mothers, which was 15% higher than that of infants born to white mothers in 2003, was 26% higher by 2017. The difference between infants born to black mothers and those born to whites rose from 32% in 2003 to 34% in 2017, the investigators reported.
The disparities were even greater among subgroups of infants categorized by gestational age. From 2003 to 2017, IMBD rates dropped by 20% for infants in the youngest group (20-27 weeks), 25% for infants in the oldest group (41-44 weeks), and 29% among those born at 39-40 weeks, they said.
For moderate- and late-preterm infants, however, IMBD rates went up: Infants born at 32-33 weeks and 34-36 weeks each had an increase of 17% over the study period, Dr. Almli and associates noted, based on data from the National Vital Statistics System.
“The observed differences in IMBD rates by race/ethnicity might be influenced by access to and utilization of health care before and during pregnancy, prenatal screening, losses of pregnancies with fetal anomalies, and insurance type,” they wrote, and trends by gestational age “could be influenced by the quantity and quality of care for infants born before 30 weeks’ gestation, compared with that of those born closer to term.”
Birth defects occur in approximately 3% of all births in the United States but accounted for 20% of infant deaths during 2003-2017, the investigators wrote, suggesting that “the results from this analysis can inform future research into areas where efforts to reduce IMBD rates are needed.”
SOURCE: Almli LM et al. MMWR. 2020 Jan 17;69(2):25-9.
according to the Centers for Disease Control and Prevention.
The total rate of IMBD dropped from 12.2 cases per 10,000 live births in 2003 to 11 cases per 10,000 in 2017, with decreases occurring “across the categories of maternal race/ethnicity, infant sex, and infant age at death,” Lynn M. Almli, PhD, of the CDC’s National Center on Birth Defects and Developmental Disabilities and associates wrote in the Morbidity and Mortality Weekly Report.
Rates were down for infants of white non-Hispanic, black non-Hispanic, and Hispanic mothers, but disparities among races/ethnicities persisted or even increased. The IMBD rate for infants born to Hispanic mothers, which was 15% higher than that of infants born to white mothers in 2003, was 26% higher by 2017. The difference between infants born to black mothers and those born to whites rose from 32% in 2003 to 34% in 2017, the investigators reported.
The disparities were even greater among subgroups of infants categorized by gestational age. From 2003 to 2017, IMBD rates dropped by 20% for infants in the youngest group (20-27 weeks), 25% for infants in the oldest group (41-44 weeks), and 29% among those born at 39-40 weeks, they said.
For moderate- and late-preterm infants, however, IMBD rates went up: Infants born at 32-33 weeks and 34-36 weeks each had an increase of 17% over the study period, Dr. Almli and associates noted, based on data from the National Vital Statistics System.
“The observed differences in IMBD rates by race/ethnicity might be influenced by access to and utilization of health care before and during pregnancy, prenatal screening, losses of pregnancies with fetal anomalies, and insurance type,” they wrote, and trends by gestational age “could be influenced by the quantity and quality of care for infants born before 30 weeks’ gestation, compared with that of those born closer to term.”
Birth defects occur in approximately 3% of all births in the United States but accounted for 20% of infant deaths during 2003-2017, the investigators wrote, suggesting that “the results from this analysis can inform future research into areas where efforts to reduce IMBD rates are needed.”
SOURCE: Almli LM et al. MMWR. 2020 Jan 17;69(2):25-9.
according to the Centers for Disease Control and Prevention.
The total rate of IMBD dropped from 12.2 cases per 10,000 live births in 2003 to 11 cases per 10,000 in 2017, with decreases occurring “across the categories of maternal race/ethnicity, infant sex, and infant age at death,” Lynn M. Almli, PhD, of the CDC’s National Center on Birth Defects and Developmental Disabilities and associates wrote in the Morbidity and Mortality Weekly Report.
Rates were down for infants of white non-Hispanic, black non-Hispanic, and Hispanic mothers, but disparities among races/ethnicities persisted or even increased. The IMBD rate for infants born to Hispanic mothers, which was 15% higher than that of infants born to white mothers in 2003, was 26% higher by 2017. The difference between infants born to black mothers and those born to whites rose from 32% in 2003 to 34% in 2017, the investigators reported.
The disparities were even greater among subgroups of infants categorized by gestational age. From 2003 to 2017, IMBD rates dropped by 20% for infants in the youngest group (20-27 weeks), 25% for infants in the oldest group (41-44 weeks), and 29% among those born at 39-40 weeks, they said.
For moderate- and late-preterm infants, however, IMBD rates went up: Infants born at 32-33 weeks and 34-36 weeks each had an increase of 17% over the study period, Dr. Almli and associates noted, based on data from the National Vital Statistics System.
“The observed differences in IMBD rates by race/ethnicity might be influenced by access to and utilization of health care before and during pregnancy, prenatal screening, losses of pregnancies with fetal anomalies, and insurance type,” they wrote, and trends by gestational age “could be influenced by the quantity and quality of care for infants born before 30 weeks’ gestation, compared with that of those born closer to term.”
Birth defects occur in approximately 3% of all births in the United States but accounted for 20% of infant deaths during 2003-2017, the investigators wrote, suggesting that “the results from this analysis can inform future research into areas where efforts to reduce IMBD rates are needed.”
SOURCE: Almli LM et al. MMWR. 2020 Jan 17;69(2):25-9.
FROM MMWR
Family-focused therapy linked to longer remissions in youth at risk for bipolar disorder
A 4-month intensive program of family-focused therapy worked better than a less-intensive program in delaying new mood episodes among young people at risk of developing bipolar disorder, new research shows.
“This study extends the results of other randomized clinical trials indicating effects of family psychoeducation and skill training on the long-term trajectory of depressive symptoms in pediatric mood disorders,” wrote David J. Miklowitz, PhD, of the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, and colleagues. The study was published in JAMA Psychiatry.
For their research, the investigators recruited 127 subjects aged 9-17 years (mean age, 13 years) deemed at high risk for later bipolar I or II disorder for having depression or subthreshold mania along with active mood symptoms and a family history of bipolar disorder. Some 85% of subjects had depression symptoms at enrollment.
Subjects were randomized to 12 sessions over 4 months of family-focused therapy – a psychoeducation, communication, and problem-solving training program incorporating caretakers and also siblings if possible (n = 61) – or to 3 sessions of family-focused therapy and an additional 3 of individual therapy in the same 4-month time frame (n = 66). Medication was allowed for all subjects, and patients were followed for a median 2 years after the intervention. Baseline characteristics, medication use, and dropout rates were similar between the groups.
Both groups saw similarly high rates of new episodes of major depression, mania, or hypomania during follow-up; however, those in the intensive family-focused therapy group saw longer intervals of wellness, with a median 81 weeks (95% confidence interval, 56-123 weeks) from randomization until the first observed mood episode, compared with 63 weeks (95% CI, 44-78 weeks) to an episode for the less-intensive group (P = .03). Dr. Miklowitz and colleagues did not find differences in the severity of mood episodes following either treatment mode or in later conversion to bipolar I or II.
The researchers described as limitations of their study its inability to measure the “temporal relationship between changes in family communication and symptom changes in patients,” which would help answer whether improvements in communication patterns aid symptom regulation, or whether more stable patients are better able to manage difficult family interactions.
Family-focused therapy “may have uniquely enduring effects that extend into the maintenance phase of treatment,” Dr. Miklowitz and colleagues wrote.
The study was funded by the National Institute of Mental Health. Several coauthors, including the lead author, reported receiving research grants from NIMH and other foundations. Two additional coauthors reported receiving pharmaceutical industry funding, including advisory board and consulting fees.
SOURCE: Miklowitz DJ et al. JAMA Psychiatry. 2020 Jan 15. doi: 10.1001/jamapsychiatry.2019.4520.
A 4-month intensive program of family-focused therapy worked better than a less-intensive program in delaying new mood episodes among young people at risk of developing bipolar disorder, new research shows.
“This study extends the results of other randomized clinical trials indicating effects of family psychoeducation and skill training on the long-term trajectory of depressive symptoms in pediatric mood disorders,” wrote David J. Miklowitz, PhD, of the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, and colleagues. The study was published in JAMA Psychiatry.
For their research, the investigators recruited 127 subjects aged 9-17 years (mean age, 13 years) deemed at high risk for later bipolar I or II disorder for having depression or subthreshold mania along with active mood symptoms and a family history of bipolar disorder. Some 85% of subjects had depression symptoms at enrollment.
Subjects were randomized to 12 sessions over 4 months of family-focused therapy – a psychoeducation, communication, and problem-solving training program incorporating caretakers and also siblings if possible (n = 61) – or to 3 sessions of family-focused therapy and an additional 3 of individual therapy in the same 4-month time frame (n = 66). Medication was allowed for all subjects, and patients were followed for a median 2 years after the intervention. Baseline characteristics, medication use, and dropout rates were similar between the groups.
Both groups saw similarly high rates of new episodes of major depression, mania, or hypomania during follow-up; however, those in the intensive family-focused therapy group saw longer intervals of wellness, with a median 81 weeks (95% confidence interval, 56-123 weeks) from randomization until the first observed mood episode, compared with 63 weeks (95% CI, 44-78 weeks) to an episode for the less-intensive group (P = .03). Dr. Miklowitz and colleagues did not find differences in the severity of mood episodes following either treatment mode or in later conversion to bipolar I or II.
The researchers described as limitations of their study its inability to measure the “temporal relationship between changes in family communication and symptom changes in patients,” which would help answer whether improvements in communication patterns aid symptom regulation, or whether more stable patients are better able to manage difficult family interactions.
Family-focused therapy “may have uniquely enduring effects that extend into the maintenance phase of treatment,” Dr. Miklowitz and colleagues wrote.
The study was funded by the National Institute of Mental Health. Several coauthors, including the lead author, reported receiving research grants from NIMH and other foundations. Two additional coauthors reported receiving pharmaceutical industry funding, including advisory board and consulting fees.
SOURCE: Miklowitz DJ et al. JAMA Psychiatry. 2020 Jan 15. doi: 10.1001/jamapsychiatry.2019.4520.
A 4-month intensive program of family-focused therapy worked better than a less-intensive program in delaying new mood episodes among young people at risk of developing bipolar disorder, new research shows.
“This study extends the results of other randomized clinical trials indicating effects of family psychoeducation and skill training on the long-term trajectory of depressive symptoms in pediatric mood disorders,” wrote David J. Miklowitz, PhD, of the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, and colleagues. The study was published in JAMA Psychiatry.
For their research, the investigators recruited 127 subjects aged 9-17 years (mean age, 13 years) deemed at high risk for later bipolar I or II disorder for having depression or subthreshold mania along with active mood symptoms and a family history of bipolar disorder. Some 85% of subjects had depression symptoms at enrollment.
Subjects were randomized to 12 sessions over 4 months of family-focused therapy – a psychoeducation, communication, and problem-solving training program incorporating caretakers and also siblings if possible (n = 61) – or to 3 sessions of family-focused therapy and an additional 3 of individual therapy in the same 4-month time frame (n = 66). Medication was allowed for all subjects, and patients were followed for a median 2 years after the intervention. Baseline characteristics, medication use, and dropout rates were similar between the groups.
Both groups saw similarly high rates of new episodes of major depression, mania, or hypomania during follow-up; however, those in the intensive family-focused therapy group saw longer intervals of wellness, with a median 81 weeks (95% confidence interval, 56-123 weeks) from randomization until the first observed mood episode, compared with 63 weeks (95% CI, 44-78 weeks) to an episode for the less-intensive group (P = .03). Dr. Miklowitz and colleagues did not find differences in the severity of mood episodes following either treatment mode or in later conversion to bipolar I or II.
The researchers described as limitations of their study its inability to measure the “temporal relationship between changes in family communication and symptom changes in patients,” which would help answer whether improvements in communication patterns aid symptom regulation, or whether more stable patients are better able to manage difficult family interactions.
Family-focused therapy “may have uniquely enduring effects that extend into the maintenance phase of treatment,” Dr. Miklowitz and colleagues wrote.
The study was funded by the National Institute of Mental Health. Several coauthors, including the lead author, reported receiving research grants from NIMH and other foundations. Two additional coauthors reported receiving pharmaceutical industry funding, including advisory board and consulting fees.
SOURCE: Miklowitz DJ et al. JAMA Psychiatry. 2020 Jan 15. doi: 10.1001/jamapsychiatry.2019.4520.
FROM JAMA PSYCHIATRY
Anxiety may be a part of healthy development, sometimes
Anxiety is probably the most common behavioral health complaint that presents in the pediatrician’s office. The prevalence of anxiety is going up every year, and we do not have a good understanding why. Is it the pressure to perform at earlier and earlier ages? Is it the press of information or rapid communication of every disaster on Earth? Or are children not developing appropriate coping skills for the expectable challenges and stresses they will face through development? We do not know.
Anxiety disorders are most likely to present in the early school years – latency – between the ages of 6 and 12 years. Teenagers may present with new anxiety disorders or may disclose symptoms that they have been quietly managing since they were younger, when they were thought to be “shy.” These disorders include separation anxiety disorder, social phobia, selective mutism, specific phobia, and generalized anxiety disorder. This age period also is marked by high levels of normal anxiety because children’s cognitive development has advanced beyond their emotional development. They are capable of logic, can understand cause and effect, and can appreciate the passage of time and serious matters such as the permanence of death. Gone is the magical thinking of the preschool years! When an elementary student learns about global warming or a refugee crisis, they can fully appreciate the serious implications of the subject. What they lack is experience with tolerating uncertainty and worry and proceeding with life, focusing on what they might address or even bearing the fact that life is sometimes unfair. This mismatch of relative cognitive maturity with emotional immaturity can lead to anxiety and distress. This is particularly true as they face these challenges while they have new independence, spending longer days at school and less time with parents. Bearing this distress with caring adults, learning to focus on what they can do, and discovering that they and the world can go on even when something very unfair has happened is central to how they develop emotional maturity.
How a child learns to manage anxiety is very much determined by how their parents manage anxiety and how well their parents can tolerate their children’s distress. A parent who becomes overwhelmed when their child is upset about missing a goal in soccer will have a difficult time helping their child learn how to manage distress. And children who are facing chronic severe stress, such as poverty, domestic violence, or chronic illness in a parent, are facing the double challenge of managing persistent anxiety that may be impairing their parents’ ability to support them. When the child and their family are connected to a community that has not been able to effectively respond to larger problems, such as creating safe schools or neighborhoods, anxiety can become entrenched in despair.
It often is tempting to jump in with reassurance when your patient or their parents present with anxiety. But when you calmly show curiosity, you model tolerance of their distress. Are they fearful about very specific situations, such as being called on in class? Or do they become dysregulated when facing a separation from their parents, such as at bedtime or before school, seeking contact with their parents with endless questions? Find out how the parents are managing separations and whether they may be inadvertently rewarding by staying with them to negotiate or answer endless questions. Find out if parents may be accommodating anxiety by allowing their children to avoid normal situations that are stirring anxiety. Do they give in anytime their child shows resistance or have they learned to pick their battles and help their children face more-modest stress while avoiding only the most intensely anxious situations? Are the parents able to speak calmly and with good humor about these challenges or do they become very stressed and defensive? Is there a family history of anxiety? Managing a child’s anxiety every day can be exhausting, and parents might need a referral in addition to a discussion about how anxiety is developmentally normal.
For those parents that can manage this discussion, suggest that, like you, if they can remain calm during these times with their child (even if they don’t feel calm), it will help their child get better at managing anxiety, even if their child has an anxiety disorder. They also should be curious about their child’s worries, learning about the details and scenarios their children may be anticipating. They should express compassion about how uncomfortable anxiety is, coupled with their confident belief that the child will be able to tolerate and manage the situation even though it’s uncomfortable. This acknowledgment should not be a dismissal of the anxiety, instead it should be confidence that the child will learn to bear it.
When your patient is a teenager describing anxiety, unpack. Are they anxious about their performance on their five Advanced Placement exams? If their anxiety sounds more like appropriate stress, be compassionate and then curious about how they are learning to relax. Are they using drugs and alcohol? Or have they found healthy ways to unwind and recharge? Focusing on ways in which they are learning to care for themselves, making time for sleep and exercise, live time with friends, and senseless fun is therapeutic. Find out if their parents are supportive of their self-care. You might even give them a prescription!
Anxiety is often a private experience, and parents might not know about it until it presents with an explosion of distress or obstinacy when an anxious child is pushed into scary territory. Asking questions about specific worries (something happening to parents, germs, weather events) can illuminate the extent of anxiety. It also is worth exploring if there are rituals that help them manage their worries, whether they are common (finding a parent, hugging a pet, prayer) or more compulsive (repetitive undoing, hair pulling). Find out if there has recently been any serious stress or change for the family, such as the loss of a job or illness in a grandparent, that may be contributing to a child’s anxiety.
Anytime you see anxieties that are broad or extreme, disrupt their ability to function (go to school, participate in activities, build friendships), or if their parents are clearly struggling with managing their child’s distress, it is worthwhile to find a referral to a psychiatrist or psychologist for evaluation and further treatment. School avoidance constitutes an urgent need for evaluation, as every day of school missed makes it harder for the child to return to school. For all of your anxious patients, even when you make a referral to a psychiatrist for evaluation, teach your patients and parents about how critical adequate sleep and regular exercise are to managing anxiety. Remind them that an appropriate level of anxiety is normal and promotes performance and grit, despite the discomfort, and that learning how to manage anxiety is essential to growing up and building mental health.
Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
Anxiety is probably the most common behavioral health complaint that presents in the pediatrician’s office. The prevalence of anxiety is going up every year, and we do not have a good understanding why. Is it the pressure to perform at earlier and earlier ages? Is it the press of information or rapid communication of every disaster on Earth? Or are children not developing appropriate coping skills for the expectable challenges and stresses they will face through development? We do not know.
Anxiety disorders are most likely to present in the early school years – latency – between the ages of 6 and 12 years. Teenagers may present with new anxiety disorders or may disclose symptoms that they have been quietly managing since they were younger, when they were thought to be “shy.” These disorders include separation anxiety disorder, social phobia, selective mutism, specific phobia, and generalized anxiety disorder. This age period also is marked by high levels of normal anxiety because children’s cognitive development has advanced beyond their emotional development. They are capable of logic, can understand cause and effect, and can appreciate the passage of time and serious matters such as the permanence of death. Gone is the magical thinking of the preschool years! When an elementary student learns about global warming or a refugee crisis, they can fully appreciate the serious implications of the subject. What they lack is experience with tolerating uncertainty and worry and proceeding with life, focusing on what they might address or even bearing the fact that life is sometimes unfair. This mismatch of relative cognitive maturity with emotional immaturity can lead to anxiety and distress. This is particularly true as they face these challenges while they have new independence, spending longer days at school and less time with parents. Bearing this distress with caring adults, learning to focus on what they can do, and discovering that they and the world can go on even when something very unfair has happened is central to how they develop emotional maturity.
How a child learns to manage anxiety is very much determined by how their parents manage anxiety and how well their parents can tolerate their children’s distress. A parent who becomes overwhelmed when their child is upset about missing a goal in soccer will have a difficult time helping their child learn how to manage distress. And children who are facing chronic severe stress, such as poverty, domestic violence, or chronic illness in a parent, are facing the double challenge of managing persistent anxiety that may be impairing their parents’ ability to support them. When the child and their family are connected to a community that has not been able to effectively respond to larger problems, such as creating safe schools or neighborhoods, anxiety can become entrenched in despair.
It often is tempting to jump in with reassurance when your patient or their parents present with anxiety. But when you calmly show curiosity, you model tolerance of their distress. Are they fearful about very specific situations, such as being called on in class? Or do they become dysregulated when facing a separation from their parents, such as at bedtime or before school, seeking contact with their parents with endless questions? Find out how the parents are managing separations and whether they may be inadvertently rewarding by staying with them to negotiate or answer endless questions. Find out if parents may be accommodating anxiety by allowing their children to avoid normal situations that are stirring anxiety. Do they give in anytime their child shows resistance or have they learned to pick their battles and help their children face more-modest stress while avoiding only the most intensely anxious situations? Are the parents able to speak calmly and with good humor about these challenges or do they become very stressed and defensive? Is there a family history of anxiety? Managing a child’s anxiety every day can be exhausting, and parents might need a referral in addition to a discussion about how anxiety is developmentally normal.
For those parents that can manage this discussion, suggest that, like you, if they can remain calm during these times with their child (even if they don’t feel calm), it will help their child get better at managing anxiety, even if their child has an anxiety disorder. They also should be curious about their child’s worries, learning about the details and scenarios their children may be anticipating. They should express compassion about how uncomfortable anxiety is, coupled with their confident belief that the child will be able to tolerate and manage the situation even though it’s uncomfortable. This acknowledgment should not be a dismissal of the anxiety, instead it should be confidence that the child will learn to bear it.
When your patient is a teenager describing anxiety, unpack. Are they anxious about their performance on their five Advanced Placement exams? If their anxiety sounds more like appropriate stress, be compassionate and then curious about how they are learning to relax. Are they using drugs and alcohol? Or have they found healthy ways to unwind and recharge? Focusing on ways in which they are learning to care for themselves, making time for sleep and exercise, live time with friends, and senseless fun is therapeutic. Find out if their parents are supportive of their self-care. You might even give them a prescription!
Anxiety is often a private experience, and parents might not know about it until it presents with an explosion of distress or obstinacy when an anxious child is pushed into scary territory. Asking questions about specific worries (something happening to parents, germs, weather events) can illuminate the extent of anxiety. It also is worth exploring if there are rituals that help them manage their worries, whether they are common (finding a parent, hugging a pet, prayer) or more compulsive (repetitive undoing, hair pulling). Find out if there has recently been any serious stress or change for the family, such as the loss of a job or illness in a grandparent, that may be contributing to a child’s anxiety.
Anytime you see anxieties that are broad or extreme, disrupt their ability to function (go to school, participate in activities, build friendships), or if their parents are clearly struggling with managing their child’s distress, it is worthwhile to find a referral to a psychiatrist or psychologist for evaluation and further treatment. School avoidance constitutes an urgent need for evaluation, as every day of school missed makes it harder for the child to return to school. For all of your anxious patients, even when you make a referral to a psychiatrist for evaluation, teach your patients and parents about how critical adequate sleep and regular exercise are to managing anxiety. Remind them that an appropriate level of anxiety is normal and promotes performance and grit, despite the discomfort, and that learning how to manage anxiety is essential to growing up and building mental health.
Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
Anxiety is probably the most common behavioral health complaint that presents in the pediatrician’s office. The prevalence of anxiety is going up every year, and we do not have a good understanding why. Is it the pressure to perform at earlier and earlier ages? Is it the press of information or rapid communication of every disaster on Earth? Or are children not developing appropriate coping skills for the expectable challenges and stresses they will face through development? We do not know.
Anxiety disorders are most likely to present in the early school years – latency – between the ages of 6 and 12 years. Teenagers may present with new anxiety disorders or may disclose symptoms that they have been quietly managing since they were younger, when they were thought to be “shy.” These disorders include separation anxiety disorder, social phobia, selective mutism, specific phobia, and generalized anxiety disorder. This age period also is marked by high levels of normal anxiety because children’s cognitive development has advanced beyond their emotional development. They are capable of logic, can understand cause and effect, and can appreciate the passage of time and serious matters such as the permanence of death. Gone is the magical thinking of the preschool years! When an elementary student learns about global warming or a refugee crisis, they can fully appreciate the serious implications of the subject. What they lack is experience with tolerating uncertainty and worry and proceeding with life, focusing on what they might address or even bearing the fact that life is sometimes unfair. This mismatch of relative cognitive maturity with emotional immaturity can lead to anxiety and distress. This is particularly true as they face these challenges while they have new independence, spending longer days at school and less time with parents. Bearing this distress with caring adults, learning to focus on what they can do, and discovering that they and the world can go on even when something very unfair has happened is central to how they develop emotional maturity.
How a child learns to manage anxiety is very much determined by how their parents manage anxiety and how well their parents can tolerate their children’s distress. A parent who becomes overwhelmed when their child is upset about missing a goal in soccer will have a difficult time helping their child learn how to manage distress. And children who are facing chronic severe stress, such as poverty, domestic violence, or chronic illness in a parent, are facing the double challenge of managing persistent anxiety that may be impairing their parents’ ability to support them. When the child and their family are connected to a community that has not been able to effectively respond to larger problems, such as creating safe schools or neighborhoods, anxiety can become entrenched in despair.
It often is tempting to jump in with reassurance when your patient or their parents present with anxiety. But when you calmly show curiosity, you model tolerance of their distress. Are they fearful about very specific situations, such as being called on in class? Or do they become dysregulated when facing a separation from their parents, such as at bedtime or before school, seeking contact with their parents with endless questions? Find out how the parents are managing separations and whether they may be inadvertently rewarding by staying with them to negotiate or answer endless questions. Find out if parents may be accommodating anxiety by allowing their children to avoid normal situations that are stirring anxiety. Do they give in anytime their child shows resistance or have they learned to pick their battles and help their children face more-modest stress while avoiding only the most intensely anxious situations? Are the parents able to speak calmly and with good humor about these challenges or do they become very stressed and defensive? Is there a family history of anxiety? Managing a child’s anxiety every day can be exhausting, and parents might need a referral in addition to a discussion about how anxiety is developmentally normal.
For those parents that can manage this discussion, suggest that, like you, if they can remain calm during these times with their child (even if they don’t feel calm), it will help their child get better at managing anxiety, even if their child has an anxiety disorder. They also should be curious about their child’s worries, learning about the details and scenarios their children may be anticipating. They should express compassion about how uncomfortable anxiety is, coupled with their confident belief that the child will be able to tolerate and manage the situation even though it’s uncomfortable. This acknowledgment should not be a dismissal of the anxiety, instead it should be confidence that the child will learn to bear it.
When your patient is a teenager describing anxiety, unpack. Are they anxious about their performance on their five Advanced Placement exams? If their anxiety sounds more like appropriate stress, be compassionate and then curious about how they are learning to relax. Are they using drugs and alcohol? Or have they found healthy ways to unwind and recharge? Focusing on ways in which they are learning to care for themselves, making time for sleep and exercise, live time with friends, and senseless fun is therapeutic. Find out if their parents are supportive of their self-care. You might even give them a prescription!
Anxiety is often a private experience, and parents might not know about it until it presents with an explosion of distress or obstinacy when an anxious child is pushed into scary territory. Asking questions about specific worries (something happening to parents, germs, weather events) can illuminate the extent of anxiety. It also is worth exploring if there are rituals that help them manage their worries, whether they are common (finding a parent, hugging a pet, prayer) or more compulsive (repetitive undoing, hair pulling). Find out if there has recently been any serious stress or change for the family, such as the loss of a job or illness in a grandparent, that may be contributing to a child’s anxiety.
Anytime you see anxieties that are broad or extreme, disrupt their ability to function (go to school, participate in activities, build friendships), or if their parents are clearly struggling with managing their child’s distress, it is worthwhile to find a referral to a psychiatrist or psychologist for evaluation and further treatment. School avoidance constitutes an urgent need for evaluation, as every day of school missed makes it harder for the child to return to school. For all of your anxious patients, even when you make a referral to a psychiatrist for evaluation, teach your patients and parents about how critical adequate sleep and regular exercise are to managing anxiety. Remind them that an appropriate level of anxiety is normal and promotes performance and grit, despite the discomfort, and that learning how to manage anxiety is essential to growing up and building mental health.
Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
Runaway youth: Knowing the risk factors and care needs
As many as 1 in 20 youth run away from home each year, and you can play a critical role in identifying adolescents at high risk through confidential social histories and discussions, according to a clinical report from the American Academy of Pediatrics.
The academy’s data-rich report, “Runaway Youth: Caring for the Nation’s Largest Segment of Missing Children,” details how unaccompanied youth who run away – either on their own or who are asked to leave home – have high rates of trauma and neglect, mental illness, substance abuse, family dysfunction, and disengagement from school.
Children who identify as lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) and youth in protective custody also are at high risk of running away and of becoming homeless – and once away from home, they and other runaways are at high risk for additional trauma, victimization, and violence, including sexual exploitation, according to the report published in Pediatrics.
“There clearly are certain populations at higher risk, and we really need to be aware of and in tune with these risks, and ask about the home and the household in order to try to decrease the risk of these kids getting into dangerous situations,” Thresia B. Gambon, MD, said in an interview. She is coauthor of the report and a pediatrician with the Citrus Health Network in Miami.
Among the AAP’s recommendations for practice is the guidance to conduct a thorough and confidential psychosocial assessment such as the HEEADSSS assessment (home environment, education and employment, eating peer-related activities, drugs, sexuality, suicide/depression, and safety) and to use a validated depression screening tool for adolescents, such as the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI).
Broadly speaking, which involves being aware of trauma and adverse childhood experiences that can affect health,” according to the report. The AAP Trauma Toolbox for Primary Care is mentioned as a resource.
Most surprising to Dr. Gambon in the research and report-writing process were data showing that disengagement from school is a significant risk factor. “This stood out to me,” she said. “If there are school problems [of various types], kids might run away to avoid attending school.”
Tasked with updating the AAP’s 2004 clinical report, “The Pediatrician’s Role in the Prevention of Missing Children,” Dr. Gambon and coauthor, Janna R. Gewirtz O’Brien, MD, decided to look more closely at runaway youth after studying the numbers – some studies estimate that between 5% and 8% of adolescents run away every year. They saw that, “in general, the number of kids who just go missing has actually decreased [with the help of] cell phones,” Dr. Gambon said in an interview.
“The numbers of kids who are actually running away are high,” she said, “and probably we’re underidentifying these in our primary care clinics.”
Because a significant number of runaway youth become homeless, data on the homeless offers a valuable window not only into the health risks of homelessness for teens (substance abuse, pregnancy, STDs,) but also into risk factors for leaving home in the first place, she noted. Research shows, for instance, that about 20%-40% of teenagers who are homeless identify as LGBTQ, compared with 4%-10% of their nonhomeless peers.
When an adolescent at high risk for running away is identified, you should use practice- and community-based resources to address key issues, support psychological and behavioral health needs of the child and family, and ensure safety.
For youth who have run away, you can share information on local resources, as well as the national Runaway Safeline (1-800-RUNAWAY), which provides 24-hour referrals to community resources, including shelter, food banks, social services, and counseling. You also can ask adolescents whether they have sources of support and shelter (safe, supportive adults who might help in a crisis), and discuss safety plans for leaving home that include health care to mitigate risk, such as reliable contraception and access to mental health care.
“The goal with talking about a safety plan isn’t, of course, to encourage a child to run away, but if they feel as if they need to find somewhere else to live or stay, to discuss what resources are available to them to try to keep them as safe as possible when they’re out of their home,” Dr. Gambon said.
Dr. Gambon speaks partly from experience. She works routinely with youth who have run away from foster care homes, youth who have been trafficked, and other runaways. “I always try to talk with them about safety. I try not to put them down for their decisions but to work with them to make better decisions,” she said. “I work closely with a psychologist because a big part of this is getting them to have self-worth. They often feel as if no one cares, and some just want to be heard and to be able to talk about their situations.”
The AAP report notes that, of more than 70,000 contacts made to Runaway Safeline in 2017, 31% were about youth who were contemplating running away, 16% were about youth who had run away, 5% were about youth asked to leave home or prevented from returning, and 9% concerned youth experiencing homelessness. About three-quarters of the calls came from the youth themselves.
Dr. Gambon and Dr. Gewirtz O’Brien, of the department of pediatrics at the University of Minnesota in Minneapolis, worked with the AAP Committee on Psychosocial Aspects of Child and Family Health and the AAP Council on Community Pediatrics in producing the report. There was no external funding for this report and the authors said they had no conflicts of interest.
SOURCE: Gambon TB et al. Pediatrics. 2020 Jan 21. doi: 10.1542/peds.2019-3752.
As many as 1 in 20 youth run away from home each year, and you can play a critical role in identifying adolescents at high risk through confidential social histories and discussions, according to a clinical report from the American Academy of Pediatrics.
The academy’s data-rich report, “Runaway Youth: Caring for the Nation’s Largest Segment of Missing Children,” details how unaccompanied youth who run away – either on their own or who are asked to leave home – have high rates of trauma and neglect, mental illness, substance abuse, family dysfunction, and disengagement from school.
Children who identify as lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) and youth in protective custody also are at high risk of running away and of becoming homeless – and once away from home, they and other runaways are at high risk for additional trauma, victimization, and violence, including sexual exploitation, according to the report published in Pediatrics.
“There clearly are certain populations at higher risk, and we really need to be aware of and in tune with these risks, and ask about the home and the household in order to try to decrease the risk of these kids getting into dangerous situations,” Thresia B. Gambon, MD, said in an interview. She is coauthor of the report and a pediatrician with the Citrus Health Network in Miami.
Among the AAP’s recommendations for practice is the guidance to conduct a thorough and confidential psychosocial assessment such as the HEEADSSS assessment (home environment, education and employment, eating peer-related activities, drugs, sexuality, suicide/depression, and safety) and to use a validated depression screening tool for adolescents, such as the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI).
Broadly speaking, which involves being aware of trauma and adverse childhood experiences that can affect health,” according to the report. The AAP Trauma Toolbox for Primary Care is mentioned as a resource.
Most surprising to Dr. Gambon in the research and report-writing process were data showing that disengagement from school is a significant risk factor. “This stood out to me,” she said. “If there are school problems [of various types], kids might run away to avoid attending school.”
Tasked with updating the AAP’s 2004 clinical report, “The Pediatrician’s Role in the Prevention of Missing Children,” Dr. Gambon and coauthor, Janna R. Gewirtz O’Brien, MD, decided to look more closely at runaway youth after studying the numbers – some studies estimate that between 5% and 8% of adolescents run away every year. They saw that, “in general, the number of kids who just go missing has actually decreased [with the help of] cell phones,” Dr. Gambon said in an interview.
“The numbers of kids who are actually running away are high,” she said, “and probably we’re underidentifying these in our primary care clinics.”
Because a significant number of runaway youth become homeless, data on the homeless offers a valuable window not only into the health risks of homelessness for teens (substance abuse, pregnancy, STDs,) but also into risk factors for leaving home in the first place, she noted. Research shows, for instance, that about 20%-40% of teenagers who are homeless identify as LGBTQ, compared with 4%-10% of their nonhomeless peers.
When an adolescent at high risk for running away is identified, you should use practice- and community-based resources to address key issues, support psychological and behavioral health needs of the child and family, and ensure safety.
For youth who have run away, you can share information on local resources, as well as the national Runaway Safeline (1-800-RUNAWAY), which provides 24-hour referrals to community resources, including shelter, food banks, social services, and counseling. You also can ask adolescents whether they have sources of support and shelter (safe, supportive adults who might help in a crisis), and discuss safety plans for leaving home that include health care to mitigate risk, such as reliable contraception and access to mental health care.
“The goal with talking about a safety plan isn’t, of course, to encourage a child to run away, but if they feel as if they need to find somewhere else to live or stay, to discuss what resources are available to them to try to keep them as safe as possible when they’re out of their home,” Dr. Gambon said.
Dr. Gambon speaks partly from experience. She works routinely with youth who have run away from foster care homes, youth who have been trafficked, and other runaways. “I always try to talk with them about safety. I try not to put them down for their decisions but to work with them to make better decisions,” she said. “I work closely with a psychologist because a big part of this is getting them to have self-worth. They often feel as if no one cares, and some just want to be heard and to be able to talk about their situations.”
The AAP report notes that, of more than 70,000 contacts made to Runaway Safeline in 2017, 31% were about youth who were contemplating running away, 16% were about youth who had run away, 5% were about youth asked to leave home or prevented from returning, and 9% concerned youth experiencing homelessness. About three-quarters of the calls came from the youth themselves.
Dr. Gambon and Dr. Gewirtz O’Brien, of the department of pediatrics at the University of Minnesota in Minneapolis, worked with the AAP Committee on Psychosocial Aspects of Child and Family Health and the AAP Council on Community Pediatrics in producing the report. There was no external funding for this report and the authors said they had no conflicts of interest.
SOURCE: Gambon TB et al. Pediatrics. 2020 Jan 21. doi: 10.1542/peds.2019-3752.
As many as 1 in 20 youth run away from home each year, and you can play a critical role in identifying adolescents at high risk through confidential social histories and discussions, according to a clinical report from the American Academy of Pediatrics.
The academy’s data-rich report, “Runaway Youth: Caring for the Nation’s Largest Segment of Missing Children,” details how unaccompanied youth who run away – either on their own or who are asked to leave home – have high rates of trauma and neglect, mental illness, substance abuse, family dysfunction, and disengagement from school.
Children who identify as lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) and youth in protective custody also are at high risk of running away and of becoming homeless – and once away from home, they and other runaways are at high risk for additional trauma, victimization, and violence, including sexual exploitation, according to the report published in Pediatrics.
“There clearly are certain populations at higher risk, and we really need to be aware of and in tune with these risks, and ask about the home and the household in order to try to decrease the risk of these kids getting into dangerous situations,” Thresia B. Gambon, MD, said in an interview. She is coauthor of the report and a pediatrician with the Citrus Health Network in Miami.
Among the AAP’s recommendations for practice is the guidance to conduct a thorough and confidential psychosocial assessment such as the HEEADSSS assessment (home environment, education and employment, eating peer-related activities, drugs, sexuality, suicide/depression, and safety) and to use a validated depression screening tool for adolescents, such as the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI).
Broadly speaking, which involves being aware of trauma and adverse childhood experiences that can affect health,” according to the report. The AAP Trauma Toolbox for Primary Care is mentioned as a resource.
Most surprising to Dr. Gambon in the research and report-writing process were data showing that disengagement from school is a significant risk factor. “This stood out to me,” she said. “If there are school problems [of various types], kids might run away to avoid attending school.”
Tasked with updating the AAP’s 2004 clinical report, “The Pediatrician’s Role in the Prevention of Missing Children,” Dr. Gambon and coauthor, Janna R. Gewirtz O’Brien, MD, decided to look more closely at runaway youth after studying the numbers – some studies estimate that between 5% and 8% of adolescents run away every year. They saw that, “in general, the number of kids who just go missing has actually decreased [with the help of] cell phones,” Dr. Gambon said in an interview.
“The numbers of kids who are actually running away are high,” she said, “and probably we’re underidentifying these in our primary care clinics.”
Because a significant number of runaway youth become homeless, data on the homeless offers a valuable window not only into the health risks of homelessness for teens (substance abuse, pregnancy, STDs,) but also into risk factors for leaving home in the first place, she noted. Research shows, for instance, that about 20%-40% of teenagers who are homeless identify as LGBTQ, compared with 4%-10% of their nonhomeless peers.
When an adolescent at high risk for running away is identified, you should use practice- and community-based resources to address key issues, support psychological and behavioral health needs of the child and family, and ensure safety.
For youth who have run away, you can share information on local resources, as well as the national Runaway Safeline (1-800-RUNAWAY), which provides 24-hour referrals to community resources, including shelter, food banks, social services, and counseling. You also can ask adolescents whether they have sources of support and shelter (safe, supportive adults who might help in a crisis), and discuss safety plans for leaving home that include health care to mitigate risk, such as reliable contraception and access to mental health care.
“The goal with talking about a safety plan isn’t, of course, to encourage a child to run away, but if they feel as if they need to find somewhere else to live or stay, to discuss what resources are available to them to try to keep them as safe as possible when they’re out of their home,” Dr. Gambon said.
Dr. Gambon speaks partly from experience. She works routinely with youth who have run away from foster care homes, youth who have been trafficked, and other runaways. “I always try to talk with them about safety. I try not to put them down for their decisions but to work with them to make better decisions,” she said. “I work closely with a psychologist because a big part of this is getting them to have self-worth. They often feel as if no one cares, and some just want to be heard and to be able to talk about their situations.”
The AAP report notes that, of more than 70,000 contacts made to Runaway Safeline in 2017, 31% were about youth who were contemplating running away, 16% were about youth who had run away, 5% were about youth asked to leave home or prevented from returning, and 9% concerned youth experiencing homelessness. About three-quarters of the calls came from the youth themselves.
Dr. Gambon and Dr. Gewirtz O’Brien, of the department of pediatrics at the University of Minnesota in Minneapolis, worked with the AAP Committee on Psychosocial Aspects of Child and Family Health and the AAP Council on Community Pediatrics in producing the report. There was no external funding for this report and the authors said they had no conflicts of interest.
SOURCE: Gambon TB et al. Pediatrics. 2020 Jan 21. doi: 10.1542/peds.2019-3752.
FROM PEDIATRICS
Flu activity declines for second straight week
Flu activity dropped nationally for a second consecutive week, but the changing predominance in type from influenza B to A suggests that “it is too early to know whether the season has peaked,” the Centers for Disease Control and Prevention said Jan. 17.
Patients with influenza-like illness (ILI) dropped from 5.7% to 4.7% of all visits to outpatient providers for the week ending Jan. 11, and the proportion of respiratory specimens positive for influenza decreased from 23.6% the week before to 22.9%, the CDC’s influenza division reported.
Despite that overall drop in positive specimens, however, “the percent positive for influenza A viruses increased and some regions are seeing increases in the proportion of influenza A(H1N1)pdm09 viruses compared to other influenza viruses,” the influenza division noted.
Outpatient activity on the state level also was down for the week. There were 23 jurisdictions – 21 states, New York City, and Puerto Rico – at level 10 on the CDC’s 1-10 scale of ILI activity for the week ending Jan. 11, compared with 33 the previous week, data from the CDC’s Outpatient Influenza-like Illness Surveillance Network show.
Indicators of ILI severity have not risen to high levels. “The percentage of deaths attributed to pneumonia and influenza increased from 6.0% to 6.9% but remains below the epidemic threshold” of 7.0% for the week, and the hospitalization rate remains at a fairly typical level for this time of year, the influenza division said.
For the week ending Jan. 11, 7 new ILI-related pediatric deaths were reported, which brings the total to 39 for the 2019-2020 season. Children aged 0-4 years are the second-most likely age group to be hospitalized with the flu (34.4/100,000 population) after adults aged 65 years and older, who have a cumulative rate of 47.6/100,000 for the season, the CDC reported.
Flu activity dropped nationally for a second consecutive week, but the changing predominance in type from influenza B to A suggests that “it is too early to know whether the season has peaked,” the Centers for Disease Control and Prevention said Jan. 17.
Patients with influenza-like illness (ILI) dropped from 5.7% to 4.7% of all visits to outpatient providers for the week ending Jan. 11, and the proportion of respiratory specimens positive for influenza decreased from 23.6% the week before to 22.9%, the CDC’s influenza division reported.
Despite that overall drop in positive specimens, however, “the percent positive for influenza A viruses increased and some regions are seeing increases in the proportion of influenza A(H1N1)pdm09 viruses compared to other influenza viruses,” the influenza division noted.
Outpatient activity on the state level also was down for the week. There were 23 jurisdictions – 21 states, New York City, and Puerto Rico – at level 10 on the CDC’s 1-10 scale of ILI activity for the week ending Jan. 11, compared with 33 the previous week, data from the CDC’s Outpatient Influenza-like Illness Surveillance Network show.
Indicators of ILI severity have not risen to high levels. “The percentage of deaths attributed to pneumonia and influenza increased from 6.0% to 6.9% but remains below the epidemic threshold” of 7.0% for the week, and the hospitalization rate remains at a fairly typical level for this time of year, the influenza division said.
For the week ending Jan. 11, 7 new ILI-related pediatric deaths were reported, which brings the total to 39 for the 2019-2020 season. Children aged 0-4 years are the second-most likely age group to be hospitalized with the flu (34.4/100,000 population) after adults aged 65 years and older, who have a cumulative rate of 47.6/100,000 for the season, the CDC reported.
Flu activity dropped nationally for a second consecutive week, but the changing predominance in type from influenza B to A suggests that “it is too early to know whether the season has peaked,” the Centers for Disease Control and Prevention said Jan. 17.
Patients with influenza-like illness (ILI) dropped from 5.7% to 4.7% of all visits to outpatient providers for the week ending Jan. 11, and the proportion of respiratory specimens positive for influenza decreased from 23.6% the week before to 22.9%, the CDC’s influenza division reported.
Despite that overall drop in positive specimens, however, “the percent positive for influenza A viruses increased and some regions are seeing increases in the proportion of influenza A(H1N1)pdm09 viruses compared to other influenza viruses,” the influenza division noted.
Outpatient activity on the state level also was down for the week. There were 23 jurisdictions – 21 states, New York City, and Puerto Rico – at level 10 on the CDC’s 1-10 scale of ILI activity for the week ending Jan. 11, compared with 33 the previous week, data from the CDC’s Outpatient Influenza-like Illness Surveillance Network show.
Indicators of ILI severity have not risen to high levels. “The percentage of deaths attributed to pneumonia and influenza increased from 6.0% to 6.9% but remains below the epidemic threshold” of 7.0% for the week, and the hospitalization rate remains at a fairly typical level for this time of year, the influenza division said.
For the week ending Jan. 11, 7 new ILI-related pediatric deaths were reported, which brings the total to 39 for the 2019-2020 season. Children aged 0-4 years are the second-most likely age group to be hospitalized with the flu (34.4/100,000 population) after adults aged 65 years and older, who have a cumulative rate of 47.6/100,000 for the season, the CDC reported.
Children with resistant UTIs unexpectedly may respond to discordant antibiotics
Children with urinary tract infections (UTIs) may improve clinically, and pyuria may resolve, during empiric treatment with an antibiotic that turns out to be discordant, according a retrospective study in Pediatrics.
“The low rate of care escalation and high rate of clinical improvement while on discordant antibiotics suggests that, for most patients, it would be reasonable to continue current empiric antibiotic practices until urine culture sensitivities return,” said first author Marie E. Wang, MD, a pediatric hospitalist at Stanford (Calif.) University, and colleagues.
The researchers examined the initial clinical response and escalation of care for 316 children with UTIs who received therapy to which the infecting isolate was not susceptible. The study included patients who had infections that were resistant to third-generation cephalosporins – that is, urinalysis found that the infections were not susceptible to ceftriaxone or cefotaxime in vitro. Before the resistant organisms were identified, however, the patients were started on discordant antibiotics.
Escalation of care was uncommon
The patients had a median age of 2.4 years, and 78% were girls. Approximately 90% were started on a cephalosporin, and about 65% received a first-generation cephalosporin. Patients presented during 2012-2017 to one of five children’s hospitals or to a large managed care organization with 10 hospitals in the United States. The investigators defined care escalation as a visit to the emergency department, hospitalization, or transfer to the ICU.
In all, seven patients (2%) had escalation of care on discordant antibiotics. Four children visited an emergency department without hospitalization, and three children were hospitalized because of persistent symptoms.
Among 230 cases for which the researchers had data about clinical response at a median follow-up of 3 days, 84% “had overall clinical improvement while on discordant antibiotics,” the authors said.
For 22 children who had repeat urine testing while on discordant antibiotics, 53% had resolution of pyuria, and 32% had improvement of pyuria, whereas 16% did not have improvement. Of the three patients without improvement, one had no change, and two had worsening.
Of 17 patients who had a repeat urine culture on discordant therapy, 65% had a negative repeat culture, and 18% grew the same pathogen with a decreased colony count. Two patients had a colony count that remained unchanged, and one patient had an increased colony count.
Small studies outside the United States have reported similar results, the researchers noted. Spontaneous resolution of UTIs or antibiotics reaching a sufficient concentration in the urine and renal parenchyma to achieve a clinical response are possible explanations for the findings, they wrote.
“Few children required escalation of care and most experienced initial clinical improvement,” noted Dr. Wang and colleagues. “Furthermore, in the small group of children that underwent repeat urine testing while on discordant therapy, most had resolution or improvement in pyuria and sterilization of their urine cultures. Our findings suggest that Additionally, given that these patients initially received what would generally be considered inadequate treatment, our findings may provide some insight into the natural history of UTIs and/or trigger further investigation into the relationship between in vitro urine culture susceptibilities and in vivo clinical response to treatment.”
‘Caution is needed’
The study “highlights an intriguing observation about children with UTIs unexpectedly responding to discordant antibiotic therapy,” Tej K. Mattoo, MD, and Basim I. Asmar, MD, wrote in an accompanying commentary.(doi: 10.1542/peds.2019-3512). Dr. Mattoo and Dr. Asmar, a pediatric nephrologist and a specialist in pediatric infectious diseases, respectively, at Wayne State University and affiliated with Children’s Hospital of Michigan, both in Detroit.
In an inpatient setting, it may be easy for physicians to reassess patients “once urine culture results reveal resistance to the treating antibiotic,” they noted. In an ambulatory setting, however, “it is likely that some patients will receive a full course of an antibiotic that does not have in vitro activity against the urinary pathogen.”
Physicians have a responsibility to use antibiotics judiciously, they said. Widely accepted principles include avoiding repeated courses of antibiotics, diagnosing UTIs appropriately, and not treating asymptomatic bacteriuria.
The study had no external funding. The authors had no relevant financial disclosures.
SOURCE: Wang ME et al. Pediatrics. 2020 Jan 17. doi: 10.1542/peds.2019-1608.
This article was updated 2/4/2020.
Children with urinary tract infections (UTIs) may improve clinically, and pyuria may resolve, during empiric treatment with an antibiotic that turns out to be discordant, according a retrospective study in Pediatrics.
“The low rate of care escalation and high rate of clinical improvement while on discordant antibiotics suggests that, for most patients, it would be reasonable to continue current empiric antibiotic practices until urine culture sensitivities return,” said first author Marie E. Wang, MD, a pediatric hospitalist at Stanford (Calif.) University, and colleagues.
The researchers examined the initial clinical response and escalation of care for 316 children with UTIs who received therapy to which the infecting isolate was not susceptible. The study included patients who had infections that were resistant to third-generation cephalosporins – that is, urinalysis found that the infections were not susceptible to ceftriaxone or cefotaxime in vitro. Before the resistant organisms were identified, however, the patients were started on discordant antibiotics.
Escalation of care was uncommon
The patients had a median age of 2.4 years, and 78% were girls. Approximately 90% were started on a cephalosporin, and about 65% received a first-generation cephalosporin. Patients presented during 2012-2017 to one of five children’s hospitals or to a large managed care organization with 10 hospitals in the United States. The investigators defined care escalation as a visit to the emergency department, hospitalization, or transfer to the ICU.
In all, seven patients (2%) had escalation of care on discordant antibiotics. Four children visited an emergency department without hospitalization, and three children were hospitalized because of persistent symptoms.
Among 230 cases for which the researchers had data about clinical response at a median follow-up of 3 days, 84% “had overall clinical improvement while on discordant antibiotics,” the authors said.
For 22 children who had repeat urine testing while on discordant antibiotics, 53% had resolution of pyuria, and 32% had improvement of pyuria, whereas 16% did not have improvement. Of the three patients without improvement, one had no change, and two had worsening.
Of 17 patients who had a repeat urine culture on discordant therapy, 65% had a negative repeat culture, and 18% grew the same pathogen with a decreased colony count. Two patients had a colony count that remained unchanged, and one patient had an increased colony count.
Small studies outside the United States have reported similar results, the researchers noted. Spontaneous resolution of UTIs or antibiotics reaching a sufficient concentration in the urine and renal parenchyma to achieve a clinical response are possible explanations for the findings, they wrote.
“Few children required escalation of care and most experienced initial clinical improvement,” noted Dr. Wang and colleagues. “Furthermore, in the small group of children that underwent repeat urine testing while on discordant therapy, most had resolution or improvement in pyuria and sterilization of their urine cultures. Our findings suggest that Additionally, given that these patients initially received what would generally be considered inadequate treatment, our findings may provide some insight into the natural history of UTIs and/or trigger further investigation into the relationship between in vitro urine culture susceptibilities and in vivo clinical response to treatment.”
‘Caution is needed’
The study “highlights an intriguing observation about children with UTIs unexpectedly responding to discordant antibiotic therapy,” Tej K. Mattoo, MD, and Basim I. Asmar, MD, wrote in an accompanying commentary.(doi: 10.1542/peds.2019-3512). Dr. Mattoo and Dr. Asmar, a pediatric nephrologist and a specialist in pediatric infectious diseases, respectively, at Wayne State University and affiliated with Children’s Hospital of Michigan, both in Detroit.
In an inpatient setting, it may be easy for physicians to reassess patients “once urine culture results reveal resistance to the treating antibiotic,” they noted. In an ambulatory setting, however, “it is likely that some patients will receive a full course of an antibiotic that does not have in vitro activity against the urinary pathogen.”
Physicians have a responsibility to use antibiotics judiciously, they said. Widely accepted principles include avoiding repeated courses of antibiotics, diagnosing UTIs appropriately, and not treating asymptomatic bacteriuria.
The study had no external funding. The authors had no relevant financial disclosures.
SOURCE: Wang ME et al. Pediatrics. 2020 Jan 17. doi: 10.1542/peds.2019-1608.
This article was updated 2/4/2020.
Children with urinary tract infections (UTIs) may improve clinically, and pyuria may resolve, during empiric treatment with an antibiotic that turns out to be discordant, according a retrospective study in Pediatrics.
“The low rate of care escalation and high rate of clinical improvement while on discordant antibiotics suggests that, for most patients, it would be reasonable to continue current empiric antibiotic practices until urine culture sensitivities return,” said first author Marie E. Wang, MD, a pediatric hospitalist at Stanford (Calif.) University, and colleagues.
The researchers examined the initial clinical response and escalation of care for 316 children with UTIs who received therapy to which the infecting isolate was not susceptible. The study included patients who had infections that were resistant to third-generation cephalosporins – that is, urinalysis found that the infections were not susceptible to ceftriaxone or cefotaxime in vitro. Before the resistant organisms were identified, however, the patients were started on discordant antibiotics.
Escalation of care was uncommon
The patients had a median age of 2.4 years, and 78% were girls. Approximately 90% were started on a cephalosporin, and about 65% received a first-generation cephalosporin. Patients presented during 2012-2017 to one of five children’s hospitals or to a large managed care organization with 10 hospitals in the United States. The investigators defined care escalation as a visit to the emergency department, hospitalization, or transfer to the ICU.
In all, seven patients (2%) had escalation of care on discordant antibiotics. Four children visited an emergency department without hospitalization, and three children were hospitalized because of persistent symptoms.
Among 230 cases for which the researchers had data about clinical response at a median follow-up of 3 days, 84% “had overall clinical improvement while on discordant antibiotics,” the authors said.
For 22 children who had repeat urine testing while on discordant antibiotics, 53% had resolution of pyuria, and 32% had improvement of pyuria, whereas 16% did not have improvement. Of the three patients without improvement, one had no change, and two had worsening.
Of 17 patients who had a repeat urine culture on discordant therapy, 65% had a negative repeat culture, and 18% grew the same pathogen with a decreased colony count. Two patients had a colony count that remained unchanged, and one patient had an increased colony count.
Small studies outside the United States have reported similar results, the researchers noted. Spontaneous resolution of UTIs or antibiotics reaching a sufficient concentration in the urine and renal parenchyma to achieve a clinical response are possible explanations for the findings, they wrote.
“Few children required escalation of care and most experienced initial clinical improvement,” noted Dr. Wang and colleagues. “Furthermore, in the small group of children that underwent repeat urine testing while on discordant therapy, most had resolution or improvement in pyuria and sterilization of their urine cultures. Our findings suggest that Additionally, given that these patients initially received what would generally be considered inadequate treatment, our findings may provide some insight into the natural history of UTIs and/or trigger further investigation into the relationship between in vitro urine culture susceptibilities and in vivo clinical response to treatment.”
‘Caution is needed’
The study “highlights an intriguing observation about children with UTIs unexpectedly responding to discordant antibiotic therapy,” Tej K. Mattoo, MD, and Basim I. Asmar, MD, wrote in an accompanying commentary.(doi: 10.1542/peds.2019-3512). Dr. Mattoo and Dr. Asmar, a pediatric nephrologist and a specialist in pediatric infectious diseases, respectively, at Wayne State University and affiliated with Children’s Hospital of Michigan, both in Detroit.
In an inpatient setting, it may be easy for physicians to reassess patients “once urine culture results reveal resistance to the treating antibiotic,” they noted. In an ambulatory setting, however, “it is likely that some patients will receive a full course of an antibiotic that does not have in vitro activity against the urinary pathogen.”
Physicians have a responsibility to use antibiotics judiciously, they said. Widely accepted principles include avoiding repeated courses of antibiotics, diagnosing UTIs appropriately, and not treating asymptomatic bacteriuria.
The study had no external funding. The authors had no relevant financial disclosures.
SOURCE: Wang ME et al. Pediatrics. 2020 Jan 17. doi: 10.1542/peds.2019-1608.
This article was updated 2/4/2020.
FROM PEDIATRICS
SHM Pediatric Core Competencies get fresh update
New core competencies reflect a decade of change
Over the past 10 years, much has changed in the world of pediatric hospital medicine. The annual national PHM conference sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) is robust; textbooks and journal articles in the field abound; and networks and training in research, quality improvement, and education are successful and ongoing.
Much of this did not exist or was in its infancy back in 2010. Since then, it has grown and greatly evolved. In parallel, medicine and society have changed. These influences on health care, along with the growth of the field over time, prompted a review and revision of the 2010 PHM Core Competencies published by SHM. With support from the society, the Pediatric Hospital Medicine Special Interest Group launched the plan for revision of the PHM Core Competencies.
The selected editors included Sandra Gage, MD, PhD, SFHM, of Phoenix Children’s Hospital; Erin Stucky Fisher, MD, MHM, of UCSD/Rady Children’s Hospital in San Diego; Jennifer Maniscalco, MD, MPH, of Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.; and Sofia Teferi, MD, SFHM, a pediatric hospitalist based at Bon Secours St. Mary’s Hospital in Richmond, Va. They began their work in 2017 along with six associate editors, meeting every 2 weeks via conference call, dividing the work accordingly.
Dr. Teferi served in a new and critical role as contributing editor. She described her role as a “sweeper” of sorts, bringing her unique perspective to the process. “The other three members are from academic settings, and I’m from a community setting, which is very different,” Dr. Teferi said. “I went through all the chapters to ensure they were inclusive of the community setting.”
According to Dr. Gage, “the purpose of the original PHM Core Competencies was to define the roles and responsibilities of a PHM practitioner. In the intervening 10 years, the field has changed and matured, and we have solidified our role since then.”
Today’s pediatric hospitalists, for instance, may coordinate care in EDs, provide inpatient consultations, engage or lead quality improvement programs, and teach. The demands for pediatric hospital care today go beyond the training provided in a standard pediatric residency. The core competencies need to provide the information necessary, therefore, to ensure pediatric hospital medicine is practiced at its most informed level.
A profession transformed
At the time of the first set of core competencies, there were over 2,500 members in three core societies in which pediatric hospitalists were members: the AAP, the APA, and SHM. As of 2017, those numbers have swelled as the care for children in the hospital setting has shifted away from these patients’ primary care providers.
The original core competencies included 54 chapters, designed to be used independent of the others. They provided a foundation for the creation of pediatric hospital medicine and served to standardize and improve inpatient training practices.
For the new core competencies, every single chapter was reviewed line by line, Dr. Gage said. Many chapters had content modified, and new chapters were added to reflect the evolution of the field and of medicine. “We added about 14 new chapters, adjusted the titles of others, and significantly changed the content of over half,” Dr. Gage explained. “They are fairly broad changes, related to the breadth of the practice today.”
Dr. Teferi noted that practitioners can use the updated competencies with additions to the service lines that have arisen since the last version. “These include areas like step down and newborn nursery, things that weren’t part of our portfolio 10 years ago,” she said. “This reflects the fact that often you’ll see a hospital leader who might want to add to a hospitalist’s portfolio of services because there is no one else to do it. Or maybe community pediatrics no longer want to treat babies, so we add that. The settings vary widely today and we need the competencies to address that.”
Practices within these settings can also vary widely. Teaching, palliative care, airway management, critical care, and anesthesia may all come into play, among other factors. Research opportunities throughout the field also continue to expand.
Dr. Fisher said that the editors and associate editors kept in mind the fact that not every hospital would have all the resources necessary at its fingertips. “The competencies must reflect the realities of the variety of community settings,” she said. “Also, on a national level, the majority of pediatric patients are not seen in a children’s hospital. Community sites are where pediatric hospitalists are not only advocates for care, but can be working with limited resources – the ‘lone soldiers.’ We wanted to make sure the competencies reflect that reality and environment community site or not; academic site or not; tertiary care site or not; rural or not – these are overlapping but independent considerations for all who practice pediatric hospital medicine – a Venn diagram, and the PHM core competencies try to attend to all of those.”
This made Dr. Teferi’s perspective all the more important. “While many, including other editors and associate editors, work in community sites, Dr. Teferi has this as her unique and sole focus. She brought a unique viewpoint to the table,” Dr. Fisher said.
A goal of the core competencies is to make it possible for a pediatric hospitalist to move to a different practice environment and still provide the same level of high-quality care. “It’s difficult but important to grasp the concepts and competencies of various settings,” Dr. Fisher said. “In this way, our competencies are a parallel model to the adult hospitalist competencies.”
The editors surveyed practitioners across the country to gather their input on content, and brought on topic experts to write the new chapters. “If we didn’t have an author for a specific chapter or area from the last set of competencies, we came to a consensus on who the new one should be,” Dr. Gage explained. “We looked for known and accepted experts in the field by reviewing the literature and conference lecturers at all major PHM meetings.”
Once the editors and associate editors worked with authors to refine their chapter(s), the chapters were sent to multiple external reviewers including subgroups of SHM, AAP, and APA, as well as a variety of other associations. They provided input that the editors and associate editors collated, reviewed, and incorporated according to consensus and discussion with the authors.
A preview
As far as the actual changes go, some of new chapters include four common clinical, two core skills, three specialized services, and five health care systems, with many others undergoing content changes, according to Dr. Gage.
Major considerations in developing the new competencies include the national trend of rising mental health issues among young patients. According to the AAP, over the last decade the number of young people aged 6-17 years requiring mental health care has risen from 9% to more than 14%. In outpatient settings, many pediatricians report that half or more of their visits are dedicated to these issues, a number that may spill out into the hospital setting as well.
According to Dr. Fisher, pediatric hospitalists today see increasing numbers of chronic and acute diseases accompanied by mental and behavioral health issues. “We wanted to underscore this complexity in the competencies,” she explained. “We needed to focus new attention on how to identify and treat children with behavioral or psychiatric diagnoses or needs.”
Other new areas of focus include infection care and antimicrobial stewardship. “We see kids on antibiotics in hospital settings and we need to focus on narrowing choices, decreasing use, and shortening duration,” Dr. Gage said.
Dr. Maniscalco said that, overall, the changes represent the evolution of the field. “Pediatric hospitalists are taking on far more patients with acute and complex issues,” she explained. “Our skill set is coming into focus.”
Dr. Gage added that there is an increased need for pediatric hospitalists to be adept at “managing acute psychiatric care and navigating the mental health care arena.”
There’s also the growing need for an understanding of neonatal abstinence and opioid withdrawal syndrome. “This is definitely a hot topic and one that most hospitalists must address today,” Dr. Gage said. “That wasn’t the case a decade ago.”
Hospital care for pediatrics today often means a team effort, including pediatric hospitalists, surgeons, mental health professionals, and others. Often missing from the picture today are primary care physicians, who instead refer a growing percentage of their patients to hospitalists. The pediatric hospitalist’s role has evolved and grown from what it was 10 years ago, as reflected in the competencies.
“We are very much coordinating care and collaborating today in ways we weren’t 10 years ago,” said Dr. Gage. “There’s a lot more attention on creating partnerships. While we may not always be the ones performing procedures, we will most likely take part in patient care, especially as surgeons step farther away from care outside of the OR.”
The field has also become more family centered, said Dr. Gage. “All of health care today is more astute about the participation of families in care,” she said. “We kept that in mind in developing the competencies.”
Also important in this set of competencies was the concept of high-value care using evidence-based medicine.
Into the field
How exactly the core competencies will be utilized from one hospital or setting to the next will vary, said Dr. Fisher. “For some sites, they can aid existing teaching programs, and they will most likely adapt their curriculum to address the new competencies, informing how they teach.”
Even in centers where there isn’t a formal academic role, teaching still occurs. “Pediatric hospitalists have roles on committees and projects, and giving a talk to respiratory therapists, having group meetings – these all involve teaching in some form,” Dr. Fisher said. “Most physicians will determine how they wish to insert the competencies into their own education, as well as use them to educate others.”
Regardless of how they may be used locally, Dr. Fisher anticipates that the entire pediatric hospitalist community will appreciate the updates. “The competencies address our rapidly changing health care environment,” she said. “We believe the field will benefit from the additions and changes.”
Indeed, the core competencies will help standardize and improve consistency of care across the board. Improved efficiencies, economics, and practices are all desired and expected outcomes from the release of the revised competencies.
To ensure that the changes to the competencies are highlighted in settings nationwide, the editors and associate editors hope to present about them at upcoming conferences, including at the SHM 2020 Annual Conference, the Pediatric Hospital Medicine conference, the Pediatric Academic Societies conference, and the American Pediatric Association.
“We want to present to as many venues as possible to bring people up to speed and ensure they are aware of the changes,” Dr. Teferi said. “We’ll be including workshops with visual aids, along with our presentations.”
While this update represents a 10-year evolution, the editors and the SHM Pediatric Special Interest Group do not have an exact time frame for when the core competencies will need another revision. As quickly as the profession is developing, it may be as few as 5 years, but may also be another full decade.
“Like most fields, we will continue to evolve as our roles become better defined and we gain more knowledge,” Dr. Maniscalco said. “The core competencies represent the field whether a senior pediatric hospitalist, a fellow, or an educator. They bring the field together and provide education for everyone. That’s their role.”
New core competencies reflect a decade of change
New core competencies reflect a decade of change
Over the past 10 years, much has changed in the world of pediatric hospital medicine. The annual national PHM conference sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) is robust; textbooks and journal articles in the field abound; and networks and training in research, quality improvement, and education are successful and ongoing.
Much of this did not exist or was in its infancy back in 2010. Since then, it has grown and greatly evolved. In parallel, medicine and society have changed. These influences on health care, along with the growth of the field over time, prompted a review and revision of the 2010 PHM Core Competencies published by SHM. With support from the society, the Pediatric Hospital Medicine Special Interest Group launched the plan for revision of the PHM Core Competencies.
The selected editors included Sandra Gage, MD, PhD, SFHM, of Phoenix Children’s Hospital; Erin Stucky Fisher, MD, MHM, of UCSD/Rady Children’s Hospital in San Diego; Jennifer Maniscalco, MD, MPH, of Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.; and Sofia Teferi, MD, SFHM, a pediatric hospitalist based at Bon Secours St. Mary’s Hospital in Richmond, Va. They began their work in 2017 along with six associate editors, meeting every 2 weeks via conference call, dividing the work accordingly.
Dr. Teferi served in a new and critical role as contributing editor. She described her role as a “sweeper” of sorts, bringing her unique perspective to the process. “The other three members are from academic settings, and I’m from a community setting, which is very different,” Dr. Teferi said. “I went through all the chapters to ensure they were inclusive of the community setting.”
According to Dr. Gage, “the purpose of the original PHM Core Competencies was to define the roles and responsibilities of a PHM practitioner. In the intervening 10 years, the field has changed and matured, and we have solidified our role since then.”
Today’s pediatric hospitalists, for instance, may coordinate care in EDs, provide inpatient consultations, engage or lead quality improvement programs, and teach. The demands for pediatric hospital care today go beyond the training provided in a standard pediatric residency. The core competencies need to provide the information necessary, therefore, to ensure pediatric hospital medicine is practiced at its most informed level.
A profession transformed
At the time of the first set of core competencies, there were over 2,500 members in three core societies in which pediatric hospitalists were members: the AAP, the APA, and SHM. As of 2017, those numbers have swelled as the care for children in the hospital setting has shifted away from these patients’ primary care providers.
The original core competencies included 54 chapters, designed to be used independent of the others. They provided a foundation for the creation of pediatric hospital medicine and served to standardize and improve inpatient training practices.
For the new core competencies, every single chapter was reviewed line by line, Dr. Gage said. Many chapters had content modified, and new chapters were added to reflect the evolution of the field and of medicine. “We added about 14 new chapters, adjusted the titles of others, and significantly changed the content of over half,” Dr. Gage explained. “They are fairly broad changes, related to the breadth of the practice today.”
Dr. Teferi noted that practitioners can use the updated competencies with additions to the service lines that have arisen since the last version. “These include areas like step down and newborn nursery, things that weren’t part of our portfolio 10 years ago,” she said. “This reflects the fact that often you’ll see a hospital leader who might want to add to a hospitalist’s portfolio of services because there is no one else to do it. Or maybe community pediatrics no longer want to treat babies, so we add that. The settings vary widely today and we need the competencies to address that.”
Practices within these settings can also vary widely. Teaching, palliative care, airway management, critical care, and anesthesia may all come into play, among other factors. Research opportunities throughout the field also continue to expand.
Dr. Fisher said that the editors and associate editors kept in mind the fact that not every hospital would have all the resources necessary at its fingertips. “The competencies must reflect the realities of the variety of community settings,” she said. “Also, on a national level, the majority of pediatric patients are not seen in a children’s hospital. Community sites are where pediatric hospitalists are not only advocates for care, but can be working with limited resources – the ‘lone soldiers.’ We wanted to make sure the competencies reflect that reality and environment community site or not; academic site or not; tertiary care site or not; rural or not – these are overlapping but independent considerations for all who practice pediatric hospital medicine – a Venn diagram, and the PHM core competencies try to attend to all of those.”
This made Dr. Teferi’s perspective all the more important. “While many, including other editors and associate editors, work in community sites, Dr. Teferi has this as her unique and sole focus. She brought a unique viewpoint to the table,” Dr. Fisher said.
A goal of the core competencies is to make it possible for a pediatric hospitalist to move to a different practice environment and still provide the same level of high-quality care. “It’s difficult but important to grasp the concepts and competencies of various settings,” Dr. Fisher said. “In this way, our competencies are a parallel model to the adult hospitalist competencies.”
The editors surveyed practitioners across the country to gather their input on content, and brought on topic experts to write the new chapters. “If we didn’t have an author for a specific chapter or area from the last set of competencies, we came to a consensus on who the new one should be,” Dr. Gage explained. “We looked for known and accepted experts in the field by reviewing the literature and conference lecturers at all major PHM meetings.”
Once the editors and associate editors worked with authors to refine their chapter(s), the chapters were sent to multiple external reviewers including subgroups of SHM, AAP, and APA, as well as a variety of other associations. They provided input that the editors and associate editors collated, reviewed, and incorporated according to consensus and discussion with the authors.
A preview
As far as the actual changes go, some of new chapters include four common clinical, two core skills, three specialized services, and five health care systems, with many others undergoing content changes, according to Dr. Gage.
Major considerations in developing the new competencies include the national trend of rising mental health issues among young patients. According to the AAP, over the last decade the number of young people aged 6-17 years requiring mental health care has risen from 9% to more than 14%. In outpatient settings, many pediatricians report that half or more of their visits are dedicated to these issues, a number that may spill out into the hospital setting as well.
According to Dr. Fisher, pediatric hospitalists today see increasing numbers of chronic and acute diseases accompanied by mental and behavioral health issues. “We wanted to underscore this complexity in the competencies,” she explained. “We needed to focus new attention on how to identify and treat children with behavioral or psychiatric diagnoses or needs.”
Other new areas of focus include infection care and antimicrobial stewardship. “We see kids on antibiotics in hospital settings and we need to focus on narrowing choices, decreasing use, and shortening duration,” Dr. Gage said.
Dr. Maniscalco said that, overall, the changes represent the evolution of the field. “Pediatric hospitalists are taking on far more patients with acute and complex issues,” she explained. “Our skill set is coming into focus.”
Dr. Gage added that there is an increased need for pediatric hospitalists to be adept at “managing acute psychiatric care and navigating the mental health care arena.”
There’s also the growing need for an understanding of neonatal abstinence and opioid withdrawal syndrome. “This is definitely a hot topic and one that most hospitalists must address today,” Dr. Gage said. “That wasn’t the case a decade ago.”
Hospital care for pediatrics today often means a team effort, including pediatric hospitalists, surgeons, mental health professionals, and others. Often missing from the picture today are primary care physicians, who instead refer a growing percentage of their patients to hospitalists. The pediatric hospitalist’s role has evolved and grown from what it was 10 years ago, as reflected in the competencies.
“We are very much coordinating care and collaborating today in ways we weren’t 10 years ago,” said Dr. Gage. “There’s a lot more attention on creating partnerships. While we may not always be the ones performing procedures, we will most likely take part in patient care, especially as surgeons step farther away from care outside of the OR.”
The field has also become more family centered, said Dr. Gage. “All of health care today is more astute about the participation of families in care,” she said. “We kept that in mind in developing the competencies.”
Also important in this set of competencies was the concept of high-value care using evidence-based medicine.
Into the field
How exactly the core competencies will be utilized from one hospital or setting to the next will vary, said Dr. Fisher. “For some sites, they can aid existing teaching programs, and they will most likely adapt their curriculum to address the new competencies, informing how they teach.”
Even in centers where there isn’t a formal academic role, teaching still occurs. “Pediatric hospitalists have roles on committees and projects, and giving a talk to respiratory therapists, having group meetings – these all involve teaching in some form,” Dr. Fisher said. “Most physicians will determine how they wish to insert the competencies into their own education, as well as use them to educate others.”
Regardless of how they may be used locally, Dr. Fisher anticipates that the entire pediatric hospitalist community will appreciate the updates. “The competencies address our rapidly changing health care environment,” she said. “We believe the field will benefit from the additions and changes.”
Indeed, the core competencies will help standardize and improve consistency of care across the board. Improved efficiencies, economics, and practices are all desired and expected outcomes from the release of the revised competencies.
To ensure that the changes to the competencies are highlighted in settings nationwide, the editors and associate editors hope to present about them at upcoming conferences, including at the SHM 2020 Annual Conference, the Pediatric Hospital Medicine conference, the Pediatric Academic Societies conference, and the American Pediatric Association.
“We want to present to as many venues as possible to bring people up to speed and ensure they are aware of the changes,” Dr. Teferi said. “We’ll be including workshops with visual aids, along with our presentations.”
While this update represents a 10-year evolution, the editors and the SHM Pediatric Special Interest Group do not have an exact time frame for when the core competencies will need another revision. As quickly as the profession is developing, it may be as few as 5 years, but may also be another full decade.
“Like most fields, we will continue to evolve as our roles become better defined and we gain more knowledge,” Dr. Maniscalco said. “The core competencies represent the field whether a senior pediatric hospitalist, a fellow, or an educator. They bring the field together and provide education for everyone. That’s their role.”
Over the past 10 years, much has changed in the world of pediatric hospital medicine. The annual national PHM conference sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) is robust; textbooks and journal articles in the field abound; and networks and training in research, quality improvement, and education are successful and ongoing.
Much of this did not exist or was in its infancy back in 2010. Since then, it has grown and greatly evolved. In parallel, medicine and society have changed. These influences on health care, along with the growth of the field over time, prompted a review and revision of the 2010 PHM Core Competencies published by SHM. With support from the society, the Pediatric Hospital Medicine Special Interest Group launched the plan for revision of the PHM Core Competencies.
The selected editors included Sandra Gage, MD, PhD, SFHM, of Phoenix Children’s Hospital; Erin Stucky Fisher, MD, MHM, of UCSD/Rady Children’s Hospital in San Diego; Jennifer Maniscalco, MD, MPH, of Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.; and Sofia Teferi, MD, SFHM, a pediatric hospitalist based at Bon Secours St. Mary’s Hospital in Richmond, Va. They began their work in 2017 along with six associate editors, meeting every 2 weeks via conference call, dividing the work accordingly.
Dr. Teferi served in a new and critical role as contributing editor. She described her role as a “sweeper” of sorts, bringing her unique perspective to the process. “The other three members are from academic settings, and I’m from a community setting, which is very different,” Dr. Teferi said. “I went through all the chapters to ensure they were inclusive of the community setting.”
According to Dr. Gage, “the purpose of the original PHM Core Competencies was to define the roles and responsibilities of a PHM practitioner. In the intervening 10 years, the field has changed and matured, and we have solidified our role since then.”
Today’s pediatric hospitalists, for instance, may coordinate care in EDs, provide inpatient consultations, engage or lead quality improvement programs, and teach. The demands for pediatric hospital care today go beyond the training provided in a standard pediatric residency. The core competencies need to provide the information necessary, therefore, to ensure pediatric hospital medicine is practiced at its most informed level.
A profession transformed
At the time of the first set of core competencies, there were over 2,500 members in three core societies in which pediatric hospitalists were members: the AAP, the APA, and SHM. As of 2017, those numbers have swelled as the care for children in the hospital setting has shifted away from these patients’ primary care providers.
The original core competencies included 54 chapters, designed to be used independent of the others. They provided a foundation for the creation of pediatric hospital medicine and served to standardize and improve inpatient training practices.
For the new core competencies, every single chapter was reviewed line by line, Dr. Gage said. Many chapters had content modified, and new chapters were added to reflect the evolution of the field and of medicine. “We added about 14 new chapters, adjusted the titles of others, and significantly changed the content of over half,” Dr. Gage explained. “They are fairly broad changes, related to the breadth of the practice today.”
Dr. Teferi noted that practitioners can use the updated competencies with additions to the service lines that have arisen since the last version. “These include areas like step down and newborn nursery, things that weren’t part of our portfolio 10 years ago,” she said. “This reflects the fact that often you’ll see a hospital leader who might want to add to a hospitalist’s portfolio of services because there is no one else to do it. Or maybe community pediatrics no longer want to treat babies, so we add that. The settings vary widely today and we need the competencies to address that.”
Practices within these settings can also vary widely. Teaching, palliative care, airway management, critical care, and anesthesia may all come into play, among other factors. Research opportunities throughout the field also continue to expand.
Dr. Fisher said that the editors and associate editors kept in mind the fact that not every hospital would have all the resources necessary at its fingertips. “The competencies must reflect the realities of the variety of community settings,” she said. “Also, on a national level, the majority of pediatric patients are not seen in a children’s hospital. Community sites are where pediatric hospitalists are not only advocates for care, but can be working with limited resources – the ‘lone soldiers.’ We wanted to make sure the competencies reflect that reality and environment community site or not; academic site or not; tertiary care site or not; rural or not – these are overlapping but independent considerations for all who practice pediatric hospital medicine – a Venn diagram, and the PHM core competencies try to attend to all of those.”
This made Dr. Teferi’s perspective all the more important. “While many, including other editors and associate editors, work in community sites, Dr. Teferi has this as her unique and sole focus. She brought a unique viewpoint to the table,” Dr. Fisher said.
A goal of the core competencies is to make it possible for a pediatric hospitalist to move to a different practice environment and still provide the same level of high-quality care. “It’s difficult but important to grasp the concepts and competencies of various settings,” Dr. Fisher said. “In this way, our competencies are a parallel model to the adult hospitalist competencies.”
The editors surveyed practitioners across the country to gather their input on content, and brought on topic experts to write the new chapters. “If we didn’t have an author for a specific chapter or area from the last set of competencies, we came to a consensus on who the new one should be,” Dr. Gage explained. “We looked for known and accepted experts in the field by reviewing the literature and conference lecturers at all major PHM meetings.”
Once the editors and associate editors worked with authors to refine their chapter(s), the chapters were sent to multiple external reviewers including subgroups of SHM, AAP, and APA, as well as a variety of other associations. They provided input that the editors and associate editors collated, reviewed, and incorporated according to consensus and discussion with the authors.
A preview
As far as the actual changes go, some of new chapters include four common clinical, two core skills, three specialized services, and five health care systems, with many others undergoing content changes, according to Dr. Gage.
Major considerations in developing the new competencies include the national trend of rising mental health issues among young patients. According to the AAP, over the last decade the number of young people aged 6-17 years requiring mental health care has risen from 9% to more than 14%. In outpatient settings, many pediatricians report that half or more of their visits are dedicated to these issues, a number that may spill out into the hospital setting as well.
According to Dr. Fisher, pediatric hospitalists today see increasing numbers of chronic and acute diseases accompanied by mental and behavioral health issues. “We wanted to underscore this complexity in the competencies,” she explained. “We needed to focus new attention on how to identify and treat children with behavioral or psychiatric diagnoses or needs.”
Other new areas of focus include infection care and antimicrobial stewardship. “We see kids on antibiotics in hospital settings and we need to focus on narrowing choices, decreasing use, and shortening duration,” Dr. Gage said.
Dr. Maniscalco said that, overall, the changes represent the evolution of the field. “Pediatric hospitalists are taking on far more patients with acute and complex issues,” she explained. “Our skill set is coming into focus.”
Dr. Gage added that there is an increased need for pediatric hospitalists to be adept at “managing acute psychiatric care and navigating the mental health care arena.”
There’s also the growing need for an understanding of neonatal abstinence and opioid withdrawal syndrome. “This is definitely a hot topic and one that most hospitalists must address today,” Dr. Gage said. “That wasn’t the case a decade ago.”
Hospital care for pediatrics today often means a team effort, including pediatric hospitalists, surgeons, mental health professionals, and others. Often missing from the picture today are primary care physicians, who instead refer a growing percentage of their patients to hospitalists. The pediatric hospitalist’s role has evolved and grown from what it was 10 years ago, as reflected in the competencies.
“We are very much coordinating care and collaborating today in ways we weren’t 10 years ago,” said Dr. Gage. “There’s a lot more attention on creating partnerships. While we may not always be the ones performing procedures, we will most likely take part in patient care, especially as surgeons step farther away from care outside of the OR.”
The field has also become more family centered, said Dr. Gage. “All of health care today is more astute about the participation of families in care,” she said. “We kept that in mind in developing the competencies.”
Also important in this set of competencies was the concept of high-value care using evidence-based medicine.
Into the field
How exactly the core competencies will be utilized from one hospital or setting to the next will vary, said Dr. Fisher. “For some sites, they can aid existing teaching programs, and they will most likely adapt their curriculum to address the new competencies, informing how they teach.”
Even in centers where there isn’t a formal academic role, teaching still occurs. “Pediatric hospitalists have roles on committees and projects, and giving a talk to respiratory therapists, having group meetings – these all involve teaching in some form,” Dr. Fisher said. “Most physicians will determine how they wish to insert the competencies into their own education, as well as use them to educate others.”
Regardless of how they may be used locally, Dr. Fisher anticipates that the entire pediatric hospitalist community will appreciate the updates. “The competencies address our rapidly changing health care environment,” she said. “We believe the field will benefit from the additions and changes.”
Indeed, the core competencies will help standardize and improve consistency of care across the board. Improved efficiencies, economics, and practices are all desired and expected outcomes from the release of the revised competencies.
To ensure that the changes to the competencies are highlighted in settings nationwide, the editors and associate editors hope to present about them at upcoming conferences, including at the SHM 2020 Annual Conference, the Pediatric Hospital Medicine conference, the Pediatric Academic Societies conference, and the American Pediatric Association.
“We want to present to as many venues as possible to bring people up to speed and ensure they are aware of the changes,” Dr. Teferi said. “We’ll be including workshops with visual aids, along with our presentations.”
While this update represents a 10-year evolution, the editors and the SHM Pediatric Special Interest Group do not have an exact time frame for when the core competencies will need another revision. As quickly as the profession is developing, it may be as few as 5 years, but may also be another full decade.
“Like most fields, we will continue to evolve as our roles become better defined and we gain more knowledge,” Dr. Maniscalco said. “The core competencies represent the field whether a senior pediatric hospitalist, a fellow, or an educator. They bring the field together and provide education for everyone. That’s their role.”
Rash on hands and feet
Lichenoid dermatoses are a heterogeneous group of diseases with varying clinical presentations. The term “lichenoid” refers to the popular lesions of certain skin disorders of which lichen planus (LP) is the prototype. The papules are shiny, flat topped, polygonal, of different sizes, and occur in clusters creating a pattern that resembles lichen growing on a rock. Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population.
Lichen striatus, lichen nitidus (LN), and lichen spinulosus are lichenoid lesions that are more common in children than adults.
LN – as seen in the patient described here – is an uncommon benign inflammatory skin disease, primarily of children. Individual lesions are sharply demarcated, pinpoint to pinhead sized, round or polygonal, and strikingly monomorphous in nature. The papules are usually flesh colored, however, the color varies from yellow and brown to violet hues depending on the background color of the patient’s skin. This variation in color is in contrast with LP which is characteristically violaceous. The surfaces of the papules are flat, shiny, and slightly elevated. They may have a fine scale or a hyperkeratotic plug. The lesions tend to occur in groups, primarily on the abdomen, chest, glans penis, and upper extremities. The Koebner phenomenon is observed and is a hallmark for the disorder. LN is generally asymptomatic, unlike LP, which is exceedingly pruritic.
The cause of LN is unknown; however, it has been proposed that LN, in particular generalized LN, may be associated with immune alterations in the patient. The course of LN is slowly progressive with a tendency toward remission. The lesions can remain stationary for years; however, they sometimes disappear spontaneously and completely.
The differential diagnosis of LN beyond the entities discussed above includes frictional lichenoid eruption, lichenoid drug eruption, LP, and keratosis pilaris.
LP is the classic lichenoid eruption. It is rare in children and occurs most frequently in individuals aged 30-60 years. LP usually manifests as an extremely pruritic eruption of flat-topped polygonal and violaceous papules that often have fine linear white scales known as Wickham striae. The distribution is usually bilateral and symmetric with most of the papules and plaques located on the legs, flexor wrists, neck, and genitalia. The lesions may exhibit the Koebner phenomenon, appearing in a linear pattern along the site of a scratch. Generally, in childhood cases there is reported itching, and oral and nail lesions are less common.
Frictional lichenoid eruption occurs in childhood. The lesions consist of lichenoid papules with regular borders 1-2 mm in diameter that generally are asymptomatic, although they may be mildly pruritic. The papules are found in a very characteristic distribution with almost exclusive involvement of the backs of the hands, fingers, elbows, and knees with occasional involvement of the extensor forearms and cheeks. This disorder occurs in predisposed children who have been exposed to significant frictional force during play, and typically resolves spontaneously after removal of the stimulus.
Keratosis pilaris is a rash that usually is found on the outer areas of the upper arms, upper thighs, buttocks, and cheeks. It consists of small bumps that are flesh colored to red. The bumps generally don’t hurt or itch.
The lack of symptoms and spontaneous healing have rendered treatment unnecessary in most cases. LN generally is self-limiting, thus treatment may not be necessary. However, topical treatment with mid- to high-potency corticosteroids has hastened resolution of lesions in some children, as have topical dinitrochlorobenzene and systemic treatment with psoralens, astemizole, etretinate, and psoralen-UVA.
Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Bhatti is a research fellow in pediatric dermatology at Rady Children’s Hospital and the University of California, San Diego. Neither Dr. Eichenfield nor Dr. Bhatti has any relevant financial disclosures. Email them at [email protected].
References
Pickert A. Cutis. 2012 Sep;90(3):E1-3. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0900300E1.pdf Tziotzios C et al. J Am Acad Dermatol. 2018 Nov;79(5):789-804. Tilly JJ et al. J Am Acad Dermatol. 2004 Oct;51(4):606-24.
Lichenoid dermatoses are a heterogeneous group of diseases with varying clinical presentations. The term “lichenoid” refers to the popular lesions of certain skin disorders of which lichen planus (LP) is the prototype. The papules are shiny, flat topped, polygonal, of different sizes, and occur in clusters creating a pattern that resembles lichen growing on a rock. Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population.
Lichen striatus, lichen nitidus (LN), and lichen spinulosus are lichenoid lesions that are more common in children than adults.
LN – as seen in the patient described here – is an uncommon benign inflammatory skin disease, primarily of children. Individual lesions are sharply demarcated, pinpoint to pinhead sized, round or polygonal, and strikingly monomorphous in nature. The papules are usually flesh colored, however, the color varies from yellow and brown to violet hues depending on the background color of the patient’s skin. This variation in color is in contrast with LP which is characteristically violaceous. The surfaces of the papules are flat, shiny, and slightly elevated. They may have a fine scale or a hyperkeratotic plug. The lesions tend to occur in groups, primarily on the abdomen, chest, glans penis, and upper extremities. The Koebner phenomenon is observed and is a hallmark for the disorder. LN is generally asymptomatic, unlike LP, which is exceedingly pruritic.
The cause of LN is unknown; however, it has been proposed that LN, in particular generalized LN, may be associated with immune alterations in the patient. The course of LN is slowly progressive with a tendency toward remission. The lesions can remain stationary for years; however, they sometimes disappear spontaneously and completely.
The differential diagnosis of LN beyond the entities discussed above includes frictional lichenoid eruption, lichenoid drug eruption, LP, and keratosis pilaris.
LP is the classic lichenoid eruption. It is rare in children and occurs most frequently in individuals aged 30-60 years. LP usually manifests as an extremely pruritic eruption of flat-topped polygonal and violaceous papules that often have fine linear white scales known as Wickham striae. The distribution is usually bilateral and symmetric with most of the papules and plaques located on the legs, flexor wrists, neck, and genitalia. The lesions may exhibit the Koebner phenomenon, appearing in a linear pattern along the site of a scratch. Generally, in childhood cases there is reported itching, and oral and nail lesions are less common.
Frictional lichenoid eruption occurs in childhood. The lesions consist of lichenoid papules with regular borders 1-2 mm in diameter that generally are asymptomatic, although they may be mildly pruritic. The papules are found in a very characteristic distribution with almost exclusive involvement of the backs of the hands, fingers, elbows, and knees with occasional involvement of the extensor forearms and cheeks. This disorder occurs in predisposed children who have been exposed to significant frictional force during play, and typically resolves spontaneously after removal of the stimulus.
Keratosis pilaris is a rash that usually is found on the outer areas of the upper arms, upper thighs, buttocks, and cheeks. It consists of small bumps that are flesh colored to red. The bumps generally don’t hurt or itch.
The lack of symptoms and spontaneous healing have rendered treatment unnecessary in most cases. LN generally is self-limiting, thus treatment may not be necessary. However, topical treatment with mid- to high-potency corticosteroids has hastened resolution of lesions in some children, as have topical dinitrochlorobenzene and systemic treatment with psoralens, astemizole, etretinate, and psoralen-UVA.
Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Bhatti is a research fellow in pediatric dermatology at Rady Children’s Hospital and the University of California, San Diego. Neither Dr. Eichenfield nor Dr. Bhatti has any relevant financial disclosures. Email them at [email protected].
References
Pickert A. Cutis. 2012 Sep;90(3):E1-3. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0900300E1.pdf Tziotzios C et al. J Am Acad Dermatol. 2018 Nov;79(5):789-804. Tilly JJ et al. J Am Acad Dermatol. 2004 Oct;51(4):606-24.
Lichenoid dermatoses are a heterogeneous group of diseases with varying clinical presentations. The term “lichenoid” refers to the popular lesions of certain skin disorders of which lichen planus (LP) is the prototype. The papules are shiny, flat topped, polygonal, of different sizes, and occur in clusters creating a pattern that resembles lichen growing on a rock. Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population.
Lichen striatus, lichen nitidus (LN), and lichen spinulosus are lichenoid lesions that are more common in children than adults.
LN – as seen in the patient described here – is an uncommon benign inflammatory skin disease, primarily of children. Individual lesions are sharply demarcated, pinpoint to pinhead sized, round or polygonal, and strikingly monomorphous in nature. The papules are usually flesh colored, however, the color varies from yellow and brown to violet hues depending on the background color of the patient’s skin. This variation in color is in contrast with LP which is characteristically violaceous. The surfaces of the papules are flat, shiny, and slightly elevated. They may have a fine scale or a hyperkeratotic plug. The lesions tend to occur in groups, primarily on the abdomen, chest, glans penis, and upper extremities. The Koebner phenomenon is observed and is a hallmark for the disorder. LN is generally asymptomatic, unlike LP, which is exceedingly pruritic.
The cause of LN is unknown; however, it has been proposed that LN, in particular generalized LN, may be associated with immune alterations in the patient. The course of LN is slowly progressive with a tendency toward remission. The lesions can remain stationary for years; however, they sometimes disappear spontaneously and completely.
The differential diagnosis of LN beyond the entities discussed above includes frictional lichenoid eruption, lichenoid drug eruption, LP, and keratosis pilaris.
LP is the classic lichenoid eruption. It is rare in children and occurs most frequently in individuals aged 30-60 years. LP usually manifests as an extremely pruritic eruption of flat-topped polygonal and violaceous papules that often have fine linear white scales known as Wickham striae. The distribution is usually bilateral and symmetric with most of the papules and plaques located on the legs, flexor wrists, neck, and genitalia. The lesions may exhibit the Koebner phenomenon, appearing in a linear pattern along the site of a scratch. Generally, in childhood cases there is reported itching, and oral and nail lesions are less common.
Frictional lichenoid eruption occurs in childhood. The lesions consist of lichenoid papules with regular borders 1-2 mm in diameter that generally are asymptomatic, although they may be mildly pruritic. The papules are found in a very characteristic distribution with almost exclusive involvement of the backs of the hands, fingers, elbows, and knees with occasional involvement of the extensor forearms and cheeks. This disorder occurs in predisposed children who have been exposed to significant frictional force during play, and typically resolves spontaneously after removal of the stimulus.
Keratosis pilaris is a rash that usually is found on the outer areas of the upper arms, upper thighs, buttocks, and cheeks. It consists of small bumps that are flesh colored to red. The bumps generally don’t hurt or itch.
The lack of symptoms and spontaneous healing have rendered treatment unnecessary in most cases. LN generally is self-limiting, thus treatment may not be necessary. However, topical treatment with mid- to high-potency corticosteroids has hastened resolution of lesions in some children, as have topical dinitrochlorobenzene and systemic treatment with psoralens, astemizole, etretinate, and psoralen-UVA.
Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Bhatti is a research fellow in pediatric dermatology at Rady Children’s Hospital and the University of California, San Diego. Neither Dr. Eichenfield nor Dr. Bhatti has any relevant financial disclosures. Email them at [email protected].
References
Pickert A. Cutis. 2012 Sep;90(3):E1-3. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0900300E1.pdf Tziotzios C et al. J Am Acad Dermatol. 2018 Nov;79(5):789-804. Tilly JJ et al. J Am Acad Dermatol. 2004 Oct;51(4):606-24.
A 9-year-old healthy Kuwaiti male with no significant past medical history presents with a rash on his hands and feet that has been present for 3 years.
His mother reports that he has been seen by dermatologists in various countries and was last seen by a dermatologist in Kuwait 3 years ago. At that time, he was told that it was dryness and advised to not shower daily. Since then he has been taking showers three times weekly and using Cetaphil once weekly without improvement. He was seen by his pediatrician 6 months ago, diagnosed with xerosis, and was given hydrocortisone 2.5% to use twice daily, again without any improvement.
The rash is not itchy, and he has no oral lesions or nail involvement. Exam revealed lichenoid papules on bilateral dorsal hands and feet, bilateral upper arms, bilateral axilla, lower abdomen, and left upper chest.
Community pediatric care is diminishing
The mantra of community hospital administrators is that pediatric care does not pay. Neonatal intensive care pays. For pediatrics, it is similar to how football programs (Medicare patients) support minor sports (pediatrics and obstetrics) at colleges. However, fewer even mildly sick newborns are cared for at community hospitals, which has led to a centralization of neonatal and pediatric care and a loss of pediatric expertise at the affected hospitals.
Pediatric hospitalists are hired to cover the pediatric floor, the emergency department, and labor and delivery, then fired over empty pediatric beds. The rationale expressed is that pediatricians have done such a good job in preventive care that children rarely need hospitalization, so why have a pediatric inpatient unit? It is true that preventive care has been an integral part of primary care for children. Significantly less that 1% of child office visits result in hospitalization.
Advocate Health Care has closed inpatient pediatric units at Illinois Masonic, on Chicago’s North Side, Good Samaritan in Downers Grove, and Good Shepherd in Barrington. Units also have been closed at Mount Sinai in North Lawndale, Norwegian American on Chicago’s West Side, Little Company of Mary in Evergreen Park, and Alexian Brothers in Elk Grove.
As a Chicago-area pediatrician for more than 30 years, I have learned several things about community-based pediatric care:
1. Pediatrics is a geographic specialty. Parents will travel to shop, but would rather walk or have a short ride to their children’s medical providers. Secondary care should be community based, and hospitalization, if necessary, should be close by as well.
2. Hospitals that ceased delivering pediatric inpatient care lost their child-friendliness and pediatric competence, becoming uncomfortable delivering almost any care for children (e.g., sedated MRIs and EEGs, x-rays and ultrasounds, ECGs and echocardiograms, and emergency care).
3. In almost all hospitals, after pediatrics was gone eventually so passed obstetrics (another less remunerative specialty). Sick newborns need immediate, competent care. Most pediatric hospitalizations are short term, often overnight. Delaying newborn care is a medicolegal nightmare. and exposes the child and his or her family to a potentially dangerous drive or helicopter ride.
4. As pediatric subspecialty care becomes more centralized, parents are asked to travel for hours to see a pediatric specialist. There are times when that is necessary (e.g., cardiovascular surgery). Pediatric subspecialists, such as pediatric otolaryngologists, then leave community hospitals, forcing even minor surgeries (e.g., ear ventilation tubes) to be done at a center. In rural areas, this could mean hours of travel, lost work days, and family disruption.
5. Children’s hospitals get uninsured and publicly insured children sent hundreds of miles, because there were no subspecialists in the community who would care for these children.
What is the solution, in our profit-focused health care system?
1. Hospitals’ Certificates of Need could include a mandate for pediatric care.
2. Children’s hospitals could be made responsible for community-based care within their geographic catchment areas.
3. The state or the federal government could mandate and financially support community-based hospital care.
4. Deciding what level of care might be appropriate for each community could depend upon closeness to a pediatric hospital, health problems in the community, and the availability of pediatric specialists.
5. A condition for medical licensure might be that a community-based pediatric subspecialist is required to care for a proportion of the uninsured or publicly insured children in his or her area.
6. Reimbursements for pediatric care need to rise enough to make caring for children worth it.
The major decision point regarding care for children cannot be financial, but must instead embrace the needs of each affected community. If quality health care is a right, and not a privilege, then it is time to stop closing pediatric inpatient units, and, instead, look for creative ways to better care for our children.
This process has led to pediatric care being available only in designated centers. The centralization of pediatric care has progressed from 30 years ago, when most community hospitals had inpatient pediatric units, to the search for innovative ways to fill pediatric beds in the mid-90s (sick day care, flex- or shared pediatric units), to the wholesale closure of community pediatric inpatient beds, from 2000 to the present. I have, unfortunately, seen this firsthand, watching the rise of pediatric mega-hospitals and the demise of community pediatrics. It is a simple financial argument. Care for children simply does not pay nearly as well as does care for adults, especially Medicaid patients. Pediatricians are the poorest paid practicing doctors (public health doctors are paid less).
It is true that pediatricians always have been at the forefront of preventive medicine, and that pediatric patients almost always get better, in spite of our best-intentioned interventions. So community-based pediatricians admit very few patients.
With the loss of pediatric units, community hospitals lose their comfort caring for children. This includes phlebotomy, x-ray, trauma, surgery, and behavioral health. And eroding community hospital pediatric expertise has catastrophic implications for rural hospitals, where parents may have to drive for hours to find a child-friendly emergency department.
Is there an answer?
1. Hospitals are responsible for the patients they serve, including children. Why should a hospital be able to close pediatric services so easily?
2. Every hospital that sees children, through the emergency department, needs to have a pediatrician available to evaluate a child, 24/7.
3. There needs to be an observation unit for children, with pediatric staffing, for overnight stays.
4. Pediatric hospitalists should be staffing community hospitals.
5. Pediatric behavioral health resources need to be available, e.g., inpatient psychiatry, partial hospitalization programs, intensive outpatient programs.
6. Telehealth communication is not adequate to address acute care problems, because the hospital caring for the child has to have the proper equipment and adequate expertise to carry out the recommendations of the teleconsultant.
If we accept that our children will shape the future, we must allow them to survive and thrive. Is health care a right or a privilege, and is it just for adults or for children, too?
Dr. Ochs is in private practice at Ravenswood Pediatrics in Chicago. He said he had no relevant financial disclosures. Email him at [email protected].
The mantra of community hospital administrators is that pediatric care does not pay. Neonatal intensive care pays. For pediatrics, it is similar to how football programs (Medicare patients) support minor sports (pediatrics and obstetrics) at colleges. However, fewer even mildly sick newborns are cared for at community hospitals, which has led to a centralization of neonatal and pediatric care and a loss of pediatric expertise at the affected hospitals.
Pediatric hospitalists are hired to cover the pediatric floor, the emergency department, and labor and delivery, then fired over empty pediatric beds. The rationale expressed is that pediatricians have done such a good job in preventive care that children rarely need hospitalization, so why have a pediatric inpatient unit? It is true that preventive care has been an integral part of primary care for children. Significantly less that 1% of child office visits result in hospitalization.
Advocate Health Care has closed inpatient pediatric units at Illinois Masonic, on Chicago’s North Side, Good Samaritan in Downers Grove, and Good Shepherd in Barrington. Units also have been closed at Mount Sinai in North Lawndale, Norwegian American on Chicago’s West Side, Little Company of Mary in Evergreen Park, and Alexian Brothers in Elk Grove.
As a Chicago-area pediatrician for more than 30 years, I have learned several things about community-based pediatric care:
1. Pediatrics is a geographic specialty. Parents will travel to shop, but would rather walk or have a short ride to their children’s medical providers. Secondary care should be community based, and hospitalization, if necessary, should be close by as well.
2. Hospitals that ceased delivering pediatric inpatient care lost their child-friendliness and pediatric competence, becoming uncomfortable delivering almost any care for children (e.g., sedated MRIs and EEGs, x-rays and ultrasounds, ECGs and echocardiograms, and emergency care).
3. In almost all hospitals, after pediatrics was gone eventually so passed obstetrics (another less remunerative specialty). Sick newborns need immediate, competent care. Most pediatric hospitalizations are short term, often overnight. Delaying newborn care is a medicolegal nightmare. and exposes the child and his or her family to a potentially dangerous drive or helicopter ride.
4. As pediatric subspecialty care becomes more centralized, parents are asked to travel for hours to see a pediatric specialist. There are times when that is necessary (e.g., cardiovascular surgery). Pediatric subspecialists, such as pediatric otolaryngologists, then leave community hospitals, forcing even minor surgeries (e.g., ear ventilation tubes) to be done at a center. In rural areas, this could mean hours of travel, lost work days, and family disruption.
5. Children’s hospitals get uninsured and publicly insured children sent hundreds of miles, because there were no subspecialists in the community who would care for these children.
What is the solution, in our profit-focused health care system?
1. Hospitals’ Certificates of Need could include a mandate for pediatric care.
2. Children’s hospitals could be made responsible for community-based care within their geographic catchment areas.
3. The state or the federal government could mandate and financially support community-based hospital care.
4. Deciding what level of care might be appropriate for each community could depend upon closeness to a pediatric hospital, health problems in the community, and the availability of pediatric specialists.
5. A condition for medical licensure might be that a community-based pediatric subspecialist is required to care for a proportion of the uninsured or publicly insured children in his or her area.
6. Reimbursements for pediatric care need to rise enough to make caring for children worth it.
The major decision point regarding care for children cannot be financial, but must instead embrace the needs of each affected community. If quality health care is a right, and not a privilege, then it is time to stop closing pediatric inpatient units, and, instead, look for creative ways to better care for our children.
This process has led to pediatric care being available only in designated centers. The centralization of pediatric care has progressed from 30 years ago, when most community hospitals had inpatient pediatric units, to the search for innovative ways to fill pediatric beds in the mid-90s (sick day care, flex- or shared pediatric units), to the wholesale closure of community pediatric inpatient beds, from 2000 to the present. I have, unfortunately, seen this firsthand, watching the rise of pediatric mega-hospitals and the demise of community pediatrics. It is a simple financial argument. Care for children simply does not pay nearly as well as does care for adults, especially Medicaid patients. Pediatricians are the poorest paid practicing doctors (public health doctors are paid less).
It is true that pediatricians always have been at the forefront of preventive medicine, and that pediatric patients almost always get better, in spite of our best-intentioned interventions. So community-based pediatricians admit very few patients.
With the loss of pediatric units, community hospitals lose their comfort caring for children. This includes phlebotomy, x-ray, trauma, surgery, and behavioral health. And eroding community hospital pediatric expertise has catastrophic implications for rural hospitals, where parents may have to drive for hours to find a child-friendly emergency department.
Is there an answer?
1. Hospitals are responsible for the patients they serve, including children. Why should a hospital be able to close pediatric services so easily?
2. Every hospital that sees children, through the emergency department, needs to have a pediatrician available to evaluate a child, 24/7.
3. There needs to be an observation unit for children, with pediatric staffing, for overnight stays.
4. Pediatric hospitalists should be staffing community hospitals.
5. Pediatric behavioral health resources need to be available, e.g., inpatient psychiatry, partial hospitalization programs, intensive outpatient programs.
6. Telehealth communication is not adequate to address acute care problems, because the hospital caring for the child has to have the proper equipment and adequate expertise to carry out the recommendations of the teleconsultant.
If we accept that our children will shape the future, we must allow them to survive and thrive. Is health care a right or a privilege, and is it just for adults or for children, too?
Dr. Ochs is in private practice at Ravenswood Pediatrics in Chicago. He said he had no relevant financial disclosures. Email him at [email protected].
The mantra of community hospital administrators is that pediatric care does not pay. Neonatal intensive care pays. For pediatrics, it is similar to how football programs (Medicare patients) support minor sports (pediatrics and obstetrics) at colleges. However, fewer even mildly sick newborns are cared for at community hospitals, which has led to a centralization of neonatal and pediatric care and a loss of pediatric expertise at the affected hospitals.
Pediatric hospitalists are hired to cover the pediatric floor, the emergency department, and labor and delivery, then fired over empty pediatric beds. The rationale expressed is that pediatricians have done such a good job in preventive care that children rarely need hospitalization, so why have a pediatric inpatient unit? It is true that preventive care has been an integral part of primary care for children. Significantly less that 1% of child office visits result in hospitalization.
Advocate Health Care has closed inpatient pediatric units at Illinois Masonic, on Chicago’s North Side, Good Samaritan in Downers Grove, and Good Shepherd in Barrington. Units also have been closed at Mount Sinai in North Lawndale, Norwegian American on Chicago’s West Side, Little Company of Mary in Evergreen Park, and Alexian Brothers in Elk Grove.
As a Chicago-area pediatrician for more than 30 years, I have learned several things about community-based pediatric care:
1. Pediatrics is a geographic specialty. Parents will travel to shop, but would rather walk or have a short ride to their children’s medical providers. Secondary care should be community based, and hospitalization, if necessary, should be close by as well.
2. Hospitals that ceased delivering pediatric inpatient care lost their child-friendliness and pediatric competence, becoming uncomfortable delivering almost any care for children (e.g., sedated MRIs and EEGs, x-rays and ultrasounds, ECGs and echocardiograms, and emergency care).
3. In almost all hospitals, after pediatrics was gone eventually so passed obstetrics (another less remunerative specialty). Sick newborns need immediate, competent care. Most pediatric hospitalizations are short term, often overnight. Delaying newborn care is a medicolegal nightmare. and exposes the child and his or her family to a potentially dangerous drive or helicopter ride.
4. As pediatric subspecialty care becomes more centralized, parents are asked to travel for hours to see a pediatric specialist. There are times when that is necessary (e.g., cardiovascular surgery). Pediatric subspecialists, such as pediatric otolaryngologists, then leave community hospitals, forcing even minor surgeries (e.g., ear ventilation tubes) to be done at a center. In rural areas, this could mean hours of travel, lost work days, and family disruption.
5. Children’s hospitals get uninsured and publicly insured children sent hundreds of miles, because there were no subspecialists in the community who would care for these children.
What is the solution, in our profit-focused health care system?
1. Hospitals’ Certificates of Need could include a mandate for pediatric care.
2. Children’s hospitals could be made responsible for community-based care within their geographic catchment areas.
3. The state or the federal government could mandate and financially support community-based hospital care.
4. Deciding what level of care might be appropriate for each community could depend upon closeness to a pediatric hospital, health problems in the community, and the availability of pediatric specialists.
5. A condition for medical licensure might be that a community-based pediatric subspecialist is required to care for a proportion of the uninsured or publicly insured children in his or her area.
6. Reimbursements for pediatric care need to rise enough to make caring for children worth it.
The major decision point regarding care for children cannot be financial, but must instead embrace the needs of each affected community. If quality health care is a right, and not a privilege, then it is time to stop closing pediatric inpatient units, and, instead, look for creative ways to better care for our children.
This process has led to pediatric care being available only in designated centers. The centralization of pediatric care has progressed from 30 years ago, when most community hospitals had inpatient pediatric units, to the search for innovative ways to fill pediatric beds in the mid-90s (sick day care, flex- or shared pediatric units), to the wholesale closure of community pediatric inpatient beds, from 2000 to the present. I have, unfortunately, seen this firsthand, watching the rise of pediatric mega-hospitals and the demise of community pediatrics. It is a simple financial argument. Care for children simply does not pay nearly as well as does care for adults, especially Medicaid patients. Pediatricians are the poorest paid practicing doctors (public health doctors are paid less).
It is true that pediatricians always have been at the forefront of preventive medicine, and that pediatric patients almost always get better, in spite of our best-intentioned interventions. So community-based pediatricians admit very few patients.
With the loss of pediatric units, community hospitals lose their comfort caring for children. This includes phlebotomy, x-ray, trauma, surgery, and behavioral health. And eroding community hospital pediatric expertise has catastrophic implications for rural hospitals, where parents may have to drive for hours to find a child-friendly emergency department.
Is there an answer?
1. Hospitals are responsible for the patients they serve, including children. Why should a hospital be able to close pediatric services so easily?
2. Every hospital that sees children, through the emergency department, needs to have a pediatrician available to evaluate a child, 24/7.
3. There needs to be an observation unit for children, with pediatric staffing, for overnight stays.
4. Pediatric hospitalists should be staffing community hospitals.
5. Pediatric behavioral health resources need to be available, e.g., inpatient psychiatry, partial hospitalization programs, intensive outpatient programs.
6. Telehealth communication is not adequate to address acute care problems, because the hospital caring for the child has to have the proper equipment and adequate expertise to carry out the recommendations of the teleconsultant.
If we accept that our children will shape the future, we must allow them to survive and thrive. Is health care a right or a privilege, and is it just for adults or for children, too?
Dr. Ochs is in private practice at Ravenswood Pediatrics in Chicago. He said he had no relevant financial disclosures. Email him at [email protected].
Promising early efficacy of venetoclax/navitoclax in r/r acute lymphoblastic leukemia
ORLANDO – A combination of venetoclax (Venclexta) and the experimental BCL-2 inhibitor navitoclax showed good activity and acceptable safety in both children and adults with relapsed or refractory acute lymphoblastic leukemia or lymphoblastic lymphoma, investigators in a phase 1 trial reported.
The overall rate of combined complete response (CR), CR with incomplete marrow recovery (CRi) or incomplete platelet recovery (CRp) was 49% among 45 patients: 24 with acute lymphoblastic leukemia of B-cell lineage (B-ALL), 18 with T-cell lineage ALL (T-ALL), and 3 with lymphoblastic lymphoma, reported Norman J. Lacayo, MD, from Stanford (Calif.) University.
“Venetoclax, navitoclax, and chemotherapy is well tolerated with few discontinuations for dose reductions due to adverse events in patients with relapsed/refractory ALL or lymphoblastic lymphoma. The preliminary efficacy was promising in this heavily pretreated population of patients, including pediatric patients and patients with prior stem cell transplantation of CAR [chimeric antigen receptor] T-cell therapy,” he said at the annual meeting of the American Society of Hematology.
Venetoclax is a highly selective inhibitor of the B-cell lymphoma 2 (BCL-2) pathway. Navitoclax inhibits BCL-2, the BCL–extra large (BCL-XL) transmembrane molecule, and the apoptotic protein BCL-W, but was associated with dose-limiting toxicities when used at standard doses in monotherapy, he noted.
To see whether adding venetoclax to low-dose navitoclax could be safe and have synergistic activity against BCL-2, Dr. Lacayo and colleagues are conducting a phase 1, open-label, dose-escalation study of patients aged 4 years and older with relapsed/refractory ALL or lymphoblastic lymphoma.
Patients receive the weight-adjusted equivalent of 200 mg venetoclax on day 1, and 400 mg equivalent daily thereafter. Beginning on day 3, patients receive oral navitoclax daily at doses of 25, 50, or 100 mg for patients weighing 45 kg or more, or 25 or 50 mg for patients weighing from 20 to less than 45 kg.
Patients can also receive two cycles of chemotherapy with asparaginase, vincristine, and dexamethasone, with additional cycles allowed at the investigators’ discretion.
The patients reported on at ASH 2019 had received a median of 4 prior lines of therapy (range, 1-10).
After a median time on study of 8 months, preliminary efficacy – a secondary endpoint of this phase 1 trial – was promising, Dr. Lacayo said. The CR rate was 25% among patients with B-ALL, 11% in patients with T-ALL, and 67% (two of three patients) with lymphoblastic lymphoma. The respective CRi rates were 13%, 17%, and 0%, and respective CRp rates were 17%, 11%, and 0%.
In addition, 3 of 24 patients (13%) with B-ALL had a partial response, as did 1 patient with lymphoblastic lymphoma.
The median time to first response was about 1.1 months. The median duration of response was 9.1 months for patients with B-ALL, 4.2 months for patients with T-ALL, and had not been reached among patients with lymphoblastic leukemia.
The median overall survival was 9.7 months for patients with B-ALL, 6.8 months for those with T-ALL, and not reached for those with lymphoblastic leukemia.
In all, 6 of 24 patients with B-ALL, 3 of 18 with T-ALL, and 2 of 3 with lymphoblastic leukemia survived long enough to proceed to stem cell transplantation or CAR T-cell therapy.
Analysis of the combination’s safety, the primary endpoint, showed that 58% of patients had grade 3-4 adverse events (AEs) related to venetoclax, and 42% had grade 3-4 AEs related to navitoclax. Four patients had to discontinue the combination because of treatment-related AEs.
Dose-limiting toxicities, which occurred in seven patients, included delayed count recovery, drug-induced liver injury, intestinal ischemia, and increase in serum bilirubin.
One patient died from an intestinal ischemic event deemed to be related to the combination, and seven other patients had fatal adverse events considered not related to the study drugs. The causes of death included sepsis, septic shock, cardiac arrest, and neurotoxicity.
The investigators are enrolling an expansion cohort to see whether a 21-day dosing schedule of venetoclax with 50 mg navitoclax, or 25 mg for patients under 45 kg, could improve count recovery time.
The study was funded by AbbVie. Dr. Lacayo reported having no conflict of interests to disclose. Several coauthors are AbbVie employees.
SOURCE: Lacayo NJ et al. ASH 2019, Abstract 285.
ORLANDO – A combination of venetoclax (Venclexta) and the experimental BCL-2 inhibitor navitoclax showed good activity and acceptable safety in both children and adults with relapsed or refractory acute lymphoblastic leukemia or lymphoblastic lymphoma, investigators in a phase 1 trial reported.
The overall rate of combined complete response (CR), CR with incomplete marrow recovery (CRi) or incomplete platelet recovery (CRp) was 49% among 45 patients: 24 with acute lymphoblastic leukemia of B-cell lineage (B-ALL), 18 with T-cell lineage ALL (T-ALL), and 3 with lymphoblastic lymphoma, reported Norman J. Lacayo, MD, from Stanford (Calif.) University.
“Venetoclax, navitoclax, and chemotherapy is well tolerated with few discontinuations for dose reductions due to adverse events in patients with relapsed/refractory ALL or lymphoblastic lymphoma. The preliminary efficacy was promising in this heavily pretreated population of patients, including pediatric patients and patients with prior stem cell transplantation of CAR [chimeric antigen receptor] T-cell therapy,” he said at the annual meeting of the American Society of Hematology.
Venetoclax is a highly selective inhibitor of the B-cell lymphoma 2 (BCL-2) pathway. Navitoclax inhibits BCL-2, the BCL–extra large (BCL-XL) transmembrane molecule, and the apoptotic protein BCL-W, but was associated with dose-limiting toxicities when used at standard doses in monotherapy, he noted.
To see whether adding venetoclax to low-dose navitoclax could be safe and have synergistic activity against BCL-2, Dr. Lacayo and colleagues are conducting a phase 1, open-label, dose-escalation study of patients aged 4 years and older with relapsed/refractory ALL or lymphoblastic lymphoma.
Patients receive the weight-adjusted equivalent of 200 mg venetoclax on day 1, and 400 mg equivalent daily thereafter. Beginning on day 3, patients receive oral navitoclax daily at doses of 25, 50, or 100 mg for patients weighing 45 kg or more, or 25 or 50 mg for patients weighing from 20 to less than 45 kg.
Patients can also receive two cycles of chemotherapy with asparaginase, vincristine, and dexamethasone, with additional cycles allowed at the investigators’ discretion.
The patients reported on at ASH 2019 had received a median of 4 prior lines of therapy (range, 1-10).
After a median time on study of 8 months, preliminary efficacy – a secondary endpoint of this phase 1 trial – was promising, Dr. Lacayo said. The CR rate was 25% among patients with B-ALL, 11% in patients with T-ALL, and 67% (two of three patients) with lymphoblastic lymphoma. The respective CRi rates were 13%, 17%, and 0%, and respective CRp rates were 17%, 11%, and 0%.
In addition, 3 of 24 patients (13%) with B-ALL had a partial response, as did 1 patient with lymphoblastic lymphoma.
The median time to first response was about 1.1 months. The median duration of response was 9.1 months for patients with B-ALL, 4.2 months for patients with T-ALL, and had not been reached among patients with lymphoblastic leukemia.
The median overall survival was 9.7 months for patients with B-ALL, 6.8 months for those with T-ALL, and not reached for those with lymphoblastic leukemia.
In all, 6 of 24 patients with B-ALL, 3 of 18 with T-ALL, and 2 of 3 with lymphoblastic leukemia survived long enough to proceed to stem cell transplantation or CAR T-cell therapy.
Analysis of the combination’s safety, the primary endpoint, showed that 58% of patients had grade 3-4 adverse events (AEs) related to venetoclax, and 42% had grade 3-4 AEs related to navitoclax. Four patients had to discontinue the combination because of treatment-related AEs.
Dose-limiting toxicities, which occurred in seven patients, included delayed count recovery, drug-induced liver injury, intestinal ischemia, and increase in serum bilirubin.
One patient died from an intestinal ischemic event deemed to be related to the combination, and seven other patients had fatal adverse events considered not related to the study drugs. The causes of death included sepsis, septic shock, cardiac arrest, and neurotoxicity.
The investigators are enrolling an expansion cohort to see whether a 21-day dosing schedule of venetoclax with 50 mg navitoclax, or 25 mg for patients under 45 kg, could improve count recovery time.
The study was funded by AbbVie. Dr. Lacayo reported having no conflict of interests to disclose. Several coauthors are AbbVie employees.
SOURCE: Lacayo NJ et al. ASH 2019, Abstract 285.
ORLANDO – A combination of venetoclax (Venclexta) and the experimental BCL-2 inhibitor navitoclax showed good activity and acceptable safety in both children and adults with relapsed or refractory acute lymphoblastic leukemia or lymphoblastic lymphoma, investigators in a phase 1 trial reported.
The overall rate of combined complete response (CR), CR with incomplete marrow recovery (CRi) or incomplete platelet recovery (CRp) was 49% among 45 patients: 24 with acute lymphoblastic leukemia of B-cell lineage (B-ALL), 18 with T-cell lineage ALL (T-ALL), and 3 with lymphoblastic lymphoma, reported Norman J. Lacayo, MD, from Stanford (Calif.) University.
“Venetoclax, navitoclax, and chemotherapy is well tolerated with few discontinuations for dose reductions due to adverse events in patients with relapsed/refractory ALL or lymphoblastic lymphoma. The preliminary efficacy was promising in this heavily pretreated population of patients, including pediatric patients and patients with prior stem cell transplantation of CAR [chimeric antigen receptor] T-cell therapy,” he said at the annual meeting of the American Society of Hematology.
Venetoclax is a highly selective inhibitor of the B-cell lymphoma 2 (BCL-2) pathway. Navitoclax inhibits BCL-2, the BCL–extra large (BCL-XL) transmembrane molecule, and the apoptotic protein BCL-W, but was associated with dose-limiting toxicities when used at standard doses in monotherapy, he noted.
To see whether adding venetoclax to low-dose navitoclax could be safe and have synergistic activity against BCL-2, Dr. Lacayo and colleagues are conducting a phase 1, open-label, dose-escalation study of patients aged 4 years and older with relapsed/refractory ALL or lymphoblastic lymphoma.
Patients receive the weight-adjusted equivalent of 200 mg venetoclax on day 1, and 400 mg equivalent daily thereafter. Beginning on day 3, patients receive oral navitoclax daily at doses of 25, 50, or 100 mg for patients weighing 45 kg or more, or 25 or 50 mg for patients weighing from 20 to less than 45 kg.
Patients can also receive two cycles of chemotherapy with asparaginase, vincristine, and dexamethasone, with additional cycles allowed at the investigators’ discretion.
The patients reported on at ASH 2019 had received a median of 4 prior lines of therapy (range, 1-10).
After a median time on study of 8 months, preliminary efficacy – a secondary endpoint of this phase 1 trial – was promising, Dr. Lacayo said. The CR rate was 25% among patients with B-ALL, 11% in patients with T-ALL, and 67% (two of three patients) with lymphoblastic lymphoma. The respective CRi rates were 13%, 17%, and 0%, and respective CRp rates were 17%, 11%, and 0%.
In addition, 3 of 24 patients (13%) with B-ALL had a partial response, as did 1 patient with lymphoblastic lymphoma.
The median time to first response was about 1.1 months. The median duration of response was 9.1 months for patients with B-ALL, 4.2 months for patients with T-ALL, and had not been reached among patients with lymphoblastic leukemia.
The median overall survival was 9.7 months for patients with B-ALL, 6.8 months for those with T-ALL, and not reached for those with lymphoblastic leukemia.
In all, 6 of 24 patients with B-ALL, 3 of 18 with T-ALL, and 2 of 3 with lymphoblastic leukemia survived long enough to proceed to stem cell transplantation or CAR T-cell therapy.
Analysis of the combination’s safety, the primary endpoint, showed that 58% of patients had grade 3-4 adverse events (AEs) related to venetoclax, and 42% had grade 3-4 AEs related to navitoclax. Four patients had to discontinue the combination because of treatment-related AEs.
Dose-limiting toxicities, which occurred in seven patients, included delayed count recovery, drug-induced liver injury, intestinal ischemia, and increase in serum bilirubin.
One patient died from an intestinal ischemic event deemed to be related to the combination, and seven other patients had fatal adverse events considered not related to the study drugs. The causes of death included sepsis, septic shock, cardiac arrest, and neurotoxicity.
The investigators are enrolling an expansion cohort to see whether a 21-day dosing schedule of venetoclax with 50 mg navitoclax, or 25 mg for patients under 45 kg, could improve count recovery time.
The study was funded by AbbVie. Dr. Lacayo reported having no conflict of interests to disclose. Several coauthors are AbbVie employees.
SOURCE: Lacayo NJ et al. ASH 2019, Abstract 285.
REPORTING FROM ASH 2019