Pediatrics

TOPLINE:

Nearly one in five adolescents are living with prediabetes, a condition where blood glucose levels are elevated, but are not high enough for a type 2 diabetes (T2D) diagnosis. According to a new study, higher levels of nonfasting glucose and hemoglobin A1c, and worsening obesity are important predictors of progression to T2D. In addition, metformin and weight stabilization may prove to be important interventions for preventing T2D in kids.

METHODOLOGY:

• Researchers did a retrospective chart review of patient data from Vanderbilt University Medical Center Pediatric Prediabetes Clinic, Nashville, Tenn., from May 2015 to August 2022.
• The study included 552 children with prediabetes, defined as abnormal blood glucose (fasting plasma glucose [FPG] ≥ 100 mg/dL, random glucose ≥ 150 mg/dL), or hemoglobin A1c equal to or greater than 5.9%.
• Based on follow-up visits, patients were classified as having progressed to T2D, or nonprogression.
• Researchers analyzed the patients’ initial visit A1c, fasting C-peptide, 2-hour glucose, fasting glucose, and body mass index (BMI), among other baseline characteristics.

TAKEAWAY:

• Thirty-six children (6.5%) progressed to T2D during the duration of the study period.
• The average time to T2D diagnosis was much longer in patients taking metformin (43 months), compared with those not taking the prescribed medication (28 months).
• Worsening obesity was strongly associated with T2D progression – patients who progressed to T2D had a higher BMI at baseline and had continued weight gain.
• A higher baseline A1c, fasting C-peptide, and 2-hour glucose were also associated with progression to T2D.
• In the multivariable analysis, both A1c and 2-hour glucose were strong independent predictors of progression.
• Fasting plasma glucose was not associated with progression to T2D.

IN PRACTICE:

“Weight stabilization and metformin therapy could be important interventions for diabetes prevention in children,” study author Ashley H. Shoemaker, MD, MSci, a pediatric endocrinologist at Vanderbilt University Medical Center in Nashville, Tenn., said in a press release.

In addition, A1c plus a nonfasting glucose may be a feasible way to identify high-risk pediatric patients in a clinical setting.
 

SOURCE:

This study was performed by Natasha Belsky, Jaclyn Tamaroff, and Ashley H. Shoemaker of the Vanderbilt University Medical Center and the Vanderbilt University School of Medicine in Nashville, Tenn. It was published October 12, 2023, in the Journal of the Endocrine Society

LIMITATIONS:

Additional patients who developed T2D may have been lost to follow-up, since the authors did not contact patients to confirm their disease status. The authors were also unable to establish racial differences in the progression to T2D because of missing data.

DISCLOSURES:

Funding for this study was provided by the National Center for Advancing Translational Sciences. One author has research contracts with Novo Nordisk and Boehringer Ingelheim.

A version of this article first appeared on Medscape.com.

TOPLINE:

Nearly one in five adolescents are living with prediabetes, a condition where blood glucose levels are elevated, but are not high enough for a type 2 diabetes (T2D) diagnosis. According to a new study, higher levels of nonfasting glucose and hemoglobin A1c, and worsening obesity are important predictors of progression to T2D. In addition, metformin and weight stabilization may prove to be important interventions for preventing T2D in kids.

METHODOLOGY:

• Researchers did a retrospective chart review of patient data from Vanderbilt University Medical Center Pediatric Prediabetes Clinic, Nashville, Tenn., from May 2015 to August 2022.
• The study included 552 children with prediabetes, defined as abnormal blood glucose (fasting plasma glucose [FPG] ≥ 100 mg/dL, random glucose ≥ 150 mg/dL), or hemoglobin A1c equal to or greater than 5.9%.
• Based on follow-up visits, patients were classified as having progressed to T2D, or nonprogression.
• Researchers analyzed the patients’ initial visit A1c, fasting C-peptide, 2-hour glucose, fasting glucose, and body mass index (BMI), among other baseline characteristics.

TAKEAWAY:

• Thirty-six children (6.5%) progressed to T2D during the duration of the study period.
• The average time to T2D diagnosis was much longer in patients taking metformin (43 months), compared with those not taking the prescribed medication (28 months).
• Worsening obesity was strongly associated with T2D progression – patients who progressed to T2D had a higher BMI at baseline and had continued weight gain.
• A higher baseline A1c, fasting C-peptide, and 2-hour glucose were also associated with progression to T2D.
• In the multivariable analysis, both A1c and 2-hour glucose were strong independent predictors of progression.
• Fasting plasma glucose was not associated with progression to T2D.

IN PRACTICE:

“Weight stabilization and metformin therapy could be important interventions for diabetes prevention in children,” study author Ashley H. Shoemaker, MD, MSci, a pediatric endocrinologist at Vanderbilt University Medical Center in Nashville, Tenn., said in a press release.

In addition, A1c plus a nonfasting glucose may be a feasible way to identify high-risk pediatric patients in a clinical setting.
 

SOURCE:

This study was performed by Natasha Belsky, Jaclyn Tamaroff, and Ashley H. Shoemaker of the Vanderbilt University Medical Center and the Vanderbilt University School of Medicine in Nashville, Tenn. It was published October 12, 2023, in the Journal of the Endocrine Society

LIMITATIONS:

Additional patients who developed T2D may have been lost to follow-up, since the authors did not contact patients to confirm their disease status. The authors were also unable to establish racial differences in the progression to T2D because of missing data.

DISCLOSURES:

Funding for this study was provided by the National Center for Advancing Translational Sciences. One author has research contracts with Novo Nordisk and Boehringer Ingelheim.

A version of this article first appeared on Medscape.com.

TOPLINE:

Nearly one in five adolescents are living with prediabetes, a condition where blood glucose levels are elevated, but are not high enough for a type 2 diabetes (T2D) diagnosis. According to a new study, higher levels of nonfasting glucose and hemoglobin A1c, and worsening obesity are important predictors of progression to T2D. In addition, metformin and weight stabilization may prove to be important interventions for preventing T2D in kids.

METHODOLOGY:

• Researchers did a retrospective chart review of patient data from Vanderbilt University Medical Center Pediatric Prediabetes Clinic, Nashville, Tenn., from May 2015 to August 2022.
• The study included 552 children with prediabetes, defined as abnormal blood glucose (fasting plasma glucose [FPG] ≥ 100 mg/dL, random glucose ≥ 150 mg/dL), or hemoglobin A1c equal to or greater than 5.9%.
• Based on follow-up visits, patients were classified as having progressed to T2D, or nonprogression.
• Researchers analyzed the patients’ initial visit A1c, fasting C-peptide, 2-hour glucose, fasting glucose, and body mass index (BMI), among other baseline characteristics.

TAKEAWAY:

• Thirty-six children (6.5%) progressed to T2D during the duration of the study period.
• The average time to T2D diagnosis was much longer in patients taking metformin (43 months), compared with those not taking the prescribed medication (28 months).
• Worsening obesity was strongly associated with T2D progression – patients who progressed to T2D had a higher BMI at baseline and had continued weight gain.
• A higher baseline A1c, fasting C-peptide, and 2-hour glucose were also associated with progression to T2D.
• In the multivariable analysis, both A1c and 2-hour glucose were strong independent predictors of progression.
• Fasting plasma glucose was not associated with progression to T2D.

IN PRACTICE:

“Weight stabilization and metformin therapy could be important interventions for diabetes prevention in children,” study author Ashley H. Shoemaker, MD, MSci, a pediatric endocrinologist at Vanderbilt University Medical Center in Nashville, Tenn., said in a press release.

In addition, A1c plus a nonfasting glucose may be a feasible way to identify high-risk pediatric patients in a clinical setting.
 

SOURCE:

This study was performed by Natasha Belsky, Jaclyn Tamaroff, and Ashley H. Shoemaker of the Vanderbilt University Medical Center and the Vanderbilt University School of Medicine in Nashville, Tenn. It was published October 12, 2023, in the Journal of the Endocrine Society

LIMITATIONS:

Additional patients who developed T2D may have been lost to follow-up, since the authors did not contact patients to confirm their disease status. The authors were also unable to establish racial differences in the progression to T2D because of missing data.

DISCLOSURES:

Funding for this study was provided by the National Center for Advancing Translational Sciences. One author has research contracts with Novo Nordisk and Boehringer Ingelheim.

A version of this article first appeared on Medscape.com.

According to the CDC, the prevalence of autism spectrum disorders (ASD) has gone from roughly 1 in 68 children in 2010 to 1 in 36 children in 2020.¹ This is nearly a 50% increase over that 10-year period. Over the last several years, there has been evidence suggesting that increasing numbers of young people with ASD or other neurodivergent conditions identify as transgender or gender diverse.² Experts agree more careful attention must be paid to these patients.

UT Southwestern Medical Center

Clinical work with neurodivergent youth, especially those with ASD, can be complicated. This includes things such as difficulty with communication, possible concrete thinking, and obsessive interests. While earlier research has shown a higher incidence of ASD in those referred to specialized gender medical clinics, it is important to realize that not all of these youth are seeking medical care. They may be brought to the attention of a primary care pediatrician (PCP) if the child has discussed their gender identity at home. It is important that PCPs approach these young people with an open mind and address any coexisting mental health conditions. PCPs must be careful not to dismiss any gender identity concerns as another of the patient’s “obsessions”; rather, they should ensure the patient receives the appropriate mental health care that they need to explore these concerns. One challenge for PCPs is that there is a dearth of mental health professionals who have experience in working with young people who have both gender dysphoria and a neurodivergent condition.

For those clinicians who provide gender-affirming medical care to these young people, it is imperative that they have a thorough understanding of the patient’s gender identity and medical goals before starting any treatment. This may require extensive collaboration with the patient’s mental health provider. The clinician providing medical care may also choose to proceed slower with the introduction of hormones and their subsequent dosing to allow the young person time to continue discussing their effects with their mental health provider. To help clinicians, Dr. John Strang and a multidisciplinary group of collaborators developed a set of guidelines for co-occurring ASD and gender dysphoria in adolescents.³ More recently, Dr. Strang and other collaborators have also developed a questionnaire that can be used by clinicians in the care of these patients.⁴ The goal of this questionnaire is to allow the young people to “communicate their experiences and needs in a report format attuned to common autistic thinking and communication styles.”

In summary, pediatricians and those who care for children and adolescents need to be aware of the increased association between those with ASD or other neurodivergent conditions and gender dysphoria. To ensure that these young people receive optimal care, it is important to connect them to experts (if possible) in coexisting ASD and gender dysphoria. If such experts are not readily available, the National LGBTQIA+ Health Education Center has developed a resource for providing an affirmative approach to care for these young people.⁵ While more research is needed to better understand young people with coexisting ASD (or other neurodivergent conditions), taking an individualized approach to their care can help ensure optimal outcomes.
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Data & Statistics on Autism Spectrum Disorder. https://www.cdc.gov/ncbddd/autism/data.html.

2. Glidden D et al. Gender dysphoria and autism spectrum disorder: A systematic review of the literature. Sex Med Rev. 2016;4(1):3-14. doi:10.1016/j.sxmr.2015.10.003.

3. Strang JF et al. Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol. 2018;47(1):105-15. doi:10.1080/15374416.2016.1228462.

4. Strang JF et. al. The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults. Autism Adulthood. 2023 Jun 1;5(2):175-90. doi: 10.1089/aut.2023.0002.

5. National LGBT Health Education Center. Neurodiversity & gender-diverse youth: An affirming approach to care 2020. https://www.lgbtqiahealtheducation.org/publication/neurodiversity-gender-diverse-youth-an-affirming-approach-to-care-2020/download

According to the CDC, the prevalence of autism spectrum disorders (ASD) has gone from roughly 1 in 68 children in 2010 to 1 in 36 children in 2020.¹ This is nearly a 50% increase over that 10-year period. Over the last several years, there has been evidence suggesting that increasing numbers of young people with ASD or other neurodivergent conditions identify as transgender or gender diverse.² Experts agree more careful attention must be paid to these patients.

UT Southwestern Medical Center

Clinical work with neurodivergent youth, especially those with ASD, can be complicated. This includes things such as difficulty with communication, possible concrete thinking, and obsessive interests. While earlier research has shown a higher incidence of ASD in those referred to specialized gender medical clinics, it is important to realize that not all of these youth are seeking medical care. They may be brought to the attention of a primary care pediatrician (PCP) if the child has discussed their gender identity at home. It is important that PCPs approach these young people with an open mind and address any coexisting mental health conditions. PCPs must be careful not to dismiss any gender identity concerns as another of the patient’s “obsessions”; rather, they should ensure the patient receives the appropriate mental health care that they need to explore these concerns. One challenge for PCPs is that there is a dearth of mental health professionals who have experience in working with young people who have both gender dysphoria and a neurodivergent condition.

For those clinicians who provide gender-affirming medical care to these young people, it is imperative that they have a thorough understanding of the patient’s gender identity and medical goals before starting any treatment. This may require extensive collaboration with the patient’s mental health provider. The clinician providing medical care may also choose to proceed slower with the introduction of hormones and their subsequent dosing to allow the young person time to continue discussing their effects with their mental health provider. To help clinicians, Dr. John Strang and a multidisciplinary group of collaborators developed a set of guidelines for co-occurring ASD and gender dysphoria in adolescents.³ More recently, Dr. Strang and other collaborators have also developed a questionnaire that can be used by clinicians in the care of these patients.⁴ The goal of this questionnaire is to allow the young people to “communicate their experiences and needs in a report format attuned to common autistic thinking and communication styles.”

In summary, pediatricians and those who care for children and adolescents need to be aware of the increased association between those with ASD or other neurodivergent conditions and gender dysphoria. To ensure that these young people receive optimal care, it is important to connect them to experts (if possible) in coexisting ASD and gender dysphoria. If such experts are not readily available, the National LGBTQIA+ Health Education Center has developed a resource for providing an affirmative approach to care for these young people.⁵ While more research is needed to better understand young people with coexisting ASD (or other neurodivergent conditions), taking an individualized approach to their care can help ensure optimal outcomes.
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Data & Statistics on Autism Spectrum Disorder. https://www.cdc.gov/ncbddd/autism/data.html.

2. Glidden D et al. Gender dysphoria and autism spectrum disorder: A systematic review of the literature. Sex Med Rev. 2016;4(1):3-14. doi:10.1016/j.sxmr.2015.10.003.

3. Strang JF et al. Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol. 2018;47(1):105-15. doi:10.1080/15374416.2016.1228462.

4. Strang JF et. al. The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults. Autism Adulthood. 2023 Jun 1;5(2):175-90. doi: 10.1089/aut.2023.0002.

5. National LGBT Health Education Center. Neurodiversity & gender-diverse youth: An affirming approach to care 2020. https://www.lgbtqiahealtheducation.org/publication/neurodiversity-gender-diverse-youth-an-affirming-approach-to-care-2020/download

According to the CDC, the prevalence of autism spectrum disorders (ASD) has gone from roughly 1 in 68 children in 2010 to 1 in 36 children in 2020.¹ This is nearly a 50% increase over that 10-year period. Over the last several years, there has been evidence suggesting that increasing numbers of young people with ASD or other neurodivergent conditions identify as transgender or gender diverse.² Experts agree more careful attention must be paid to these patients.

UT Southwestern Medical Center

Clinical work with neurodivergent youth, especially those with ASD, can be complicated. This includes things such as difficulty with communication, possible concrete thinking, and obsessive interests. While earlier research has shown a higher incidence of ASD in those referred to specialized gender medical clinics, it is important to realize that not all of these youth are seeking medical care. They may be brought to the attention of a primary care pediatrician (PCP) if the child has discussed their gender identity at home. It is important that PCPs approach these young people with an open mind and address any coexisting mental health conditions. PCPs must be careful not to dismiss any gender identity concerns as another of the patient’s “obsessions”; rather, they should ensure the patient receives the appropriate mental health care that they need to explore these concerns. One challenge for PCPs is that there is a dearth of mental health professionals who have experience in working with young people who have both gender dysphoria and a neurodivergent condition.

For those clinicians who provide gender-affirming medical care to these young people, it is imperative that they have a thorough understanding of the patient’s gender identity and medical goals before starting any treatment. This may require extensive collaboration with the patient’s mental health provider. The clinician providing medical care may also choose to proceed slower with the introduction of hormones and their subsequent dosing to allow the young person time to continue discussing their effects with their mental health provider. To help clinicians, Dr. John Strang and a multidisciplinary group of collaborators developed a set of guidelines for co-occurring ASD and gender dysphoria in adolescents.³ More recently, Dr. Strang and other collaborators have also developed a questionnaire that can be used by clinicians in the care of these patients.⁴ The goal of this questionnaire is to allow the young people to “communicate their experiences and needs in a report format attuned to common autistic thinking and communication styles.”

In summary, pediatricians and those who care for children and adolescents need to be aware of the increased association between those with ASD or other neurodivergent conditions and gender dysphoria. To ensure that these young people receive optimal care, it is important to connect them to experts (if possible) in coexisting ASD and gender dysphoria. If such experts are not readily available, the National LGBTQIA+ Health Education Center has developed a resource for providing an affirmative approach to care for these young people.⁵ While more research is needed to better understand young people with coexisting ASD (or other neurodivergent conditions), taking an individualized approach to their care can help ensure optimal outcomes.
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Data & Statistics on Autism Spectrum Disorder. https://www.cdc.gov/ncbddd/autism/data.html.

2. Glidden D et al. Gender dysphoria and autism spectrum disorder: A systematic review of the literature. Sex Med Rev. 2016;4(1):3-14. doi:10.1016/j.sxmr.2015.10.003.

3. Strang JF et al. Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol. 2018;47(1):105-15. doi:10.1080/15374416.2016.1228462.

4. Strang JF et. al. The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults. Autism Adulthood. 2023 Jun 1;5(2):175-90. doi: 10.1089/aut.2023.0002.

5. National LGBT Health Education Center. Neurodiversity & gender-diverse youth: An affirming approach to care 2020. https://www.lgbtqiahealtheducation.org/publication/neurodiversity-gender-diverse-youth-an-affirming-approach-to-care-2020/download

Considerable hair regrowth can be achieved in children with alopecia areata with the use of a novel plant-based drug, according to research presented during the first late-breaking news session at the annual congress of the European Academy of Dermatology and Venereology.

In the RAAINBOW study, a greater mean relative improvement in the Severity of Alopecia Tool (SALT) scores at 24 weeks was recorded in children who had been treated topically with coacillium (22.9%) than in those who had received a topical placebo (–8.0%), with a significant 31% overall difference (P < .0001).

“Coacillium cutaneous solution was used for the first time for treatment of alopecia areata and also for the first time used in a pediatric population,” the presenting investigator Ulrike Blume-Peytavi, MD, said at the meeting.

“It’s well tolerated, and in fact what is interesting is, it has a durable response, even after treatment discontinuation,” added Dr. Blume-Peytavi, who is the deputy head of the department of dermatology, venereology and allergology at Charité-Universitätsmedizin Berlin.
 

Backing the botanical?

Paola Pasquali, MD, a dermatologist at Pius Hospital de Valls in Spain, who cochaired the session where the findings were presented, commented, “Thank you for showing that chocolate is great! I knew it. It is fantastic to see how chocolate is used.”

Dr. Pasquali was referring to the coacillium ingredient Theobroma cacao extract. The seeds of T. cacao, or the cocoa tree, are used to make various types of chocolate products. Theobroma cacao is one of four plant extracts that make up coacillium, the others being Allium cepa (onion), Citrus limon (lemon), and Paullinia cupana (guaraná, a source of caffeine).

The four plant extracts are classified as “generally regarded as safe” (GRAS), Dr. Blume-Peytavi observed, noting that the development of coacillium fell under the category of a prescription botanical drug as set out by the U.S. Food and Drug Administration or a herbal medicinal product as set out by the European Medicines Agency.

But how does it work?

The botanical’s mode of action of acting positively on hair follicle cycling and endothelial cell activation was called into question, however, by Emma Guttman-Yassky, MD, PhD, who was in the audience.

She asked, “So how do you explain that, after three large studies with topical JAK inhibitors that did not work actually in alopecia areata because it’s very hard to penetrate the scalp for a topical [drug], this one works?”

Dr. Guttman-Yassky, professor of dermatology and immunology at the Icahn School of Medicine at Mount Sinai, New York, added: “Looking at the ingredients, to me, it seems that it’s more like a DPCP [diphenylcyclopropenone]-like reaction.”

DPCP, which has been used to treat alopecia, purportedly works by stimulating the immune response to target the skin surface – causing an allergic reaction – rather than the hair follicle.

It’s an interesting question as to how a molecule penetrates the hair follicle, and it depends on the size of the molecule, Dr. Blume-Peytavi responded.

“We have done a lot of studies on follicular penetration, and we are quite aware that you need a certain size of the molecule,” she said. Between 14 and 200 nanometers appears to produce “the best penetrators,” she observed.

Dr. Blume-Peytavi commented that even after topical JAK inhibitors are applied, the molecules that penetrate do not remain in the local area for very long, yet still produce an inhibitory signaling effect.

No scalp irritation was seen in the trial, which suggests that coacillium is not working in the same way as DPCP, Dr. Blume-Peytavi countered.
 

Evaluating efficacy and safety: The RAAINBOW study

Dr. Blume-Peytavi acknowledged that JAK inhibitors were “a tremendous advance in treating severe and very severe alopecia areata,” but because of their benefit-to-risk ratio, there was still an unmet need for new treatments, particularly in children, in whom drug safety is of critical importance.

Having a drug that could be given safely and also have an effect early on in the disease, while it is still at a mild to moderate stage, would be of considerable value, Dr. Blume-Peytavi maintained.

The RAAINBOW study was a randomized, double-blind, phase 2/3 trial conducted at 12 sites in Germany and three other countries between March 2018 and March 2022 to evaluate the efficacy and safety of coacillium in the treatment of children and adolescents with moderate to severe alopecia areata.

In all, 62 children aged 2-18 years (mean age, 11 years) participated; 42 were treated twice daily with coacillium cutaneous solution 22.5% and 20 received placebo for 24 weeks. Treatment was then stopped, and participants followed for another 24 weeks off treatment to check for disease relapse, bringing the total study duration up to 48 weeks.

Baseline characteristics were “relatively comparable for severity,” Dr. Blume-Peytavi said. Most of the children had severe alopecia areata (57% for coacillium and 65% for placebo); the remainder had moderate disease (43% vs. 35%, respectively).

The average SALT scores at the start of treatment were 56 in the coacillium group and 62 in the placebo group, and a respective 44 and 61 at the end of 24 weeks’ treatment.

Perhaps the most important results, Dr. Blume-Peytavi said, was that at 48 weeks of follow-up, which was 24 weeks after treatment had been discontinued, the mean SALT scores were 29 for coacillium and 56 for placebo (P < .0001).

“You can see the improvement in the treated group is continuing even without treatment. However, the placebo group stays relatively about the same range,” she said.

Overall, 82% of patients treated with coacillium and 37% of those who received placebo experienced hair growth after treatment had stopped, and by week 48, a respective 46.7% vs. 9.1% had a SALT score of 20 or less, and 30.0% vs. 0% had a SALT score of 10 or less.

No safety concerns were raised, with no serious treatment-related reactions, no immunosuppressant-like reactions, and no steroidlike side effects.
 

Beyond the RAAINBOW

Larger studies are needed, Dr. Blume-Peytavi said. According to developer Legacy Healthcare’s website, coacillium cutaneous solution is not being developed just for childhood alopecia areata. It is also under investigation as a treatment for persistent chemotherapy-induced alopecia, atopic dermatitis, and psoriasis. In addition, an oral solution is being tested for cancer-related fatigue.

The study was funded by Legacy Healthcare. Dr. Blume-Peytavi has received research funding and acts as an advisor to the company, among others; four of the study’s coauthors are employees of the company. Dr. Pasquali and Dr. Guttman-Yassky were not involved in the study and had no relevant financial ties to disclose.

A version of this article first appeared on Medscape.com.

Considerable hair regrowth can be achieved in children with alopecia areata with the use of a novel plant-based drug, according to research presented during the first late-breaking news session at the annual congress of the European Academy of Dermatology and Venereology.

In the RAAINBOW study, a greater mean relative improvement in the Severity of Alopecia Tool (SALT) scores at 24 weeks was recorded in children who had been treated topically with coacillium (22.9%) than in those who had received a topical placebo (–8.0%), with a significant 31% overall difference (P < .0001).

“Coacillium cutaneous solution was used for the first time for treatment of alopecia areata and also for the first time used in a pediatric population,” the presenting investigator Ulrike Blume-Peytavi, MD, said at the meeting.

“It’s well tolerated, and in fact what is interesting is, it has a durable response, even after treatment discontinuation,” added Dr. Blume-Peytavi, who is the deputy head of the department of dermatology, venereology and allergology at Charité-Universitätsmedizin Berlin.
 

Backing the botanical?

Paola Pasquali, MD, a dermatologist at Pius Hospital de Valls in Spain, who cochaired the session where the findings were presented, commented, “Thank you for showing that chocolate is great! I knew it. It is fantastic to see how chocolate is used.”

Dr. Pasquali was referring to the coacillium ingredient Theobroma cacao extract. The seeds of T. cacao, or the cocoa tree, are used to make various types of chocolate products. Theobroma cacao is one of four plant extracts that make up coacillium, the others being Allium cepa (onion), Citrus limon (lemon), and Paullinia cupana (guaraná, a source of caffeine).

The four plant extracts are classified as “generally regarded as safe” (GRAS), Dr. Blume-Peytavi observed, noting that the development of coacillium fell under the category of a prescription botanical drug as set out by the U.S. Food and Drug Administration or a herbal medicinal product as set out by the European Medicines Agency.

But how does it work?

The botanical’s mode of action of acting positively on hair follicle cycling and endothelial cell activation was called into question, however, by Emma Guttman-Yassky, MD, PhD, who was in the audience.

She asked, “So how do you explain that, after three large studies with topical JAK inhibitors that did not work actually in alopecia areata because it’s very hard to penetrate the scalp for a topical [drug], this one works?”

Dr. Guttman-Yassky, professor of dermatology and immunology at the Icahn School of Medicine at Mount Sinai, New York, added: “Looking at the ingredients, to me, it seems that it’s more like a DPCP [diphenylcyclopropenone]-like reaction.”

DPCP, which has been used to treat alopecia, purportedly works by stimulating the immune response to target the skin surface – causing an allergic reaction – rather than the hair follicle.

It’s an interesting question as to how a molecule penetrates the hair follicle, and it depends on the size of the molecule, Dr. Blume-Peytavi responded.

“We have done a lot of studies on follicular penetration, and we are quite aware that you need a certain size of the molecule,” she said. Between 14 and 200 nanometers appears to produce “the best penetrators,” she observed.

Dr. Blume-Peytavi commented that even after topical JAK inhibitors are applied, the molecules that penetrate do not remain in the local area for very long, yet still produce an inhibitory signaling effect.

No scalp irritation was seen in the trial, which suggests that coacillium is not working in the same way as DPCP, Dr. Blume-Peytavi countered.
 

Evaluating efficacy and safety: The RAAINBOW study

Dr. Blume-Peytavi acknowledged that JAK inhibitors were “a tremendous advance in treating severe and very severe alopecia areata,” but because of their benefit-to-risk ratio, there was still an unmet need for new treatments, particularly in children, in whom drug safety is of critical importance.

Having a drug that could be given safely and also have an effect early on in the disease, while it is still at a mild to moderate stage, would be of considerable value, Dr. Blume-Peytavi maintained.

The RAAINBOW study was a randomized, double-blind, phase 2/3 trial conducted at 12 sites in Germany and three other countries between March 2018 and March 2022 to evaluate the efficacy and safety of coacillium in the treatment of children and adolescents with moderate to severe alopecia areata.

In all, 62 children aged 2-18 years (mean age, 11 years) participated; 42 were treated twice daily with coacillium cutaneous solution 22.5% and 20 received placebo for 24 weeks. Treatment was then stopped, and participants followed for another 24 weeks off treatment to check for disease relapse, bringing the total study duration up to 48 weeks.

Baseline characteristics were “relatively comparable for severity,” Dr. Blume-Peytavi said. Most of the children had severe alopecia areata (57% for coacillium and 65% for placebo); the remainder had moderate disease (43% vs. 35%, respectively).

The average SALT scores at the start of treatment were 56 in the coacillium group and 62 in the placebo group, and a respective 44 and 61 at the end of 24 weeks’ treatment.

Perhaps the most important results, Dr. Blume-Peytavi said, was that at 48 weeks of follow-up, which was 24 weeks after treatment had been discontinued, the mean SALT scores were 29 for coacillium and 56 for placebo (P < .0001).

“You can see the improvement in the treated group is continuing even without treatment. However, the placebo group stays relatively about the same range,” she said.

Overall, 82% of patients treated with coacillium and 37% of those who received placebo experienced hair growth after treatment had stopped, and by week 48, a respective 46.7% vs. 9.1% had a SALT score of 20 or less, and 30.0% vs. 0% had a SALT score of 10 or less.

No safety concerns were raised, with no serious treatment-related reactions, no immunosuppressant-like reactions, and no steroidlike side effects.
 

Beyond the RAAINBOW

Larger studies are needed, Dr. Blume-Peytavi said. According to developer Legacy Healthcare’s website, coacillium cutaneous solution is not being developed just for childhood alopecia areata. It is also under investigation as a treatment for persistent chemotherapy-induced alopecia, atopic dermatitis, and psoriasis. In addition, an oral solution is being tested for cancer-related fatigue.

The study was funded by Legacy Healthcare. Dr. Blume-Peytavi has received research funding and acts as an advisor to the company, among others; four of the study’s coauthors are employees of the company. Dr. Pasquali and Dr. Guttman-Yassky were not involved in the study and had no relevant financial ties to disclose.

A version of this article first appeared on Medscape.com.

Considerable hair regrowth can be achieved in children with alopecia areata with the use of a novel plant-based drug, according to research presented during the first late-breaking news session at the annual congress of the European Academy of Dermatology and Venereology.

In the RAAINBOW study, a greater mean relative improvement in the Severity of Alopecia Tool (SALT) scores at 24 weeks was recorded in children who had been treated topically with coacillium (22.9%) than in those who had received a topical placebo (–8.0%), with a significant 31% overall difference (P < .0001).

“Coacillium cutaneous solution was used for the first time for treatment of alopecia areata and also for the first time used in a pediatric population,” the presenting investigator Ulrike Blume-Peytavi, MD, said at the meeting.

“It’s well tolerated, and in fact what is interesting is, it has a durable response, even after treatment discontinuation,” added Dr. Blume-Peytavi, who is the deputy head of the department of dermatology, venereology and allergology at Charité-Universitätsmedizin Berlin.
 

Backing the botanical?

Paola Pasquali, MD, a dermatologist at Pius Hospital de Valls in Spain, who cochaired the session where the findings were presented, commented, “Thank you for showing that chocolate is great! I knew it. It is fantastic to see how chocolate is used.”

Dr. Pasquali was referring to the coacillium ingredient Theobroma cacao extract. The seeds of T. cacao, or the cocoa tree, are used to make various types of chocolate products. Theobroma cacao is one of four plant extracts that make up coacillium, the others being Allium cepa (onion), Citrus limon (lemon), and Paullinia cupana (guaraná, a source of caffeine).

The four plant extracts are classified as “generally regarded as safe” (GRAS), Dr. Blume-Peytavi observed, noting that the development of coacillium fell under the category of a prescription botanical drug as set out by the U.S. Food and Drug Administration or a herbal medicinal product as set out by the European Medicines Agency.

But how does it work?

The botanical’s mode of action of acting positively on hair follicle cycling and endothelial cell activation was called into question, however, by Emma Guttman-Yassky, MD, PhD, who was in the audience.

She asked, “So how do you explain that, after three large studies with topical JAK inhibitors that did not work actually in alopecia areata because it’s very hard to penetrate the scalp for a topical [drug], this one works?”

Dr. Guttman-Yassky, professor of dermatology and immunology at the Icahn School of Medicine at Mount Sinai, New York, added: “Looking at the ingredients, to me, it seems that it’s more like a DPCP [diphenylcyclopropenone]-like reaction.”

DPCP, which has been used to treat alopecia, purportedly works by stimulating the immune response to target the skin surface – causing an allergic reaction – rather than the hair follicle.

It’s an interesting question as to how a molecule penetrates the hair follicle, and it depends on the size of the molecule, Dr. Blume-Peytavi responded.

“We have done a lot of studies on follicular penetration, and we are quite aware that you need a certain size of the molecule,” she said. Between 14 and 200 nanometers appears to produce “the best penetrators,” she observed.

Dr. Blume-Peytavi commented that even after topical JAK inhibitors are applied, the molecules that penetrate do not remain in the local area for very long, yet still produce an inhibitory signaling effect.

No scalp irritation was seen in the trial, which suggests that coacillium is not working in the same way as DPCP, Dr. Blume-Peytavi countered.
 

Evaluating efficacy and safety: The RAAINBOW study

Dr. Blume-Peytavi acknowledged that JAK inhibitors were “a tremendous advance in treating severe and very severe alopecia areata,” but because of their benefit-to-risk ratio, there was still an unmet need for new treatments, particularly in children, in whom drug safety is of critical importance.

Having a drug that could be given safely and also have an effect early on in the disease, while it is still at a mild to moderate stage, would be of considerable value, Dr. Blume-Peytavi maintained.

The RAAINBOW study was a randomized, double-blind, phase 2/3 trial conducted at 12 sites in Germany and three other countries between March 2018 and March 2022 to evaluate the efficacy and safety of coacillium in the treatment of children and adolescents with moderate to severe alopecia areata.

In all, 62 children aged 2-18 years (mean age, 11 years) participated; 42 were treated twice daily with coacillium cutaneous solution 22.5% and 20 received placebo for 24 weeks. Treatment was then stopped, and participants followed for another 24 weeks off treatment to check for disease relapse, bringing the total study duration up to 48 weeks.

Baseline characteristics were “relatively comparable for severity,” Dr. Blume-Peytavi said. Most of the children had severe alopecia areata (57% for coacillium and 65% for placebo); the remainder had moderate disease (43% vs. 35%, respectively).

The average SALT scores at the start of treatment were 56 in the coacillium group and 62 in the placebo group, and a respective 44 and 61 at the end of 24 weeks’ treatment.

Perhaps the most important results, Dr. Blume-Peytavi said, was that at 48 weeks of follow-up, which was 24 weeks after treatment had been discontinued, the mean SALT scores were 29 for coacillium and 56 for placebo (P < .0001).

“You can see the improvement in the treated group is continuing even without treatment. However, the placebo group stays relatively about the same range,” she said.

Overall, 82% of patients treated with coacillium and 37% of those who received placebo experienced hair growth after treatment had stopped, and by week 48, a respective 46.7% vs. 9.1% had a SALT score of 20 or less, and 30.0% vs. 0% had a SALT score of 10 or less.

No safety concerns were raised, with no serious treatment-related reactions, no immunosuppressant-like reactions, and no steroidlike side effects.
 

Beyond the RAAINBOW

Larger studies are needed, Dr. Blume-Peytavi said. According to developer Legacy Healthcare’s website, coacillium cutaneous solution is not being developed just for childhood alopecia areata. It is also under investigation as a treatment for persistent chemotherapy-induced alopecia, atopic dermatitis, and psoriasis. In addition, an oral solution is being tested for cancer-related fatigue.

The study was funded by Legacy Healthcare. Dr. Blume-Peytavi has received research funding and acts as an advisor to the company, among others; four of the study’s coauthors are employees of the company. Dr. Pasquali and Dr. Guttman-Yassky were not involved in the study and had no relevant financial ties to disclose.

A version of this article first appeared on Medscape.com.

The newly approved respiratory syncytial virus vaccine administered during pregnancy substantially reduces the clinical and economic burden of lower respiratory tract disease caused by RSV, according to research presented at an annual scientific meeting on infectious diseases.

“With RSV maternal vaccination that is associated with clinical efficacy of 69% against severe RSV disease at 6 months, we estimated that up to 200,000 cases can be averted, and that is associated with almost $800 million in total,” presenting author Amy W. Law, PharmD, director of global value and evidence at Pfizer, pointed out during a news briefing.

“RSV is associated with a significant burden in the U.S. and this newly approved and recommended maternal RSV vaccine can have substantial impact in easing some of that burden,” Dr. Law explained.

This study is “particularly timely as we head into RSV peak season,” said briefing moderator Natasha Halasa, MD, MPH, professor of pediatrics, division of pediatric infectious diseases at Vanderbilt University, Nashville, Tenn.

The challenge, said Dr. Halasa, is that uptake of maternal vaccines and vaccines in general is “not optimal,” making increased awareness of this new maternal RSV vaccine important.
 

Strong efficacy data

Most children are infected with RSV at least once by the time they reach age 2 years. Very young children are at particular risk of severe complications, such as pneumonia or bronchitis.

As reported previously by this news organization, in the randomized, double-blind, placebo-controlled phase 3 study, Pfizer’s maternal RSV vaccine had an almost 82% efficacy against severe RSV infection in infants from birth through the first 90 days of life.

The vaccine also had a 69% efficacy against severe disease through the first 6 months of life. As part of the trial, a total of 7,400 women received a single dose of the vaccine in the late second or third trimester of their pregnancy. There were no signs of safety issues for the mothers or infants.

Based on the results, the U.S. Food and Drug Administration approved the vaccine, known as Abrysvo, in August, to be given between weeks 32 and 36 of pregnancy.
 

New modeling study

Dr. Law and colleagues modeled the potential public health impact – both clinical and economic – of the maternal RSV vaccine among the population of all pregnant women and their infants born during a 12-month period in the United States. The model focused on severe RSV disease in babies that required medical attention.

According to their model, without widespread use of the maternal RSV vaccine, 48,246 hospitalizations, 144,495 emergency department encounters, and 399,313 outpatient clinic visits related to RSV are projected to occur annually among the U.S. birth cohort of 3.7 million infants younger than 12 months.

With widespread use of the vaccine, annual hospitalizations resulting from infant RSV would fall by 51%, emergency department encounters would decline by 32%, and outpatient clinic visits by 32% – corresponding to a decrease in direct medical costs of about $692 million and indirect nonmedical costs of roughly $110 million.

Dr. Law highlighted two important caveats to the data. “The protections are based on the year-round administration of the vaccine to pregnant women at 32 to 36 weeks’ gestational age, and this is also assuming 100% uptake. Of course, in reality, that most likely is not the case,” she told the briefing.

Dr. Halasa noted that the peak age for severe RSV illness is 3 months and it’s tough to identify infants at highest risk for severe RSV.

Nearly 80% of infants with RSV who are hospitalized do not have an underlying medical condition, “so we don’t even know who those high-risk infants are. That’s why having this vaccine is so exciting,” she told the briefing.

Dr. Halasa said it’s also important to note that infants with severe RSV typically make not just one but multiple visits to the clinic or emergency department, leading to missed days of work for the parent, not to mention the “emotional burden of having your otherwise healthy newborn or young infant in the hospital.”

In addition to Pfizer’s maternal RSV vaccine, the FDA in July approved AstraZeneca’s monoclonal antibody nirsevimab (Beyfortus) for the prevention of RSV in neonates and infants entering their first RSV season, and in children up to 24 months who remain vulnerable to severe RSV disease through their second RSV season.

The study was funded by Pfizer. Dr. Law is employed by Pfizer. Dr. Halasa has received grant and research support from Merck.

A version of this article first appeared on Medscape.com.

The newly approved respiratory syncytial virus vaccine administered during pregnancy substantially reduces the clinical and economic burden of lower respiratory tract disease caused by RSV, according to research presented at an annual scientific meeting on infectious diseases.

“With RSV maternal vaccination that is associated with clinical efficacy of 69% against severe RSV disease at 6 months, we estimated that up to 200,000 cases can be averted, and that is associated with almost $800 million in total,” presenting author Amy W. Law, PharmD, director of global value and evidence at Pfizer, pointed out during a news briefing.

“RSV is associated with a significant burden in the U.S. and this newly approved and recommended maternal RSV vaccine can have substantial impact in easing some of that burden,” Dr. Law explained.

This study is “particularly timely as we head into RSV peak season,” said briefing moderator Natasha Halasa, MD, MPH, professor of pediatrics, division of pediatric infectious diseases at Vanderbilt University, Nashville, Tenn.

The challenge, said Dr. Halasa, is that uptake of maternal vaccines and vaccines in general is “not optimal,” making increased awareness of this new maternal RSV vaccine important.
 

Strong efficacy data

Most children are infected with RSV at least once by the time they reach age 2 years. Very young children are at particular risk of severe complications, such as pneumonia or bronchitis.

As reported previously by this news organization, in the randomized, double-blind, placebo-controlled phase 3 study, Pfizer’s maternal RSV vaccine had an almost 82% efficacy against severe RSV infection in infants from birth through the first 90 days of life.

The vaccine also had a 69% efficacy against severe disease through the first 6 months of life. As part of the trial, a total of 7,400 women received a single dose of the vaccine in the late second or third trimester of their pregnancy. There were no signs of safety issues for the mothers or infants.

Based on the results, the U.S. Food and Drug Administration approved the vaccine, known as Abrysvo, in August, to be given between weeks 32 and 36 of pregnancy.
 

New modeling study

Dr. Law and colleagues modeled the potential public health impact – both clinical and economic – of the maternal RSV vaccine among the population of all pregnant women and their infants born during a 12-month period in the United States. The model focused on severe RSV disease in babies that required medical attention.

According to their model, without widespread use of the maternal RSV vaccine, 48,246 hospitalizations, 144,495 emergency department encounters, and 399,313 outpatient clinic visits related to RSV are projected to occur annually among the U.S. birth cohort of 3.7 million infants younger than 12 months.

With widespread use of the vaccine, annual hospitalizations resulting from infant RSV would fall by 51%, emergency department encounters would decline by 32%, and outpatient clinic visits by 32% – corresponding to a decrease in direct medical costs of about $692 million and indirect nonmedical costs of roughly $110 million.

Dr. Law highlighted two important caveats to the data. “The protections are based on the year-round administration of the vaccine to pregnant women at 32 to 36 weeks’ gestational age, and this is also assuming 100% uptake. Of course, in reality, that most likely is not the case,” she told the briefing.

Dr. Halasa noted that the peak age for severe RSV illness is 3 months and it’s tough to identify infants at highest risk for severe RSV.

Nearly 80% of infants with RSV who are hospitalized do not have an underlying medical condition, “so we don’t even know who those high-risk infants are. That’s why having this vaccine is so exciting,” she told the briefing.

Dr. Halasa said it’s also important to note that infants with severe RSV typically make not just one but multiple visits to the clinic or emergency department, leading to missed days of work for the parent, not to mention the “emotional burden of having your otherwise healthy newborn or young infant in the hospital.”

In addition to Pfizer’s maternal RSV vaccine, the FDA in July approved AstraZeneca’s monoclonal antibody nirsevimab (Beyfortus) for the prevention of RSV in neonates and infants entering their first RSV season, and in children up to 24 months who remain vulnerable to severe RSV disease through their second RSV season.

The study was funded by Pfizer. Dr. Law is employed by Pfizer. Dr. Halasa has received grant and research support from Merck.

A version of this article first appeared on Medscape.com.

The newly approved respiratory syncytial virus vaccine administered during pregnancy substantially reduces the clinical and economic burden of lower respiratory tract disease caused by RSV, according to research presented at an annual scientific meeting on infectious diseases.

“With RSV maternal vaccination that is associated with clinical efficacy of 69% against severe RSV disease at 6 months, we estimated that up to 200,000 cases can be averted, and that is associated with almost $800 million in total,” presenting author Amy W. Law, PharmD, director of global value and evidence at Pfizer, pointed out during a news briefing.

“RSV is associated with a significant burden in the U.S. and this newly approved and recommended maternal RSV vaccine can have substantial impact in easing some of that burden,” Dr. Law explained.

This study is “particularly timely as we head into RSV peak season,” said briefing moderator Natasha Halasa, MD, MPH, professor of pediatrics, division of pediatric infectious diseases at Vanderbilt University, Nashville, Tenn.

The challenge, said Dr. Halasa, is that uptake of maternal vaccines and vaccines in general is “not optimal,” making increased awareness of this new maternal RSV vaccine important.
 

Strong efficacy data

Most children are infected with RSV at least once by the time they reach age 2 years. Very young children are at particular risk of severe complications, such as pneumonia or bronchitis.

As reported previously by this news organization, in the randomized, double-blind, placebo-controlled phase 3 study, Pfizer’s maternal RSV vaccine had an almost 82% efficacy against severe RSV infection in infants from birth through the first 90 days of life.

The vaccine also had a 69% efficacy against severe disease through the first 6 months of life. As part of the trial, a total of 7,400 women received a single dose of the vaccine in the late second or third trimester of their pregnancy. There were no signs of safety issues for the mothers or infants.

Based on the results, the U.S. Food and Drug Administration approved the vaccine, known as Abrysvo, in August, to be given between weeks 32 and 36 of pregnancy.
 

New modeling study

Dr. Law and colleagues modeled the potential public health impact – both clinical and economic – of the maternal RSV vaccine among the population of all pregnant women and their infants born during a 12-month period in the United States. The model focused on severe RSV disease in babies that required medical attention.

According to their model, without widespread use of the maternal RSV vaccine, 48,246 hospitalizations, 144,495 emergency department encounters, and 399,313 outpatient clinic visits related to RSV are projected to occur annually among the U.S. birth cohort of 3.7 million infants younger than 12 months.

With widespread use of the vaccine, annual hospitalizations resulting from infant RSV would fall by 51%, emergency department encounters would decline by 32%, and outpatient clinic visits by 32% – corresponding to a decrease in direct medical costs of about $692 million and indirect nonmedical costs of roughly $110 million.

Dr. Law highlighted two important caveats to the data. “The protections are based on the year-round administration of the vaccine to pregnant women at 32 to 36 weeks’ gestational age, and this is also assuming 100% uptake. Of course, in reality, that most likely is not the case,” she told the briefing.

Dr. Halasa noted that the peak age for severe RSV illness is 3 months and it’s tough to identify infants at highest risk for severe RSV.

Nearly 80% of infants with RSV who are hospitalized do not have an underlying medical condition, “so we don’t even know who those high-risk infants are. That’s why having this vaccine is so exciting,” she told the briefing.

Dr. Halasa said it’s also important to note that infants with severe RSV typically make not just one but multiple visits to the clinic or emergency department, leading to missed days of work for the parent, not to mention the “emotional burden of having your otherwise healthy newborn or young infant in the hospital.”

In addition to Pfizer’s maternal RSV vaccine, the FDA in July approved AstraZeneca’s monoclonal antibody nirsevimab (Beyfortus) for the prevention of RSV in neonates and infants entering their first RSV season, and in children up to 24 months who remain vulnerable to severe RSV disease through their second RSV season.

The study was funded by Pfizer. Dr. Law is employed by Pfizer. Dr. Halasa has received grant and research support from Merck.

A version of this article first appeared on Medscape.com.

New guidelines on determining brain death offer the first updated recommendations in more than a decade for adult and pediatric patients.

The consensus practice guideline on brain death, also known as death by neurologic criteria (BD/DNC), was developed by a panel of 20 experts from different specialties, institutions, and medical societies.

As with previous guidelines, the updated version stipulates that brain death should be declared when a patient with a known cause of catastrophic brain injury has permanent loss of function of the brain, including the brain stem, which results in coma, brain stem areflexia, and apnea in the setting of an adequate stimulus.

But the updated version also clarifies questions on neurological examinations and apnea testing and offers new guidance on pre-evaluation targets for blood pressure and body temperature and evaluating brain death in patients who are pregnant, are on extracorporeal membrane oxygenation, or have an injury to the base of the brain.

Also, for the first time, the guidance clarifies that clinicians don’t need to obtain consent before performing a brain death evaluation, unless institutional policy, state laws, or regulations stipulate otherwise.

“The 2023 guidelines will be considered the standard of care in the U.S.,” lead author David M. Greer, MD, chair and chief of neurology, Boston University, and chief of neurology, Boston Medical Center, said in an interview. “Each hospital in the U.S. is responsible for its own policy for BD/DNC determination, and our hope is that they will quickly revise their policies in accordance with this new national standard.”

The guidelines, which are accompanied by a three-page checklist and a free digital app, were published online in Neurology.
 

Four years in the making

Work on the 85 recommendations in the new report began more than 4 years ago as a collaborative effort by the American Academy of Neurology, the American Academy of Pediatrics, the Child Neurology Society, and the Society of Critical Care Medicine.

A lack of high-quality evidence on brain death determination led panelists to devise an evidence-informed formal consensus process to develop the guidelines, which involved three rounds of anonymous voting on each recommendation and the rationales behind them.

The strength of each recommendation was based on the level of consensus reached through voting, with Level A denoting a recommendation that “must” be followed, Level B one that “should” be followed, and Level C one that “may” be followed.

The majority of recommendations received an A or B rating. Only one recommendation, about whether a second clinical exam is needed in adults, garnered a C rating.

In children, the guidelines recommend that clinicians must perform two clinical examinations and two apnea tests 12 hours apart. In adults, only one exam is required. Both of those recommendations were rated Level A. A recommendation for a second exam in adults received the single Level C rating.
 

A uniform set of guidelines?

The new guidelines replace adult practice guidance published by AAN in 2010 and guideline for infants and children released in 2011 by AAP, CNS, and SCCM, and for the first time combine brain death guidelines for adult and pediatric patients into one document.

“It is important for clinicians to review the new guideline carefully and ensure their hospital brain death guidelines are updated to be consistent with the new guideline in order to prevent inaccurate determinations of death,” guidelines coauthor Ariane Lewis, MD, NYU Langone Health, New York, said in an interview.

The 1981 Uniform Determination of Death Act (UDDA) is the legal foundation for the declaration of BD/DNC in the United States, but it only stipulates that brain death determination must be made in accordance with accepted medical standards.

There is no single national standard, and states and hospitals are free to adopt their own, which many have done. One goal of the new guidelines was to create a uniform set of guidelines that all institutions follow.

“This is a step toward having a set of guidelines that are accepted by most of the societies and clinical specialties involved in this sort of diagnosis,” that could lead to a national-level policy, Fernando Goldenberg, MD, professor of neurology and director of neuroscience critical care, University of Chicago Medicine, said in an interview.

Dr. Goldenberg was not part of the panel that developed the updated guidelines, but was a coauthor of a consensus statement from the World Brain Death Project in 2020.

Developing a singular global guideline for brain death determination is unlikely, Dr. Goldenberg said. Policies vary widely across the world, and some countries don’t even recognize brain death.

“But this attempts to unify things at the U.S. level, which is very important,” he said.
 

Permanent vs. irreversible

Dr. Goldenberg said that combining adult and pediatric guidelines into one document will be very helpful for clinicians like him who treat patients from age 16 years and up.

The expanded guidance on apnea testing, recommendations on specific ancillary tests to use or avoid, and inclusion of language stipulating that prior consent is not needed to perform a brain death evaluation are also useful.

He also noted that the section on credentialing and training of clinicians who perform BD/DNC evaluations recognizes advanced practice providers, the first time he recalls seeing these professionals included in brain death guidelines.

However, the panel’s decision to use the term “permanent” to describe loss of brain function instead of “irreversible” gave Dr. Goldenberg pause.

The UDDA provides that an individual is declared legally dead when “circulatory and respiratory functions irreversibly stop; or all functions of the entire brain, including the brain stem, irreversibly stop.”

Earlier in October, the American College of Physicians released a position paper on cardiorespiratory death determination that called for a revision of the UDDA language.

The ACP suggested that “irreversibly” be replaced with “permanently” with regard to the cessation of circulatory and respiratory functions, but that “irreversible” be kept in the description of brain death.

“Permanent means that there is damage that is potentially reversible and irreversible means that the damage is so profound, it cannot be reversed even if an attempt to do so is performed,” Dr. Goldenberg said.

Even though the World Brain Death Project, on which he worked, also used “permanent” to describe brain function loss, Dr. Goldenberg said he aligns with ACP’s position.

“The understanding of brain death is that the damage is so profound, it is irreversible, even if you were to try,” he said. “Therefore, I think that the most appropriate term for brain death should be irreversible as opposed to permanent.”

The report was funded by the American Academy of Neurology. Dr. Greer has received travel funding from Boston University; serves as editor-in-chief for Seminars in Neurology; receives publishing royalties for 50 Studies Every Neurologist Should Know and Successful Leadership in Academic Medicine; has received honoraria from AAN; has received research funding from Becton, Dickinson, and Company; and has served as expert witness in legal proceedings. Dr. Lewis has received honoraria from AAN and Neurodiem, serves as Neurology deputy editor of disputes and debates, and serves as deputy editor of seminars in Neurology. Dr. Goldenberg reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

New guidelines on determining brain death offer the first updated recommendations in more than a decade for adult and pediatric patients.

The consensus practice guideline on brain death, also known as death by neurologic criteria (BD/DNC), was developed by a panel of 20 experts from different specialties, institutions, and medical societies.

As with previous guidelines, the updated version stipulates that brain death should be declared when a patient with a known cause of catastrophic brain injury has permanent loss of function of the brain, including the brain stem, which results in coma, brain stem areflexia, and apnea in the setting of an adequate stimulus.

But the updated version also clarifies questions on neurological examinations and apnea testing and offers new guidance on pre-evaluation targets for blood pressure and body temperature and evaluating brain death in patients who are pregnant, are on extracorporeal membrane oxygenation, or have an injury to the base of the brain.

Also, for the first time, the guidance clarifies that clinicians don’t need to obtain consent before performing a brain death evaluation, unless institutional policy, state laws, or regulations stipulate otherwise.

“The 2023 guidelines will be considered the standard of care in the U.S.,” lead author David M. Greer, MD, chair and chief of neurology, Boston University, and chief of neurology, Boston Medical Center, said in an interview. “Each hospital in the U.S. is responsible for its own policy for BD/DNC determination, and our hope is that they will quickly revise their policies in accordance with this new national standard.”

The guidelines, which are accompanied by a three-page checklist and a free digital app, were published online in Neurology.
 

Four years in the making

Work on the 85 recommendations in the new report began more than 4 years ago as a collaborative effort by the American Academy of Neurology, the American Academy of Pediatrics, the Child Neurology Society, and the Society of Critical Care Medicine.

A lack of high-quality evidence on brain death determination led panelists to devise an evidence-informed formal consensus process to develop the guidelines, which involved three rounds of anonymous voting on each recommendation and the rationales behind them.

The strength of each recommendation was based on the level of consensus reached through voting, with Level A denoting a recommendation that “must” be followed, Level B one that “should” be followed, and Level C one that “may” be followed.

The majority of recommendations received an A or B rating. Only one recommendation, about whether a second clinical exam is needed in adults, garnered a C rating.

In children, the guidelines recommend that clinicians must perform two clinical examinations and two apnea tests 12 hours apart. In adults, only one exam is required. Both of those recommendations were rated Level A. A recommendation for a second exam in adults received the single Level C rating.
 

A uniform set of guidelines?

The new guidelines replace adult practice guidance published by AAN in 2010 and guideline for infants and children released in 2011 by AAP, CNS, and SCCM, and for the first time combine brain death guidelines for adult and pediatric patients into one document.

“It is important for clinicians to review the new guideline carefully and ensure their hospital brain death guidelines are updated to be consistent with the new guideline in order to prevent inaccurate determinations of death,” guidelines coauthor Ariane Lewis, MD, NYU Langone Health, New York, said in an interview.

The 1981 Uniform Determination of Death Act (UDDA) is the legal foundation for the declaration of BD/DNC in the United States, but it only stipulates that brain death determination must be made in accordance with accepted medical standards.

There is no single national standard, and states and hospitals are free to adopt their own, which many have done. One goal of the new guidelines was to create a uniform set of guidelines that all institutions follow.

“This is a step toward having a set of guidelines that are accepted by most of the societies and clinical specialties involved in this sort of diagnosis,” that could lead to a national-level policy, Fernando Goldenberg, MD, professor of neurology and director of neuroscience critical care, University of Chicago Medicine, said in an interview.

Dr. Goldenberg was not part of the panel that developed the updated guidelines, but was a coauthor of a consensus statement from the World Brain Death Project in 2020.

Developing a singular global guideline for brain death determination is unlikely, Dr. Goldenberg said. Policies vary widely across the world, and some countries don’t even recognize brain death.

“But this attempts to unify things at the U.S. level, which is very important,” he said.
 

Permanent vs. irreversible

Dr. Goldenberg said that combining adult and pediatric guidelines into one document will be very helpful for clinicians like him who treat patients from age 16 years and up.

The expanded guidance on apnea testing, recommendations on specific ancillary tests to use or avoid, and inclusion of language stipulating that prior consent is not needed to perform a brain death evaluation are also useful.

He also noted that the section on credentialing and training of clinicians who perform BD/DNC evaluations recognizes advanced practice providers, the first time he recalls seeing these professionals included in brain death guidelines.

However, the panel’s decision to use the term “permanent” to describe loss of brain function instead of “irreversible” gave Dr. Goldenberg pause.

The UDDA provides that an individual is declared legally dead when “circulatory and respiratory functions irreversibly stop; or all functions of the entire brain, including the brain stem, irreversibly stop.”

Earlier in October, the American College of Physicians released a position paper on cardiorespiratory death determination that called for a revision of the UDDA language.

The ACP suggested that “irreversibly” be replaced with “permanently” with regard to the cessation of circulatory and respiratory functions, but that “irreversible” be kept in the description of brain death.

“Permanent means that there is damage that is potentially reversible and irreversible means that the damage is so profound, it cannot be reversed even if an attempt to do so is performed,” Dr. Goldenberg said.

Even though the World Brain Death Project, on which he worked, also used “permanent” to describe brain function loss, Dr. Goldenberg said he aligns with ACP’s position.

“The understanding of brain death is that the damage is so profound, it is irreversible, even if you were to try,” he said. “Therefore, I think that the most appropriate term for brain death should be irreversible as opposed to permanent.”

The report was funded by the American Academy of Neurology. Dr. Greer has received travel funding from Boston University; serves as editor-in-chief for Seminars in Neurology; receives publishing royalties for 50 Studies Every Neurologist Should Know and Successful Leadership in Academic Medicine; has received honoraria from AAN; has received research funding from Becton, Dickinson, and Company; and has served as expert witness in legal proceedings. Dr. Lewis has received honoraria from AAN and Neurodiem, serves as Neurology deputy editor of disputes and debates, and serves as deputy editor of seminars in Neurology. Dr. Goldenberg reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

New guidelines on determining brain death offer the first updated recommendations in more than a decade for adult and pediatric patients.

The consensus practice guideline on brain death, also known as death by neurologic criteria (BD/DNC), was developed by a panel of 20 experts from different specialties, institutions, and medical societies.

As with previous guidelines, the updated version stipulates that brain death should be declared when a patient with a known cause of catastrophic brain injury has permanent loss of function of the brain, including the brain stem, which results in coma, brain stem areflexia, and apnea in the setting of an adequate stimulus.

But the updated version also clarifies questions on neurological examinations and apnea testing and offers new guidance on pre-evaluation targets for blood pressure and body temperature and evaluating brain death in patients who are pregnant, are on extracorporeal membrane oxygenation, or have an injury to the base of the brain.

Also, for the first time, the guidance clarifies that clinicians don’t need to obtain consent before performing a brain death evaluation, unless institutional policy, state laws, or regulations stipulate otherwise.

“The 2023 guidelines will be considered the standard of care in the U.S.,” lead author David M. Greer, MD, chair and chief of neurology, Boston University, and chief of neurology, Boston Medical Center, said in an interview. “Each hospital in the U.S. is responsible for its own policy for BD/DNC determination, and our hope is that they will quickly revise their policies in accordance with this new national standard.”

The guidelines, which are accompanied by a three-page checklist and a free digital app, were published online in Neurology.
 

Four years in the making

Work on the 85 recommendations in the new report began more than 4 years ago as a collaborative effort by the American Academy of Neurology, the American Academy of Pediatrics, the Child Neurology Society, and the Society of Critical Care Medicine.

A lack of high-quality evidence on brain death determination led panelists to devise an evidence-informed formal consensus process to develop the guidelines, which involved three rounds of anonymous voting on each recommendation and the rationales behind them.

The strength of each recommendation was based on the level of consensus reached through voting, with Level A denoting a recommendation that “must” be followed, Level B one that “should” be followed, and Level C one that “may” be followed.

The majority of recommendations received an A or B rating. Only one recommendation, about whether a second clinical exam is needed in adults, garnered a C rating.

In children, the guidelines recommend that clinicians must perform two clinical examinations and two apnea tests 12 hours apart. In adults, only one exam is required. Both of those recommendations were rated Level A. A recommendation for a second exam in adults received the single Level C rating.
 

A uniform set of guidelines?

The new guidelines replace adult practice guidance published by AAN in 2010 and guideline for infants and children released in 2011 by AAP, CNS, and SCCM, and for the first time combine brain death guidelines for adult and pediatric patients into one document.

“It is important for clinicians to review the new guideline carefully and ensure their hospital brain death guidelines are updated to be consistent with the new guideline in order to prevent inaccurate determinations of death,” guidelines coauthor Ariane Lewis, MD, NYU Langone Health, New York, said in an interview.

The 1981 Uniform Determination of Death Act (UDDA) is the legal foundation for the declaration of BD/DNC in the United States, but it only stipulates that brain death determination must be made in accordance with accepted medical standards.

There is no single national standard, and states and hospitals are free to adopt their own, which many have done. One goal of the new guidelines was to create a uniform set of guidelines that all institutions follow.

“This is a step toward having a set of guidelines that are accepted by most of the societies and clinical specialties involved in this sort of diagnosis,” that could lead to a national-level policy, Fernando Goldenberg, MD, professor of neurology and director of neuroscience critical care, University of Chicago Medicine, said in an interview.

Dr. Goldenberg was not part of the panel that developed the updated guidelines, but was a coauthor of a consensus statement from the World Brain Death Project in 2020.

Developing a singular global guideline for brain death determination is unlikely, Dr. Goldenberg said. Policies vary widely across the world, and some countries don’t even recognize brain death.

“But this attempts to unify things at the U.S. level, which is very important,” he said.
 

Permanent vs. irreversible

Dr. Goldenberg said that combining adult and pediatric guidelines into one document will be very helpful for clinicians like him who treat patients from age 16 years and up.

The expanded guidance on apnea testing, recommendations on specific ancillary tests to use or avoid, and inclusion of language stipulating that prior consent is not needed to perform a brain death evaluation are also useful.

He also noted that the section on credentialing and training of clinicians who perform BD/DNC evaluations recognizes advanced practice providers, the first time he recalls seeing these professionals included in brain death guidelines.

However, the panel’s decision to use the term “permanent” to describe loss of brain function instead of “irreversible” gave Dr. Goldenberg pause.

The UDDA provides that an individual is declared legally dead when “circulatory and respiratory functions irreversibly stop; or all functions of the entire brain, including the brain stem, irreversibly stop.”

Earlier in October, the American College of Physicians released a position paper on cardiorespiratory death determination that called for a revision of the UDDA language.

The ACP suggested that “irreversibly” be replaced with “permanently” with regard to the cessation of circulatory and respiratory functions, but that “irreversible” be kept in the description of brain death.

“Permanent means that there is damage that is potentially reversible and irreversible means that the damage is so profound, it cannot be reversed even if an attempt to do so is performed,” Dr. Goldenberg said.

Even though the World Brain Death Project, on which he worked, also used “permanent” to describe brain function loss, Dr. Goldenberg said he aligns with ACP’s position.

“The understanding of brain death is that the damage is so profound, it is irreversible, even if you were to try,” he said. “Therefore, I think that the most appropriate term for brain death should be irreversible as opposed to permanent.”

The report was funded by the American Academy of Neurology. Dr. Greer has received travel funding from Boston University; serves as editor-in-chief for Seminars in Neurology; receives publishing royalties for 50 Studies Every Neurologist Should Know and Successful Leadership in Academic Medicine; has received honoraria from AAN; has received research funding from Becton, Dickinson, and Company; and has served as expert witness in legal proceedings. Dr. Lewis has received honoraria from AAN and Neurodiem, serves as Neurology deputy editor of disputes and debates, and serves as deputy editor of seminars in Neurology. Dr. Goldenberg reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

TOPLINE:

Noninvasive three-dimensional (3D) stereophotogrammetry may be a valuable adjunctive tool to detect progression of craniofacial morphea (CM) over time.

METHODOLOGY:

• Existing tools that detect disease progression in patients with CM are limited.
• In a prospective cohort study, researchers evaluated the use of 3-D stereophotogrammetry, a noninvasive, radiation-free imaging modality, to detect disease progression in 27 consecutive patients with CM seen at Boston Children’s Hospital and Brigham and Women’s Hospital from April 1, 2019, to March 1, 2023.
• After clinical and 3-D stereophotogrammetry assessments were performed at 2- to 12-month intervals, the 3-D images were rated by an expert (a board-certified plastic craniofacial surgeon) and a nonexpert (a board-certified dermatologist) as demonstrating progression or no progression.
• Kappa coefficients were used to calculate inter-rater reliability.

TAKEAWAY:

• Most of the study participants (73%) were female, their median age was 14 years (range, 5-40 years), and each underwent 3-D stereophotogrammetry imaging at least two times spaced a median of 3 months apart.
• On the basis of clinical assessments during the 48-month study period, 10 patients (37%) experienced progression of their disease.
• 3-D stereophotogrammetry not only corroborated clinical impressions of disease progression with strong inter-rater reliability (kappa = 0.80; 95% confidence interval, 0.61-0.99), but it also detected occult progression of asymmetry not noted on clinical examination in three additional patients.
• In subgroup analyses, assessment of 3-D images demonstrated substantial to near-perfect inter-rater reliability in patients with Fitzpatrick skin types IV-VI.

IN PRACTICE:

“Further work is necessary to validate this measure in a larger cohort and to guide its incorporation into medical decision-making for patients with CM,” the researchers wrote.

SOURCE:

Katharina S. Shaw, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, led the research. The study was published online in JAMA Dermatology.

LIMITATIONS:

The sample was small, and a criterion standard for assessing CM was lacking.

DISCLOSURES:

The researchers reported having no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Noninvasive three-dimensional (3D) stereophotogrammetry may be a valuable adjunctive tool to detect progression of craniofacial morphea (CM) over time.

METHODOLOGY:

• Existing tools that detect disease progression in patients with CM are limited.
• In a prospective cohort study, researchers evaluated the use of 3-D stereophotogrammetry, a noninvasive, radiation-free imaging modality, to detect disease progression in 27 consecutive patients with CM seen at Boston Children’s Hospital and Brigham and Women’s Hospital from April 1, 2019, to March 1, 2023.
• After clinical and 3-D stereophotogrammetry assessments were performed at 2- to 12-month intervals, the 3-D images were rated by an expert (a board-certified plastic craniofacial surgeon) and a nonexpert (a board-certified dermatologist) as demonstrating progression or no progression.
• Kappa coefficients were used to calculate inter-rater reliability.

TAKEAWAY:

• Most of the study participants (73%) were female, their median age was 14 years (range, 5-40 years), and each underwent 3-D stereophotogrammetry imaging at least two times spaced a median of 3 months apart.
• On the basis of clinical assessments during the 48-month study period, 10 patients (37%) experienced progression of their disease.
• 3-D stereophotogrammetry not only corroborated clinical impressions of disease progression with strong inter-rater reliability (kappa = 0.80; 95% confidence interval, 0.61-0.99), but it also detected occult progression of asymmetry not noted on clinical examination in three additional patients.
• In subgroup analyses, assessment of 3-D images demonstrated substantial to near-perfect inter-rater reliability in patients with Fitzpatrick skin types IV-VI.

IN PRACTICE:

“Further work is necessary to validate this measure in a larger cohort and to guide its incorporation into medical decision-making for patients with CM,” the researchers wrote.

SOURCE:

Katharina S. Shaw, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, led the research. The study was published online in JAMA Dermatology.

LIMITATIONS:

The sample was small, and a criterion standard for assessing CM was lacking.

DISCLOSURES:

The researchers reported having no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Noninvasive three-dimensional (3D) stereophotogrammetry may be a valuable adjunctive tool to detect progression of craniofacial morphea (CM) over time.

METHODOLOGY:

• Existing tools that detect disease progression in patients with CM are limited.
• In a prospective cohort study, researchers evaluated the use of 3-D stereophotogrammetry, a noninvasive, radiation-free imaging modality, to detect disease progression in 27 consecutive patients with CM seen at Boston Children’s Hospital and Brigham and Women’s Hospital from April 1, 2019, to March 1, 2023.
• After clinical and 3-D stereophotogrammetry assessments were performed at 2- to 12-month intervals, the 3-D images were rated by an expert (a board-certified plastic craniofacial surgeon) and a nonexpert (a board-certified dermatologist) as demonstrating progression or no progression.
• Kappa coefficients were used to calculate inter-rater reliability.

TAKEAWAY:

• Most of the study participants (73%) were female, their median age was 14 years (range, 5-40 years), and each underwent 3-D stereophotogrammetry imaging at least two times spaced a median of 3 months apart.
• On the basis of clinical assessments during the 48-month study period, 10 patients (37%) experienced progression of their disease.
• 3-D stereophotogrammetry not only corroborated clinical impressions of disease progression with strong inter-rater reliability (kappa = 0.80; 95% confidence interval, 0.61-0.99), but it also detected occult progression of asymmetry not noted on clinical examination in three additional patients.
• In subgroup analyses, assessment of 3-D images demonstrated substantial to near-perfect inter-rater reliability in patients with Fitzpatrick skin types IV-VI.

IN PRACTICE:

“Further work is necessary to validate this measure in a larger cohort and to guide its incorporation into medical decision-making for patients with CM,” the researchers wrote.

SOURCE:

Katharina S. Shaw, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, led the research. The study was published online in JAMA Dermatology.

LIMITATIONS:

The sample was small, and a criterion standard for assessing CM was lacking.

DISCLOSURES:

The researchers reported having no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

In the first study evaluating pediatric sleep-disordered breathing (SDB) from both indoor environment and neighborhood perspectives, multilevel risk factors were revealed as being associated with SDB-related symptoms. Beyond known associations with environmental tobacco smoke (ETS), a novel association with SDB symptoms was observed for exposure to indoor pests such as mice, cockroaches, and rats.

Although it has been well known that pediatric SDB affects low socioeconomic status (SES) children disproportionately, the roles of multilevel risk factor drivers including individual health, household SES, indoor exposures to environmental tobacco smoke, pests, and neighborhood characteristics have not been well studied, Gueye-Ndiaye et al. wrote in CHEST Pulmonary.

Pediatric SDB, a known risk factor for many health, neurobehavioral, and functional outcomes, includes habitual snoring and obstructive sleep apnea and may contribute to health disparities. Adenotonsillar hypertrophy and obesity are the most commonly recognized risk factors for SDB in generally healthy school-aged children. A role for other risk factors, however, is suggested by the fact that Black children have a fourfold increased risk for obstructive sleep apnea (OSA), compared with White children, unexplained by obesity, and have decreased response to treatment of OSA with adenotonsillectomy, compared with White children. Several studies point in the direction of neighborhood disadvantages as factors in heightened SDB prevalence or severity, Gueye-Ndiaye et al. stated.

The authors performed cross-sectional analyses on data recorded from 303 children (aged 6-12 years) enrolled in the Environmental Assessment of Sleep Youth (EASY) study from 2018 to 2022. Among them, 39% were Hispanic, Latino, Latina, or Spanish origin, 30% were Black or African American, 22% were White, and 11% were other. Maternal education attainment of a high school diploma or less was reported in 27%, and 65% of the sample lived in disadvantaged neighborhoods. Twenty-eight percent of children met criteria for objective SDB (Apnea-Hypopnea Index/Oxygen Desaturation Index ≥ 5/hr). Exposure documentation was informed by caregiver reports, assays of measured settled dust from the child’s bedroom, and neighborhood-level census data from which the Childhood Opportunity Index characterizing neighborhood disadvantage (ND) was derived. The study primary outcome was the SDB-related symptom burden assessed by the OSA-18 questionnaire total score.

Compared with children with no adverse indoor exposures to ETS and pests, children with such exposures had an approximately 4-12 point increase in total OSA-18 scores, and the increase among those with exposure to both ETS and pests was about 20 points (approximately a 1.3 standard deviation increase), Gueye-Ndiaye et al. reported.

In models adjusted for age, sex, minority race, and ethnicity, low maternal education was associated with a 7.55 (95% confidence interval, 3.44-11.66; P < .01) increased OSA-18 score. In models adjusted for sociodemographics including maternal education, history of asthma and allergic rhinitis were associated with a 13.63 (95% CI, 9.44-17.82; P < .01) and a 6.95 (95% CI, 2.62-11.29; P < .02) increased OSA-18 score, respectively. The authors noted that prior Canadian studies have shown OSA to be three times as likely in children with mothers reporting less than a high school education than in children with university educated mothers.

Speculating on the drivers of this association, they noted that the poor air quality due to tobacco smoke and allergen exposures to rodents, mold, and cockroaches are known contributors to asthma symptoms. Despite the differing pathogenesis of OSA and asthma, they suggest overlapping risk factors. Irritants and allergens may exacerbate SDB by stimulating immune responses manifested as adenotonsillar hypertrophy and by amplifying nasopharyngeal inflammation, adversely affecting upper airway patency. While ETS was not common in the sample, it was associated strongly with SDB. Gueye-Ndiaye et al. also showed associations between pest exposure, bedroom dust, and SDB symptoms. The findings, they concluded, support the importance of household- and bedroom-environmental conditions and sleep health.

OSA-18 scores were also elevated by about 7-14 points with allergic rhinitis and asthma, respectively. The findings, Gueye-Ndiaye et al. stated, underscore that asthma prevention strategies can be leveraged to address SDB disparities. No amplification of pest exposure effects, however, was found for asthma or allergic rhinitis.

“This is an incredibly important study, one that adds to our understanding of the risk factors that contribute to pediatric sleep health disparities,” said assistant professor of pediatrics Anne C. Coates, MD, Tufts University, Boston. “We have previously understood risk factors for sleep-disordered breathing like adenotonsillar hypertrophy, but this adds other elements like environmental tobacco smoke, pests, and home and neighborhood factors,” she told this news organization. “One of the most important takeaways is that beyond the importance of accurate diagnosis, there is the importance of advocating for our patients to ensure that they have the healthiest homes and neighborhoods. We need to inspire our colleagues to be advocates – for example – for pest mitigation, for antismoking policies, for every policy preventing the factors that contribute to the burden of disease.”

Dr. Coates is coauthor of “Advocacy and Health Equity: The Role of the Pediatric Pulmonologist,” currently in press (Clinics in Chest Medicine), and a member of the CHEST Physician Editorial Board.

The authors noted that a study limitation was that the sample was from one geographic area (Boston). Neither the authors nor Dr. Coates listed any conflicts.
 

In the first study evaluating pediatric sleep-disordered breathing (SDB) from both indoor environment and neighborhood perspectives, multilevel risk factors were revealed as being associated with SDB-related symptoms. Beyond known associations with environmental tobacco smoke (ETS), a novel association with SDB symptoms was observed for exposure to indoor pests such as mice, cockroaches, and rats.

Although it has been well known that pediatric SDB affects low socioeconomic status (SES) children disproportionately, the roles of multilevel risk factor drivers including individual health, household SES, indoor exposures to environmental tobacco smoke, pests, and neighborhood characteristics have not been well studied, Gueye-Ndiaye et al. wrote in CHEST Pulmonary.

Pediatric SDB, a known risk factor for many health, neurobehavioral, and functional outcomes, includes habitual snoring and obstructive sleep apnea and may contribute to health disparities. Adenotonsillar hypertrophy and obesity are the most commonly recognized risk factors for SDB in generally healthy school-aged children. A role for other risk factors, however, is suggested by the fact that Black children have a fourfold increased risk for obstructive sleep apnea (OSA), compared with White children, unexplained by obesity, and have decreased response to treatment of OSA with adenotonsillectomy, compared with White children. Several studies point in the direction of neighborhood disadvantages as factors in heightened SDB prevalence or severity, Gueye-Ndiaye et al. stated.

The authors performed cross-sectional analyses on data recorded from 303 children (aged 6-12 years) enrolled in the Environmental Assessment of Sleep Youth (EASY) study from 2018 to 2022. Among them, 39% were Hispanic, Latino, Latina, or Spanish origin, 30% were Black or African American, 22% were White, and 11% were other. Maternal education attainment of a high school diploma or less was reported in 27%, and 65% of the sample lived in disadvantaged neighborhoods. Twenty-eight percent of children met criteria for objective SDB (Apnea-Hypopnea Index/Oxygen Desaturation Index ≥ 5/hr). Exposure documentation was informed by caregiver reports, assays of measured settled dust from the child’s bedroom, and neighborhood-level census data from which the Childhood Opportunity Index characterizing neighborhood disadvantage (ND) was derived. The study primary outcome was the SDB-related symptom burden assessed by the OSA-18 questionnaire total score.

Compared with children with no adverse indoor exposures to ETS and pests, children with such exposures had an approximately 4-12 point increase in total OSA-18 scores, and the increase among those with exposure to both ETS and pests was about 20 points (approximately a 1.3 standard deviation increase), Gueye-Ndiaye et al. reported.

In models adjusted for age, sex, minority race, and ethnicity, low maternal education was associated with a 7.55 (95% confidence interval, 3.44-11.66; P < .01) increased OSA-18 score. In models adjusted for sociodemographics including maternal education, history of asthma and allergic rhinitis were associated with a 13.63 (95% CI, 9.44-17.82; P < .01) and a 6.95 (95% CI, 2.62-11.29; P < .02) increased OSA-18 score, respectively. The authors noted that prior Canadian studies have shown OSA to be three times as likely in children with mothers reporting less than a high school education than in children with university educated mothers.

Speculating on the drivers of this association, they noted that the poor air quality due to tobacco smoke and allergen exposures to rodents, mold, and cockroaches are known contributors to asthma symptoms. Despite the differing pathogenesis of OSA and asthma, they suggest overlapping risk factors. Irritants and allergens may exacerbate SDB by stimulating immune responses manifested as adenotonsillar hypertrophy and by amplifying nasopharyngeal inflammation, adversely affecting upper airway patency. While ETS was not common in the sample, it was associated strongly with SDB. Gueye-Ndiaye et al. also showed associations between pest exposure, bedroom dust, and SDB symptoms. The findings, they concluded, support the importance of household- and bedroom-environmental conditions and sleep health.

OSA-18 scores were also elevated by about 7-14 points with allergic rhinitis and asthma, respectively. The findings, Gueye-Ndiaye et al. stated, underscore that asthma prevention strategies can be leveraged to address SDB disparities. No amplification of pest exposure effects, however, was found for asthma or allergic rhinitis.

“This is an incredibly important study, one that adds to our understanding of the risk factors that contribute to pediatric sleep health disparities,” said assistant professor of pediatrics Anne C. Coates, MD, Tufts University, Boston. “We have previously understood risk factors for sleep-disordered breathing like adenotonsillar hypertrophy, but this adds other elements like environmental tobacco smoke, pests, and home and neighborhood factors,” she told this news organization. “One of the most important takeaways is that beyond the importance of accurate diagnosis, there is the importance of advocating for our patients to ensure that they have the healthiest homes and neighborhoods. We need to inspire our colleagues to be advocates – for example – for pest mitigation, for antismoking policies, for every policy preventing the factors that contribute to the burden of disease.”

Dr. Coates is coauthor of “Advocacy and Health Equity: The Role of the Pediatric Pulmonologist,” currently in press (Clinics in Chest Medicine), and a member of the CHEST Physician Editorial Board.

The authors noted that a study limitation was that the sample was from one geographic area (Boston). Neither the authors nor Dr. Coates listed any conflicts.
 

In the first study evaluating pediatric sleep-disordered breathing (SDB) from both indoor environment and neighborhood perspectives, multilevel risk factors were revealed as being associated with SDB-related symptoms. Beyond known associations with environmental tobacco smoke (ETS), a novel association with SDB symptoms was observed for exposure to indoor pests such as mice, cockroaches, and rats.

Although it has been well known that pediatric SDB affects low socioeconomic status (SES) children disproportionately, the roles of multilevel risk factor drivers including individual health, household SES, indoor exposures to environmental tobacco smoke, pests, and neighborhood characteristics have not been well studied, Gueye-Ndiaye et al. wrote in CHEST Pulmonary.

Pediatric SDB, a known risk factor for many health, neurobehavioral, and functional outcomes, includes habitual snoring and obstructive sleep apnea and may contribute to health disparities. Adenotonsillar hypertrophy and obesity are the most commonly recognized risk factors for SDB in generally healthy school-aged children. A role for other risk factors, however, is suggested by the fact that Black children have a fourfold increased risk for obstructive sleep apnea (OSA), compared with White children, unexplained by obesity, and have decreased response to treatment of OSA with adenotonsillectomy, compared with White children. Several studies point in the direction of neighborhood disadvantages as factors in heightened SDB prevalence or severity, Gueye-Ndiaye et al. stated.

The authors performed cross-sectional analyses on data recorded from 303 children (aged 6-12 years) enrolled in the Environmental Assessment of Sleep Youth (EASY) study from 2018 to 2022. Among them, 39% were Hispanic, Latino, Latina, or Spanish origin, 30% were Black or African American, 22% were White, and 11% were other. Maternal education attainment of a high school diploma or less was reported in 27%, and 65% of the sample lived in disadvantaged neighborhoods. Twenty-eight percent of children met criteria for objective SDB (Apnea-Hypopnea Index/Oxygen Desaturation Index ≥ 5/hr). Exposure documentation was informed by caregiver reports, assays of measured settled dust from the child’s bedroom, and neighborhood-level census data from which the Childhood Opportunity Index characterizing neighborhood disadvantage (ND) was derived. The study primary outcome was the SDB-related symptom burden assessed by the OSA-18 questionnaire total score.

Compared with children with no adverse indoor exposures to ETS and pests, children with such exposures had an approximately 4-12 point increase in total OSA-18 scores, and the increase among those with exposure to both ETS and pests was about 20 points (approximately a 1.3 standard deviation increase), Gueye-Ndiaye et al. reported.

In models adjusted for age, sex, minority race, and ethnicity, low maternal education was associated with a 7.55 (95% confidence interval, 3.44-11.66; P < .01) increased OSA-18 score. In models adjusted for sociodemographics including maternal education, history of asthma and allergic rhinitis were associated with a 13.63 (95% CI, 9.44-17.82; P < .01) and a 6.95 (95% CI, 2.62-11.29; P < .02) increased OSA-18 score, respectively. The authors noted that prior Canadian studies have shown OSA to be three times as likely in children with mothers reporting less than a high school education than in children with university educated mothers.

Speculating on the drivers of this association, they noted that the poor air quality due to tobacco smoke and allergen exposures to rodents, mold, and cockroaches are known contributors to asthma symptoms. Despite the differing pathogenesis of OSA and asthma, they suggest overlapping risk factors. Irritants and allergens may exacerbate SDB by stimulating immune responses manifested as adenotonsillar hypertrophy and by amplifying nasopharyngeal inflammation, adversely affecting upper airway patency. While ETS was not common in the sample, it was associated strongly with SDB. Gueye-Ndiaye et al. also showed associations between pest exposure, bedroom dust, and SDB symptoms. The findings, they concluded, support the importance of household- and bedroom-environmental conditions and sleep health.

OSA-18 scores were also elevated by about 7-14 points with allergic rhinitis and asthma, respectively. The findings, Gueye-Ndiaye et al. stated, underscore that asthma prevention strategies can be leveraged to address SDB disparities. No amplification of pest exposure effects, however, was found for asthma or allergic rhinitis.

“This is an incredibly important study, one that adds to our understanding of the risk factors that contribute to pediatric sleep health disparities,” said assistant professor of pediatrics Anne C. Coates, MD, Tufts University, Boston. “We have previously understood risk factors for sleep-disordered breathing like adenotonsillar hypertrophy, but this adds other elements like environmental tobacco smoke, pests, and home and neighborhood factors,” she told this news organization. “One of the most important takeaways is that beyond the importance of accurate diagnosis, there is the importance of advocating for our patients to ensure that they have the healthiest homes and neighborhoods. We need to inspire our colleagues to be advocates – for example – for pest mitigation, for antismoking policies, for every policy preventing the factors that contribute to the burden of disease.”

Dr. Coates is coauthor of “Advocacy and Health Equity: The Role of the Pediatric Pulmonologist,” currently in press (Clinics in Chest Medicine), and a member of the CHEST Physician Editorial Board.

The authors noted that a study limitation was that the sample was from one geographic area (Boston). Neither the authors nor Dr. Coates listed any conflicts.
 

TOPLINE:

Among pediatric patients with psoriasis, Black children and male children are significantly more likely to have palmoplantar psoriasis.

METHODOLOGY:

• Researchers reviewed data on 330 children and youths aged 0-18 years who had received a primary psoriasis diagnosis and who were seen at an academic pediatric dermatology clinic from 2012 to 2022. Among these patients, 50 cases of palmoplantar psoriasis (PP) were identified by pediatric dermatologists.
• The study population was stratified by race/ethnicity on the basis of self-identification. The cohort included White, Black, and Hispanic/Latino patients, as well as patients who identified as other; 71.5% were White persons, 59.1% were female patients.
• The researchers used a regression analysis to investigate the association between race/ethnicity and PP after controlling for multiple confounding variables, including age and gender.

TAKEAWAY:

• Black children were significantly more likely to have PP than White children (adjusted odds ratio, 6.386; P < .0001). PP was diagnosed in 41.9%, 11.5%, and 8.9% of Black, Hispanic/Latino, and White children, respectively.
• Male gender was also identified as an independent risk factor for PP (aOR, 2.241).
• Nail involvement occurred in significantly more Black and Hispanic/Latino patients than in White patients (53.2%, 50.0%, and 33.9%, respectively).
• Black patients had significantly more palm and sole involvement, compared with the other groups (P < .0001 for both); however, White children had significantly more scalp involvement, compared with the other groups (P = .04).

IN PRACTICE:

“Further research is warranted to better understand the degree to which these associations are affected by racial disparities and environmental factors,” as well as potential genetic associations, the researchers noted.

SOURCE:

The corresponding author on the study was Amy Theos, MD, of the department of dermatology at the University of Alabama, Birmingham. The study was published online in Pediatric Dermatology.

LIMITATIONS:

The findings were limited by the small sample size and incomplete data for some patients.

DISCLOSURES:

The study received no outside funding. The researchers had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among pediatric patients with psoriasis, Black children and male children are significantly more likely to have palmoplantar psoriasis.

METHODOLOGY:

• Researchers reviewed data on 330 children and youths aged 0-18 years who had received a primary psoriasis diagnosis and who were seen at an academic pediatric dermatology clinic from 2012 to 2022. Among these patients, 50 cases of palmoplantar psoriasis (PP) were identified by pediatric dermatologists.
• The study population was stratified by race/ethnicity on the basis of self-identification. The cohort included White, Black, and Hispanic/Latino patients, as well as patients who identified as other; 71.5% were White persons, 59.1% were female patients.
• The researchers used a regression analysis to investigate the association between race/ethnicity and PP after controlling for multiple confounding variables, including age and gender.

TAKEAWAY:

• Black children were significantly more likely to have PP than White children (adjusted odds ratio, 6.386; P < .0001). PP was diagnosed in 41.9%, 11.5%, and 8.9% of Black, Hispanic/Latino, and White children, respectively.
• Male gender was also identified as an independent risk factor for PP (aOR, 2.241).
• Nail involvement occurred in significantly more Black and Hispanic/Latino patients than in White patients (53.2%, 50.0%, and 33.9%, respectively).
• Black patients had significantly more palm and sole involvement, compared with the other groups (P < .0001 for both); however, White children had significantly more scalp involvement, compared with the other groups (P = .04).

IN PRACTICE:

“Further research is warranted to better understand the degree to which these associations are affected by racial disparities and environmental factors,” as well as potential genetic associations, the researchers noted.

SOURCE:

The corresponding author on the study was Amy Theos, MD, of the department of dermatology at the University of Alabama, Birmingham. The study was published online in Pediatric Dermatology.

LIMITATIONS:

The findings were limited by the small sample size and incomplete data for some patients.

DISCLOSURES:

The study received no outside funding. The researchers had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among pediatric patients with psoriasis, Black children and male children are significantly more likely to have palmoplantar psoriasis.

METHODOLOGY:

• Researchers reviewed data on 330 children and youths aged 0-18 years who had received a primary psoriasis diagnosis and who were seen at an academic pediatric dermatology clinic from 2012 to 2022. Among these patients, 50 cases of palmoplantar psoriasis (PP) were identified by pediatric dermatologists.
• The study population was stratified by race/ethnicity on the basis of self-identification. The cohort included White, Black, and Hispanic/Latino patients, as well as patients who identified as other; 71.5% were White persons, 59.1% were female patients.
• The researchers used a regression analysis to investigate the association between race/ethnicity and PP after controlling for multiple confounding variables, including age and gender.

TAKEAWAY:

• Black children were significantly more likely to have PP than White children (adjusted odds ratio, 6.386; P < .0001). PP was diagnosed in 41.9%, 11.5%, and 8.9% of Black, Hispanic/Latino, and White children, respectively.
• Male gender was also identified as an independent risk factor for PP (aOR, 2.241).
• Nail involvement occurred in significantly more Black and Hispanic/Latino patients than in White patients (53.2%, 50.0%, and 33.9%, respectively).
• Black patients had significantly more palm and sole involvement, compared with the other groups (P < .0001 for both); however, White children had significantly more scalp involvement, compared with the other groups (P = .04).

IN PRACTICE:

“Further research is warranted to better understand the degree to which these associations are affected by racial disparities and environmental factors,” as well as potential genetic associations, the researchers noted.

SOURCE:

The corresponding author on the study was Amy Theos, MD, of the department of dermatology at the University of Alabama, Birmingham. The study was published online in Pediatric Dermatology.

LIMITATIONS:

The findings were limited by the small sample size and incomplete data for some patients.

DISCLOSURES:

The study received no outside funding. The researchers had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.

A 16-year-old female presents for a self-identified concern around the possibility that she is experiencing an autism spectrum disorder. She relays to the developmental pediatrician that she has been learning a lot about autism on TikTok and through other social media sites, and has become strongly convinced that she meets medical criteria for this disorder.

Oregon Health &amp; Science University (OHSU)

A careful developmental history via a detailed interview with the mother reveals normal acquisition of early developmental milestones in addition to long-standing well-modulated eye contact felt to be paired fluidly with directed affect and gestures. The teen is described as having been an engaging toddler and preschooler, without restricted interests or repetitive behaviors, and having had no major challenges in grade school with behaviors, friendships, or academics.

During the pandemic, however, the teen became quite isolated. She developed anxiety with depression, and then started having some new repetitive arm movements within the last 12-18 months. In clinic, the teen makes robustly effortful arm-waving movements, which are noted to wane when she becomes more animated and excited during conversation, and to increase when she is less distracted by conversation and more focused on the movements.

She directs affect nicely toward her mother, while avoiding looking in the direction of the examiner until later in the evaluation when she becomes more relaxed. Prosody of speech and intonation are typical, and she describes having a close group of friends with whom she spends quite a bit of time.

The Autism Diagnostic Observation Schedule (ADOS-2 module 3) is used to gather structured observations, and these social presses yield flowing social engagement with the examiner, good understanding of humor, and overall excellent verbal and nonverbal communication skills. The teen describes hypervigilance around the emotions of others, a natural ease in understanding the perspectives of others, and a quick ability to read the energy of a room. She does have some interest in some more obscure online game forums, but her friends do as well, and she otherwise does not have a history of intrusive fixations. A social history reveals past significant verbal abuse in the home by means of her father during her first 11 years of life, which is described as quite traumatic.

After careful and thoughtful consideration (recognizing the known statistics around girls assigned female at birth, as well as nonbinary individuals and minoritized groups being underdiagnosed with autism), the history and observations are not felt to be consistent with autism, but with anxiety within the context of a trauma and stressor-related disorder. Even when accounting for the possibility of “masking,” the teen still does not meet criteria for autism based on history and presentation. The habit movements are not typical of usual stereotypies or of tics (which tend to increase with excitement and tend to have a more effortless quality), and are felt to possibly be functional in origin. Upon gently sharing these conclusions with the teen, she bursts into tears, stating her friends may now accuse her of lying, as she has already been claiming to have autism online and in person at school.
 

Countering social media diagnoses

This type of scenario is becoming increasingly common, with teens turning online primarily to social media accounts to gain knowledge around various neurologic and mental health conditions. Greater normalization of neurodiversity and greater access to high-quality information about neurodevelopmental differences is certainly progress, though unfortunately some online depictions of these conditions are simply not accurate. Many adolescents are keenly searching for both their personal identity and also a community through which they might feel wholly accepted, after experiencing some level of isolation during the pandemic followed by increased social discomfort in attempting to reintegrate into school life and society. It is important to take time to understand the drive behind an adolescent’s apparent desire for a specific diagnosis, particularly if that diagnosis is not felt to be an accurate conceptualization of the teen’s presentation by a skilled professional. Connecting the teen with a good-fit therapist and working to replace excessive screen time with exercise, outdoor activities, and in-person engagement with friends and family are also crucial interventions, though they can be incredibly difficult for families to achieve given various patient-specific and societal barriers. The overlap in symptomatology among anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorders is expansive, making it understandable that young people might misjudge their personal experience of life for a neurodevelopmental disorder for which they do not truly meet criteria. Increasing access to therapists well versed in trauma-informed care is a frequently referenced need, highlighted in this case.

Another case

In contrast to the case scenario above is that of a 19-year-old female presenting for a formal autism evaluation at the urging of her father, who has had concerns around her severe “shyness” throughout her life. He is concerned that she was not able to obtain a high school diploma despite appearing to have adequate cognitive skills, is currently quite isolated, and does not appear equipped to hold a job at this time. He describes her as having been a very quiet and self-directed young child who greatly benefited from the communication and social scaffolding provided by her slightly older and neurotypical sister. She has generally not had true friends, though she had no behavioral or academic difficulties in school other than seeming aloof and unusually quiet. Atypical social approaches have become more apparent over time, as relationship navigation has become more complex with age. She is noted to have frequent stereotyped hand-to-face movements throughout the evaluation, as well as a flat affect and unusual voice quality. She speaks slowly and softly, and while she does make eye contact, it is less well modulated than would be expected. She is very focused on her cat and online interests during conversation, and tends to give stilted answers to open-ended questions. During the interview portion of the ADOS, she demonstrates little insight into friendships and reports feeling very content on her own, though is open to the idea of relationships in the future and would like to learn how to achieve connections with others. Her father reports she tends to be generally quite blunt and has difficulty understanding humor and others’ perspectives. An autism diagnosis is made with the recommendation of application to Developmental Disability Services, given impaired adaptive skills, as a means of utilizing community-based supports to facilitate eventually obtaining a high school equivalency credential, a job, healthier living habits, and comfortable social outlets.

Discussion

It is crucial for providers to be aware of nuanced presentations of autism spectrum disorders that may have been missed in early childhood when social demands are less complicated, particularly in persons identified as female at birth, nonbinary individuals, and those belonging to minority groups. It is also important to address the widely acknowledged trend of adolescents turning to social media influencers for information around neurodevelopmental conditions, at a time in their lives when social anxiety and self-awareness are generally heightened. For an adolescent, a young social media influencer may feel like a more salient and reliable source of information than an adult with various letters after their name. A respectful relationship between a teen and a thoughtful primary care provider can help gain trust to foster open conversations around their concerns, which can further help determine if a referral to a psychologist or developmental pediatrician for a formal autism assessment is truly warranted, highlighting the need for increased diagnostic capacity for such. While it is certainly important for providers to keep an open mind and to have continued awareness around the concept of late autism diagnoses, it is wise to also be aware of this recent trend among adolescents as providers seek to guide youth toward appropriate therapies and services.

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Ore. She has no conflicts of interest.

A 16-year-old female presents for a self-identified concern around the possibility that she is experiencing an autism spectrum disorder. She relays to the developmental pediatrician that she has been learning a lot about autism on TikTok and through other social media sites, and has become strongly convinced that she meets medical criteria for this disorder.

Oregon Health &amp; Science University (OHSU)

A careful developmental history via a detailed interview with the mother reveals normal acquisition of early developmental milestones in addition to long-standing well-modulated eye contact felt to be paired fluidly with directed affect and gestures. The teen is described as having been an engaging toddler and preschooler, without restricted interests or repetitive behaviors, and having had no major challenges in grade school with behaviors, friendships, or academics.

During the pandemic, however, the teen became quite isolated. She developed anxiety with depression, and then started having some new repetitive arm movements within the last 12-18 months. In clinic, the teen makes robustly effortful arm-waving movements, which are noted to wane when she becomes more animated and excited during conversation, and to increase when she is less distracted by conversation and more focused on the movements.

She directs affect nicely toward her mother, while avoiding looking in the direction of the examiner until later in the evaluation when she becomes more relaxed. Prosody of speech and intonation are typical, and she describes having a close group of friends with whom she spends quite a bit of time.

The Autism Diagnostic Observation Schedule (ADOS-2 module 3) is used to gather structured observations, and these social presses yield flowing social engagement with the examiner, good understanding of humor, and overall excellent verbal and nonverbal communication skills. The teen describes hypervigilance around the emotions of others, a natural ease in understanding the perspectives of others, and a quick ability to read the energy of a room. She does have some interest in some more obscure online game forums, but her friends do as well, and she otherwise does not have a history of intrusive fixations. A social history reveals past significant verbal abuse in the home by means of her father during her first 11 years of life, which is described as quite traumatic.

After careful and thoughtful consideration (recognizing the known statistics around girls assigned female at birth, as well as nonbinary individuals and minoritized groups being underdiagnosed with autism), the history and observations are not felt to be consistent with autism, but with anxiety within the context of a trauma and stressor-related disorder. Even when accounting for the possibility of “masking,” the teen still does not meet criteria for autism based on history and presentation. The habit movements are not typical of usual stereotypies or of tics (which tend to increase with excitement and tend to have a more effortless quality), and are felt to possibly be functional in origin. Upon gently sharing these conclusions with the teen, she bursts into tears, stating her friends may now accuse her of lying, as she has already been claiming to have autism online and in person at school.
 

Countering social media diagnoses

This type of scenario is becoming increasingly common, with teens turning online primarily to social media accounts to gain knowledge around various neurologic and mental health conditions. Greater normalization of neurodiversity and greater access to high-quality information about neurodevelopmental differences is certainly progress, though unfortunately some online depictions of these conditions are simply not accurate. Many adolescents are keenly searching for both their personal identity and also a community through which they might feel wholly accepted, after experiencing some level of isolation during the pandemic followed by increased social discomfort in attempting to reintegrate into school life and society. It is important to take time to understand the drive behind an adolescent’s apparent desire for a specific diagnosis, particularly if that diagnosis is not felt to be an accurate conceptualization of the teen’s presentation by a skilled professional. Connecting the teen with a good-fit therapist and working to replace excessive screen time with exercise, outdoor activities, and in-person engagement with friends and family are also crucial interventions, though they can be incredibly difficult for families to achieve given various patient-specific and societal barriers. The overlap in symptomatology among anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorders is expansive, making it understandable that young people might misjudge their personal experience of life for a neurodevelopmental disorder for which they do not truly meet criteria. Increasing access to therapists well versed in trauma-informed care is a frequently referenced need, highlighted in this case.

Another case

In contrast to the case scenario above is that of a 19-year-old female presenting for a formal autism evaluation at the urging of her father, who has had concerns around her severe “shyness” throughout her life. He is concerned that she was not able to obtain a high school diploma despite appearing to have adequate cognitive skills, is currently quite isolated, and does not appear equipped to hold a job at this time. He describes her as having been a very quiet and self-directed young child who greatly benefited from the communication and social scaffolding provided by her slightly older and neurotypical sister. She has generally not had true friends, though she had no behavioral or academic difficulties in school other than seeming aloof and unusually quiet. Atypical social approaches have become more apparent over time, as relationship navigation has become more complex with age. She is noted to have frequent stereotyped hand-to-face movements throughout the evaluation, as well as a flat affect and unusual voice quality. She speaks slowly and softly, and while she does make eye contact, it is less well modulated than would be expected. She is very focused on her cat and online interests during conversation, and tends to give stilted answers to open-ended questions. During the interview portion of the ADOS, she demonstrates little insight into friendships and reports feeling very content on her own, though is open to the idea of relationships in the future and would like to learn how to achieve connections with others. Her father reports she tends to be generally quite blunt and has difficulty understanding humor and others’ perspectives. An autism diagnosis is made with the recommendation of application to Developmental Disability Services, given impaired adaptive skills, as a means of utilizing community-based supports to facilitate eventually obtaining a high school equivalency credential, a job, healthier living habits, and comfortable social outlets.

Discussion

It is crucial for providers to be aware of nuanced presentations of autism spectrum disorders that may have been missed in early childhood when social demands are less complicated, particularly in persons identified as female at birth, nonbinary individuals, and those belonging to minority groups. It is also important to address the widely acknowledged trend of adolescents turning to social media influencers for information around neurodevelopmental conditions, at a time in their lives when social anxiety and self-awareness are generally heightened. For an adolescent, a young social media influencer may feel like a more salient and reliable source of information than an adult with various letters after their name. A respectful relationship between a teen and a thoughtful primary care provider can help gain trust to foster open conversations around their concerns, which can further help determine if a referral to a psychologist or developmental pediatrician for a formal autism assessment is truly warranted, highlighting the need for increased diagnostic capacity for such. While it is certainly important for providers to keep an open mind and to have continued awareness around the concept of late autism diagnoses, it is wise to also be aware of this recent trend among adolescents as providers seek to guide youth toward appropriate therapies and services.

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Ore. She has no conflicts of interest.

A 16-year-old female presents for a self-identified concern around the possibility that she is experiencing an autism spectrum disorder. She relays to the developmental pediatrician that she has been learning a lot about autism on TikTok and through other social media sites, and has become strongly convinced that she meets medical criteria for this disorder.

Oregon Health &amp; Science University (OHSU)

A careful developmental history via a detailed interview with the mother reveals normal acquisition of early developmental milestones in addition to long-standing well-modulated eye contact felt to be paired fluidly with directed affect and gestures. The teen is described as having been an engaging toddler and preschooler, without restricted interests or repetitive behaviors, and having had no major challenges in grade school with behaviors, friendships, or academics.

During the pandemic, however, the teen became quite isolated. She developed anxiety with depression, and then started having some new repetitive arm movements within the last 12-18 months. In clinic, the teen makes robustly effortful arm-waving movements, which are noted to wane when she becomes more animated and excited during conversation, and to increase when she is less distracted by conversation and more focused on the movements.

She directs affect nicely toward her mother, while avoiding looking in the direction of the examiner until later in the evaluation when she becomes more relaxed. Prosody of speech and intonation are typical, and she describes having a close group of friends with whom she spends quite a bit of time.

The Autism Diagnostic Observation Schedule (ADOS-2 module 3) is used to gather structured observations, and these social presses yield flowing social engagement with the examiner, good understanding of humor, and overall excellent verbal and nonverbal communication skills. The teen describes hypervigilance around the emotions of others, a natural ease in understanding the perspectives of others, and a quick ability to read the energy of a room. She does have some interest in some more obscure online game forums, but her friends do as well, and she otherwise does not have a history of intrusive fixations. A social history reveals past significant verbal abuse in the home by means of her father during her first 11 years of life, which is described as quite traumatic.

After careful and thoughtful consideration (recognizing the known statistics around girls assigned female at birth, as well as nonbinary individuals and minoritized groups being underdiagnosed with autism), the history and observations are not felt to be consistent with autism, but with anxiety within the context of a trauma and stressor-related disorder. Even when accounting for the possibility of “masking,” the teen still does not meet criteria for autism based on history and presentation. The habit movements are not typical of usual stereotypies or of tics (which tend to increase with excitement and tend to have a more effortless quality), and are felt to possibly be functional in origin. Upon gently sharing these conclusions with the teen, she bursts into tears, stating her friends may now accuse her of lying, as she has already been claiming to have autism online and in person at school.
 

Countering social media diagnoses

This type of scenario is becoming increasingly common, with teens turning online primarily to social media accounts to gain knowledge around various neurologic and mental health conditions. Greater normalization of neurodiversity and greater access to high-quality information about neurodevelopmental differences is certainly progress, though unfortunately some online depictions of these conditions are simply not accurate. Many adolescents are keenly searching for both their personal identity and also a community through which they might feel wholly accepted, after experiencing some level of isolation during the pandemic followed by increased social discomfort in attempting to reintegrate into school life and society. It is important to take time to understand the drive behind an adolescent’s apparent desire for a specific diagnosis, particularly if that diagnosis is not felt to be an accurate conceptualization of the teen’s presentation by a skilled professional. Connecting the teen with a good-fit therapist and working to replace excessive screen time with exercise, outdoor activities, and in-person engagement with friends and family are also crucial interventions, though they can be incredibly difficult for families to achieve given various patient-specific and societal barriers. The overlap in symptomatology among anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorders is expansive, making it understandable that young people might misjudge their personal experience of life for a neurodevelopmental disorder for which they do not truly meet criteria. Increasing access to therapists well versed in trauma-informed care is a frequently referenced need, highlighted in this case.

Another case

In contrast to the case scenario above is that of a 19-year-old female presenting for a formal autism evaluation at the urging of her father, who has had concerns around her severe “shyness” throughout her life. He is concerned that she was not able to obtain a high school diploma despite appearing to have adequate cognitive skills, is currently quite isolated, and does not appear equipped to hold a job at this time. He describes her as having been a very quiet and self-directed young child who greatly benefited from the communication and social scaffolding provided by her slightly older and neurotypical sister. She has generally not had true friends, though she had no behavioral or academic difficulties in school other than seeming aloof and unusually quiet. Atypical social approaches have become more apparent over time, as relationship navigation has become more complex with age. She is noted to have frequent stereotyped hand-to-face movements throughout the evaluation, as well as a flat affect and unusual voice quality. She speaks slowly and softly, and while she does make eye contact, it is less well modulated than would be expected. She is very focused on her cat and online interests during conversation, and tends to give stilted answers to open-ended questions. During the interview portion of the ADOS, she demonstrates little insight into friendships and reports feeling very content on her own, though is open to the idea of relationships in the future and would like to learn how to achieve connections with others. Her father reports she tends to be generally quite blunt and has difficulty understanding humor and others’ perspectives. An autism diagnosis is made with the recommendation of application to Developmental Disability Services, given impaired adaptive skills, as a means of utilizing community-based supports to facilitate eventually obtaining a high school equivalency credential, a job, healthier living habits, and comfortable social outlets.

Discussion

It is crucial for providers to be aware of nuanced presentations of autism spectrum disorders that may have been missed in early childhood when social demands are less complicated, particularly in persons identified as female at birth, nonbinary individuals, and those belonging to minority groups. It is also important to address the widely acknowledged trend of adolescents turning to social media influencers for information around neurodevelopmental conditions, at a time in their lives when social anxiety and self-awareness are generally heightened. For an adolescent, a young social media influencer may feel like a more salient and reliable source of information than an adult with various letters after their name. A respectful relationship between a teen and a thoughtful primary care provider can help gain trust to foster open conversations around their concerns, which can further help determine if a referral to a psychologist or developmental pediatrician for a formal autism assessment is truly warranted, highlighting the need for increased diagnostic capacity for such. While it is certainly important for providers to keep an open mind and to have continued awareness around the concept of late autism diagnoses, it is wise to also be aware of this recent trend among adolescents as providers seek to guide youth toward appropriate therapies and services.

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Ore. She has no conflicts of interest.

Children with atopic dermatitis (AD) were significantly more likely to have positive patch test results than were children without AD, according to a study of over 900 children evaluated for allergic contact dermatitis (ACD) with patch testing, a finding that investigators say underscores the value of considering ACD in patients with AD and referring more children for testing.

ACD is underdetected in children with AD. In some cases, it may be misconstrued to be AD, and patch testing, the gold standard for diagnosing ACD, is often not performed, said senior author JiaDe Yu, MD, MS, a pediatric dermatologist and director of contact and occupational dermatology at Massachusetts General Hospital, Boston, and his co-authors, in the study published in the Journal of the American Academy of Dermatology.

Dr. JiaDe Yu

UCHealth

Top allergens

The top 10 allergens between children with and without AD were largely similar, the authors of the study report. Nickel was the most common allergen identified in both groups, and cobalt was in the top five for both groups. Fragrances (including hydroperoxides of linalool), preservatives (including methylisothiazolinone [MI]), and neomycin ranked in the top 10 in both groups, though prevalence differed.

MI, a preservative frequently used in personal care products and in other products like school glue and paint, was the second most common allergen identified in children with AD. Allergy to MI has “recently become an epidemic in the United States, with rapidly increasing prevalence and importance as a source of ACD among both children and adults,” the authors note.

Children with AD were significantly more likely, however, to have ACD to bacitracin (OR, 3.23; P = .030) and to cocamidopropyl betaine (OR, 3.69; P = .0007), the latter of which is a popular surfactant used in “baby” and “gentle” skincare products. This is unsurprising, given that children with AD are “more often exposed to a myriad of topical treatments,” Dr. Yu and his colleagues write.

Although not a top 10 allergen for either group, ACD to “carba mix,” a combination of three chemicals used to make medical adhesives and other rubber products (such as pacifiers, toys, school supplies, and rubber gloves) was significantly more common in children with AD than in those without (OR, 3.36; P = .025).

Among other findings from the study: Children with AD were more likely to have a longer history of dermatitis (4.1 vs. 1.6 years, P < .0001) prior to patch testing. Testing occurred at a mean age of 11 and 12.3 years for children with and without AD, respectively.

The number of allergens tested and the patch testing series chosen per patient were “not statistically different” between the children with and without AD, the researchers report.

Patch testing availability

Clinicians may be hesitant to subject a child to patch testing, but the process is well tolerated in most children, Dr. Perryman said. She uses a modified panel for children that omits less relevant allergens and usually limits patch testing to age 2 years or older due to a young child’s smaller surface area.

Dr. Yu, who developed an interest in patch testing during his residency at the Medical College of Wisconsin, Milwaukee, where he worked with a patch-testing expert, will test children as young as 3-4 months with a “small selection of patches.”

The challenge with a call for more patch testing is a shortage of trained physicians. “In all of Boston, where we have hundreds of dermatologists, there are only about four of us who really do patch testing. My wait time is about 6 months,” said Dr. Yu, who is also an assistant professor at Harvard Medical School, Boston.

Allergists at Massachusetts General Hospital do “some patch testing ... but they refer a lot of the most complicated cases to me,” he said, noting that patch testing and management of ACD involves detailed counseling for patients about avoidance of allergens. “Overall dermatologists represent the largest group of doctors who have proficiency in patch testing, and there just aren’t many of us.”

Dr. Perryman also said that patch testing is often performed by dermatologists who specialize in treating ACD and AD, though there seems to be “regional variance” in the level of involvement of dermatologists and allergists in patch testing.

Not all residency programs have hands-on patch testing opportunities, Dr. Yu said. A study published in Dermatitis, which he co-authored, showed that in 2020, 47.5% of dermatology residency programs had formal patch testing rotations. This represented improvement but is still not enough, he said.

The American Contact Dermatitis Society offers patch-testing mentorship programs, and the American Academy of Dermatology has recently begun offered a patch testing workshop at its annual meetings, said Dr. Yu, who received 4 weeks of training in the Society’s mentorship program and is now involved in the American Academy of Dermatology’s workshops and as a trainer/lecturer at the Contact Dermatitis Institute.

The study was supported by the Dermatology Foundation. Dr. Yu and his co-investigators reported no conflicts of interest. Dr. Perryman had no disclosures.

A version of this article first appeared on Medscape.com.

Children with atopic dermatitis (AD) were significantly more likely to have positive patch test results than were children without AD, according to a study of over 900 children evaluated for allergic contact dermatitis (ACD) with patch testing, a finding that investigators say underscores the value of considering ACD in patients with AD and referring more children for testing.

ACD is underdetected in children with AD. In some cases, it may be misconstrued to be AD, and patch testing, the gold standard for diagnosing ACD, is often not performed, said senior author JiaDe Yu, MD, MS, a pediatric dermatologist and director of contact and occupational dermatology at Massachusetts General Hospital, Boston, and his co-authors, in the study published in the Journal of the American Academy of Dermatology.

Dr. JiaDe Yu

UCHealth

Top allergens

The top 10 allergens between children with and without AD were largely similar, the authors of the study report. Nickel was the most common allergen identified in both groups, and cobalt was in the top five for both groups. Fragrances (including hydroperoxides of linalool), preservatives (including methylisothiazolinone [MI]), and neomycin ranked in the top 10 in both groups, though prevalence differed.

MI, a preservative frequently used in personal care products and in other products like school glue and paint, was the second most common allergen identified in children with AD. Allergy to MI has “recently become an epidemic in the United States, with rapidly increasing prevalence and importance as a source of ACD among both children and adults,” the authors note.

Children with AD were significantly more likely, however, to have ACD to bacitracin (OR, 3.23; P = .030) and to cocamidopropyl betaine (OR, 3.69; P = .0007), the latter of which is a popular surfactant used in “baby” and “gentle” skincare products. This is unsurprising, given that children with AD are “more often exposed to a myriad of topical treatments,” Dr. Yu and his colleagues write.

Although not a top 10 allergen for either group, ACD to “carba mix,” a combination of three chemicals used to make medical adhesives and other rubber products (such as pacifiers, toys, school supplies, and rubber gloves) was significantly more common in children with AD than in those without (OR, 3.36; P = .025).

Among other findings from the study: Children with AD were more likely to have a longer history of dermatitis (4.1 vs. 1.6 years, P < .0001) prior to patch testing. Testing occurred at a mean age of 11 and 12.3 years for children with and without AD, respectively.

The number of allergens tested and the patch testing series chosen per patient were “not statistically different” between the children with and without AD, the researchers report.

Patch testing availability

Clinicians may be hesitant to subject a child to patch testing, but the process is well tolerated in most children, Dr. Perryman said. She uses a modified panel for children that omits less relevant allergens and usually limits patch testing to age 2 years or older due to a young child’s smaller surface area.

Dr. Yu, who developed an interest in patch testing during his residency at the Medical College of Wisconsin, Milwaukee, where he worked with a patch-testing expert, will test children as young as 3-4 months with a “small selection of patches.”

The challenge with a call for more patch testing is a shortage of trained physicians. “In all of Boston, where we have hundreds of dermatologists, there are only about four of us who really do patch testing. My wait time is about 6 months,” said Dr. Yu, who is also an assistant professor at Harvard Medical School, Boston.

Allergists at Massachusetts General Hospital do “some patch testing ... but they refer a lot of the most complicated cases to me,” he said, noting that patch testing and management of ACD involves detailed counseling for patients about avoidance of allergens. “Overall dermatologists represent the largest group of doctors who have proficiency in patch testing, and there just aren’t many of us.”

Dr. Perryman also said that patch testing is often performed by dermatologists who specialize in treating ACD and AD, though there seems to be “regional variance” in the level of involvement of dermatologists and allergists in patch testing.

Not all residency programs have hands-on patch testing opportunities, Dr. Yu said. A study published in Dermatitis, which he co-authored, showed that in 2020, 47.5% of dermatology residency programs had formal patch testing rotations. This represented improvement but is still not enough, he said.

The American Contact Dermatitis Society offers patch-testing mentorship programs, and the American Academy of Dermatology has recently begun offered a patch testing workshop at its annual meetings, said Dr. Yu, who received 4 weeks of training in the Society’s mentorship program and is now involved in the American Academy of Dermatology’s workshops and as a trainer/lecturer at the Contact Dermatitis Institute.

The study was supported by the Dermatology Foundation. Dr. Yu and his co-investigators reported no conflicts of interest. Dr. Perryman had no disclosures.

A version of this article first appeared on Medscape.com.

Children with atopic dermatitis (AD) were significantly more likely to have positive patch test results than were children without AD, according to a study of over 900 children evaluated for allergic contact dermatitis (ACD) with patch testing, a finding that investigators say underscores the value of considering ACD in patients with AD and referring more children for testing.

ACD is underdetected in children with AD. In some cases, it may be misconstrued to be AD, and patch testing, the gold standard for diagnosing ACD, is often not performed, said senior author JiaDe Yu, MD, MS, a pediatric dermatologist and director of contact and occupational dermatology at Massachusetts General Hospital, Boston, and his co-authors, in the study published in the Journal of the American Academy of Dermatology.

Dr. JiaDe Yu

UCHealth

Top allergens

The top 10 allergens between children with and without AD were largely similar, the authors of the study report. Nickel was the most common allergen identified in both groups, and cobalt was in the top five for both groups. Fragrances (including hydroperoxides of linalool), preservatives (including methylisothiazolinone [MI]), and neomycin ranked in the top 10 in both groups, though prevalence differed.

MI, a preservative frequently used in personal care products and in other products like school glue and paint, was the second most common allergen identified in children with AD. Allergy to MI has “recently become an epidemic in the United States, with rapidly increasing prevalence and importance as a source of ACD among both children and adults,” the authors note.

Children with AD were significantly more likely, however, to have ACD to bacitracin (OR, 3.23; P = .030) and to cocamidopropyl betaine (OR, 3.69; P = .0007), the latter of which is a popular surfactant used in “baby” and “gentle” skincare products. This is unsurprising, given that children with AD are “more often exposed to a myriad of topical treatments,” Dr. Yu and his colleagues write.

Although not a top 10 allergen for either group, ACD to “carba mix,” a combination of three chemicals used to make medical adhesives and other rubber products (such as pacifiers, toys, school supplies, and rubber gloves) was significantly more common in children with AD than in those without (OR, 3.36; P = .025).

Among other findings from the study: Children with AD were more likely to have a longer history of dermatitis (4.1 vs. 1.6 years, P < .0001) prior to patch testing. Testing occurred at a mean age of 11 and 12.3 years for children with and without AD, respectively.

The number of allergens tested and the patch testing series chosen per patient were “not statistically different” between the children with and without AD, the researchers report.

Patch testing availability

Clinicians may be hesitant to subject a child to patch testing, but the process is well tolerated in most children, Dr. Perryman said. She uses a modified panel for children that omits less relevant allergens and usually limits patch testing to age 2 years or older due to a young child’s smaller surface area.

Dr. Yu, who developed an interest in patch testing during his residency at the Medical College of Wisconsin, Milwaukee, where he worked with a patch-testing expert, will test children as young as 3-4 months with a “small selection of patches.”

The challenge with a call for more patch testing is a shortage of trained physicians. “In all of Boston, where we have hundreds of dermatologists, there are only about four of us who really do patch testing. My wait time is about 6 months,” said Dr. Yu, who is also an assistant professor at Harvard Medical School, Boston.

Allergists at Massachusetts General Hospital do “some patch testing ... but they refer a lot of the most complicated cases to me,” he said, noting that patch testing and management of ACD involves detailed counseling for patients about avoidance of allergens. “Overall dermatologists represent the largest group of doctors who have proficiency in patch testing, and there just aren’t many of us.”

Dr. Perryman also said that patch testing is often performed by dermatologists who specialize in treating ACD and AD, though there seems to be “regional variance” in the level of involvement of dermatologists and allergists in patch testing.

Not all residency programs have hands-on patch testing opportunities, Dr. Yu said. A study published in Dermatitis, which he co-authored, showed that in 2020, 47.5% of dermatology residency programs had formal patch testing rotations. This represented improvement but is still not enough, he said.

The American Contact Dermatitis Society offers patch-testing mentorship programs, and the American Academy of Dermatology has recently begun offered a patch testing workshop at its annual meetings, said Dr. Yu, who received 4 weeks of training in the Society’s mentorship program and is now involved in the American Academy of Dermatology’s workshops and as a trainer/lecturer at the Contact Dermatitis Institute.

The study was supported by the Dermatology Foundation. Dr. Yu and his co-investigators reported no conflicts of interest. Dr. Perryman had no disclosures.

A version of this article first appeared on Medscape.com.