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Obesity dropping in kids aged 2-4 years in WIC program
During 2010-2016, the prevalence of obesity among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program significantly decreased in 73% of 56 states and territories, Liping Pan, MD, and colleagues reported in the Morbidity and Mortality Weekly Report.
The obesity prevalence decreases varied, but exceeded 3% in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Puerto Rico experienced the greatest benefit, with an 8% decrease in obesity among children aged 2-4 years enrolled in the WIC program, wrote Dr. Pan, an epidemiologist at the Centers for Disease Control and Prevention and coauthors.
Although the changes were small, the positive trend gains more import when viewed in light of the country’s long-term obesity trends, Dr. Pan and his team wrote. After a short-lived dip during 2007-2012, obesity has been on the rise among these children, jumping from 8% in 2012 to 14% in 2016. “Thus, even these small decreases indicate progress for this vulnerable WIC population,” the team said.
WIC extends nutritional assistance to families whose income is 185% or less of the federal poverty guideline or are eligible for other programs, as well as being deemed at nutritional risk.
The current study looked at obesity trends during 2010-2016 among 12,403,629 WIC recipients aged 2-4 years in all 50 U.S. states and five territories.
In 2010, obesity prevalence ranged from a low of 10% in Colorado to a high of 22% in Virginia. In Alaska, Puerto Rico, and Virginia, it was 20% or higher. Only in Colorado and Hawaii was obesity prevalence 10% or less among these children.
By 2016, obesity prevalence among children aged 2-4 years ranged from 8% in the Northern Mariana Islands to 19.8% in Alaska. It was less than 20% in all the states and territories, and less than 10% in Colorado, Guam, Hawaii, Northern Mariana Islands, Utah, and Wyoming.
It increased during 2010-2016, however, in Alabama (0.5%), North Carolina (0.6%), and West Virginia (2.2%).
The changes reflect the 2009 program revisions made to adhere to the 2005 Dietary Guidelines for Americans and the infant food and feeding practice guidelines of the American Academy of Pediatrics, Dr. Pan and associates wrote.
“The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences,” the authors noted.
In response to the changes, Dr. Pan and associates noted, authorized WIC stores began carrying healthier offerings. Tracking showed that children in the program consumed more fruits, vegetables, and whole grain products and less juice, white bread, and whole milk after the revisions than they did previously.
Despite the good news, childhood obesity rates still are too high and much remains to be done, they noted.
“Multiple approaches are needed to address and eliminate childhood obesity. The National Academy of Medicine and other groups have recommended a comprehensive and integrated approach that calls for positive changes in physical activity and food and beverage environments in multiple settings including home, early care and education [such as nutrition standards for food served], and community [such as neighborhood designs that encourage walking and biking] to promote healthy eating and physical activity for young children. Further implementation of these positive changes across the United States could further the decreases in child-hood obesity,” Dr. Pan and coauthors concluded.
Dr. Pan and coauthors had no financial disclosures.
SOURCE: Pan L et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1057-61.
During 2010-2016, the prevalence of obesity among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program significantly decreased in 73% of 56 states and territories, Liping Pan, MD, and colleagues reported in the Morbidity and Mortality Weekly Report.
The obesity prevalence decreases varied, but exceeded 3% in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Puerto Rico experienced the greatest benefit, with an 8% decrease in obesity among children aged 2-4 years enrolled in the WIC program, wrote Dr. Pan, an epidemiologist at the Centers for Disease Control and Prevention and coauthors.
Although the changes were small, the positive trend gains more import when viewed in light of the country’s long-term obesity trends, Dr. Pan and his team wrote. After a short-lived dip during 2007-2012, obesity has been on the rise among these children, jumping from 8% in 2012 to 14% in 2016. “Thus, even these small decreases indicate progress for this vulnerable WIC population,” the team said.
WIC extends nutritional assistance to families whose income is 185% or less of the federal poverty guideline or are eligible for other programs, as well as being deemed at nutritional risk.
The current study looked at obesity trends during 2010-2016 among 12,403,629 WIC recipients aged 2-4 years in all 50 U.S. states and five territories.
In 2010, obesity prevalence ranged from a low of 10% in Colorado to a high of 22% in Virginia. In Alaska, Puerto Rico, and Virginia, it was 20% or higher. Only in Colorado and Hawaii was obesity prevalence 10% or less among these children.
By 2016, obesity prevalence among children aged 2-4 years ranged from 8% in the Northern Mariana Islands to 19.8% in Alaska. It was less than 20% in all the states and territories, and less than 10% in Colorado, Guam, Hawaii, Northern Mariana Islands, Utah, and Wyoming.
It increased during 2010-2016, however, in Alabama (0.5%), North Carolina (0.6%), and West Virginia (2.2%).
The changes reflect the 2009 program revisions made to adhere to the 2005 Dietary Guidelines for Americans and the infant food and feeding practice guidelines of the American Academy of Pediatrics, Dr. Pan and associates wrote.
“The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences,” the authors noted.
In response to the changes, Dr. Pan and associates noted, authorized WIC stores began carrying healthier offerings. Tracking showed that children in the program consumed more fruits, vegetables, and whole grain products and less juice, white bread, and whole milk after the revisions than they did previously.
Despite the good news, childhood obesity rates still are too high and much remains to be done, they noted.
“Multiple approaches are needed to address and eliminate childhood obesity. The National Academy of Medicine and other groups have recommended a comprehensive and integrated approach that calls for positive changes in physical activity and food and beverage environments in multiple settings including home, early care and education [such as nutrition standards for food served], and community [such as neighborhood designs that encourage walking and biking] to promote healthy eating and physical activity for young children. Further implementation of these positive changes across the United States could further the decreases in child-hood obesity,” Dr. Pan and coauthors concluded.
Dr. Pan and coauthors had no financial disclosures.
SOURCE: Pan L et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1057-61.
During 2010-2016, the prevalence of obesity among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program significantly decreased in 73% of 56 states and territories, Liping Pan, MD, and colleagues reported in the Morbidity and Mortality Weekly Report.
The obesity prevalence decreases varied, but exceeded 3% in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Puerto Rico experienced the greatest benefit, with an 8% decrease in obesity among children aged 2-4 years enrolled in the WIC program, wrote Dr. Pan, an epidemiologist at the Centers for Disease Control and Prevention and coauthors.
Although the changes were small, the positive trend gains more import when viewed in light of the country’s long-term obesity trends, Dr. Pan and his team wrote. After a short-lived dip during 2007-2012, obesity has been on the rise among these children, jumping from 8% in 2012 to 14% in 2016. “Thus, even these small decreases indicate progress for this vulnerable WIC population,” the team said.
WIC extends nutritional assistance to families whose income is 185% or less of the federal poverty guideline or are eligible for other programs, as well as being deemed at nutritional risk.
The current study looked at obesity trends during 2010-2016 among 12,403,629 WIC recipients aged 2-4 years in all 50 U.S. states and five territories.
In 2010, obesity prevalence ranged from a low of 10% in Colorado to a high of 22% in Virginia. In Alaska, Puerto Rico, and Virginia, it was 20% or higher. Only in Colorado and Hawaii was obesity prevalence 10% or less among these children.
By 2016, obesity prevalence among children aged 2-4 years ranged from 8% in the Northern Mariana Islands to 19.8% in Alaska. It was less than 20% in all the states and territories, and less than 10% in Colorado, Guam, Hawaii, Northern Mariana Islands, Utah, and Wyoming.
It increased during 2010-2016, however, in Alabama (0.5%), North Carolina (0.6%), and West Virginia (2.2%).
The changes reflect the 2009 program revisions made to adhere to the 2005 Dietary Guidelines for Americans and the infant food and feeding practice guidelines of the American Academy of Pediatrics, Dr. Pan and associates wrote.
“The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences,” the authors noted.
In response to the changes, Dr. Pan and associates noted, authorized WIC stores began carrying healthier offerings. Tracking showed that children in the program consumed more fruits, vegetables, and whole grain products and less juice, white bread, and whole milk after the revisions than they did previously.
Despite the good news, childhood obesity rates still are too high and much remains to be done, they noted.
“Multiple approaches are needed to address and eliminate childhood obesity. The National Academy of Medicine and other groups have recommended a comprehensive and integrated approach that calls for positive changes in physical activity and food and beverage environments in multiple settings including home, early care and education [such as nutrition standards for food served], and community [such as neighborhood designs that encourage walking and biking] to promote healthy eating and physical activity for young children. Further implementation of these positive changes across the United States could further the decreases in child-hood obesity,” Dr. Pan and coauthors concluded.
Dr. Pan and coauthors had no financial disclosures.
SOURCE: Pan L et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1057-61.
FROM THE MORBIDITY AND MORTALITY WEEKLY REPORT
Managing pain in kids during minor procedures: A tricky balance
NEW ORLEANS – Baruch S. Krauss, MD, EdM said at the annual meeting of the American Academy of Pediatrics.
Dr. Krauss, a pediatric emergency physician at Boston Children’s Hospital, shared tips for producing a positive experience when children present for minor procedures such as an intravenous catheter insertion or a laceration repair.
Control the environment
Setting the stage for a positive experience for children and their parents involves decreasing sensory stimuli by minimizing noise and bustle, the number of people in the room, and the reminder cues. “Even if you have trust with the child, there are certain things that could trigger the child to become fearful and anxious,” said Dr. Krauss, who also holds an academic post in the department of pediatrics at Harvard Medical School, Boston. “You want to make sure that medical equipment or a syringe is covered – anything that would remind the child or trigger the child to be more concerned and anxious.”
He recommends careful use of lighting, particularly in children who present with a head laceration or a facial laceration. “You may need to put a light near the wound, but that may be fearful for the child,” said Dr. Krauss, who coauthored a recent article on the topic that contains links to instructional videos (Ann Emerg Med 2019;74[1]:30-5). “Read the cues of the child,” he said. One desensitization technique he uses in such cases is to tell the child a story about the sun. He then goes on to liken the warmth of the exam light to the warmth of the sun.
Limiting the number of clinicians who speak to the child during the procedure also is key. “One person should speak to the child,” he advised. “Otherwise, it creates confusion for the child and it is hard for them to focus their attention. What you really want is to be able to control the child’s attention. You want to be able to capture their attention.”
It’s also important to keep medical equipment out of view. “I can’t tell you how many times I’ve seen consultants come in and a child needs to have a laceration repair, and they’re filling the syringe with lidocaine in front of the child,” Dr. Krauss said. “You want to avoid that. You also want to work outside of the child’s visual field if you can. Positioning is critical. I will try whatever position works for the child and the family.” This may including asking the parent to hold and swaddle an infant during the procedure, or positioning young children in the parent’s lap with their arm secured.
“Two things that upset kids during laceration repair are water dripping into their eyes during irrigation and the suture falling across their face as you’re stitching,” he added. “You want to develop your procedural skills so you can avoid that happening.”
Tailor the approach to the individual child
Some children will want to watch what you’re doing, but normally Dr. Krauss uses towels or blankets to cover the area being worked on. “If the child is part of your practice and you know his temperament and coping style, that makes it a lot easier; you know how to approach him,” he said. “They can trust you but they still can be quite fearful.” Sometimes, the child is relaxed but the parent becomes anxious. That anxiety can be transmitted to child. “If I see that the parents are anxious, I work directly with the child, and not the parent,” he said. “There’s not much I can tell a parent verbally that’s going to change their anxiety or fear level. But, as soon I start moving the child’s emotional state from fear to trust, the parent senses that and they relax, and that gets transmitted back to the child.”
Use age-appropriate language
When treating infants and children, Dr. Krauss often uses “parentese,” a simplified way that parents use to talk to young children. “It’s clearer, simpler, more attention-maintaining, and has longer pauses,” he said. “That can be very comforting to children.” Content and phrasing become important in older children. “You want to avoid the nocebo effect,” he continued. “If you tell a child, ‘This is really going to sting or hurt,’ you’re tipping the scales toward them having that experience.”
In an article about behavioral approaches to anxiety and pain management for pediatric venous access, Lindsey L. Cohen, PhD, devised a list of suggested phrasing to use. For example, instead of saying “You will be fine; there is nothing to worry about,” ask, “What did you do in school today?” as a form of distraction. Instead of saying, “It will feel like a bee sting,” ask, “Tell me how it feels.” And instead of saying, “Don’t cry,” say, “That was hard; I am proud of you” (Pediatrics 2008;122[suppl 3]:S134-9).
In a more recent article, Dr. Krauss and colleagues discussed current concepts of managing pain in children who present to the emergency department (Lancet 2016;387:83-92). Among distracting activities to try with infants and preschoolers are blowing bubbles, the use of a lighted wand, sound, music, or books, they noted. Distracting activities to try with preschoolers and in older children include art activities such as drawing, coloring, and the use of play dough, and computer games.
Clinicians also can ask the child to engage in a developmental task as a form of distraction. Dr. Krauss recalled a 22-month-old boy who presented to the emergency department with a forehead laceration. Mindful that the boy was developing eye-hand coordination and fine motor activity, Dr. Krauss offered him a coloring book that contained a picture of a clown, and instructed him to color the clown’s eyes red while Dr. Krauss tended to the wound. “His attention was completely fixed on that learning task,” he said.
Dr. Krauss reported having no financial disclosures.
NEW ORLEANS – Baruch S. Krauss, MD, EdM said at the annual meeting of the American Academy of Pediatrics.
Dr. Krauss, a pediatric emergency physician at Boston Children’s Hospital, shared tips for producing a positive experience when children present for minor procedures such as an intravenous catheter insertion or a laceration repair.
Control the environment
Setting the stage for a positive experience for children and their parents involves decreasing sensory stimuli by minimizing noise and bustle, the number of people in the room, and the reminder cues. “Even if you have trust with the child, there are certain things that could trigger the child to become fearful and anxious,” said Dr. Krauss, who also holds an academic post in the department of pediatrics at Harvard Medical School, Boston. “You want to make sure that medical equipment or a syringe is covered – anything that would remind the child or trigger the child to be more concerned and anxious.”
He recommends careful use of lighting, particularly in children who present with a head laceration or a facial laceration. “You may need to put a light near the wound, but that may be fearful for the child,” said Dr. Krauss, who coauthored a recent article on the topic that contains links to instructional videos (Ann Emerg Med 2019;74[1]:30-5). “Read the cues of the child,” he said. One desensitization technique he uses in such cases is to tell the child a story about the sun. He then goes on to liken the warmth of the exam light to the warmth of the sun.
Limiting the number of clinicians who speak to the child during the procedure also is key. “One person should speak to the child,” he advised. “Otherwise, it creates confusion for the child and it is hard for them to focus their attention. What you really want is to be able to control the child’s attention. You want to be able to capture their attention.”
It’s also important to keep medical equipment out of view. “I can’t tell you how many times I’ve seen consultants come in and a child needs to have a laceration repair, and they’re filling the syringe with lidocaine in front of the child,” Dr. Krauss said. “You want to avoid that. You also want to work outside of the child’s visual field if you can. Positioning is critical. I will try whatever position works for the child and the family.” This may including asking the parent to hold and swaddle an infant during the procedure, or positioning young children in the parent’s lap with their arm secured.
“Two things that upset kids during laceration repair are water dripping into their eyes during irrigation and the suture falling across their face as you’re stitching,” he added. “You want to develop your procedural skills so you can avoid that happening.”
Tailor the approach to the individual child
Some children will want to watch what you’re doing, but normally Dr. Krauss uses towels or blankets to cover the area being worked on. “If the child is part of your practice and you know his temperament and coping style, that makes it a lot easier; you know how to approach him,” he said. “They can trust you but they still can be quite fearful.” Sometimes, the child is relaxed but the parent becomes anxious. That anxiety can be transmitted to child. “If I see that the parents are anxious, I work directly with the child, and not the parent,” he said. “There’s not much I can tell a parent verbally that’s going to change their anxiety or fear level. But, as soon I start moving the child’s emotional state from fear to trust, the parent senses that and they relax, and that gets transmitted back to the child.”
Use age-appropriate language
When treating infants and children, Dr. Krauss often uses “parentese,” a simplified way that parents use to talk to young children. “It’s clearer, simpler, more attention-maintaining, and has longer pauses,” he said. “That can be very comforting to children.” Content and phrasing become important in older children. “You want to avoid the nocebo effect,” he continued. “If you tell a child, ‘This is really going to sting or hurt,’ you’re tipping the scales toward them having that experience.”
In an article about behavioral approaches to anxiety and pain management for pediatric venous access, Lindsey L. Cohen, PhD, devised a list of suggested phrasing to use. For example, instead of saying “You will be fine; there is nothing to worry about,” ask, “What did you do in school today?” as a form of distraction. Instead of saying, “It will feel like a bee sting,” ask, “Tell me how it feels.” And instead of saying, “Don’t cry,” say, “That was hard; I am proud of you” (Pediatrics 2008;122[suppl 3]:S134-9).
In a more recent article, Dr. Krauss and colleagues discussed current concepts of managing pain in children who present to the emergency department (Lancet 2016;387:83-92). Among distracting activities to try with infants and preschoolers are blowing bubbles, the use of a lighted wand, sound, music, or books, they noted. Distracting activities to try with preschoolers and in older children include art activities such as drawing, coloring, and the use of play dough, and computer games.
Clinicians also can ask the child to engage in a developmental task as a form of distraction. Dr. Krauss recalled a 22-month-old boy who presented to the emergency department with a forehead laceration. Mindful that the boy was developing eye-hand coordination and fine motor activity, Dr. Krauss offered him a coloring book that contained a picture of a clown, and instructed him to color the clown’s eyes red while Dr. Krauss tended to the wound. “His attention was completely fixed on that learning task,” he said.
Dr. Krauss reported having no financial disclosures.
NEW ORLEANS – Baruch S. Krauss, MD, EdM said at the annual meeting of the American Academy of Pediatrics.
Dr. Krauss, a pediatric emergency physician at Boston Children’s Hospital, shared tips for producing a positive experience when children present for minor procedures such as an intravenous catheter insertion or a laceration repair.
Control the environment
Setting the stage for a positive experience for children and their parents involves decreasing sensory stimuli by minimizing noise and bustle, the number of people in the room, and the reminder cues. “Even if you have trust with the child, there are certain things that could trigger the child to become fearful and anxious,” said Dr. Krauss, who also holds an academic post in the department of pediatrics at Harvard Medical School, Boston. “You want to make sure that medical equipment or a syringe is covered – anything that would remind the child or trigger the child to be more concerned and anxious.”
He recommends careful use of lighting, particularly in children who present with a head laceration or a facial laceration. “You may need to put a light near the wound, but that may be fearful for the child,” said Dr. Krauss, who coauthored a recent article on the topic that contains links to instructional videos (Ann Emerg Med 2019;74[1]:30-5). “Read the cues of the child,” he said. One desensitization technique he uses in such cases is to tell the child a story about the sun. He then goes on to liken the warmth of the exam light to the warmth of the sun.
Limiting the number of clinicians who speak to the child during the procedure also is key. “One person should speak to the child,” he advised. “Otherwise, it creates confusion for the child and it is hard for them to focus their attention. What you really want is to be able to control the child’s attention. You want to be able to capture their attention.”
It’s also important to keep medical equipment out of view. “I can’t tell you how many times I’ve seen consultants come in and a child needs to have a laceration repair, and they’re filling the syringe with lidocaine in front of the child,” Dr. Krauss said. “You want to avoid that. You also want to work outside of the child’s visual field if you can. Positioning is critical. I will try whatever position works for the child and the family.” This may including asking the parent to hold and swaddle an infant during the procedure, or positioning young children in the parent’s lap with their arm secured.
“Two things that upset kids during laceration repair are water dripping into their eyes during irrigation and the suture falling across their face as you’re stitching,” he added. “You want to develop your procedural skills so you can avoid that happening.”
Tailor the approach to the individual child
Some children will want to watch what you’re doing, but normally Dr. Krauss uses towels or blankets to cover the area being worked on. “If the child is part of your practice and you know his temperament and coping style, that makes it a lot easier; you know how to approach him,” he said. “They can trust you but they still can be quite fearful.” Sometimes, the child is relaxed but the parent becomes anxious. That anxiety can be transmitted to child. “If I see that the parents are anxious, I work directly with the child, and not the parent,” he said. “There’s not much I can tell a parent verbally that’s going to change their anxiety or fear level. But, as soon I start moving the child’s emotional state from fear to trust, the parent senses that and they relax, and that gets transmitted back to the child.”
Use age-appropriate language
When treating infants and children, Dr. Krauss often uses “parentese,” a simplified way that parents use to talk to young children. “It’s clearer, simpler, more attention-maintaining, and has longer pauses,” he said. “That can be very comforting to children.” Content and phrasing become important in older children. “You want to avoid the nocebo effect,” he continued. “If you tell a child, ‘This is really going to sting or hurt,’ you’re tipping the scales toward them having that experience.”
In an article about behavioral approaches to anxiety and pain management for pediatric venous access, Lindsey L. Cohen, PhD, devised a list of suggested phrasing to use. For example, instead of saying “You will be fine; there is nothing to worry about,” ask, “What did you do in school today?” as a form of distraction. Instead of saying, “It will feel like a bee sting,” ask, “Tell me how it feels.” And instead of saying, “Don’t cry,” say, “That was hard; I am proud of you” (Pediatrics 2008;122[suppl 3]:S134-9).
In a more recent article, Dr. Krauss and colleagues discussed current concepts of managing pain in children who present to the emergency department (Lancet 2016;387:83-92). Among distracting activities to try with infants and preschoolers are blowing bubbles, the use of a lighted wand, sound, music, or books, they noted. Distracting activities to try with preschoolers and in older children include art activities such as drawing, coloring, and the use of play dough, and computer games.
Clinicians also can ask the child to engage in a developmental task as a form of distraction. Dr. Krauss recalled a 22-month-old boy who presented to the emergency department with a forehead laceration. Mindful that the boy was developing eye-hand coordination and fine motor activity, Dr. Krauss offered him a coloring book that contained a picture of a clown, and instructed him to color the clown’s eyes red while Dr. Krauss tended to the wound. “His attention was completely fixed on that learning task,” he said.
Dr. Krauss reported having no financial disclosures.
EXPERT ANALYSIS AT AAP 19
Inexperience is the main cause of unsafe driving among teens
NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.
Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.
“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”
Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.
How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).
But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.
Risk factors for accidents
Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.
Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).
But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.
Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.
But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.
“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.
Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.
Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.
One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.
Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.
As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.
A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.
ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.
Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.
Interventions to improve teens’ driving safety
Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.
What helps teens most is, ironically, more driving.
“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.
Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”
Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.
Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.
Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.
Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.
Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.
Dr. Johnston had no disclosures.
NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.
Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.
“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”
Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.
How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).
But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.
Risk factors for accidents
Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.
Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).
But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.
Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.
But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.
“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.
Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.
Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.
One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.
Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.
As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.
A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.
ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.
Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.
Interventions to improve teens’ driving safety
Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.
What helps teens most is, ironically, more driving.
“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.
Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”
Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.
Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.
Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.
Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.
Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.
Dr. Johnston had no disclosures.
NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.
Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.
“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”
Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.
How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).
But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.
Risk factors for accidents
Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.
Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).
But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.
Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.
But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.
“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.
Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.
Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.
One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.
Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.
As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.
A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.
ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.
Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.
Interventions to improve teens’ driving safety
Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.
What helps teens most is, ironically, more driving.
“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.
Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”
Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.
Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.
Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.
Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.
Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.
Dr. Johnston had no disclosures.
Not All Stool Discussions Are Unproductive
On August 22, 2014, a baby girl was born healthy and at full term. She was discharged on August 24 after a routine hospital stay. A day later, the infant’s mother called the pediatrician’s emergency after-hours hotline, in distress. She was concerned because the infant had not had a bowel movement since August 23. She was also concerned that each feeding was lasting an hour. A nurse told the mother that her concerns would be discussed in a routine follow-up appointment scheduled for the next morning.
At the appointment, the pediatrician noted the infant was having feeding problems and had lost 11% of her at-birth weight. The pediatrician also noted a high respiratory rate and abnormal skin coloring. However, the pediatrician concluded that the infant’s feeding problems had resolved, reassured the parents she was healthy, and discharged her, telling her parents to return in 2 weeks.
On August 29, the mother again called the pediatrician’s office, this time with concerns over a decrease in the infant’s feeding. A nurse told her to bring the infant to the emergency department (ED). At the ED, the infant was found to have lost 12% of her weight since birth and to be severely dehydrated. Due to hypovolemia, health care providers could not complete lab tests on the infant until aggressive resuscitation had been performed for 4 hours. The infant’s lab values showed she had hypernatremia, which put her at risk for brain injury through a decrease in cellular hydration, increased vascular permeability, or elevated intracranial pressure.
The infant did sustain a permanent brain injury from the condition: right-side paralysis. Her multi-organ failure from dehydration also caused significant damage to her left kidney, which stopped functioning altogether in 2017.
The infant sued her pediatrician and his office. Plaintiff’s counsel stated that the infant’s early weight loss was a red flag and that the standard of care required the pediatrician to order in-office follow-up within 24 hours to confirm if the loss had been corrected. Plaintiff’s counsel also alleged the baby’s respiratory rate and poor coloring were also red flags for dehydration. He further alleged that if the infant had returned to the office, her weight loss would have prompted supplementation before the dehydration caused her brain injury.
VERDICT
The case was settled for $1,375,000.
COMMENTARY
This case merits discussion because it involves a type of patient many clinicians see in practice. Complaints of newborn and infant feeding problems are common. Most cases require reassurance and troubleshooting about common feeding problems—but the clinician must be on the lookout for serious issues. Thus, it is helpful to revisit expected newborn feeding, stooling, and weight status.
Continue to: With regard to feeding...
With regard to feeding, breastfed infants should receive between 8-12 feeds per day during the newborn hospitalization.1 Bottlefed infants should be fed 20 kcal per 30 mL of iron-containing formula. Infants are fed on demand, and the duration of the feeding should not exceed 4 hours. The volume of the feed for the first few days of life should be 15-30 mL per feed.
For breastfed infants, clinicians should be attentive to issues that can impact nutrition, including latching difficulties, pain, mastitis, blocked duct, and engorgement. These can limit nutrition and be extremely upsetting to the mother.
Stooling frequency for newborns varies and depends on whether the infant is bottle fed or breast fed. During the first week of life, infants pass a mean of 4 stools per day.2 Breastfed infants may have as few as one stool per day, increasing as mother’s milk production increases.2
With regard to weight loss, term infants may lose up to 10% of their birth weight in the first few days of life, which is typically regained in 10 to 14 days.1 Infants born via cesarean section lose more weight, with 25% of these babies losing more than 10% by 72 hours. Of them, 76% return to birth weight by 14 days and 92% by 21 days. By contrast, vaginally born infants regain weight faster, with 86% returning to their birth weight by 14 days and 95% by the 21st day.1
Here, the infant was term and healthy, but we are not told some important details. Was she breast fed or bottle fed? Was she born by cesarean section or vaginally? We do know she was discharged on August 24th, her mother called the hotline on the 25th, and she was seen by the pediatrician on the 26th—at which point the infant had not stooled in 3 days. The mother called the physician’s office again on August 29th and was sent to the ED. We are told only that each feeding lasted an hour and the infant hadn’t stooled.
Continue to: Regarding stool...
Regarding stool—we have all had discussions with patients regarding hypervigilant concerns about stool color. We know there are some big things to look for with stool color (eg, black tarry reveals upper GI bleeding, while clay-colored or pale may reveal the absence of bile). Yet, patients’ expectations of the color-coded diagnostic abilities of their stool knows no bounds. Patients are convinced that we have some color wheel in our jacket pocket corresponding to stool color—and that the nuances between shades have important medical implications. If you ask, “Would you say it is more marigold, butterscotch yellow, or Tuscan sun?” … your patient will have an answer.
Patients reveal stool color hesitantly, reservedly, with nervous expectation. They wait for your response in quivering anticipation that the coming reply will include words to the effect that a boysenberry-purple stool is equivalent to a Death tarot card. A subconjunctival hemorrhage is the only thing that approaches the anxiety level of the oddly hued stool (Oddly Hued Stool Anxiety). Woe be the patient with both. For a patient bearing a subconjunctival hemorrhage who has also passed a jungle-green stool in the past 24 hours fully expects to explode within the next 60 minutes.
I’ve been rather facetious for a reason. My purpose is to acknowledge and to help you recognize that most discussions regarding stooling will not be (forgive me) productive. They are not productive because most stool coloration issues are nonentities—yet they produce patient anxiety that takes some time to address, leaving a busy clinician prone to curtly dismiss such discussions out of hand. Because many patient-initiated stool discussions aren’t productive, there is the risk for stool tune-out. As gross and unproductive as they can be, don’t tune out all stool discussions.
In this case, the appropriate frequency of stooling should have been at least once per day. For newborns, a stool color question is helpful; stool should not be white, pale, or clay-colored, which is suggestive of acholic stools from biliary atresia. Here, despite the absence of stool over a 3-day period, the defendant concluded the feeding problem was resolved and set a return visit for 2 weeks later. The plaintiff’s expert contended that the weight loss and absence of stooling was evidence of inadequate intake and warranted a return check the next day. Rather than risk the case going to trial, the defendant settled for $1,375,000.
IN SUM
Newborn nutrition is important. Understand that parents will be anxious about newborn feeding, although often there is no major medical concern. However, do not be dismissive of feeding concerns because of this expected anxiety. Listen to the parents fully, paying particular attention to quantifying feeding difficulty and stooling frequency matters. Don’t let patients’ rainbow parade of needless stool concerns blind you to considering important information. In other words, don’t be a stool fool.
1. McKee-Garrett TM. Overview of the routine management of the healthy newborn infant. UpToDate. Updated July 12, 2019. www.uptodate.com/contents/overview-of-the-routine-management-of-the-healthy-newborn-infant. Accessed November 18, 2019.
2. Sood MR. Constipation in infants and children: evaluation. UpToDate. Updated August 1, 2019. www.uptodate.com/contents/constipation-in-infants-and-children-evaluation. Accessed November 18, 2019.
On August 22, 2014, a baby girl was born healthy and at full term. She was discharged on August 24 after a routine hospital stay. A day later, the infant’s mother called the pediatrician’s emergency after-hours hotline, in distress. She was concerned because the infant had not had a bowel movement since August 23. She was also concerned that each feeding was lasting an hour. A nurse told the mother that her concerns would be discussed in a routine follow-up appointment scheduled for the next morning.
At the appointment, the pediatrician noted the infant was having feeding problems and had lost 11% of her at-birth weight. The pediatrician also noted a high respiratory rate and abnormal skin coloring. However, the pediatrician concluded that the infant’s feeding problems had resolved, reassured the parents she was healthy, and discharged her, telling her parents to return in 2 weeks.
On August 29, the mother again called the pediatrician’s office, this time with concerns over a decrease in the infant’s feeding. A nurse told her to bring the infant to the emergency department (ED). At the ED, the infant was found to have lost 12% of her weight since birth and to be severely dehydrated. Due to hypovolemia, health care providers could not complete lab tests on the infant until aggressive resuscitation had been performed for 4 hours. The infant’s lab values showed she had hypernatremia, which put her at risk for brain injury through a decrease in cellular hydration, increased vascular permeability, or elevated intracranial pressure.
The infant did sustain a permanent brain injury from the condition: right-side paralysis. Her multi-organ failure from dehydration also caused significant damage to her left kidney, which stopped functioning altogether in 2017.
The infant sued her pediatrician and his office. Plaintiff’s counsel stated that the infant’s early weight loss was a red flag and that the standard of care required the pediatrician to order in-office follow-up within 24 hours to confirm if the loss had been corrected. Plaintiff’s counsel also alleged the baby’s respiratory rate and poor coloring were also red flags for dehydration. He further alleged that if the infant had returned to the office, her weight loss would have prompted supplementation before the dehydration caused her brain injury.
VERDICT
The case was settled for $1,375,000.
COMMENTARY
This case merits discussion because it involves a type of patient many clinicians see in practice. Complaints of newborn and infant feeding problems are common. Most cases require reassurance and troubleshooting about common feeding problems—but the clinician must be on the lookout for serious issues. Thus, it is helpful to revisit expected newborn feeding, stooling, and weight status.
Continue to: With regard to feeding...
With regard to feeding, breastfed infants should receive between 8-12 feeds per day during the newborn hospitalization.1 Bottlefed infants should be fed 20 kcal per 30 mL of iron-containing formula. Infants are fed on demand, and the duration of the feeding should not exceed 4 hours. The volume of the feed for the first few days of life should be 15-30 mL per feed.
For breastfed infants, clinicians should be attentive to issues that can impact nutrition, including latching difficulties, pain, mastitis, blocked duct, and engorgement. These can limit nutrition and be extremely upsetting to the mother.
Stooling frequency for newborns varies and depends on whether the infant is bottle fed or breast fed. During the first week of life, infants pass a mean of 4 stools per day.2 Breastfed infants may have as few as one stool per day, increasing as mother’s milk production increases.2
With regard to weight loss, term infants may lose up to 10% of their birth weight in the first few days of life, which is typically regained in 10 to 14 days.1 Infants born via cesarean section lose more weight, with 25% of these babies losing more than 10% by 72 hours. Of them, 76% return to birth weight by 14 days and 92% by 21 days. By contrast, vaginally born infants regain weight faster, with 86% returning to their birth weight by 14 days and 95% by the 21st day.1
Here, the infant was term and healthy, but we are not told some important details. Was she breast fed or bottle fed? Was she born by cesarean section or vaginally? We do know she was discharged on August 24th, her mother called the hotline on the 25th, and she was seen by the pediatrician on the 26th—at which point the infant had not stooled in 3 days. The mother called the physician’s office again on August 29th and was sent to the ED. We are told only that each feeding lasted an hour and the infant hadn’t stooled.
Continue to: Regarding stool...
Regarding stool—we have all had discussions with patients regarding hypervigilant concerns about stool color. We know there are some big things to look for with stool color (eg, black tarry reveals upper GI bleeding, while clay-colored or pale may reveal the absence of bile). Yet, patients’ expectations of the color-coded diagnostic abilities of their stool knows no bounds. Patients are convinced that we have some color wheel in our jacket pocket corresponding to stool color—and that the nuances between shades have important medical implications. If you ask, “Would you say it is more marigold, butterscotch yellow, or Tuscan sun?” … your patient will have an answer.
Patients reveal stool color hesitantly, reservedly, with nervous expectation. They wait for your response in quivering anticipation that the coming reply will include words to the effect that a boysenberry-purple stool is equivalent to a Death tarot card. A subconjunctival hemorrhage is the only thing that approaches the anxiety level of the oddly hued stool (Oddly Hued Stool Anxiety). Woe be the patient with both. For a patient bearing a subconjunctival hemorrhage who has also passed a jungle-green stool in the past 24 hours fully expects to explode within the next 60 minutes.
I’ve been rather facetious for a reason. My purpose is to acknowledge and to help you recognize that most discussions regarding stooling will not be (forgive me) productive. They are not productive because most stool coloration issues are nonentities—yet they produce patient anxiety that takes some time to address, leaving a busy clinician prone to curtly dismiss such discussions out of hand. Because many patient-initiated stool discussions aren’t productive, there is the risk for stool tune-out. As gross and unproductive as they can be, don’t tune out all stool discussions.
In this case, the appropriate frequency of stooling should have been at least once per day. For newborns, a stool color question is helpful; stool should not be white, pale, or clay-colored, which is suggestive of acholic stools from biliary atresia. Here, despite the absence of stool over a 3-day period, the defendant concluded the feeding problem was resolved and set a return visit for 2 weeks later. The plaintiff’s expert contended that the weight loss and absence of stooling was evidence of inadequate intake and warranted a return check the next day. Rather than risk the case going to trial, the defendant settled for $1,375,000.
IN SUM
Newborn nutrition is important. Understand that parents will be anxious about newborn feeding, although often there is no major medical concern. However, do not be dismissive of feeding concerns because of this expected anxiety. Listen to the parents fully, paying particular attention to quantifying feeding difficulty and stooling frequency matters. Don’t let patients’ rainbow parade of needless stool concerns blind you to considering important information. In other words, don’t be a stool fool.
On August 22, 2014, a baby girl was born healthy and at full term. She was discharged on August 24 after a routine hospital stay. A day later, the infant’s mother called the pediatrician’s emergency after-hours hotline, in distress. She was concerned because the infant had not had a bowel movement since August 23. She was also concerned that each feeding was lasting an hour. A nurse told the mother that her concerns would be discussed in a routine follow-up appointment scheduled for the next morning.
At the appointment, the pediatrician noted the infant was having feeding problems and had lost 11% of her at-birth weight. The pediatrician also noted a high respiratory rate and abnormal skin coloring. However, the pediatrician concluded that the infant’s feeding problems had resolved, reassured the parents she was healthy, and discharged her, telling her parents to return in 2 weeks.
On August 29, the mother again called the pediatrician’s office, this time with concerns over a decrease in the infant’s feeding. A nurse told her to bring the infant to the emergency department (ED). At the ED, the infant was found to have lost 12% of her weight since birth and to be severely dehydrated. Due to hypovolemia, health care providers could not complete lab tests on the infant until aggressive resuscitation had been performed for 4 hours. The infant’s lab values showed she had hypernatremia, which put her at risk for brain injury through a decrease in cellular hydration, increased vascular permeability, or elevated intracranial pressure.
The infant did sustain a permanent brain injury from the condition: right-side paralysis. Her multi-organ failure from dehydration also caused significant damage to her left kidney, which stopped functioning altogether in 2017.
The infant sued her pediatrician and his office. Plaintiff’s counsel stated that the infant’s early weight loss was a red flag and that the standard of care required the pediatrician to order in-office follow-up within 24 hours to confirm if the loss had been corrected. Plaintiff’s counsel also alleged the baby’s respiratory rate and poor coloring were also red flags for dehydration. He further alleged that if the infant had returned to the office, her weight loss would have prompted supplementation before the dehydration caused her brain injury.
VERDICT
The case was settled for $1,375,000.
COMMENTARY
This case merits discussion because it involves a type of patient many clinicians see in practice. Complaints of newborn and infant feeding problems are common. Most cases require reassurance and troubleshooting about common feeding problems—but the clinician must be on the lookout for serious issues. Thus, it is helpful to revisit expected newborn feeding, stooling, and weight status.
Continue to: With regard to feeding...
With regard to feeding, breastfed infants should receive between 8-12 feeds per day during the newborn hospitalization.1 Bottlefed infants should be fed 20 kcal per 30 mL of iron-containing formula. Infants are fed on demand, and the duration of the feeding should not exceed 4 hours. The volume of the feed for the first few days of life should be 15-30 mL per feed.
For breastfed infants, clinicians should be attentive to issues that can impact nutrition, including latching difficulties, pain, mastitis, blocked duct, and engorgement. These can limit nutrition and be extremely upsetting to the mother.
Stooling frequency for newborns varies and depends on whether the infant is bottle fed or breast fed. During the first week of life, infants pass a mean of 4 stools per day.2 Breastfed infants may have as few as one stool per day, increasing as mother’s milk production increases.2
With regard to weight loss, term infants may lose up to 10% of their birth weight in the first few days of life, which is typically regained in 10 to 14 days.1 Infants born via cesarean section lose more weight, with 25% of these babies losing more than 10% by 72 hours. Of them, 76% return to birth weight by 14 days and 92% by 21 days. By contrast, vaginally born infants regain weight faster, with 86% returning to their birth weight by 14 days and 95% by the 21st day.1
Here, the infant was term and healthy, but we are not told some important details. Was she breast fed or bottle fed? Was she born by cesarean section or vaginally? We do know she was discharged on August 24th, her mother called the hotline on the 25th, and she was seen by the pediatrician on the 26th—at which point the infant had not stooled in 3 days. The mother called the physician’s office again on August 29th and was sent to the ED. We are told only that each feeding lasted an hour and the infant hadn’t stooled.
Continue to: Regarding stool...
Regarding stool—we have all had discussions with patients regarding hypervigilant concerns about stool color. We know there are some big things to look for with stool color (eg, black tarry reveals upper GI bleeding, while clay-colored or pale may reveal the absence of bile). Yet, patients’ expectations of the color-coded diagnostic abilities of their stool knows no bounds. Patients are convinced that we have some color wheel in our jacket pocket corresponding to stool color—and that the nuances between shades have important medical implications. If you ask, “Would you say it is more marigold, butterscotch yellow, or Tuscan sun?” … your patient will have an answer.
Patients reveal stool color hesitantly, reservedly, with nervous expectation. They wait for your response in quivering anticipation that the coming reply will include words to the effect that a boysenberry-purple stool is equivalent to a Death tarot card. A subconjunctival hemorrhage is the only thing that approaches the anxiety level of the oddly hued stool (Oddly Hued Stool Anxiety). Woe be the patient with both. For a patient bearing a subconjunctival hemorrhage who has also passed a jungle-green stool in the past 24 hours fully expects to explode within the next 60 minutes.
I’ve been rather facetious for a reason. My purpose is to acknowledge and to help you recognize that most discussions regarding stooling will not be (forgive me) productive. They are not productive because most stool coloration issues are nonentities—yet they produce patient anxiety that takes some time to address, leaving a busy clinician prone to curtly dismiss such discussions out of hand. Because many patient-initiated stool discussions aren’t productive, there is the risk for stool tune-out. As gross and unproductive as they can be, don’t tune out all stool discussions.
In this case, the appropriate frequency of stooling should have been at least once per day. For newborns, a stool color question is helpful; stool should not be white, pale, or clay-colored, which is suggestive of acholic stools from biliary atresia. Here, despite the absence of stool over a 3-day period, the defendant concluded the feeding problem was resolved and set a return visit for 2 weeks later. The plaintiff’s expert contended that the weight loss and absence of stooling was evidence of inadequate intake and warranted a return check the next day. Rather than risk the case going to trial, the defendant settled for $1,375,000.
IN SUM
Newborn nutrition is important. Understand that parents will be anxious about newborn feeding, although often there is no major medical concern. However, do not be dismissive of feeding concerns because of this expected anxiety. Listen to the parents fully, paying particular attention to quantifying feeding difficulty and stooling frequency matters. Don’t let patients’ rainbow parade of needless stool concerns blind you to considering important information. In other words, don’t be a stool fool.
1. McKee-Garrett TM. Overview of the routine management of the healthy newborn infant. UpToDate. Updated July 12, 2019. www.uptodate.com/contents/overview-of-the-routine-management-of-the-healthy-newborn-infant. Accessed November 18, 2019.
2. Sood MR. Constipation in infants and children: evaluation. UpToDate. Updated August 1, 2019. www.uptodate.com/contents/constipation-in-infants-and-children-evaluation. Accessed November 18, 2019.
1. McKee-Garrett TM. Overview of the routine management of the healthy newborn infant. UpToDate. Updated July 12, 2019. www.uptodate.com/contents/overview-of-the-routine-management-of-the-healthy-newborn-infant. Accessed November 18, 2019.
2. Sood MR. Constipation in infants and children: evaluation. UpToDate. Updated August 1, 2019. www.uptodate.com/contents/constipation-in-infants-and-children-evaluation. Accessed November 18, 2019.
Omalizumab proves effective for severe pediatric atopic dermatitis
A new study has found that omalizumab (Xolair) reduced severity and improved quality of life in pediatric patients with severe atopic dermatitis.
“Future work with an even larger sample size, a longer duration, and higher-affinity versions of omalizumab would clarify the precise role of anti-IgE therapy and its ideal target population,” wrote Susan Chan, MD, of Guy’s and St. Thomas’ NHS Foundation Trust in London and her coauthors. The study was published in JAMA Pediatrics.
To determine the benefits of omalizumab in reducing immunoglobulin E levels and thereby treating severe childhood eczema, the researchers launched the Atopic Dermatitis Anti-IgE Pediatric Trial (ADAPT). This randomized clinical trial recruited 62 patients between the ages of 4 and 19 years with severe eczema, which was defined as a score over 40 on the objective Scoring Atopic Dermatitis (SCORAD) index. They received 24 weeks of treatment with either omalizumab (n = 30) or placebo (n = 32) followed by 24 weeks of follow-up. Participants had a mean age of 10.3 years.
After 24 weeks, the adjusted mean difference in objective SCORAD index between the two groups was –6.9 (95% confidence interval, –12.2 to –1.5; P = .01) and significantly favored omalizumab therapy. The adjusted mean difference for the Eczema Area and Severity Index (–6.7; 95% CI, –13.2 to –0.1) also favored omalizumab. In regard to quality of life, after 24 weeks the Children’s Dermatology Life Quality Index/Dermatology Life Quality Index favored the omalizumab group with an adjusted mean difference of –3.5 (95% CI, –6.4 to –0.5).
In an accompanying editorial, Ann Chen Wu, MD, of Harvard Medical School in Boston noted that the results of the study from Chan et al. were promising but “more questions need to be answered before the drug can be used to treat atopic dermatitis in clinical practice” (JAMA Pediatr. 2019 Nov. 25. doi: 10.1001/jamapediatrics.2019.4509).
Her initial concern was price; she acknowledged that “omalizumab is a costly intervention” but said atopic dermatitis is also costly, raising the question as to whether the high costs of both justify treatment. In addition, omalizumab as treatment can come with both benefits and harms. Severe atopic dermatitis can decrease quality of life and, though omalizumab appears to be safe, there are adverse effects and logistical burdens to overcome.
More than anything, she recognized the need to prioritize, wondering what level of atopic dermatitis patients would truly benefit from this level of treatment. “Is using a $100,000-per-year medication for an itchy condition an overtreatment,” she asked, “or a lifesaver?”
The study was funded by the National Institute for Health Research Efficacy and Mechanism Evaluation Programme and Guy’s and St. Thomas’ Charity. The authors had numerous financial disclosures, including receiving grants from the NIHR EME Programme and Guy’s and St. Thomas’ Charity along with active and placebo drugs from Novartis for use in the study. Dr. Wu reported receiving a grant from GlaxoSmithKline.
SOURCE: Chan S et al. JAMA Pediatr. 2019 Nov 25. doi: 10.1001/jamapediatrics.2019.4476.
A new study has found that omalizumab (Xolair) reduced severity and improved quality of life in pediatric patients with severe atopic dermatitis.
“Future work with an even larger sample size, a longer duration, and higher-affinity versions of omalizumab would clarify the precise role of anti-IgE therapy and its ideal target population,” wrote Susan Chan, MD, of Guy’s and St. Thomas’ NHS Foundation Trust in London and her coauthors. The study was published in JAMA Pediatrics.
To determine the benefits of omalizumab in reducing immunoglobulin E levels and thereby treating severe childhood eczema, the researchers launched the Atopic Dermatitis Anti-IgE Pediatric Trial (ADAPT). This randomized clinical trial recruited 62 patients between the ages of 4 and 19 years with severe eczema, which was defined as a score over 40 on the objective Scoring Atopic Dermatitis (SCORAD) index. They received 24 weeks of treatment with either omalizumab (n = 30) or placebo (n = 32) followed by 24 weeks of follow-up. Participants had a mean age of 10.3 years.
After 24 weeks, the adjusted mean difference in objective SCORAD index between the two groups was –6.9 (95% confidence interval, –12.2 to –1.5; P = .01) and significantly favored omalizumab therapy. The adjusted mean difference for the Eczema Area and Severity Index (–6.7; 95% CI, –13.2 to –0.1) also favored omalizumab. In regard to quality of life, after 24 weeks the Children’s Dermatology Life Quality Index/Dermatology Life Quality Index favored the omalizumab group with an adjusted mean difference of –3.5 (95% CI, –6.4 to –0.5).
In an accompanying editorial, Ann Chen Wu, MD, of Harvard Medical School in Boston noted that the results of the study from Chan et al. were promising but “more questions need to be answered before the drug can be used to treat atopic dermatitis in clinical practice” (JAMA Pediatr. 2019 Nov. 25. doi: 10.1001/jamapediatrics.2019.4509).
Her initial concern was price; she acknowledged that “omalizumab is a costly intervention” but said atopic dermatitis is also costly, raising the question as to whether the high costs of both justify treatment. In addition, omalizumab as treatment can come with both benefits and harms. Severe atopic dermatitis can decrease quality of life and, though omalizumab appears to be safe, there are adverse effects and logistical burdens to overcome.
More than anything, she recognized the need to prioritize, wondering what level of atopic dermatitis patients would truly benefit from this level of treatment. “Is using a $100,000-per-year medication for an itchy condition an overtreatment,” she asked, “or a lifesaver?”
The study was funded by the National Institute for Health Research Efficacy and Mechanism Evaluation Programme and Guy’s and St. Thomas’ Charity. The authors had numerous financial disclosures, including receiving grants from the NIHR EME Programme and Guy’s and St. Thomas’ Charity along with active and placebo drugs from Novartis for use in the study. Dr. Wu reported receiving a grant from GlaxoSmithKline.
SOURCE: Chan S et al. JAMA Pediatr. 2019 Nov 25. doi: 10.1001/jamapediatrics.2019.4476.
A new study has found that omalizumab (Xolair) reduced severity and improved quality of life in pediatric patients with severe atopic dermatitis.
“Future work with an even larger sample size, a longer duration, and higher-affinity versions of omalizumab would clarify the precise role of anti-IgE therapy and its ideal target population,” wrote Susan Chan, MD, of Guy’s and St. Thomas’ NHS Foundation Trust in London and her coauthors. The study was published in JAMA Pediatrics.
To determine the benefits of omalizumab in reducing immunoglobulin E levels and thereby treating severe childhood eczema, the researchers launched the Atopic Dermatitis Anti-IgE Pediatric Trial (ADAPT). This randomized clinical trial recruited 62 patients between the ages of 4 and 19 years with severe eczema, which was defined as a score over 40 on the objective Scoring Atopic Dermatitis (SCORAD) index. They received 24 weeks of treatment with either omalizumab (n = 30) or placebo (n = 32) followed by 24 weeks of follow-up. Participants had a mean age of 10.3 years.
After 24 weeks, the adjusted mean difference in objective SCORAD index between the two groups was –6.9 (95% confidence interval, –12.2 to –1.5; P = .01) and significantly favored omalizumab therapy. The adjusted mean difference for the Eczema Area and Severity Index (–6.7; 95% CI, –13.2 to –0.1) also favored omalizumab. In regard to quality of life, after 24 weeks the Children’s Dermatology Life Quality Index/Dermatology Life Quality Index favored the omalizumab group with an adjusted mean difference of –3.5 (95% CI, –6.4 to –0.5).
In an accompanying editorial, Ann Chen Wu, MD, of Harvard Medical School in Boston noted that the results of the study from Chan et al. were promising but “more questions need to be answered before the drug can be used to treat atopic dermatitis in clinical practice” (JAMA Pediatr. 2019 Nov. 25. doi: 10.1001/jamapediatrics.2019.4509).
Her initial concern was price; she acknowledged that “omalizumab is a costly intervention” but said atopic dermatitis is also costly, raising the question as to whether the high costs of both justify treatment. In addition, omalizumab as treatment can come with both benefits and harms. Severe atopic dermatitis can decrease quality of life and, though omalizumab appears to be safe, there are adverse effects and logistical burdens to overcome.
More than anything, she recognized the need to prioritize, wondering what level of atopic dermatitis patients would truly benefit from this level of treatment. “Is using a $100,000-per-year medication for an itchy condition an overtreatment,” she asked, “or a lifesaver?”
The study was funded by the National Institute for Health Research Efficacy and Mechanism Evaluation Programme and Guy’s and St. Thomas’ Charity. The authors had numerous financial disclosures, including receiving grants from the NIHR EME Programme and Guy’s and St. Thomas’ Charity along with active and placebo drugs from Novartis for use in the study. Dr. Wu reported receiving a grant from GlaxoSmithKline.
SOURCE: Chan S et al. JAMA Pediatr. 2019 Nov 25. doi: 10.1001/jamapediatrics.2019.4476.
FROM JAMA PEDIATRICS
Pediatric dermatology update: New research offers insight into psoriasis, alopecia
LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.
Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:
Psoriasis
It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.
The good news, he said, is that “our new biologic agents are now being studied in children.”
Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.
It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.
“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”
Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.
The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”
Alopecia
Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”
He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).
Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.
He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.
Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.
What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.
Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).
In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”
Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”
Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.
Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:
Psoriasis
It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.
The good news, he said, is that “our new biologic agents are now being studied in children.”
Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.
It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.
“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”
Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.
The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”
Alopecia
Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”
He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).
Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.
He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.
Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.
What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.
Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).
In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”
Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”
Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.
Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:
Psoriasis
It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.
The good news, he said, is that “our new biologic agents are now being studied in children.”
Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.
It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.
“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”
Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.
The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”
Alopecia
Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”
He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).
Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.
He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.
Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.
What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.
Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).
In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”
Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”
Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
The 2018 SoHM Report: Takeaways for pediatric hospitalists
Increased complexity in workforce staffing
In November 2019, more than 1,500 pediatric hospitalists will be first to take the subspecialty exam approved by the American Board of Pediatrics (ABP) for certification in pediatric hospital medicine (PHM). This landmark signifies the recognition of hospital medicine as an essential component of the health care landscape and further acknowledges the importance of our expanding field.
But recent controversy over the requirements set by the ABP to sit for the exam has highlighted the new considerations for practice management that will be associated with this change. The need to analyze and understand how PHM programs function has never been more important for hospital medicine groups that care for children. This information is essential if they are to remain nimble in their approach to the changes that will occur in the years ahead.
To understand the impact that the new subspecialty board exam will have on groups that care for children, we need to first understand the criteria for eligibility. As for all ABP subspecialty boards, applicants must be Pediatric Board certified. The ABP has established three pathways by which practitioners can attain eligibility to sit for the PHM exam.1 Most currently practicing hospitalists have applied to take the exam under the “practice pathway,” which will be available temporarily to allow candidates to apply for the certifying exam based on experience rather than fellowship training. This temporary period will span the first three examination cycles (2019, 2021, 2023). The requirements for inclusion via this pathway, recently modified by the ABP in response to concerns voiced by the PHM community at large,2 consist of the following:
1. Practice period of 4 years (with a start date of July 2015 to be eligible for the November 2019 exam.
2. Work hours for all PHM professional activities of more than 900-1000 hours/year.
3. Patient care hours in PHM of more than 450-500 hours per year, every year for the preceding 4 years.
4. Scope of practice covering the full range of hospitalized children.
5. Practice experience and hours acquired in the United States or Canada.
This set of criteria raises several questions about the eligibility of the physicians currently caring for children in the hospital setting. The State of Hospital Medicine Report is an excellent source of information about hospital medicine trends in staffing and much more. While the response to the survey is more robust from practices that care for adults only, important information can be gleaned from the participant groups that care for children.
Question 1: How many clinicians that care for children in the hospital are trained in pediatrics, thereby meeting the first criteria to sit for the boards?
Based on the 2018 State of Hospital Medicine Report, 100% of groups that treat only children had physicians trained in pediatrics, 41.7% employed physicians trained in med/peds, and 5.6% had clinicians trained in internal medicine.
In groups that treat both children and adults the variation in practitioner type was much broader. While 85.7% of groups reported employing physicians trained in internal medicine and 64.3% employed family medicine practitioners, only 35.7% reported employing physicians trained in pediatrics and 46.4% with training in med/peds. A smattering of other clinician types was also noted, most of which were not likely to be pediatrics trained.
If information based on this relatively small number of respondents is generalizable, it means that a large number of the practitioners currently caring for hospitalized children are not pediatrics board-certified and therefore will not be eligible to sit for the subspecialty exam.
Question 2: What portion of the current PHM new hires are fellowship trained?
The 2018 State of Hospital Medicine Report notes that over 50% of new physicians joining a group treating only children come directly from residency, while only 5.1% come from a hospital medicine fellowship. For groups that treat adults and children, this percentage is even more significant, with 63% coming directly from residency and only 2.2% coming from a fellowship program.
The residents who recently graduated in 2019 are the last to be eligible to meet the practice duration criteria (4 years) during the “practice pathway” temporary period, thereby allowing them to sit for the subspecialty board exam without completing a fellowship. Recent surveys have shown that over 10% of graduating residents in pediatrics plan to pursue a career in PHM (over 280 respondents), however only under 75 fellows graduate from PHM fellowships each year.3 As the current number of fellowship positions in PHM are not adequate to meet the demand of the rapidly expanding workforce, groups treating children will need to continue to fill staff vacancies with variably trained clinicians.
In the years to come, information from the State of Hospital Medicine Report will be increasingly important, as programs that care for children meet the challenge of blending their workforce to include members with variable board certification and eligibility.
Question 3: How do the “patient care hours” and “work hours for all PHM activities” requirements affect currently practicing hospitalists in terms of their board eligibility?
Because of rigorous ABP criteria to sit for the PHM subspecialty exam, especially those regarding the minimum clinical and overall work hours in the care of children, many part time and med-peds practitioners may find that they are not board eligible. Variations in clinical coverage needs at individual sites, as well as competing nonclinical tasks in the adult setting, may limit pediatric-specific work hours for med/peds trained hospitalists.
As noted above, in groups that treat only children and groups that treat both adults and children, the 2018 State of Hospital Medicine Report shows that over 40% had physicians trained in med-peds. These highly trained and capable physicians will continue to be assets to their group; however, they may wish to find other ways to achieve merit-based distinction. For these physicians, the Fellow designation through SHM may provide an alternate means of recognition.
With the increasing complexity of staffing a workforce for the treatment of children that the PHM board subspecialty exam brings, the SHM Practice Analysis Committee developed a task force of pediatric leaders from across the country to aid in the development of additional pediatric-specific questions for the 2020 version of the State of Hospital Medicine Report. The questions to be included in the 2020 version will request information about the number of clinical hours (rather than shifts) per year required for full-time faculty, the percentage of the workforce that is part time, and the percentage of personnel in each group that is board certified in pediatric hospital medicine.
It is our hope that all groups treating children will respond to the 2020 State of Hospital Medicine survey, as a robust response will provide meaningful information to direct the leaders of these groups in the changing days ahead.
Dr. Gage is associate division chief, department of hospital medicine, at Phoenix Children’s Hospital and clinical associate professor, University of Arizona, Phoenix. She is a member of the SHM Practice Analysis Committee.
References
1. American Board of Pediatrics. Pediatric Hospital Medicine Certification. 2019 Edition.
2. American Board of Pediatrics. ABP responds to pediatric hospital medicine petition. 2019 Aug 29.
3. Pediatric Hospital Medicine Fellows. 2019 Edition.
Increased complexity in workforce staffing
Increased complexity in workforce staffing
In November 2019, more than 1,500 pediatric hospitalists will be first to take the subspecialty exam approved by the American Board of Pediatrics (ABP) for certification in pediatric hospital medicine (PHM). This landmark signifies the recognition of hospital medicine as an essential component of the health care landscape and further acknowledges the importance of our expanding field.
But recent controversy over the requirements set by the ABP to sit for the exam has highlighted the new considerations for practice management that will be associated with this change. The need to analyze and understand how PHM programs function has never been more important for hospital medicine groups that care for children. This information is essential if they are to remain nimble in their approach to the changes that will occur in the years ahead.
To understand the impact that the new subspecialty board exam will have on groups that care for children, we need to first understand the criteria for eligibility. As for all ABP subspecialty boards, applicants must be Pediatric Board certified. The ABP has established three pathways by which practitioners can attain eligibility to sit for the PHM exam.1 Most currently practicing hospitalists have applied to take the exam under the “practice pathway,” which will be available temporarily to allow candidates to apply for the certifying exam based on experience rather than fellowship training. This temporary period will span the first three examination cycles (2019, 2021, 2023). The requirements for inclusion via this pathway, recently modified by the ABP in response to concerns voiced by the PHM community at large,2 consist of the following:
1. Practice period of 4 years (with a start date of July 2015 to be eligible for the November 2019 exam.
2. Work hours for all PHM professional activities of more than 900-1000 hours/year.
3. Patient care hours in PHM of more than 450-500 hours per year, every year for the preceding 4 years.
4. Scope of practice covering the full range of hospitalized children.
5. Practice experience and hours acquired in the United States or Canada.
This set of criteria raises several questions about the eligibility of the physicians currently caring for children in the hospital setting. The State of Hospital Medicine Report is an excellent source of information about hospital medicine trends in staffing and much more. While the response to the survey is more robust from practices that care for adults only, important information can be gleaned from the participant groups that care for children.
Question 1: How many clinicians that care for children in the hospital are trained in pediatrics, thereby meeting the first criteria to sit for the boards?
Based on the 2018 State of Hospital Medicine Report, 100% of groups that treat only children had physicians trained in pediatrics, 41.7% employed physicians trained in med/peds, and 5.6% had clinicians trained in internal medicine.
In groups that treat both children and adults the variation in practitioner type was much broader. While 85.7% of groups reported employing physicians trained in internal medicine and 64.3% employed family medicine practitioners, only 35.7% reported employing physicians trained in pediatrics and 46.4% with training in med/peds. A smattering of other clinician types was also noted, most of which were not likely to be pediatrics trained.
If information based on this relatively small number of respondents is generalizable, it means that a large number of the practitioners currently caring for hospitalized children are not pediatrics board-certified and therefore will not be eligible to sit for the subspecialty exam.
Question 2: What portion of the current PHM new hires are fellowship trained?
The 2018 State of Hospital Medicine Report notes that over 50% of new physicians joining a group treating only children come directly from residency, while only 5.1% come from a hospital medicine fellowship. For groups that treat adults and children, this percentage is even more significant, with 63% coming directly from residency and only 2.2% coming from a fellowship program.
The residents who recently graduated in 2019 are the last to be eligible to meet the practice duration criteria (4 years) during the “practice pathway” temporary period, thereby allowing them to sit for the subspecialty board exam without completing a fellowship. Recent surveys have shown that over 10% of graduating residents in pediatrics plan to pursue a career in PHM (over 280 respondents), however only under 75 fellows graduate from PHM fellowships each year.3 As the current number of fellowship positions in PHM are not adequate to meet the demand of the rapidly expanding workforce, groups treating children will need to continue to fill staff vacancies with variably trained clinicians.
In the years to come, information from the State of Hospital Medicine Report will be increasingly important, as programs that care for children meet the challenge of blending their workforce to include members with variable board certification and eligibility.
Question 3: How do the “patient care hours” and “work hours for all PHM activities” requirements affect currently practicing hospitalists in terms of their board eligibility?
Because of rigorous ABP criteria to sit for the PHM subspecialty exam, especially those regarding the minimum clinical and overall work hours in the care of children, many part time and med-peds practitioners may find that they are not board eligible. Variations in clinical coverage needs at individual sites, as well as competing nonclinical tasks in the adult setting, may limit pediatric-specific work hours for med/peds trained hospitalists.
As noted above, in groups that treat only children and groups that treat both adults and children, the 2018 State of Hospital Medicine Report shows that over 40% had physicians trained in med-peds. These highly trained and capable physicians will continue to be assets to their group; however, they may wish to find other ways to achieve merit-based distinction. For these physicians, the Fellow designation through SHM may provide an alternate means of recognition.
With the increasing complexity of staffing a workforce for the treatment of children that the PHM board subspecialty exam brings, the SHM Practice Analysis Committee developed a task force of pediatric leaders from across the country to aid in the development of additional pediatric-specific questions for the 2020 version of the State of Hospital Medicine Report. The questions to be included in the 2020 version will request information about the number of clinical hours (rather than shifts) per year required for full-time faculty, the percentage of the workforce that is part time, and the percentage of personnel in each group that is board certified in pediatric hospital medicine.
It is our hope that all groups treating children will respond to the 2020 State of Hospital Medicine survey, as a robust response will provide meaningful information to direct the leaders of these groups in the changing days ahead.
Dr. Gage is associate division chief, department of hospital medicine, at Phoenix Children’s Hospital and clinical associate professor, University of Arizona, Phoenix. She is a member of the SHM Practice Analysis Committee.
References
1. American Board of Pediatrics. Pediatric Hospital Medicine Certification. 2019 Edition.
2. American Board of Pediatrics. ABP responds to pediatric hospital medicine petition. 2019 Aug 29.
3. Pediatric Hospital Medicine Fellows. 2019 Edition.
In November 2019, more than 1,500 pediatric hospitalists will be first to take the subspecialty exam approved by the American Board of Pediatrics (ABP) for certification in pediatric hospital medicine (PHM). This landmark signifies the recognition of hospital medicine as an essential component of the health care landscape and further acknowledges the importance of our expanding field.
But recent controversy over the requirements set by the ABP to sit for the exam has highlighted the new considerations for practice management that will be associated with this change. The need to analyze and understand how PHM programs function has never been more important for hospital medicine groups that care for children. This information is essential if they are to remain nimble in their approach to the changes that will occur in the years ahead.
To understand the impact that the new subspecialty board exam will have on groups that care for children, we need to first understand the criteria for eligibility. As for all ABP subspecialty boards, applicants must be Pediatric Board certified. The ABP has established three pathways by which practitioners can attain eligibility to sit for the PHM exam.1 Most currently practicing hospitalists have applied to take the exam under the “practice pathway,” which will be available temporarily to allow candidates to apply for the certifying exam based on experience rather than fellowship training. This temporary period will span the first three examination cycles (2019, 2021, 2023). The requirements for inclusion via this pathway, recently modified by the ABP in response to concerns voiced by the PHM community at large,2 consist of the following:
1. Practice period of 4 years (with a start date of July 2015 to be eligible for the November 2019 exam.
2. Work hours for all PHM professional activities of more than 900-1000 hours/year.
3. Patient care hours in PHM of more than 450-500 hours per year, every year for the preceding 4 years.
4. Scope of practice covering the full range of hospitalized children.
5. Practice experience and hours acquired in the United States or Canada.
This set of criteria raises several questions about the eligibility of the physicians currently caring for children in the hospital setting. The State of Hospital Medicine Report is an excellent source of information about hospital medicine trends in staffing and much more. While the response to the survey is more robust from practices that care for adults only, important information can be gleaned from the participant groups that care for children.
Question 1: How many clinicians that care for children in the hospital are trained in pediatrics, thereby meeting the first criteria to sit for the boards?
Based on the 2018 State of Hospital Medicine Report, 100% of groups that treat only children had physicians trained in pediatrics, 41.7% employed physicians trained in med/peds, and 5.6% had clinicians trained in internal medicine.
In groups that treat both children and adults the variation in practitioner type was much broader. While 85.7% of groups reported employing physicians trained in internal medicine and 64.3% employed family medicine practitioners, only 35.7% reported employing physicians trained in pediatrics and 46.4% with training in med/peds. A smattering of other clinician types was also noted, most of which were not likely to be pediatrics trained.
If information based on this relatively small number of respondents is generalizable, it means that a large number of the practitioners currently caring for hospitalized children are not pediatrics board-certified and therefore will not be eligible to sit for the subspecialty exam.
Question 2: What portion of the current PHM new hires are fellowship trained?
The 2018 State of Hospital Medicine Report notes that over 50% of new physicians joining a group treating only children come directly from residency, while only 5.1% come from a hospital medicine fellowship. For groups that treat adults and children, this percentage is even more significant, with 63% coming directly from residency and only 2.2% coming from a fellowship program.
The residents who recently graduated in 2019 are the last to be eligible to meet the practice duration criteria (4 years) during the “practice pathway” temporary period, thereby allowing them to sit for the subspecialty board exam without completing a fellowship. Recent surveys have shown that over 10% of graduating residents in pediatrics plan to pursue a career in PHM (over 280 respondents), however only under 75 fellows graduate from PHM fellowships each year.3 As the current number of fellowship positions in PHM are not adequate to meet the demand of the rapidly expanding workforce, groups treating children will need to continue to fill staff vacancies with variably trained clinicians.
In the years to come, information from the State of Hospital Medicine Report will be increasingly important, as programs that care for children meet the challenge of blending their workforce to include members with variable board certification and eligibility.
Question 3: How do the “patient care hours” and “work hours for all PHM activities” requirements affect currently practicing hospitalists in terms of their board eligibility?
Because of rigorous ABP criteria to sit for the PHM subspecialty exam, especially those regarding the minimum clinical and overall work hours in the care of children, many part time and med-peds practitioners may find that they are not board eligible. Variations in clinical coverage needs at individual sites, as well as competing nonclinical tasks in the adult setting, may limit pediatric-specific work hours for med/peds trained hospitalists.
As noted above, in groups that treat only children and groups that treat both adults and children, the 2018 State of Hospital Medicine Report shows that over 40% had physicians trained in med-peds. These highly trained and capable physicians will continue to be assets to their group; however, they may wish to find other ways to achieve merit-based distinction. For these physicians, the Fellow designation through SHM may provide an alternate means of recognition.
With the increasing complexity of staffing a workforce for the treatment of children that the PHM board subspecialty exam brings, the SHM Practice Analysis Committee developed a task force of pediatric leaders from across the country to aid in the development of additional pediatric-specific questions for the 2020 version of the State of Hospital Medicine Report. The questions to be included in the 2020 version will request information about the number of clinical hours (rather than shifts) per year required for full-time faculty, the percentage of the workforce that is part time, and the percentage of personnel in each group that is board certified in pediatric hospital medicine.
It is our hope that all groups treating children will respond to the 2020 State of Hospital Medicine survey, as a robust response will provide meaningful information to direct the leaders of these groups in the changing days ahead.
Dr. Gage is associate division chief, department of hospital medicine, at Phoenix Children’s Hospital and clinical associate professor, University of Arizona, Phoenix. She is a member of the SHM Practice Analysis Committee.
References
1. American Board of Pediatrics. Pediatric Hospital Medicine Certification. 2019 Edition.
2. American Board of Pediatrics. ABP responds to pediatric hospital medicine petition. 2019 Aug 29.
3. Pediatric Hospital Medicine Fellows. 2019 Edition.
Learning about and prescribing emergency contraception
As health care providers to children, we always are learning. And with new knowledge we sometimes can be taken out of our comfort zone. One of those areas are teenagers, contraception, safe-sex counseling, and now emergency contraception (EC). In residency you have your 1-month adolescent medicine rotation to try and absorb every bit of information like a sponge, but there also will be a level of discomfort and uncertainty. However, as medical providers we cannot let the above prevent us from giving well-rounded and informed care.
When our teens disclose the most private moment of their life, we have to be armed and ready to not only comfort them, but advise and guide them to making a decision so that they can ensure their safety. The answers regarding sexual activity are becoming more and more alarming, especially in our younger patients. Therefore, this is an important discussion to have at every visit (not just well-child checks), so that education opportunities are not missed and our patients feel a sense of normalcy about discussing reproductive health with their health care provider and or parents.
We all have our personal beliefs, but we cannot let that guide our decision on what care or education we give our patients. Unfortunately, I have heard many health care providers judge our patients for their promiscuity, when we need to educate them – not be their judge and jury. Our teens go through different stages of growth and development, and with these stages come experimentation and risk taking. So as their health care providers, we need to be up to date on the information out there.
With regards with EC, some of our patients think that they can get it only after having unprotected sex. However, they should know that the oral ECs can be given to them at any time, so should they be in the situation above, they have an immediate remedy. With the different options come different counseling and different instructions on administration and follow-up. In residency, we might not have learned the skill of inserting an IUD, which is another form of EC; that is why there are many resources available. These resources include hands-on workshops, videos on counseling, and your friendly neighborhood adolescent medicine physician or ob.gyn.
EC can give our patients that sense of relief, especially when they have unprotected sex. However, they also need to have a sense of responsibility for their actions because you do not want them to engage in high-risk behaviors. Just as we are responsible to provide up-to-date care, our patients must take ownership of their health and well-being. Also If they are engaging in unprotected sex, they are just as responsible; therefore, they should know everything about contraception as well as EC. They should feel comfortable talking to their partners about contraception. Health care providers should make them feel comfortable receiving EC that they can give to their female partner.
We need to become knowledgeable and comfortable prescribing EC, as well as incorporating it in our routine care. This is a policy that I strongly believe should be part of every pediatrician’s and family physician’s office, especially when there is a lack of resources. Of the different options that are available, the oral forms of EC – especially Ella or Plan B step 1 (levonorgestrel) – would be the easiest to prescribe and counsel on. I would not recommend the options where multiple pills need to be taken more than once a day, because compliance becomes a factor. Also knowing that these options are available over the counter also is helpful because our community pharmacist also can help with medication administration and counseling.
In summary, I strongly recommend the discussion of EC in the office, especially the general pediatrician’s office. I recommend that, for those physicians’ who may be uncomfortable, that they should start with the “easier” options of oral progestins (Ella or Plan B step 1). As you become more comfortable with the information and counseling, you can learn skills such as IUD insertions, so you then can offer more options.
As health care providers to children, we always are learning. And with new knowledge we sometimes can be taken out of our comfort zone. One of those areas are teenagers, contraception, safe-sex counseling, and now emergency contraception (EC). In residency you have your 1-month adolescent medicine rotation to try and absorb every bit of information like a sponge, but there also will be a level of discomfort and uncertainty. However, as medical providers we cannot let the above prevent us from giving well-rounded and informed care.
When our teens disclose the most private moment of their life, we have to be armed and ready to not only comfort them, but advise and guide them to making a decision so that they can ensure their safety. The answers regarding sexual activity are becoming more and more alarming, especially in our younger patients. Therefore, this is an important discussion to have at every visit (not just well-child checks), so that education opportunities are not missed and our patients feel a sense of normalcy about discussing reproductive health with their health care provider and or parents.
We all have our personal beliefs, but we cannot let that guide our decision on what care or education we give our patients. Unfortunately, I have heard many health care providers judge our patients for their promiscuity, when we need to educate them – not be their judge and jury. Our teens go through different stages of growth and development, and with these stages come experimentation and risk taking. So as their health care providers, we need to be up to date on the information out there.
With regards with EC, some of our patients think that they can get it only after having unprotected sex. However, they should know that the oral ECs can be given to them at any time, so should they be in the situation above, they have an immediate remedy. With the different options come different counseling and different instructions on administration and follow-up. In residency, we might not have learned the skill of inserting an IUD, which is another form of EC; that is why there are many resources available. These resources include hands-on workshops, videos on counseling, and your friendly neighborhood adolescent medicine physician or ob.gyn.
EC can give our patients that sense of relief, especially when they have unprotected sex. However, they also need to have a sense of responsibility for their actions because you do not want them to engage in high-risk behaviors. Just as we are responsible to provide up-to-date care, our patients must take ownership of their health and well-being. Also If they are engaging in unprotected sex, they are just as responsible; therefore, they should know everything about contraception as well as EC. They should feel comfortable talking to their partners about contraception. Health care providers should make them feel comfortable receiving EC that they can give to their female partner.
We need to become knowledgeable and comfortable prescribing EC, as well as incorporating it in our routine care. This is a policy that I strongly believe should be part of every pediatrician’s and family physician’s office, especially when there is a lack of resources. Of the different options that are available, the oral forms of EC – especially Ella or Plan B step 1 (levonorgestrel) – would be the easiest to prescribe and counsel on. I would not recommend the options where multiple pills need to be taken more than once a day, because compliance becomes a factor. Also knowing that these options are available over the counter also is helpful because our community pharmacist also can help with medication administration and counseling.
In summary, I strongly recommend the discussion of EC in the office, especially the general pediatrician’s office. I recommend that, for those physicians’ who may be uncomfortable, that they should start with the “easier” options of oral progestins (Ella or Plan B step 1). As you become more comfortable with the information and counseling, you can learn skills such as IUD insertions, so you then can offer more options.
As health care providers to children, we always are learning. And with new knowledge we sometimes can be taken out of our comfort zone. One of those areas are teenagers, contraception, safe-sex counseling, and now emergency contraception (EC). In residency you have your 1-month adolescent medicine rotation to try and absorb every bit of information like a sponge, but there also will be a level of discomfort and uncertainty. However, as medical providers we cannot let the above prevent us from giving well-rounded and informed care.
When our teens disclose the most private moment of their life, we have to be armed and ready to not only comfort them, but advise and guide them to making a decision so that they can ensure their safety. The answers regarding sexual activity are becoming more and more alarming, especially in our younger patients. Therefore, this is an important discussion to have at every visit (not just well-child checks), so that education opportunities are not missed and our patients feel a sense of normalcy about discussing reproductive health with their health care provider and or parents.
We all have our personal beliefs, but we cannot let that guide our decision on what care or education we give our patients. Unfortunately, I have heard many health care providers judge our patients for their promiscuity, when we need to educate them – not be their judge and jury. Our teens go through different stages of growth and development, and with these stages come experimentation and risk taking. So as their health care providers, we need to be up to date on the information out there.
With regards with EC, some of our patients think that they can get it only after having unprotected sex. However, they should know that the oral ECs can be given to them at any time, so should they be in the situation above, they have an immediate remedy. With the different options come different counseling and different instructions on administration and follow-up. In residency, we might not have learned the skill of inserting an IUD, which is another form of EC; that is why there are many resources available. These resources include hands-on workshops, videos on counseling, and your friendly neighborhood adolescent medicine physician or ob.gyn.
EC can give our patients that sense of relief, especially when they have unprotected sex. However, they also need to have a sense of responsibility for their actions because you do not want them to engage in high-risk behaviors. Just as we are responsible to provide up-to-date care, our patients must take ownership of their health and well-being. Also If they are engaging in unprotected sex, they are just as responsible; therefore, they should know everything about contraception as well as EC. They should feel comfortable talking to their partners about contraception. Health care providers should make them feel comfortable receiving EC that they can give to their female partner.
We need to become knowledgeable and comfortable prescribing EC, as well as incorporating it in our routine care. This is a policy that I strongly believe should be part of every pediatrician’s and family physician’s office, especially when there is a lack of resources. Of the different options that are available, the oral forms of EC – especially Ella or Plan B step 1 (levonorgestrel) – would be the easiest to prescribe and counsel on. I would not recommend the options where multiple pills need to be taken more than once a day, because compliance becomes a factor. Also knowing that these options are available over the counter also is helpful because our community pharmacist also can help with medication administration and counseling.
In summary, I strongly recommend the discussion of EC in the office, especially the general pediatrician’s office. I recommend that, for those physicians’ who may be uncomfortable, that they should start with the “easier” options of oral progestins (Ella or Plan B step 1). As you become more comfortable with the information and counseling, you can learn skills such as IUD insertions, so you then can offer more options.
Early onset of atopic dermatitis linked to poorer control
according to a study published in the Journal of the American Academy of Dermatology.
Atopic dermatitis most commonly arises in infancy but also can emerge in later childhood and even adolescence, leading to a distinction between early- and late-onset disease, wrote Joy Wan, MD, of the University of Pennsylvania, Philadelphia, and coauthors.
“Early-onset, mid-onset, and late-onset AD appear to differ in the presence of active disease over time; however, whether these groups also differ in terms of the severity of AD is unknown,” they wrote.
In this observational cohort study, 8,015 individuals with childhood-onset atopic dermatitis – 53% of whom were female – were assessed twice-yearly for up to 10 years. Nearly three-quarters (72%) of the group had early-onset atopic dermatitis – defined as onset before 2 years of age – while 19% had mid-onset disease (3-7 years) and 9% had late-onset disease (8-17 years).
The study found that older age of onset was associated with better control, such that for each additional year of age at the onset of disease, there was a 7% reduction in the odds of poorer control of disease. Those who had mid-onset disease had a 29% lower odds of poorer control compared with those with early-onset, while those with late-onset disease had a 49% lower odds of poorer control.
The likelihood of atopic dermatitis persisting beyond childhood also appeared to be linked to the age of onset. Those with mid-onset disease had a 55% lower odds of persistent atopic dermatitis, compared with those with early-onset disease, while those with late-onset disease had an 81% lower odds.
“In all 3 groups, the proportion of subjects reporting persistent AD generally declined with older age, and the differences among the 3 onset age groups were most pronounced from early adolescence onward,” the authors wrote.
They noted that there was considerable research currently focused on identifying distinct atopic dermatitis phenotypes and endotypes, and their evidence on the different disease course for early-, mid-, and late-onset disease supported this idea of disease subtypes.
“However, additional research is needed to understand whether and how early-, mid-, and late-onset AD differ molecularly or immunologically, and whether they respond differentially to treatment,” they wrote. They also suggested that the timing of onset could help identify patients who were at greater risk of persistent or poorly controlled disease, and who benefits from more intensive monitoring or treatment.
The study was partly supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Dermatology Foundation. Three authors declared funding, consultancies, or advisory board positions with the pharmaceutical sector. No other conflicts of interest were declared.
SOURCE: Wan J et al. J Am Acad Dermatol. 2019 Dec;81(6):1292-9.
according to a study published in the Journal of the American Academy of Dermatology.
Atopic dermatitis most commonly arises in infancy but also can emerge in later childhood and even adolescence, leading to a distinction between early- and late-onset disease, wrote Joy Wan, MD, of the University of Pennsylvania, Philadelphia, and coauthors.
“Early-onset, mid-onset, and late-onset AD appear to differ in the presence of active disease over time; however, whether these groups also differ in terms of the severity of AD is unknown,” they wrote.
In this observational cohort study, 8,015 individuals with childhood-onset atopic dermatitis – 53% of whom were female – were assessed twice-yearly for up to 10 years. Nearly three-quarters (72%) of the group had early-onset atopic dermatitis – defined as onset before 2 years of age – while 19% had mid-onset disease (3-7 years) and 9% had late-onset disease (8-17 years).
The study found that older age of onset was associated with better control, such that for each additional year of age at the onset of disease, there was a 7% reduction in the odds of poorer control of disease. Those who had mid-onset disease had a 29% lower odds of poorer control compared with those with early-onset, while those with late-onset disease had a 49% lower odds of poorer control.
The likelihood of atopic dermatitis persisting beyond childhood also appeared to be linked to the age of onset. Those with mid-onset disease had a 55% lower odds of persistent atopic dermatitis, compared with those with early-onset disease, while those with late-onset disease had an 81% lower odds.
“In all 3 groups, the proportion of subjects reporting persistent AD generally declined with older age, and the differences among the 3 onset age groups were most pronounced from early adolescence onward,” the authors wrote.
They noted that there was considerable research currently focused on identifying distinct atopic dermatitis phenotypes and endotypes, and their evidence on the different disease course for early-, mid-, and late-onset disease supported this idea of disease subtypes.
“However, additional research is needed to understand whether and how early-, mid-, and late-onset AD differ molecularly or immunologically, and whether they respond differentially to treatment,” they wrote. They also suggested that the timing of onset could help identify patients who were at greater risk of persistent or poorly controlled disease, and who benefits from more intensive monitoring or treatment.
The study was partly supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Dermatology Foundation. Three authors declared funding, consultancies, or advisory board positions with the pharmaceutical sector. No other conflicts of interest were declared.
SOURCE: Wan J et al. J Am Acad Dermatol. 2019 Dec;81(6):1292-9.
according to a study published in the Journal of the American Academy of Dermatology.
Atopic dermatitis most commonly arises in infancy but also can emerge in later childhood and even adolescence, leading to a distinction between early- and late-onset disease, wrote Joy Wan, MD, of the University of Pennsylvania, Philadelphia, and coauthors.
“Early-onset, mid-onset, and late-onset AD appear to differ in the presence of active disease over time; however, whether these groups also differ in terms of the severity of AD is unknown,” they wrote.
In this observational cohort study, 8,015 individuals with childhood-onset atopic dermatitis – 53% of whom were female – were assessed twice-yearly for up to 10 years. Nearly three-quarters (72%) of the group had early-onset atopic dermatitis – defined as onset before 2 years of age – while 19% had mid-onset disease (3-7 years) and 9% had late-onset disease (8-17 years).
The study found that older age of onset was associated with better control, such that for each additional year of age at the onset of disease, there was a 7% reduction in the odds of poorer control of disease. Those who had mid-onset disease had a 29% lower odds of poorer control compared with those with early-onset, while those with late-onset disease had a 49% lower odds of poorer control.
The likelihood of atopic dermatitis persisting beyond childhood also appeared to be linked to the age of onset. Those with mid-onset disease had a 55% lower odds of persistent atopic dermatitis, compared with those with early-onset disease, while those with late-onset disease had an 81% lower odds.
“In all 3 groups, the proportion of subjects reporting persistent AD generally declined with older age, and the differences among the 3 onset age groups were most pronounced from early adolescence onward,” the authors wrote.
They noted that there was considerable research currently focused on identifying distinct atopic dermatitis phenotypes and endotypes, and their evidence on the different disease course for early-, mid-, and late-onset disease supported this idea of disease subtypes.
“However, additional research is needed to understand whether and how early-, mid-, and late-onset AD differ molecularly or immunologically, and whether they respond differentially to treatment,” they wrote. They also suggested that the timing of onset could help identify patients who were at greater risk of persistent or poorly controlled disease, and who benefits from more intensive monitoring or treatment.
The study was partly supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Dermatology Foundation. Three authors declared funding, consultancies, or advisory board positions with the pharmaceutical sector. No other conflicts of interest were declared.
SOURCE: Wan J et al. J Am Acad Dermatol. 2019 Dec;81(6):1292-9.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Two national analyses confirm safety of 9vHPV vaccine
most of which cannot be definitively tied to the vaccine, according to two large studies published simultaneously in Pediatrics.
“The body of evidence on the safety of 9vHPV now includes prelicensure clinical trial data on 15,000 study subjects, reassuring results from postlicensure near real-time sequential monitoring by the Centers for Disease Control and Prevention’s Vaccine Safety Datalink, on approximately 839 000 doses administered, and our review of VAERS [Vaccine Adverse Event Reporting System] reports over a 3-year period, during which time approximately 28 million doses were distributed in the United States,” Tom T. Shimabukuro, MD, and colleagues reported in Pediatrics.
James G. Donahue, PhD, and colleagues, authors of the Vaccine Safety Datalink study published in the same issue, concluded much the same thing.
The new numbers bolster extant safety data on the vaccine, which was approved in 2015, wrote Dr. Donahue, an epidemiologist at the Marshfield (Wis.) Clinic Research Institute, and coauthors. “With this large observational study, we contribute reassuring postlicensure data that will help bolster the safety profile of 9vHPV. Although we detected several unexpected potential safety signals, none were confirmed after further evaluation.”
The Vaccine Safety Datalink study of 838,991 doses looked for safety signals in a prespecified group of potential events, including anaphylaxis, appendicitis, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, pancreatitis, seizures, stroke, and venous thromboembolism.
Dr. Donahue and coauthors used real-time vaccination data and time-matched historical controls to evaluate any changes in expected disease rates, compared with those occurring in vaccine recipients.
Most doses in the study (76%) were given to children aged 9-17 years, with 48% going to girls. The remaining 24% of doses were given to persons aged 18-26 years, with 64% going to women.
The analysis found potential safety signals in allergic reactions (43 cases), appendicitis (30 cases), pancreatitis (8 cases), and syncope (67). None of these were confirmed after further investigation.
“The safety profile of 9vHPV is favorable and comparable to that of its predecessor, 4vHPV,” Dr. Donahue and associates concluded.
The VAERS analysis was similarly reassuring. It examined all reported adverse events, not predetermined events.
Among 28 million doses, there were 7,244 adverse event reports – a rate of about 1 event per 7 million doses. Of these, 97% were nonserious, wrote Dr. Shimabukuro, deputy director of the CDC’s Immunization Safety Office, and colleagues.
The vaccine manufacturer submitted 64% of these to VAERS; health care providers submitted 27%. Adverse events were reported from postvaccine day 0 to 2 years afterward. 9vHPV was the only vaccine given in 75% of reports. Coadministered vaccines included meningococcal conjugate (1,028); tetanus and diphtheria (Td) or Tdap (673); and hepatitis A (434).
There were nine reports of anaphylaxis (five males, four females); 9vHPV was the only vaccine administered in five cases. Three reports involved coadministration of meningococcal vaccine, two with hepatitis A, one with TDaP, and one with varicella.
There were eight reports of Guillain-Barré.
There were 17 reports of postural orthostatic tachycardia syndrome, most of which (71%) did not meet diagnostic criteria. Five cases, however, did.
One possible case of complex regional pain syndrome was reported in a 13-year-old girl with comorbid anxiety.
There were two reports of acute disseminated encephalomyelitis, both in boys. There were no reports of transverse myelitis or chronic inflammatory demyelinating polyneuropathy.
Seven vaccine recipients died after vaccination. Five of these reports did not contain medical information or any proof-of-death confirmation. The other two were verified by autopsy. A 14-year-old girl who received a flu vaccination with 9vHPV died of a thoracic aorta dissection 7 days postvaccination. The other death was a 16-year-old boy who received a concurrent hepatitis A vaccine. Four days later, he died of a cerebellar hemorrhage.
“We did not identify any unusual or unexpected safety concerns in our review of 9vHPV reports to the VAERS; most (97%) reports were nonserious, and adverse events were analogous to those observed in the prelicensure clinical trials,” Dr. Shimabukuro and associates concluded.
Neither Dr. Shimabukuro nor Dr. Donahue had financial disclosures. Dr. Donahue’s study was funded by the Centers for Disease Control and Prevention. One coauthor had ties to several pharmaceutical companies. Dr. Shimabukuro’s study had no external funding. One coauthor is employed by Merck, but was not at the time of the study.
SOURCES: Shimabukuro T et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1791; Donahue J et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1808.
most of which cannot be definitively tied to the vaccine, according to two large studies published simultaneously in Pediatrics.
“The body of evidence on the safety of 9vHPV now includes prelicensure clinical trial data on 15,000 study subjects, reassuring results from postlicensure near real-time sequential monitoring by the Centers for Disease Control and Prevention’s Vaccine Safety Datalink, on approximately 839 000 doses administered, and our review of VAERS [Vaccine Adverse Event Reporting System] reports over a 3-year period, during which time approximately 28 million doses were distributed in the United States,” Tom T. Shimabukuro, MD, and colleagues reported in Pediatrics.
James G. Donahue, PhD, and colleagues, authors of the Vaccine Safety Datalink study published in the same issue, concluded much the same thing.
The new numbers bolster extant safety data on the vaccine, which was approved in 2015, wrote Dr. Donahue, an epidemiologist at the Marshfield (Wis.) Clinic Research Institute, and coauthors. “With this large observational study, we contribute reassuring postlicensure data that will help bolster the safety profile of 9vHPV. Although we detected several unexpected potential safety signals, none were confirmed after further evaluation.”
The Vaccine Safety Datalink study of 838,991 doses looked for safety signals in a prespecified group of potential events, including anaphylaxis, appendicitis, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, pancreatitis, seizures, stroke, and venous thromboembolism.
Dr. Donahue and coauthors used real-time vaccination data and time-matched historical controls to evaluate any changes in expected disease rates, compared with those occurring in vaccine recipients.
Most doses in the study (76%) were given to children aged 9-17 years, with 48% going to girls. The remaining 24% of doses were given to persons aged 18-26 years, with 64% going to women.
The analysis found potential safety signals in allergic reactions (43 cases), appendicitis (30 cases), pancreatitis (8 cases), and syncope (67). None of these were confirmed after further investigation.
“The safety profile of 9vHPV is favorable and comparable to that of its predecessor, 4vHPV,” Dr. Donahue and associates concluded.
The VAERS analysis was similarly reassuring. It examined all reported adverse events, not predetermined events.
Among 28 million doses, there were 7,244 adverse event reports – a rate of about 1 event per 7 million doses. Of these, 97% were nonserious, wrote Dr. Shimabukuro, deputy director of the CDC’s Immunization Safety Office, and colleagues.
The vaccine manufacturer submitted 64% of these to VAERS; health care providers submitted 27%. Adverse events were reported from postvaccine day 0 to 2 years afterward. 9vHPV was the only vaccine given in 75% of reports. Coadministered vaccines included meningococcal conjugate (1,028); tetanus and diphtheria (Td) or Tdap (673); and hepatitis A (434).
There were nine reports of anaphylaxis (five males, four females); 9vHPV was the only vaccine administered in five cases. Three reports involved coadministration of meningococcal vaccine, two with hepatitis A, one with TDaP, and one with varicella.
There were eight reports of Guillain-Barré.
There were 17 reports of postural orthostatic tachycardia syndrome, most of which (71%) did not meet diagnostic criteria. Five cases, however, did.
One possible case of complex regional pain syndrome was reported in a 13-year-old girl with comorbid anxiety.
There were two reports of acute disseminated encephalomyelitis, both in boys. There were no reports of transverse myelitis or chronic inflammatory demyelinating polyneuropathy.
Seven vaccine recipients died after vaccination. Five of these reports did not contain medical information or any proof-of-death confirmation. The other two were verified by autopsy. A 14-year-old girl who received a flu vaccination with 9vHPV died of a thoracic aorta dissection 7 days postvaccination. The other death was a 16-year-old boy who received a concurrent hepatitis A vaccine. Four days later, he died of a cerebellar hemorrhage.
“We did not identify any unusual or unexpected safety concerns in our review of 9vHPV reports to the VAERS; most (97%) reports were nonserious, and adverse events were analogous to those observed in the prelicensure clinical trials,” Dr. Shimabukuro and associates concluded.
Neither Dr. Shimabukuro nor Dr. Donahue had financial disclosures. Dr. Donahue’s study was funded by the Centers for Disease Control and Prevention. One coauthor had ties to several pharmaceutical companies. Dr. Shimabukuro’s study had no external funding. One coauthor is employed by Merck, but was not at the time of the study.
SOURCES: Shimabukuro T et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1791; Donahue J et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1808.
most of which cannot be definitively tied to the vaccine, according to two large studies published simultaneously in Pediatrics.
“The body of evidence on the safety of 9vHPV now includes prelicensure clinical trial data on 15,000 study subjects, reassuring results from postlicensure near real-time sequential monitoring by the Centers for Disease Control and Prevention’s Vaccine Safety Datalink, on approximately 839 000 doses administered, and our review of VAERS [Vaccine Adverse Event Reporting System] reports over a 3-year period, during which time approximately 28 million doses were distributed in the United States,” Tom T. Shimabukuro, MD, and colleagues reported in Pediatrics.
James G. Donahue, PhD, and colleagues, authors of the Vaccine Safety Datalink study published in the same issue, concluded much the same thing.
The new numbers bolster extant safety data on the vaccine, which was approved in 2015, wrote Dr. Donahue, an epidemiologist at the Marshfield (Wis.) Clinic Research Institute, and coauthors. “With this large observational study, we contribute reassuring postlicensure data that will help bolster the safety profile of 9vHPV. Although we detected several unexpected potential safety signals, none were confirmed after further evaluation.”
The Vaccine Safety Datalink study of 838,991 doses looked for safety signals in a prespecified group of potential events, including anaphylaxis, appendicitis, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, pancreatitis, seizures, stroke, and venous thromboembolism.
Dr. Donahue and coauthors used real-time vaccination data and time-matched historical controls to evaluate any changes in expected disease rates, compared with those occurring in vaccine recipients.
Most doses in the study (76%) were given to children aged 9-17 years, with 48% going to girls. The remaining 24% of doses were given to persons aged 18-26 years, with 64% going to women.
The analysis found potential safety signals in allergic reactions (43 cases), appendicitis (30 cases), pancreatitis (8 cases), and syncope (67). None of these were confirmed after further investigation.
“The safety profile of 9vHPV is favorable and comparable to that of its predecessor, 4vHPV,” Dr. Donahue and associates concluded.
The VAERS analysis was similarly reassuring. It examined all reported adverse events, not predetermined events.
Among 28 million doses, there were 7,244 adverse event reports – a rate of about 1 event per 7 million doses. Of these, 97% were nonserious, wrote Dr. Shimabukuro, deputy director of the CDC’s Immunization Safety Office, and colleagues.
The vaccine manufacturer submitted 64% of these to VAERS; health care providers submitted 27%. Adverse events were reported from postvaccine day 0 to 2 years afterward. 9vHPV was the only vaccine given in 75% of reports. Coadministered vaccines included meningococcal conjugate (1,028); tetanus and diphtheria (Td) or Tdap (673); and hepatitis A (434).
There were nine reports of anaphylaxis (five males, four females); 9vHPV was the only vaccine administered in five cases. Three reports involved coadministration of meningococcal vaccine, two with hepatitis A, one with TDaP, and one with varicella.
There were eight reports of Guillain-Barré.
There were 17 reports of postural orthostatic tachycardia syndrome, most of which (71%) did not meet diagnostic criteria. Five cases, however, did.
One possible case of complex regional pain syndrome was reported in a 13-year-old girl with comorbid anxiety.
There were two reports of acute disseminated encephalomyelitis, both in boys. There were no reports of transverse myelitis or chronic inflammatory demyelinating polyneuropathy.
Seven vaccine recipients died after vaccination. Five of these reports did not contain medical information or any proof-of-death confirmation. The other two were verified by autopsy. A 14-year-old girl who received a flu vaccination with 9vHPV died of a thoracic aorta dissection 7 days postvaccination. The other death was a 16-year-old boy who received a concurrent hepatitis A vaccine. Four days later, he died of a cerebellar hemorrhage.
“We did not identify any unusual or unexpected safety concerns in our review of 9vHPV reports to the VAERS; most (97%) reports were nonserious, and adverse events were analogous to those observed in the prelicensure clinical trials,” Dr. Shimabukuro and associates concluded.
Neither Dr. Shimabukuro nor Dr. Donahue had financial disclosures. Dr. Donahue’s study was funded by the Centers for Disease Control and Prevention. One coauthor had ties to several pharmaceutical companies. Dr. Shimabukuro’s study had no external funding. One coauthor is employed by Merck, but was not at the time of the study.
SOURCES: Shimabukuro T et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1791; Donahue J et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1808.
FROM PEDIATRICS
Key clinical point: Postlicensure studies confirm the safety of the 9vHPV vaccine.
Major finding: The adverse event rate is 1 in 7 million doses. Most of these events were not definitively tied to the vaccine.
Study details: The two studies covered all doses given in the United States since vaccine approval in 2015.
Disclosures: Neither Dr. Shimabukuro nor Dr. Donahue had financial disclosures. Dr. Donahue’s study was funded by the Centers for Disease Control and Prevention. One coauthor on his study had ties to several pharmaceutical companies. Dr. Shimabukuro’s study had no external funding. One coauthor is employed by Merck, but was not at the time of the study.
Sources: Shimabukuro T et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1791; Donahue J et al. Pediatrics. 2019 Nov 1. doi: 10.1542/peds.2019-1808.