Pediatrics

SAN FRANCISCO – Children who witnessed the 9/11 attacks on the World Trade Center are almost fivefold as likely to suffer comorbid physical and psychiatric problems as adults, according to a case-control study presented at the American Psychiatric Association annual meeting.

The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.

In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.

Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.

They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.

Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.

The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.

“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.

“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.

There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.

Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.

Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.

The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.

The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.

[email protected]

SAN FRANCISCO – Children who witnessed the 9/11 attacks on the World Trade Center are almost fivefold as likely to suffer comorbid physical and psychiatric problems as adults, according to a case-control study presented at the American Psychiatric Association annual meeting.

The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.

In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.

Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.

They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.

Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.

The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.

“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.

“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.

There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.

Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.

Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.

The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.

The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.

[email protected]

SAN FRANCISCO – Children who witnessed the 9/11 attacks on the World Trade Center are almost fivefold as likely to suffer comorbid physical and psychiatric problems as adults, according to a case-control study presented at the American Psychiatric Association annual meeting.

The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.

In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.

Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.

They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.

Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.

The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.

“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.

“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.

There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.

Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.

Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.

The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.

The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.

[email protected]

The U.S. measles count for 2019 had its smallest weekly increase in over 2 months last week as the total for the year hit 880 cases, according to the Centers for Disease Control and Prevention.

The U.S. measles count for 2019 had its smallest weekly increase in over 2 months last week as the total for the year hit 880 cases, according to the Centers for Disease Control and Prevention.

The U.S. measles count for 2019 had its smallest weekly increase in over 2 months last week as the total for the year hit 880 cases, according to the Centers for Disease Control and Prevention.

SAN DIEGO – A button battery lodged in a child’s esophagus is an acknowledged emergency, but there is less evidence about retrieval of button batteries that have passed to the stomach. Observation alone has been recommended when an x-ray determines that the button battery has passed to the stomach within 2 hours of ingestion, when the battery is less than 20 mm, and the child is aged at least 5 years.

At the annual Digestive Disease Week, Racha Khalaf, MD, and Thomas Walker, MD, both of Children’s Hospital Colorado, Aurora, presented data that call this approach into question. Their retrospective cohort study of 4 years’ worth of records from four pediatric centers in the United States identified 68 cases in which a pediatric gastroenterologist had endoscopically removed the button battery. In 60% of those cases, the battery had already caused mucosal damage varying from minor to deep necrosis and perforation.

Further, the degree of injury was not correlated with symptoms, strengthening the recommendation for retrieving the button battery from the stomach.

In our exclusive video interview, Dr. Khalaf and Dr. Walker discussed the impact of their findings for guidelines for pediatric gastroenterologists and Poison Control Center advice to parents about ingestion of button batteries.

Their study was partly supported by a Cystic Fibrosis Foundational Grant Award and by National Institutes of Health Training Grants.

[email protected]

SAN DIEGO – A button battery lodged in a child’s esophagus is an acknowledged emergency, but there is less evidence about retrieval of button batteries that have passed to the stomach. Observation alone has been recommended when an x-ray determines that the button battery has passed to the stomach within 2 hours of ingestion, when the battery is less than 20 mm, and the child is aged at least 5 years.

At the annual Digestive Disease Week, Racha Khalaf, MD, and Thomas Walker, MD, both of Children’s Hospital Colorado, Aurora, presented data that call this approach into question. Their retrospective cohort study of 4 years’ worth of records from four pediatric centers in the United States identified 68 cases in which a pediatric gastroenterologist had endoscopically removed the button battery. In 60% of those cases, the battery had already caused mucosal damage varying from minor to deep necrosis and perforation.

Further, the degree of injury was not correlated with symptoms, strengthening the recommendation for retrieving the button battery from the stomach.

In our exclusive video interview, Dr. Khalaf and Dr. Walker discussed the impact of their findings for guidelines for pediatric gastroenterologists and Poison Control Center advice to parents about ingestion of button batteries.

Their study was partly supported by a Cystic Fibrosis Foundational Grant Award and by National Institutes of Health Training Grants.

[email protected]

SAN DIEGO – A button battery lodged in a child’s esophagus is an acknowledged emergency, but there is less evidence about retrieval of button batteries that have passed to the stomach. Observation alone has been recommended when an x-ray determines that the button battery has passed to the stomach within 2 hours of ingestion, when the battery is less than 20 mm, and the child is aged at least 5 years.

At the annual Digestive Disease Week, Racha Khalaf, MD, and Thomas Walker, MD, both of Children’s Hospital Colorado, Aurora, presented data that call this approach into question. Their retrospective cohort study of 4 years’ worth of records from four pediatric centers in the United States identified 68 cases in which a pediatric gastroenterologist had endoscopically removed the button battery. In 60% of those cases, the battery had already caused mucosal damage varying from minor to deep necrosis and perforation.

Further, the degree of injury was not correlated with symptoms, strengthening the recommendation for retrieving the button battery from the stomach.

In our exclusive video interview, Dr. Khalaf and Dr. Walker discussed the impact of their findings for guidelines for pediatric gastroenterologists and Poison Control Center advice to parents about ingestion of button batteries.

Their study was partly supported by a Cystic Fibrosis Foundational Grant Award and by National Institutes of Health Training Grants.

[email protected]

BALTIMORE – Lower levels of vitamin D in adolescents appear to be associated with a higher risk of depression, according to new preliminary findings Anna-Lisa Munson, MD, MPH, of Denver Health Medical Center in Colorado, told attendees at the Pediatric Academic Societies annual meeting.

JochenSchoenfeld/Thinkstock

Although several studies in adults have suggested a link between vitamin D deficiency and depression, no large-scale studies have investigated whether such a relationship exists in adolescents, up to half of whom have a vitamin D deficiency, Dr Munson said.

The researchers relied on National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 to assess prevalence of major depressive disorder and vitamin D 25-hydroxy levels in teens aged 12-17 years. Serum vitamin D levels of less than 30 nmol/L were considered deficient while 30-50 nmol/L was considered insufficient, and at least 50 nmol/L was sufficient. A score between 10 and 27 on the Patient Health Questionnaire-9 (PHQ-9) qualified as depression.

The researchers adjusted their findings for age and sex, as well as other covariates linked to vitamin D levels or depression in previous research: latitude, season, race/ethnicity, and poverty to income ratio.

Among the 2,815 participants who completed the National Institute of Mental Health Diagnostic Interview Schedule for Children (NIMH-DISC), 8% had major depression. Among the 2,420 of participants with serum vitamin D values, 8% had vitamin D deficiency, 33% had insufficiency, and 59% had sufficiency.

Risk of depression dropped 10% for every additional 10 nmol/L of vitamin D, the analysis showed (odds ratio, 0.90).

Although non-Hispanic white students had about twice the odds of depression as other ethnic groups, risk of depression did not vary according to gender, age, season, latitude, poverty to income ratio, or use of vitamin D supplements.

The findings are limited by the cross-sectional data and lack of data regarding other factors that could affect vitamin D absorption, such as sunscreen use or clothing worn in the sun. The researchers also had only broad – not precise – data on latitude, and the PHQ-9 was used as a proxy for major depression instead of a clinical diagnosis.

The research was funded by the Denver Health Division of General Pediatrics. The authors had no relevant financial disclosures.
 

BALTIMORE – Lower levels of vitamin D in adolescents appear to be associated with a higher risk of depression, according to new preliminary findings Anna-Lisa Munson, MD, MPH, of Denver Health Medical Center in Colorado, told attendees at the Pediatric Academic Societies annual meeting.

JochenSchoenfeld/Thinkstock

Although several studies in adults have suggested a link between vitamin D deficiency and depression, no large-scale studies have investigated whether such a relationship exists in adolescents, up to half of whom have a vitamin D deficiency, Dr Munson said.

The researchers relied on National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 to assess prevalence of major depressive disorder and vitamin D 25-hydroxy levels in teens aged 12-17 years. Serum vitamin D levels of less than 30 nmol/L were considered deficient while 30-50 nmol/L was considered insufficient, and at least 50 nmol/L was sufficient. A score between 10 and 27 on the Patient Health Questionnaire-9 (PHQ-9) qualified as depression.

The researchers adjusted their findings for age and sex, as well as other covariates linked to vitamin D levels or depression in previous research: latitude, season, race/ethnicity, and poverty to income ratio.

Among the 2,815 participants who completed the National Institute of Mental Health Diagnostic Interview Schedule for Children (NIMH-DISC), 8% had major depression. Among the 2,420 of participants with serum vitamin D values, 8% had vitamin D deficiency, 33% had insufficiency, and 59% had sufficiency.

Risk of depression dropped 10% for every additional 10 nmol/L of vitamin D, the analysis showed (odds ratio, 0.90).

Although non-Hispanic white students had about twice the odds of depression as other ethnic groups, risk of depression did not vary according to gender, age, season, latitude, poverty to income ratio, or use of vitamin D supplements.

The findings are limited by the cross-sectional data and lack of data regarding other factors that could affect vitamin D absorption, such as sunscreen use or clothing worn in the sun. The researchers also had only broad – not precise – data on latitude, and the PHQ-9 was used as a proxy for major depression instead of a clinical diagnosis.

The research was funded by the Denver Health Division of General Pediatrics. The authors had no relevant financial disclosures.
 

BALTIMORE – Lower levels of vitamin D in adolescents appear to be associated with a higher risk of depression, according to new preliminary findings Anna-Lisa Munson, MD, MPH, of Denver Health Medical Center in Colorado, told attendees at the Pediatric Academic Societies annual meeting.

JochenSchoenfeld/Thinkstock

Although several studies in adults have suggested a link between vitamin D deficiency and depression, no large-scale studies have investigated whether such a relationship exists in adolescents, up to half of whom have a vitamin D deficiency, Dr Munson said.

The researchers relied on National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 to assess prevalence of major depressive disorder and vitamin D 25-hydroxy levels in teens aged 12-17 years. Serum vitamin D levels of less than 30 nmol/L were considered deficient while 30-50 nmol/L was considered insufficient, and at least 50 nmol/L was sufficient. A score between 10 and 27 on the Patient Health Questionnaire-9 (PHQ-9) qualified as depression.

The researchers adjusted their findings for age and sex, as well as other covariates linked to vitamin D levels or depression in previous research: latitude, season, race/ethnicity, and poverty to income ratio.

Among the 2,815 participants who completed the National Institute of Mental Health Diagnostic Interview Schedule for Children (NIMH-DISC), 8% had major depression. Among the 2,420 of participants with serum vitamin D values, 8% had vitamin D deficiency, 33% had insufficiency, and 59% had sufficiency.

Risk of depression dropped 10% for every additional 10 nmol/L of vitamin D, the analysis showed (odds ratio, 0.90).

Although non-Hispanic white students had about twice the odds of depression as other ethnic groups, risk of depression did not vary according to gender, age, season, latitude, poverty to income ratio, or use of vitamin D supplements.

The findings are limited by the cross-sectional data and lack of data regarding other factors that could affect vitamin D absorption, such as sunscreen use or clothing worn in the sun. The researchers also had only broad – not precise – data on latitude, and the PHQ-9 was used as a proxy for major depression instead of a clinical diagnosis.

The research was funded by the Denver Health Division of General Pediatrics. The authors had no relevant financial disclosures.
 

Lichen striatus (LS) is a common benign skin condition that presents in children between the ages of 5 and 15 years.¹ The rash is typically unilateral and most frequently on the extremities, although it may appear on the face, trunk, or buttocks. The lesions start as pink or skin-colored asymptomatic papules in a linear orientation following the lines of Blaschko. Lesions usually evolve over several weeks, and typically resolve in 6-12 months. There may be residual postinflammatory hypo- or hyperpigmentation which often improves within a few years.

Of note, there are subsets of lichen striatus: Hypopigmented lichen striatus with minimal papules has been termed “lichen striatus albus.” Nail lichen striatus may present as onycholysis or fissuring of nails, present as an isolated finding, or more commonly in association with concurrent affected skin. Nail lichen striatus typically resolves on its own, however there are case reports of improvement with intralesional steroids.²

There is no established etiology for LS. Autoimmune disease, viruses, immunizations, medications, and hypersensitivity reactions have been associated with triggering LS in various case reports, although strength of the associations is low. Children have been reported to have LS following scarlet fever and Candida vulvitis.³ Diagnosis usually is clinical, although biopsy may be helpful for histopathologic confirmation. No work-up for associated infections or conditions is warranted.

The differential for linear papular lesions includes inflammatory linear verrucous epidermal nevus (ILVEN), blaschkitis, or linear morphea. ILVEN is a hamartoma that usually is congenital or presents in early childhood; presents with linear or whorled, hyperkeratotic papules and plaque in similar linear “line of Blaschko” patterns; and represents cutaneous mosaicism. It is often difficult to differentiate between lichen striatus and ILVEN, however lichen striatus is not congenital, and is a self-limited condition. Under dermoscopy (polarized light systems) findings of LS more frequently demonstrate gray granular pigmentation. ILVEN is more frequently associated with cerebriform pattern.⁴ Blaschkitis is a term for a blaschkoid inflammation of the skin that presents with more eczematous findings and histology of spongiosis, unlike the lichenoid findings of LS. It is typically accompanied by noticeable pruritus and broader bands of involved area, and has older age of onset than LS. Linear morphea is a deeper inflammatory process of the dermis or subcutaneous fat, presenting with sclerotic skin, and typically has associated atrophy.

Treatment need not be pursued for lichen striatus because it is a benign condition. The lesions typically self-resolve without any residual scarring. If patients have associated pruritus then low- to midpotency topical steroids can be used for symptomatic relief.
 

Dr. Kaushik is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego, and Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. There are no conflicts of interest or financial disclosures for Dr. Kaushik or Dr. Eichenfield. Email them at [email protected].

References

1. Gupta D, Mathes E. Lichen Striatus. (Levy ML ed.) 2019: UpToDate.

2. Dermatol Ther. 2018 Nov;31(6):e12713.

3. Int J Dermatol. 2018 Sep;57(9):1118-9.

4. J Dermatol. 2017 Dec;44(12):e355-6.

Lichen striatus (LS) is a common benign skin condition that presents in children between the ages of 5 and 15 years.¹ The rash is typically unilateral and most frequently on the extremities, although it may appear on the face, trunk, or buttocks. The lesions start as pink or skin-colored asymptomatic papules in a linear orientation following the lines of Blaschko. Lesions usually evolve over several weeks, and typically resolve in 6-12 months. There may be residual postinflammatory hypo- or hyperpigmentation which often improves within a few years.

Of note, there are subsets of lichen striatus: Hypopigmented lichen striatus with minimal papules has been termed “lichen striatus albus.” Nail lichen striatus may present as onycholysis or fissuring of nails, present as an isolated finding, or more commonly in association with concurrent affected skin. Nail lichen striatus typically resolves on its own, however there are case reports of improvement with intralesional steroids.²

There is no established etiology for LS. Autoimmune disease, viruses, immunizations, medications, and hypersensitivity reactions have been associated with triggering LS in various case reports, although strength of the associations is low. Children have been reported to have LS following scarlet fever and Candida vulvitis.³ Diagnosis usually is clinical, although biopsy may be helpful for histopathologic confirmation. No work-up for associated infections or conditions is warranted.

The differential for linear papular lesions includes inflammatory linear verrucous epidermal nevus (ILVEN), blaschkitis, or linear morphea. ILVEN is a hamartoma that usually is congenital or presents in early childhood; presents with linear or whorled, hyperkeratotic papules and plaque in similar linear “line of Blaschko” patterns; and represents cutaneous mosaicism. It is often difficult to differentiate between lichen striatus and ILVEN, however lichen striatus is not congenital, and is a self-limited condition. Under dermoscopy (polarized light systems) findings of LS more frequently demonstrate gray granular pigmentation. ILVEN is more frequently associated with cerebriform pattern.⁴ Blaschkitis is a term for a blaschkoid inflammation of the skin that presents with more eczematous findings and histology of spongiosis, unlike the lichenoid findings of LS. It is typically accompanied by noticeable pruritus and broader bands of involved area, and has older age of onset than LS. Linear morphea is a deeper inflammatory process of the dermis or subcutaneous fat, presenting with sclerotic skin, and typically has associated atrophy.

Treatment need not be pursued for lichen striatus because it is a benign condition. The lesions typically self-resolve without any residual scarring. If patients have associated pruritus then low- to midpotency topical steroids can be used for symptomatic relief.
 

Dr. Kaushik is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego, and Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. There are no conflicts of interest or financial disclosures for Dr. Kaushik or Dr. Eichenfield. Email them at [email protected].

References

1. Gupta D, Mathes E. Lichen Striatus. (Levy ML ed.) 2019: UpToDate.

2. Dermatol Ther. 2018 Nov;31(6):e12713.

3. Int J Dermatol. 2018 Sep;57(9):1118-9.

4. J Dermatol. 2017 Dec;44(12):e355-6.

Lichen striatus (LS) is a common benign skin condition that presents in children between the ages of 5 and 15 years.¹ The rash is typically unilateral and most frequently on the extremities, although it may appear on the face, trunk, or buttocks. The lesions start as pink or skin-colored asymptomatic papules in a linear orientation following the lines of Blaschko. Lesions usually evolve over several weeks, and typically resolve in 6-12 months. There may be residual postinflammatory hypo- or hyperpigmentation which often improves within a few years.

Of note, there are subsets of lichen striatus: Hypopigmented lichen striatus with minimal papules has been termed “lichen striatus albus.” Nail lichen striatus may present as onycholysis or fissuring of nails, present as an isolated finding, or more commonly in association with concurrent affected skin. Nail lichen striatus typically resolves on its own, however there are case reports of improvement with intralesional steroids.²

There is no established etiology for LS. Autoimmune disease, viruses, immunizations, medications, and hypersensitivity reactions have been associated with triggering LS in various case reports, although strength of the associations is low. Children have been reported to have LS following scarlet fever and Candida vulvitis.³ Diagnosis usually is clinical, although biopsy may be helpful for histopathologic confirmation. No work-up for associated infections or conditions is warranted.

The differential for linear papular lesions includes inflammatory linear verrucous epidermal nevus (ILVEN), blaschkitis, or linear morphea. ILVEN is a hamartoma that usually is congenital or presents in early childhood; presents with linear or whorled, hyperkeratotic papules and plaque in similar linear “line of Blaschko” patterns; and represents cutaneous mosaicism. It is often difficult to differentiate between lichen striatus and ILVEN, however lichen striatus is not congenital, and is a self-limited condition. Under dermoscopy (polarized light systems) findings of LS more frequently demonstrate gray granular pigmentation. ILVEN is more frequently associated with cerebriform pattern.⁴ Blaschkitis is a term for a blaschkoid inflammation of the skin that presents with more eczematous findings and histology of spongiosis, unlike the lichenoid findings of LS. It is typically accompanied by noticeable pruritus and broader bands of involved area, and has older age of onset than LS. Linear morphea is a deeper inflammatory process of the dermis or subcutaneous fat, presenting with sclerotic skin, and typically has associated atrophy.

Treatment need not be pursued for lichen striatus because it is a benign condition. The lesions typically self-resolve without any residual scarring. If patients have associated pruritus then low- to midpotency topical steroids can be used for symptomatic relief.
 

Dr. Kaushik is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego, and Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. There are no conflicts of interest or financial disclosures for Dr. Kaushik or Dr. Eichenfield. Email them at [email protected].

References

1. Gupta D, Mathes E. Lichen Striatus. (Levy ML ed.) 2019: UpToDate.

2. Dermatol Ther. 2018 Nov;31(6):e12713.

3. Int J Dermatol. 2018 Sep;57(9):1118-9.

4. J Dermatol. 2017 Dec;44(12):e355-6.

NEW ORLEANS – Next-generation sequencing of peripheral blood is at least as effective as flow cytometry of bone marrow for assessing minimal residual disease, according to a new study.

Researchers compared bone marrow flow cytometry (FC) and peripheral blood next-generation sequencing (NGS) for minimal residual disease (MRD) assessment in pediatric and young adult patients with B-cell acute lymphoblastic leukemia (B-ALL) who received treatment with tisagenlecleucel. There was a high level of concordance between the assays, but the NGS assay detected more MRD-positive samples and NGS results provided a longer lead time to relapse.

Michael A. Pulsipher, MD, of the Children’s Hospital Los Angeles, presented these results at the annual meeting of the American Society of Pediatric Hematology/Oncology.

The researchers analyzed samples from pediatric and young adult patients aged 2-25 years who had relapsed or refractory B-ALL and received treatment with tisagenlecleucel on the ELIANA or ENSIGN trials.

The patients had received at least two prior lines of therapy and were ineligible for allogeneic transplant. They received a single dose of tisagenlecleucel. MRD was assessed before tisagenlecleucel infusion, at various time points after infusion, and at relapse.

Dr. Pulsipher and his colleagues compared MRD results from an NGS assay – Adaptive Biotechnologies’ clonoSEQ – using peripheral blood and results from FC of bone marrow. NGS and FC results were available for 237 samples from 83 patients.

After treatment, NGS detected more MRD-positive samples at each sensitivity level tested (10^-4, 10^-5, and 10^-6). At 10^-6, NGS detected 18% more MRD-positive samples than did FC – 50% and 32%, respectively.

Detection of MRD positivity prior to relapse was faster with NGS than with FC. In 17 of 34 patients with morphological relapse, NGS provided a median lead time of 67 days. FC provided a median lead time of 39 days in 11 of the 34 patients.

About 80% of patients who had an MRD status of zero by NGS at day 28 remained relapse-free for up to 3 years.

Among complete responders (n = 50), the duration of response was significantly longer in patients who had an MRD status of zero at day 28 by NGS than in patients who had an MRD status greater than zero (P = .0003). Overall survival was significantly better among patients with an MRD status of zero as well (P = .0004).

Dr. Pulsipher said additional studies are needed to confirm these findings and determine the best way to know if a patient has been cured or needs additional therapy after tisagenlecleucel.

Dr. Pulsipher reported relationships with Adaptive Biotech, Novartis, Incyte, Amgen, Bellicum Pharmaceuticals, Medac Pharma, and Miltenyi Biotec. ELIANA and ENSIGN were funded by Novartis, which markets tisagenlecleucel as Kymriah.

[email protected]

SOURCE: Pulsipher MA et al. ASPHO 2019, Abstract 2001.

NEW ORLEANS – Next-generation sequencing of peripheral blood is at least as effective as flow cytometry of bone marrow for assessing minimal residual disease, according to a new study.

Researchers compared bone marrow flow cytometry (FC) and peripheral blood next-generation sequencing (NGS) for minimal residual disease (MRD) assessment in pediatric and young adult patients with B-cell acute lymphoblastic leukemia (B-ALL) who received treatment with tisagenlecleucel. There was a high level of concordance between the assays, but the NGS assay detected more MRD-positive samples and NGS results provided a longer lead time to relapse.

Michael A. Pulsipher, MD, of the Children’s Hospital Los Angeles, presented these results at the annual meeting of the American Society of Pediatric Hematology/Oncology.

The researchers analyzed samples from pediatric and young adult patients aged 2-25 years who had relapsed or refractory B-ALL and received treatment with tisagenlecleucel on the ELIANA or ENSIGN trials.

The patients had received at least two prior lines of therapy and were ineligible for allogeneic transplant. They received a single dose of tisagenlecleucel. MRD was assessed before tisagenlecleucel infusion, at various time points after infusion, and at relapse.

Dr. Pulsipher and his colleagues compared MRD results from an NGS assay – Adaptive Biotechnologies’ clonoSEQ – using peripheral blood and results from FC of bone marrow. NGS and FC results were available for 237 samples from 83 patients.

After treatment, NGS detected more MRD-positive samples at each sensitivity level tested (10^-4, 10^-5, and 10^-6). At 10^-6, NGS detected 18% more MRD-positive samples than did FC – 50% and 32%, respectively.

Detection of MRD positivity prior to relapse was faster with NGS than with FC. In 17 of 34 patients with morphological relapse, NGS provided a median lead time of 67 days. FC provided a median lead time of 39 days in 11 of the 34 patients.

About 80% of patients who had an MRD status of zero by NGS at day 28 remained relapse-free for up to 3 years.

Among complete responders (n = 50), the duration of response was significantly longer in patients who had an MRD status of zero at day 28 by NGS than in patients who had an MRD status greater than zero (P = .0003). Overall survival was significantly better among patients with an MRD status of zero as well (P = .0004).

Dr. Pulsipher said additional studies are needed to confirm these findings and determine the best way to know if a patient has been cured or needs additional therapy after tisagenlecleucel.

Dr. Pulsipher reported relationships with Adaptive Biotech, Novartis, Incyte, Amgen, Bellicum Pharmaceuticals, Medac Pharma, and Miltenyi Biotec. ELIANA and ENSIGN were funded by Novartis, which markets tisagenlecleucel as Kymriah.

[email protected]

SOURCE: Pulsipher MA et al. ASPHO 2019, Abstract 2001.

NEW ORLEANS – Next-generation sequencing of peripheral blood is at least as effective as flow cytometry of bone marrow for assessing minimal residual disease, according to a new study.

Researchers compared bone marrow flow cytometry (FC) and peripheral blood next-generation sequencing (NGS) for minimal residual disease (MRD) assessment in pediatric and young adult patients with B-cell acute lymphoblastic leukemia (B-ALL) who received treatment with tisagenlecleucel. There was a high level of concordance between the assays, but the NGS assay detected more MRD-positive samples and NGS results provided a longer lead time to relapse.

Michael A. Pulsipher, MD, of the Children’s Hospital Los Angeles, presented these results at the annual meeting of the American Society of Pediatric Hematology/Oncology.

The researchers analyzed samples from pediatric and young adult patients aged 2-25 years who had relapsed or refractory B-ALL and received treatment with tisagenlecleucel on the ELIANA or ENSIGN trials.

The patients had received at least two prior lines of therapy and were ineligible for allogeneic transplant. They received a single dose of tisagenlecleucel. MRD was assessed before tisagenlecleucel infusion, at various time points after infusion, and at relapse.

Dr. Pulsipher and his colleagues compared MRD results from an NGS assay – Adaptive Biotechnologies’ clonoSEQ – using peripheral blood and results from FC of bone marrow. NGS and FC results were available for 237 samples from 83 patients.

After treatment, NGS detected more MRD-positive samples at each sensitivity level tested (10^-4, 10^-5, and 10^-6). At 10^-6, NGS detected 18% more MRD-positive samples than did FC – 50% and 32%, respectively.

Detection of MRD positivity prior to relapse was faster with NGS than with FC. In 17 of 34 patients with morphological relapse, NGS provided a median lead time of 67 days. FC provided a median lead time of 39 days in 11 of the 34 patients.

About 80% of patients who had an MRD status of zero by NGS at day 28 remained relapse-free for up to 3 years.

Among complete responders (n = 50), the duration of response was significantly longer in patients who had an MRD status of zero at day 28 by NGS than in patients who had an MRD status greater than zero (P = .0003). Overall survival was significantly better among patients with an MRD status of zero as well (P = .0004).

Dr. Pulsipher said additional studies are needed to confirm these findings and determine the best way to know if a patient has been cured or needs additional therapy after tisagenlecleucel.

Dr. Pulsipher reported relationships with Adaptive Biotech, Novartis, Incyte, Amgen, Bellicum Pharmaceuticals, Medac Pharma, and Miltenyi Biotec. ELIANA and ENSIGN were funded by Novartis, which markets tisagenlecleucel as Kymriah.

[email protected]

SOURCE: Pulsipher MA et al. ASPHO 2019, Abstract 2001.

Youth suicide rates appear to be increasing faster in girls than in boys, narrowing the historical gap between the two, according to research published in JAMA Network Open.

From 1999 to 2014, suicide rates in the United States have increased by 33%, but the incidence always has been higher among men than women in all age groups.

Recent reports suggesting that suicide rates were increasing in girls prompted Donna A. Ruch, PhD, from the the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and her coauthors to undertake a cross-sectional study of all suicides in the United States among individuals aged 10-19 years, between 1975 and 2016.

During that time there were a total of 85,051 suicide deaths in youth aged 10-19 years; approximately 80% of the deaths were in males, representing a nearly fourfold higher rate in males than females (incidence rate ratio [IRR], 3.82).

From 1975 to 1993, researchers noted a 5.4% increase each year in suicide rates among girls aged 10-14 years and a 4.5% increase among boys in the same age group. From 2003-2007, suicide rates among both sexes declined until 2007, at which point the suicide rates among girls increased annually by 12.7%, compared with 7.1% among boys.

Overall, the male to female incidence rate ratio among youth aged 10-14 decreased from 3.14 in 1975-1991 to 1.80 from 2007-2016, a statistically significant difference.

“The narrowing gap between male and female rates of suicide was most pronounced among youth aged 10 to 14 years, underscoring the importance of early prevention efforts that take both sex and developmental level into consideration,” the authors wrote.

Ethnicity was an influence, with the most consistent declining trend in male to female incidence rate ratio seen in non-Hispanic white youth, and also was significant in non-Hispanic youth of other races. There was no significant change in the male to female incidence rate ratio seen with younger non-Hispanic black youth or Hispanic youth.

Among youth aged 15-19, the differences between male and female suicide rates decreased significantly in non-Hispanic youth of other race, and a significant downward trend also was seen in Hispanic youth.

The analysis also looked at method of suicide. The results showed that while the male to female incidence rate ratio for shooting suicides increased significantly in youth aged 15-19 years, it decreased for suicide by hanging or suffocation across all ages groups.

“Future research to identify sex-specific risk factors for youth suicide and distinct mechanisms of suicide in male and female individuals within racial/ethnic groups could lead to improved suicide prevention strategies and interventions,” the authors wrote.

One author was supported by a grant from the National Institute of Mental Health, and declared unpaid board membership for the scientific advisory board of a mental health company. No other conflicts of interest were declared.

SOURCE: Ruch D et al. JAMA Network Open. 2019, May 17. doi:10.1001/jamanetworkopen.2019.3886.

Youth suicide rates appear to be increasing faster in girls than in boys, narrowing the historical gap between the two, according to research published in JAMA Network Open.

From 1999 to 2014, suicide rates in the United States have increased by 33%, but the incidence always has been higher among men than women in all age groups.

Recent reports suggesting that suicide rates were increasing in girls prompted Donna A. Ruch, PhD, from the the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and her coauthors to undertake a cross-sectional study of all suicides in the United States among individuals aged 10-19 years, between 1975 and 2016.

During that time there were a total of 85,051 suicide deaths in youth aged 10-19 years; approximately 80% of the deaths were in males, representing a nearly fourfold higher rate in males than females (incidence rate ratio [IRR], 3.82).

From 1975 to 1993, researchers noted a 5.4% increase each year in suicide rates among girls aged 10-14 years and a 4.5% increase among boys in the same age group. From 2003-2007, suicide rates among both sexes declined until 2007, at which point the suicide rates among girls increased annually by 12.7%, compared with 7.1% among boys.

Overall, the male to female incidence rate ratio among youth aged 10-14 decreased from 3.14 in 1975-1991 to 1.80 from 2007-2016, a statistically significant difference.

“The narrowing gap between male and female rates of suicide was most pronounced among youth aged 10 to 14 years, underscoring the importance of early prevention efforts that take both sex and developmental level into consideration,” the authors wrote.

Ethnicity was an influence, with the most consistent declining trend in male to female incidence rate ratio seen in non-Hispanic white youth, and also was significant in non-Hispanic youth of other races. There was no significant change in the male to female incidence rate ratio seen with younger non-Hispanic black youth or Hispanic youth.

Among youth aged 15-19, the differences between male and female suicide rates decreased significantly in non-Hispanic youth of other race, and a significant downward trend also was seen in Hispanic youth.

The analysis also looked at method of suicide. The results showed that while the male to female incidence rate ratio for shooting suicides increased significantly in youth aged 15-19 years, it decreased for suicide by hanging or suffocation across all ages groups.

“Future research to identify sex-specific risk factors for youth suicide and distinct mechanisms of suicide in male and female individuals within racial/ethnic groups could lead to improved suicide prevention strategies and interventions,” the authors wrote.

One author was supported by a grant from the National Institute of Mental Health, and declared unpaid board membership for the scientific advisory board of a mental health company. No other conflicts of interest were declared.

SOURCE: Ruch D et al. JAMA Network Open. 2019, May 17. doi:10.1001/jamanetworkopen.2019.3886.

Youth suicide rates appear to be increasing faster in girls than in boys, narrowing the historical gap between the two, according to research published in JAMA Network Open.

From 1999 to 2014, suicide rates in the United States have increased by 33%, but the incidence always has been higher among men than women in all age groups.

Recent reports suggesting that suicide rates were increasing in girls prompted Donna A. Ruch, PhD, from the the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and her coauthors to undertake a cross-sectional study of all suicides in the United States among individuals aged 10-19 years, between 1975 and 2016.

During that time there were a total of 85,051 suicide deaths in youth aged 10-19 years; approximately 80% of the deaths were in males, representing a nearly fourfold higher rate in males than females (incidence rate ratio [IRR], 3.82).

From 1975 to 1993, researchers noted a 5.4% increase each year in suicide rates among girls aged 10-14 years and a 4.5% increase among boys in the same age group. From 2003-2007, suicide rates among both sexes declined until 2007, at which point the suicide rates among girls increased annually by 12.7%, compared with 7.1% among boys.

Overall, the male to female incidence rate ratio among youth aged 10-14 decreased from 3.14 in 1975-1991 to 1.80 from 2007-2016, a statistically significant difference.

“The narrowing gap between male and female rates of suicide was most pronounced among youth aged 10 to 14 years, underscoring the importance of early prevention efforts that take both sex and developmental level into consideration,” the authors wrote.

Ethnicity was an influence, with the most consistent declining trend in male to female incidence rate ratio seen in non-Hispanic white youth, and also was significant in non-Hispanic youth of other races. There was no significant change in the male to female incidence rate ratio seen with younger non-Hispanic black youth or Hispanic youth.

Among youth aged 15-19, the differences between male and female suicide rates decreased significantly in non-Hispanic youth of other race, and a significant downward trend also was seen in Hispanic youth.

The analysis also looked at method of suicide. The results showed that while the male to female incidence rate ratio for shooting suicides increased significantly in youth aged 15-19 years, it decreased for suicide by hanging or suffocation across all ages groups.

“Future research to identify sex-specific risk factors for youth suicide and distinct mechanisms of suicide in male and female individuals within racial/ethnic groups could lead to improved suicide prevention strategies and interventions,” the authors wrote.

One author was supported by a grant from the National Institute of Mental Health, and declared unpaid board membership for the scientific advisory board of a mental health company. No other conflicts of interest were declared.

SOURCE: Ruch D et al. JAMA Network Open. 2019, May 17. doi:10.1001/jamanetworkopen.2019.3886.

BALTIMORE – Some infants, especially among those with persistent pulmonary hypertension, are at risk for developing iatrogenic neonatal abstinence syndrome, according to Amber Dave, MD, a neonatal-perinatal medicine fellow at Georgetown University Hospital in Washington.

M. Alexander Otto/MDedge News

Of 70 infants administered morphine or fentanyl for longer than a day in the neonatal ICU, almost a third (22, or 31%) developed iatrogenic neonatal abstinence syndrome (INAS). As a result, they needed prolonged respiratory support, more time to reach full feeds, and extended lengths of stay. Children exposed to opioids before birth were excluded from the analysis.

The greatest risk was in infants with persistent pulmonary hypertension; INAS was diagnosed in 13 of 22 (57%).

Opioid dosing also was all over the map for a given Neonatal Pain, Agitation, and Sedation Scale (N-PASS) score, Dr. Dave said. Some infants with an N-PASS pain score of 2, for instance, received no opioids, while others received up to 1,500 mg/kg morphine equivalents.

N-PASS is used in NICUs nationwide to guide dosing, but the variability seen in the study suggests that there’s need for a more objective measure of neonatal distress and for neonatologists to establish ground rules for NICU opioid use, she added.

The use of opioids has been increasing in NICUs for years (J Opioid Manag. 2015 Jul-Aug;11[4]:305-12), and at least one institution (J Perinatol. 2017 Sep;37[9]:1038-42) already has established guidelines to curb overuse. Dr. Dave said that several neonatologists, after viewing her poster at the Pediatric Academic Societies annual meeting, told her that they probably had the same problem at their NICUs but had not examined their data.

“We are using” these medications more in the NICU, “but how much is too much? We need to find that balance. We need to improve our practice.”

“The overarching question is if there are better alternatives for treating pain and stress in critically ill neonates.” Dexmedetomidine, an opioid-sparing alpha-2 agonist adrenoreceptor sedative, analgesic, and anxiolytic, is one of several options “being looked at closely in this population. We also need to think of nonpharmacologic measures,” Dr. Dave said.

In addition to infants with persistent pulmonary hypertension, the 22 INAS cases at the study site included, among others, three children on extracorporeal membrane oxygenation, one with meconium aspiration syndrome, and one surgical case, out of the 15 included in the study. The common denominator was the need to keep infants calm and comfortable during prolonged intubation, which was a mean of 10.5 days among INAS infants versus 5 among children who didn’t go into opioid withdrawal.

INAS infants had a daily mean morphine-equivalent dose of 106.6 mg/kg, with a mean exposure of 17 days and mean cumulative dose of 1,515 mg/kg. The daily mean morphine-equivalent dose among infants who didn’t develop INAS was 42.4 mg/kg, with a mean exposure of 4 days and mean cumulative dose of 246 mg/kg.

INAS infants spent a mean of 27 days in the hospital, and it took them a mean of almost 6 days to reach full feeds, versus 15 days for the other infants full feeds by day 4. Over half of the INAS infants (12) also were on midazolam, and they had higher cumulative doses of the sedative than infants who didn’t develop INAS (mean, 2.64 mg/kg vs. 0.19 mg/kg). The findings all were statistically significant.

Dr. Dave said the most surprising finding was the variability in opioid dosing. In another example, some infants received up to 1,400 mg/kg morphine equivalents even when their fraction of inspired oxygen requirement fell below 60%, which meant that they were getting better. Other infants by that point were off opioids altogether.

“This has definitely brought awareness to my practice. Before I would say, ‘Okay, let’s just go up,’ ” when a nurse requested an opioid increase based on N-PASS scores. Now, “I try to really figure out why they think the baby needs an increase, and I may say ‘Actually, we are turning a corner now, and maybe the baby can be a little bit more awake. How do you feel about that?’ ” she said.

“My long-term goal for this project is putting some guidelines in place,” she said.

There was no industry funding for the work, and Dr. Dave didn’t have any disclosures.

[email protected]

BALTIMORE – Some infants, especially among those with persistent pulmonary hypertension, are at risk for developing iatrogenic neonatal abstinence syndrome, according to Amber Dave, MD, a neonatal-perinatal medicine fellow at Georgetown University Hospital in Washington.

M. Alexander Otto/MDedge News

Of 70 infants administered morphine or fentanyl for longer than a day in the neonatal ICU, almost a third (22, or 31%) developed iatrogenic neonatal abstinence syndrome (INAS). As a result, they needed prolonged respiratory support, more time to reach full feeds, and extended lengths of stay. Children exposed to opioids before birth were excluded from the analysis.

The greatest risk was in infants with persistent pulmonary hypertension; INAS was diagnosed in 13 of 22 (57%).

Opioid dosing also was all over the map for a given Neonatal Pain, Agitation, and Sedation Scale (N-PASS) score, Dr. Dave said. Some infants with an N-PASS pain score of 2, for instance, received no opioids, while others received up to 1,500 mg/kg morphine equivalents.

N-PASS is used in NICUs nationwide to guide dosing, but the variability seen in the study suggests that there’s need for a more objective measure of neonatal distress and for neonatologists to establish ground rules for NICU opioid use, she added.

The use of opioids has been increasing in NICUs for years (J Opioid Manag. 2015 Jul-Aug;11[4]:305-12), and at least one institution (J Perinatol. 2017 Sep;37[9]:1038-42) already has established guidelines to curb overuse. Dr. Dave said that several neonatologists, after viewing her poster at the Pediatric Academic Societies annual meeting, told her that they probably had the same problem at their NICUs but had not examined their data.

“We are using” these medications more in the NICU, “but how much is too much? We need to find that balance. We need to improve our practice.”

“The overarching question is if there are better alternatives for treating pain and stress in critically ill neonates.” Dexmedetomidine, an opioid-sparing alpha-2 agonist adrenoreceptor sedative, analgesic, and anxiolytic, is one of several options “being looked at closely in this population. We also need to think of nonpharmacologic measures,” Dr. Dave said.

In addition to infants with persistent pulmonary hypertension, the 22 INAS cases at the study site included, among others, three children on extracorporeal membrane oxygenation, one with meconium aspiration syndrome, and one surgical case, out of the 15 included in the study. The common denominator was the need to keep infants calm and comfortable during prolonged intubation, which was a mean of 10.5 days among INAS infants versus 5 among children who didn’t go into opioid withdrawal.

INAS infants had a daily mean morphine-equivalent dose of 106.6 mg/kg, with a mean exposure of 17 days and mean cumulative dose of 1,515 mg/kg. The daily mean morphine-equivalent dose among infants who didn’t develop INAS was 42.4 mg/kg, with a mean exposure of 4 days and mean cumulative dose of 246 mg/kg.

INAS infants spent a mean of 27 days in the hospital, and it took them a mean of almost 6 days to reach full feeds, versus 15 days for the other infants full feeds by day 4. Over half of the INAS infants (12) also were on midazolam, and they had higher cumulative doses of the sedative than infants who didn’t develop INAS (mean, 2.64 mg/kg vs. 0.19 mg/kg). The findings all were statistically significant.

Dr. Dave said the most surprising finding was the variability in opioid dosing. In another example, some infants received up to 1,400 mg/kg morphine equivalents even when their fraction of inspired oxygen requirement fell below 60%, which meant that they were getting better. Other infants by that point were off opioids altogether.

“This has definitely brought awareness to my practice. Before I would say, ‘Okay, let’s just go up,’ ” when a nurse requested an opioid increase based on N-PASS scores. Now, “I try to really figure out why they think the baby needs an increase, and I may say ‘Actually, we are turning a corner now, and maybe the baby can be a little bit more awake. How do you feel about that?’ ” she said.

“My long-term goal for this project is putting some guidelines in place,” she said.

There was no industry funding for the work, and Dr. Dave didn’t have any disclosures.

[email protected]

BALTIMORE – Some infants, especially among those with persistent pulmonary hypertension, are at risk for developing iatrogenic neonatal abstinence syndrome, according to Amber Dave, MD, a neonatal-perinatal medicine fellow at Georgetown University Hospital in Washington.

M. Alexander Otto/MDedge News

Of 70 infants administered morphine or fentanyl for longer than a day in the neonatal ICU, almost a third (22, or 31%) developed iatrogenic neonatal abstinence syndrome (INAS). As a result, they needed prolonged respiratory support, more time to reach full feeds, and extended lengths of stay. Children exposed to opioids before birth were excluded from the analysis.

The greatest risk was in infants with persistent pulmonary hypertension; INAS was diagnosed in 13 of 22 (57%).

Opioid dosing also was all over the map for a given Neonatal Pain, Agitation, and Sedation Scale (N-PASS) score, Dr. Dave said. Some infants with an N-PASS pain score of 2, for instance, received no opioids, while others received up to 1,500 mg/kg morphine equivalents.

N-PASS is used in NICUs nationwide to guide dosing, but the variability seen in the study suggests that there’s need for a more objective measure of neonatal distress and for neonatologists to establish ground rules for NICU opioid use, she added.

The use of opioids has been increasing in NICUs for years (J Opioid Manag. 2015 Jul-Aug;11[4]:305-12), and at least one institution (J Perinatol. 2017 Sep;37[9]:1038-42) already has established guidelines to curb overuse. Dr. Dave said that several neonatologists, after viewing her poster at the Pediatric Academic Societies annual meeting, told her that they probably had the same problem at their NICUs but had not examined their data.

“We are using” these medications more in the NICU, “but how much is too much? We need to find that balance. We need to improve our practice.”

“The overarching question is if there are better alternatives for treating pain and stress in critically ill neonates.” Dexmedetomidine, an opioid-sparing alpha-2 agonist adrenoreceptor sedative, analgesic, and anxiolytic, is one of several options “being looked at closely in this population. We also need to think of nonpharmacologic measures,” Dr. Dave said.

In addition to infants with persistent pulmonary hypertension, the 22 INAS cases at the study site included, among others, three children on extracorporeal membrane oxygenation, one with meconium aspiration syndrome, and one surgical case, out of the 15 included in the study. The common denominator was the need to keep infants calm and comfortable during prolonged intubation, which was a mean of 10.5 days among INAS infants versus 5 among children who didn’t go into opioid withdrawal.

INAS infants had a daily mean morphine-equivalent dose of 106.6 mg/kg, with a mean exposure of 17 days and mean cumulative dose of 1,515 mg/kg. The daily mean morphine-equivalent dose among infants who didn’t develop INAS was 42.4 mg/kg, with a mean exposure of 4 days and mean cumulative dose of 246 mg/kg.

INAS infants spent a mean of 27 days in the hospital, and it took them a mean of almost 6 days to reach full feeds, versus 15 days for the other infants full feeds by day 4. Over half of the INAS infants (12) also were on midazolam, and they had higher cumulative doses of the sedative than infants who didn’t develop INAS (mean, 2.64 mg/kg vs. 0.19 mg/kg). The findings all were statistically significant.

Dr. Dave said the most surprising finding was the variability in opioid dosing. In another example, some infants received up to 1,400 mg/kg morphine equivalents even when their fraction of inspired oxygen requirement fell below 60%, which meant that they were getting better. Other infants by that point were off opioids altogether.

“This has definitely brought awareness to my practice. Before I would say, ‘Okay, let’s just go up,’ ” when a nurse requested an opioid increase based on N-PASS scores. Now, “I try to really figure out why they think the baby needs an increase, and I may say ‘Actually, we are turning a corner now, and maybe the baby can be a little bit more awake. How do you feel about that?’ ” she said.

“My long-term goal for this project is putting some guidelines in place,” she said.

There was no industry funding for the work, and Dr. Dave didn’t have any disclosures.

[email protected]

Two-thirds of pediatricians and other primary care physicians expect deaths from measles or resulting diseases to increase, according to a recent survey by real-time market insights technology firm InCrowd.

Among the 180 physicians with experience treating measles, 23% agreed and 44% said that they strongly agreed with the statement that measles deaths would increase, and another 18% said that they somewhat agreed. Only 9% expressed some level of disagreement, InCrowd said.

Most of those respondents also believe that summer travel will increase measles outbreaks (29% agreed and 30% strongly agreed) and that more communities will adopt requirements for measles vaccinations (26% and 36%). A majority also said that education about vaccinations will improve (26% agreed and 29% strongly agreed), but almost half of the physicians surveyed also expect vaccination misinformation to get worse (29% and 19%), InCrowd reported.

“With 44% of respondents predicting a high likelihood that deaths caused by measles will increase, the data show the imperative for physicians and patients to keep up the dialogue. … We have a long way to go before declaring victory,” said Diane Hayes, PhD, president and cofounder of InCrowd.

The InCrowd 5-minute microsurvey was conducted on April 18-19, 2019, and included 455 primary care physicians, of whom 40% said that they have treated or knew of colleagues in their facility or community who have treated patients with measles. Of those 180 respondents, 89 were pediatricians and 91 were in other primary care specialties.

Two-thirds of pediatricians and other primary care physicians expect deaths from measles or resulting diseases to increase, according to a recent survey by real-time market insights technology firm InCrowd.

Among the 180 physicians with experience treating measles, 23% agreed and 44% said that they strongly agreed with the statement that measles deaths would increase, and another 18% said that they somewhat agreed. Only 9% expressed some level of disagreement, InCrowd said.

Most of those respondents also believe that summer travel will increase measles outbreaks (29% agreed and 30% strongly agreed) and that more communities will adopt requirements for measles vaccinations (26% and 36%). A majority also said that education about vaccinations will improve (26% agreed and 29% strongly agreed), but almost half of the physicians surveyed also expect vaccination misinformation to get worse (29% and 19%), InCrowd reported.

“With 44% of respondents predicting a high likelihood that deaths caused by measles will increase, the data show the imperative for physicians and patients to keep up the dialogue. … We have a long way to go before declaring victory,” said Diane Hayes, PhD, president and cofounder of InCrowd.

The InCrowd 5-minute microsurvey was conducted on April 18-19, 2019, and included 455 primary care physicians, of whom 40% said that they have treated or knew of colleagues in their facility or community who have treated patients with measles. Of those 180 respondents, 89 were pediatricians and 91 were in other primary care specialties.

Two-thirds of pediatricians and other primary care physicians expect deaths from measles or resulting diseases to increase, according to a recent survey by real-time market insights technology firm InCrowd.

Among the 180 physicians with experience treating measles, 23% agreed and 44% said that they strongly agreed with the statement that measles deaths would increase, and another 18% said that they somewhat agreed. Only 9% expressed some level of disagreement, InCrowd said.

Most of those respondents also believe that summer travel will increase measles outbreaks (29% agreed and 30% strongly agreed) and that more communities will adopt requirements for measles vaccinations (26% and 36%). A majority also said that education about vaccinations will improve (26% agreed and 29% strongly agreed), but almost half of the physicians surveyed also expect vaccination misinformation to get worse (29% and 19%), InCrowd reported.

“With 44% of respondents predicting a high likelihood that deaths caused by measles will increase, the data show the imperative for physicians and patients to keep up the dialogue. … We have a long way to go before declaring victory,” said Diane Hayes, PhD, president and cofounder of InCrowd.

The InCrowd 5-minute microsurvey was conducted on April 18-19, 2019, and included 455 primary care physicians, of whom 40% said that they have treated or knew of colleagues in their facility or community who have treated patients with measles. Of those 180 respondents, 89 were pediatricians and 91 were in other primary care specialties.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.