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NSAIDs work best in selected systemic JIA kids
BALTIMORE – Children with systemic juvenile idiopathic arthritis have the best odds for responding to initial treatment with a nonsteroidal anti-inflammatory drug if they are no older than 6 years old, have five or fewer involved joints, and have a serum level of C-reactive protein that is at or below 13 mg/dL, based on a review of 57 children with systemic juvenile idiopathic arthritis treated with these drugs at a single U.S. center during 2000-2014.
“We recommend a trial of NSAID [nonsteroidal anti-inflammatory drug] monotherapy for these patients with systemic juvenile idiopathic arthritis [JIA],” Dr. Anjali S. Sura said at the annual meeting of the Pediatric Academic Societies. A reasonable trial of NSAID monotherapy would last 6 weeks; if patients failed to adequately respond at the end of 6 weeks, it would be reasonable to switch to another of the first-line drugs recommended for children starting treatment for JIA, either a glucocorticoid or the biological agent anakinra (Kineret), said Dr. Sura, a pediatrician at the University of Michigan in Ann Arbor.
Initial treatment with a NSAID is preferred, even though it will probably work in only about a quarter of patients, because it generally has the best safety profile among these three options, Dr. Sura said in an interview. “If we can risk-stratify children with systemic JIA for NSAID therapy” using these three criteria, “then NSAID monotherapy may be more effective,” she explained.
The NSAIDs most commonly used to treat systemic JIA are naproxen or indomethacin, at anti-inflammatory dosages, which for naproxen is 15-20 mg/kg per day, and for indomethacin 3-4 mg/kg per day, she said.
But Dr. Sura also cautioned that the analysis she presented focused on a relatively small and selected group of children with systemic JIA who received initial NSAID monotherapy. The series she and her associates reviewed included 99 patients, of whom 57 received NSAID monotherapy; 35 of these patients were 6 years old or younger.
The researchers compared the 15 NSAID responders (26%), defined as patients who had clinically inactive disease, with the 42 nonresponders and identified the three clinical and demographic characteristics that occurred much more often among responders. The ideal candidates for initial NSAID monotherapy should fulfill all three criteria: age, number of affected joints, and serum level of C-reactive protein, Dr. Sura said in her report.
Dr. Sura noted that a panel of the American College of Rheumatology said that NSAIDs, glucocorticoids, and anakinra were equally good options for initial treatment of JIA in their 2013 update of JIA recommendations (Arthritis Rheum. 2013 Oct;65[10]:2499-512). This 2013 update excepted patients with no actively affected joints, whom the panel said should specifically receive an NSAID, and excepted patients with a high global severity score as rated by their physicians, whom the panel said should receive either a glucocorticoid or anakinra but not NSAID monotherapy. The European League Against Rheumatism has not issued recommendations for managing systemic JIA.
Dr. Sura had no disclosures.
On Twitter @mitchelzoler
BALTIMORE – Children with systemic juvenile idiopathic arthritis have the best odds for responding to initial treatment with a nonsteroidal anti-inflammatory drug if they are no older than 6 years old, have five or fewer involved joints, and have a serum level of C-reactive protein that is at or below 13 mg/dL, based on a review of 57 children with systemic juvenile idiopathic arthritis treated with these drugs at a single U.S. center during 2000-2014.
“We recommend a trial of NSAID [nonsteroidal anti-inflammatory drug] monotherapy for these patients with systemic juvenile idiopathic arthritis [JIA],” Dr. Anjali S. Sura said at the annual meeting of the Pediatric Academic Societies. A reasonable trial of NSAID monotherapy would last 6 weeks; if patients failed to adequately respond at the end of 6 weeks, it would be reasonable to switch to another of the first-line drugs recommended for children starting treatment for JIA, either a glucocorticoid or the biological agent anakinra (Kineret), said Dr. Sura, a pediatrician at the University of Michigan in Ann Arbor.
Initial treatment with a NSAID is preferred, even though it will probably work in only about a quarter of patients, because it generally has the best safety profile among these three options, Dr. Sura said in an interview. “If we can risk-stratify children with systemic JIA for NSAID therapy” using these three criteria, “then NSAID monotherapy may be more effective,” she explained.
The NSAIDs most commonly used to treat systemic JIA are naproxen or indomethacin, at anti-inflammatory dosages, which for naproxen is 15-20 mg/kg per day, and for indomethacin 3-4 mg/kg per day, she said.
But Dr. Sura also cautioned that the analysis she presented focused on a relatively small and selected group of children with systemic JIA who received initial NSAID monotherapy. The series she and her associates reviewed included 99 patients, of whom 57 received NSAID monotherapy; 35 of these patients were 6 years old or younger.
The researchers compared the 15 NSAID responders (26%), defined as patients who had clinically inactive disease, with the 42 nonresponders and identified the three clinical and demographic characteristics that occurred much more often among responders. The ideal candidates for initial NSAID monotherapy should fulfill all three criteria: age, number of affected joints, and serum level of C-reactive protein, Dr. Sura said in her report.
Dr. Sura noted that a panel of the American College of Rheumatology said that NSAIDs, glucocorticoids, and anakinra were equally good options for initial treatment of JIA in their 2013 update of JIA recommendations (Arthritis Rheum. 2013 Oct;65[10]:2499-512). This 2013 update excepted patients with no actively affected joints, whom the panel said should specifically receive an NSAID, and excepted patients with a high global severity score as rated by their physicians, whom the panel said should receive either a glucocorticoid or anakinra but not NSAID monotherapy. The European League Against Rheumatism has not issued recommendations for managing systemic JIA.
Dr. Sura had no disclosures.
On Twitter @mitchelzoler
BALTIMORE – Children with systemic juvenile idiopathic arthritis have the best odds for responding to initial treatment with a nonsteroidal anti-inflammatory drug if they are no older than 6 years old, have five or fewer involved joints, and have a serum level of C-reactive protein that is at or below 13 mg/dL, based on a review of 57 children with systemic juvenile idiopathic arthritis treated with these drugs at a single U.S. center during 2000-2014.
“We recommend a trial of NSAID [nonsteroidal anti-inflammatory drug] monotherapy for these patients with systemic juvenile idiopathic arthritis [JIA],” Dr. Anjali S. Sura said at the annual meeting of the Pediatric Academic Societies. A reasonable trial of NSAID monotherapy would last 6 weeks; if patients failed to adequately respond at the end of 6 weeks, it would be reasonable to switch to another of the first-line drugs recommended for children starting treatment for JIA, either a glucocorticoid or the biological agent anakinra (Kineret), said Dr. Sura, a pediatrician at the University of Michigan in Ann Arbor.
Initial treatment with a NSAID is preferred, even though it will probably work in only about a quarter of patients, because it generally has the best safety profile among these three options, Dr. Sura said in an interview. “If we can risk-stratify children with systemic JIA for NSAID therapy” using these three criteria, “then NSAID monotherapy may be more effective,” she explained.
The NSAIDs most commonly used to treat systemic JIA are naproxen or indomethacin, at anti-inflammatory dosages, which for naproxen is 15-20 mg/kg per day, and for indomethacin 3-4 mg/kg per day, she said.
But Dr. Sura also cautioned that the analysis she presented focused on a relatively small and selected group of children with systemic JIA who received initial NSAID monotherapy. The series she and her associates reviewed included 99 patients, of whom 57 received NSAID monotherapy; 35 of these patients were 6 years old or younger.
The researchers compared the 15 NSAID responders (26%), defined as patients who had clinically inactive disease, with the 42 nonresponders and identified the three clinical and demographic characteristics that occurred much more often among responders. The ideal candidates for initial NSAID monotherapy should fulfill all three criteria: age, number of affected joints, and serum level of C-reactive protein, Dr. Sura said in her report.
Dr. Sura noted that a panel of the American College of Rheumatology said that NSAIDs, glucocorticoids, and anakinra were equally good options for initial treatment of JIA in their 2013 update of JIA recommendations (Arthritis Rheum. 2013 Oct;65[10]:2499-512). This 2013 update excepted patients with no actively affected joints, whom the panel said should specifically receive an NSAID, and excepted patients with a high global severity score as rated by their physicians, whom the panel said should receive either a glucocorticoid or anakinra but not NSAID monotherapy. The European League Against Rheumatism has not issued recommendations for managing systemic JIA.
Dr. Sura had no disclosures.
On Twitter @mitchelzoler
AT THE PAS ANNUAL MEETING
Key clinical point: Three clinical parameters identified the children with systemic juvenile idiopathic arthritis who historically responded best to initial treatment with a nonsteroidal anti-inflammatory drug.
Major finding: Five or fewer involved joints, 6 years old or younger, and C-reactive protein of 13 mg/dL or less identified the best NSAID responders.
Data source: Review of 57 children with systemic juvenile idiopathic arthritis treated initially with NSAID monotherapy at one U.S. center.
Disclosures: Dr. Sura had no disclosures.
Pediatric providers willing and able to insert LARCs
BALTIMORE – A pilot program that trained pediatric primary care providers to insert long-acting reversible contraceptives (LARCs) delivered etonogestrel contraceptive implants to 135 adolescent and young women, with insertions provided by 16 providers within the first 16 months of the project.
“Pediatric offices offer a unique opportunity to provide contraceptive education and offer LARCs, reducing the need for referrals and potential delay in LARC provision that could lead to an unintended pregnancy,” wrote Dr. Kristine Schmitz, director of medical services for the Healthy Generations Program at Children’s National Health System, and her collaborators.
In a poster session of the annual meeting of the Pediatric Academic Societies, Dr. Schmitz reported that 20 general pediatricians and 2 pediatric nurse practitioners participated in LARC insertion training, and 16 providers, some of whom had previously received training, went on to begin LARC education and insertion as part of their primary care practice. Merck, the company that manufactures the etonogestrel implant marketed as Nexplanon, requires training and a certification for providers who implant the devices, which provide contraception for 3 years but can be removed at any time.
Intrauterine devices constitute the other form of LARC; taken together, they are the most effective form of contraception, but have historically been underutilized in the teen population.
In structuring the pilot program, Dr. Schmitz and her coinvestigators sought to assess not just the willingness of pediatricians to insert LARCs, but also to see how willing teenage girls were to receive the implants in their pediatricians’ offices; those data were not analyzed for this poster presentation. The study also polled clinicians to see what barriers existed to providing LARCs in a primary care setting.
In the pilot program, pediatricians at six general pediatric offices received etonogestrel implant insertion certification. Over the 16 months of the pilot study, a total of 135 teenage girls received implants. The number of insertions performed per provider during the study period ranged from 1 to 31.
Patient age for those receiving implants ranged from 12 to 22 years, with a median age of 18.
An electronic survey tracking clinician attitudes about LARC counseling and implantation was conducted 10 months into the study. The voluntary, non-anonymous survey was given to all providers at the pilot clinics, whether or not they were trained to insert LARCs. When providers were questioned about barriers to offering LARCs in the pediatric medical home, the primary barrier was simply the lack of availability of insertion trainings, cited by 48% of respondents as a “moderate” or “significant” barrier. Patient no-show rate was the second most common barrier, falling into the “moderate” or “significant” category for 29% of providers.
When surveyed, most pediatric primary care providers in the participating practices felt “comfortable” or “very comfortable” counseling teens on all birth control options (24/30 providers). Most (20/30) also felt “comfortable” or “very comfortable” providing anticipatory guidance about side effects of etonogestrel implants. Fewer clinicians (14/30) had the same degree of assurance that they could provide follow-up care for patients who experienced negative side effects from the implants, prompting Dr. Schmitz and her colleagues to comment that “Clinicians need additional training on side effect management.”
In an interview, Dr. Schmitz commented that pediatric primary care providers have relationships with patients and their family members, and can build on that trust to provide optimal contraceptive counseling.
Still, Dr. Schmitz and her colleagues quoted a survey response that observed, “The biggest difficulty in inserting and removing Nexplanon is time constraints – fitting patients into the schedule... and patients not showing up for scheduled procedures.”
Some providers also called for more case management support, she said.
Overall, she thinks the project shows great promise, saying, “It’s exciting to see how passionate our pediatric providers are about preventing unintended teen pregnancies, and how receptive our teen patients have been to receiving their chosen birth control method from their pediatrician.”
The study was funded by the Naomi and Nehemiah Cohen Foundation and the Children’s Health Board. Dr. Schmitz had no relevant financial disclosures.
On Twitter @karioakes
BALTIMORE – A pilot program that trained pediatric primary care providers to insert long-acting reversible contraceptives (LARCs) delivered etonogestrel contraceptive implants to 135 adolescent and young women, with insertions provided by 16 providers within the first 16 months of the project.
“Pediatric offices offer a unique opportunity to provide contraceptive education and offer LARCs, reducing the need for referrals and potential delay in LARC provision that could lead to an unintended pregnancy,” wrote Dr. Kristine Schmitz, director of medical services for the Healthy Generations Program at Children’s National Health System, and her collaborators.
In a poster session of the annual meeting of the Pediatric Academic Societies, Dr. Schmitz reported that 20 general pediatricians and 2 pediatric nurse practitioners participated in LARC insertion training, and 16 providers, some of whom had previously received training, went on to begin LARC education and insertion as part of their primary care practice. Merck, the company that manufactures the etonogestrel implant marketed as Nexplanon, requires training and a certification for providers who implant the devices, which provide contraception for 3 years but can be removed at any time.
Intrauterine devices constitute the other form of LARC; taken together, they are the most effective form of contraception, but have historically been underutilized in the teen population.
In structuring the pilot program, Dr. Schmitz and her coinvestigators sought to assess not just the willingness of pediatricians to insert LARCs, but also to see how willing teenage girls were to receive the implants in their pediatricians’ offices; those data were not analyzed for this poster presentation. The study also polled clinicians to see what barriers existed to providing LARCs in a primary care setting.
In the pilot program, pediatricians at six general pediatric offices received etonogestrel implant insertion certification. Over the 16 months of the pilot study, a total of 135 teenage girls received implants. The number of insertions performed per provider during the study period ranged from 1 to 31.
Patient age for those receiving implants ranged from 12 to 22 years, with a median age of 18.
An electronic survey tracking clinician attitudes about LARC counseling and implantation was conducted 10 months into the study. The voluntary, non-anonymous survey was given to all providers at the pilot clinics, whether or not they were trained to insert LARCs. When providers were questioned about barriers to offering LARCs in the pediatric medical home, the primary barrier was simply the lack of availability of insertion trainings, cited by 48% of respondents as a “moderate” or “significant” barrier. Patient no-show rate was the second most common barrier, falling into the “moderate” or “significant” category for 29% of providers.
When surveyed, most pediatric primary care providers in the participating practices felt “comfortable” or “very comfortable” counseling teens on all birth control options (24/30 providers). Most (20/30) also felt “comfortable” or “very comfortable” providing anticipatory guidance about side effects of etonogestrel implants. Fewer clinicians (14/30) had the same degree of assurance that they could provide follow-up care for patients who experienced negative side effects from the implants, prompting Dr. Schmitz and her colleagues to comment that “Clinicians need additional training on side effect management.”
In an interview, Dr. Schmitz commented that pediatric primary care providers have relationships with patients and their family members, and can build on that trust to provide optimal contraceptive counseling.
Still, Dr. Schmitz and her colleagues quoted a survey response that observed, “The biggest difficulty in inserting and removing Nexplanon is time constraints – fitting patients into the schedule... and patients not showing up for scheduled procedures.”
Some providers also called for more case management support, she said.
Overall, she thinks the project shows great promise, saying, “It’s exciting to see how passionate our pediatric providers are about preventing unintended teen pregnancies, and how receptive our teen patients have been to receiving their chosen birth control method from their pediatrician.”
The study was funded by the Naomi and Nehemiah Cohen Foundation and the Children’s Health Board. Dr. Schmitz had no relevant financial disclosures.
On Twitter @karioakes
BALTIMORE – A pilot program that trained pediatric primary care providers to insert long-acting reversible contraceptives (LARCs) delivered etonogestrel contraceptive implants to 135 adolescent and young women, with insertions provided by 16 providers within the first 16 months of the project.
“Pediatric offices offer a unique opportunity to provide contraceptive education and offer LARCs, reducing the need for referrals and potential delay in LARC provision that could lead to an unintended pregnancy,” wrote Dr. Kristine Schmitz, director of medical services for the Healthy Generations Program at Children’s National Health System, and her collaborators.
In a poster session of the annual meeting of the Pediatric Academic Societies, Dr. Schmitz reported that 20 general pediatricians and 2 pediatric nurse practitioners participated in LARC insertion training, and 16 providers, some of whom had previously received training, went on to begin LARC education and insertion as part of their primary care practice. Merck, the company that manufactures the etonogestrel implant marketed as Nexplanon, requires training and a certification for providers who implant the devices, which provide contraception for 3 years but can be removed at any time.
Intrauterine devices constitute the other form of LARC; taken together, they are the most effective form of contraception, but have historically been underutilized in the teen population.
In structuring the pilot program, Dr. Schmitz and her coinvestigators sought to assess not just the willingness of pediatricians to insert LARCs, but also to see how willing teenage girls were to receive the implants in their pediatricians’ offices; those data were not analyzed for this poster presentation. The study also polled clinicians to see what barriers existed to providing LARCs in a primary care setting.
In the pilot program, pediatricians at six general pediatric offices received etonogestrel implant insertion certification. Over the 16 months of the pilot study, a total of 135 teenage girls received implants. The number of insertions performed per provider during the study period ranged from 1 to 31.
Patient age for those receiving implants ranged from 12 to 22 years, with a median age of 18.
An electronic survey tracking clinician attitudes about LARC counseling and implantation was conducted 10 months into the study. The voluntary, non-anonymous survey was given to all providers at the pilot clinics, whether or not they were trained to insert LARCs. When providers were questioned about barriers to offering LARCs in the pediatric medical home, the primary barrier was simply the lack of availability of insertion trainings, cited by 48% of respondents as a “moderate” or “significant” barrier. Patient no-show rate was the second most common barrier, falling into the “moderate” or “significant” category for 29% of providers.
When surveyed, most pediatric primary care providers in the participating practices felt “comfortable” or “very comfortable” counseling teens on all birth control options (24/30 providers). Most (20/30) also felt “comfortable” or “very comfortable” providing anticipatory guidance about side effects of etonogestrel implants. Fewer clinicians (14/30) had the same degree of assurance that they could provide follow-up care for patients who experienced negative side effects from the implants, prompting Dr. Schmitz and her colleagues to comment that “Clinicians need additional training on side effect management.”
In an interview, Dr. Schmitz commented that pediatric primary care providers have relationships with patients and their family members, and can build on that trust to provide optimal contraceptive counseling.
Still, Dr. Schmitz and her colleagues quoted a survey response that observed, “The biggest difficulty in inserting and removing Nexplanon is time constraints – fitting patients into the schedule... and patients not showing up for scheduled procedures.”
Some providers also called for more case management support, she said.
Overall, she thinks the project shows great promise, saying, “It’s exciting to see how passionate our pediatric providers are about preventing unintended teen pregnancies, and how receptive our teen patients have been to receiving their chosen birth control method from their pediatrician.”
The study was funded by the Naomi and Nehemiah Cohen Foundation and the Children’s Health Board. Dr. Schmitz had no relevant financial disclosures.
On Twitter @karioakes
AT THE PAS ANNUAL MEETING
Key clinical point: In a six-clinic pilot study, pediatric providers were successfully trained to insert etonogestrel implants.
Major finding: Over the 16-month pilot study period, 16 providers inserted 135 implants into patients aged 12-22 years.
Data source: Pilot study to assess feasibility and clinician and patient acceptance of LARC insertion in the pediatric primary care setting.
Disclosures: The study was funded by the Naomi and Nehemiah Cohen Foundation and the Children’s Health Board. Dr. Schmitz reported no relevant disclosures.
Ambulatory blood pressure rules hypertension diagnosis and follow-up
Evidence is becoming overwhelming that ambulatory blood pressure monitoring is the only reliable way to measure blood pressure for both diagnosing hypertension and following patients once they are diagnosed.
Office-based blood pressure measurement is out, be it a one-off reading or a cluster of sequential readings during a single office visit. Ambulatory blood pressure monitoring (ABPM) increasingly is the standard of care.
One recent nail in the coffin of office-based measurement came in a modestly-sized but revealing study reported by Dr. Joyce P. Samuel, a pediatric hypertension specialist at the University of Texas in Houston. She reported her experience directly comparing ambulatory and carefully-done office-based blood pressure measurement in a presentation at the annual meeting of the Pediatric Academic Societies in Baltimore.
Dr. Samuel followed 40 patients age 9-21 years whom she had previously diagnosed with essential hypertension (children with a systolic blood pressure at or above the 95th percentile for sex, age, and height), and repeatedly measured their blood pressures by both ambulatory and office-based readings at 2-week intervals as she searched for the best combination of antihypertensive drugs for each patient. She sent patients home for 24 hours of blood-pressure monitoring with an ambulatory device, and when they returned to her office the next day, she performed an office-based measurement using meticulous technique: Each child was seated and calm, measured on the right arm, with four measurements taken sequentially at about 1 minute intervals with the first reading discarded and the remaining three averaged.
Over the course of several months, she collected 173 paired ambulatory and office-based systolic blood pressure readings from individual patients. Substantial differences between the two forms of measurement were remarkably common. In 20% of the pairs, the ambulatory systolic reading was at least 10 mm Hg higher than the office-based reading, and for some pairs the differences ran as high as 30 mm Hg. In an additional 32% of the paired readings, office-based systolic pressure ran at least 10 mm Hg higher and in some cases as much as 35 mm Hg higher than the ambulatory reading.
Dr. Samuel also analyzed her findings a different way to assess the clinical consequences of these differences based on whether a child’s systolic pressure identified the patient as normotensive, hypertensive, or prehypertensive (a systolic pressure at the 90-94th percentile for the child’s age, sex and height). She found that the diagnoses matched for only 49% of the paired measurements. In 24% of the paired readings, ABPM identified children with hypertension that was not seen with concurrent office-based measurement, cases of masked hypertension. In 17% of the pairs, office-based measurement diagnosed hypertension that was not confirmed by ABPM, cases of white-coat hypertension. The remaining 10% of pairs were mismatched by showing normotensive with one method and prehypertensive with the other method. Dr. Samuel searched for any consistent patterns in these differences and found none. The disparate results with ambulatory and office-based measurements seemed almost random, with no correlation with age, sex, race, the medications patients received, or how many times a patient had already undergone dual blood-pressure monitoring. Individual patients had no meaningful differences between some of their paired measurements but had a meaningful disparity for others.
“We were unable to predict discrepancies,” said Dr. Samuels.
“You can’t get around it, you need ambulatory blood pressure monitoring to make the best diagnosis” of hypertension, she told me. “We need to push to make ambulatory monitoring more available. I am moving toward believing that ambulatory blood pressure monitoring must be routinely done on everyone. This is what the data suggest.”
It’s also where medicine is headed. In 2015, the U.S. Preventative Services Task Force (USPSTF) issued new recommendations for hypertension screening in adults aged 18 years or older, indicating that there was “convincing evidence that ABPM is the best method for diagnosing hypertension,” and the agency further recommended that ABPM is “the reference standard for confirming the diagnosis of hypertension.” Another endorsement of ambulatory blood pressure monitoring came out last year from the International Society for Chronobiology.
Recommendations are not yet as evolved for children. The USPSTF last weighed in on screening kids for hypertension in 2013, and said the evidence as of then was “insufficient” to assess the benefits and harms of screening for hypertension in children and adolescents. That document endorsed careful office-based blood pressure measurement, which highlights how recently expert sentiment has shifted on the issue of measurement. In response to the USPSTF 2013 statement, the American Academy of Pediatrics noted that it continued to back recommendations that are more than a decade old from the National High Blood Pressure Education Program that called for hypertension screening in children starting when they are 3 years old. Neither of these two groups has made any recent statement about the preferred method to measure blood pressure.
On Twitter @mitchelzoler
Evidence is becoming overwhelming that ambulatory blood pressure monitoring is the only reliable way to measure blood pressure for both diagnosing hypertension and following patients once they are diagnosed.
Office-based blood pressure measurement is out, be it a one-off reading or a cluster of sequential readings during a single office visit. Ambulatory blood pressure monitoring (ABPM) increasingly is the standard of care.
One recent nail in the coffin of office-based measurement came in a modestly-sized but revealing study reported by Dr. Joyce P. Samuel, a pediatric hypertension specialist at the University of Texas in Houston. She reported her experience directly comparing ambulatory and carefully-done office-based blood pressure measurement in a presentation at the annual meeting of the Pediatric Academic Societies in Baltimore.
Dr. Samuel followed 40 patients age 9-21 years whom she had previously diagnosed with essential hypertension (children with a systolic blood pressure at or above the 95th percentile for sex, age, and height), and repeatedly measured their blood pressures by both ambulatory and office-based readings at 2-week intervals as she searched for the best combination of antihypertensive drugs for each patient. She sent patients home for 24 hours of blood-pressure monitoring with an ambulatory device, and when they returned to her office the next day, she performed an office-based measurement using meticulous technique: Each child was seated and calm, measured on the right arm, with four measurements taken sequentially at about 1 minute intervals with the first reading discarded and the remaining three averaged.
Over the course of several months, she collected 173 paired ambulatory and office-based systolic blood pressure readings from individual patients. Substantial differences between the two forms of measurement were remarkably common. In 20% of the pairs, the ambulatory systolic reading was at least 10 mm Hg higher than the office-based reading, and for some pairs the differences ran as high as 30 mm Hg. In an additional 32% of the paired readings, office-based systolic pressure ran at least 10 mm Hg higher and in some cases as much as 35 mm Hg higher than the ambulatory reading.
Dr. Samuel also analyzed her findings a different way to assess the clinical consequences of these differences based on whether a child’s systolic pressure identified the patient as normotensive, hypertensive, or prehypertensive (a systolic pressure at the 90-94th percentile for the child’s age, sex and height). She found that the diagnoses matched for only 49% of the paired measurements. In 24% of the paired readings, ABPM identified children with hypertension that was not seen with concurrent office-based measurement, cases of masked hypertension. In 17% of the pairs, office-based measurement diagnosed hypertension that was not confirmed by ABPM, cases of white-coat hypertension. The remaining 10% of pairs were mismatched by showing normotensive with one method and prehypertensive with the other method. Dr. Samuel searched for any consistent patterns in these differences and found none. The disparate results with ambulatory and office-based measurements seemed almost random, with no correlation with age, sex, race, the medications patients received, or how many times a patient had already undergone dual blood-pressure monitoring. Individual patients had no meaningful differences between some of their paired measurements but had a meaningful disparity for others.
“We were unable to predict discrepancies,” said Dr. Samuels.
“You can’t get around it, you need ambulatory blood pressure monitoring to make the best diagnosis” of hypertension, she told me. “We need to push to make ambulatory monitoring more available. I am moving toward believing that ambulatory blood pressure monitoring must be routinely done on everyone. This is what the data suggest.”
It’s also where medicine is headed. In 2015, the U.S. Preventative Services Task Force (USPSTF) issued new recommendations for hypertension screening in adults aged 18 years or older, indicating that there was “convincing evidence that ABPM is the best method for diagnosing hypertension,” and the agency further recommended that ABPM is “the reference standard for confirming the diagnosis of hypertension.” Another endorsement of ambulatory blood pressure monitoring came out last year from the International Society for Chronobiology.
Recommendations are not yet as evolved for children. The USPSTF last weighed in on screening kids for hypertension in 2013, and said the evidence as of then was “insufficient” to assess the benefits and harms of screening for hypertension in children and adolescents. That document endorsed careful office-based blood pressure measurement, which highlights how recently expert sentiment has shifted on the issue of measurement. In response to the USPSTF 2013 statement, the American Academy of Pediatrics noted that it continued to back recommendations that are more than a decade old from the National High Blood Pressure Education Program that called for hypertension screening in children starting when they are 3 years old. Neither of these two groups has made any recent statement about the preferred method to measure blood pressure.
On Twitter @mitchelzoler
Evidence is becoming overwhelming that ambulatory blood pressure monitoring is the only reliable way to measure blood pressure for both diagnosing hypertension and following patients once they are diagnosed.
Office-based blood pressure measurement is out, be it a one-off reading or a cluster of sequential readings during a single office visit. Ambulatory blood pressure monitoring (ABPM) increasingly is the standard of care.
One recent nail in the coffin of office-based measurement came in a modestly-sized but revealing study reported by Dr. Joyce P. Samuel, a pediatric hypertension specialist at the University of Texas in Houston. She reported her experience directly comparing ambulatory and carefully-done office-based blood pressure measurement in a presentation at the annual meeting of the Pediatric Academic Societies in Baltimore.
Dr. Samuel followed 40 patients age 9-21 years whom she had previously diagnosed with essential hypertension (children with a systolic blood pressure at or above the 95th percentile for sex, age, and height), and repeatedly measured their blood pressures by both ambulatory and office-based readings at 2-week intervals as she searched for the best combination of antihypertensive drugs for each patient. She sent patients home for 24 hours of blood-pressure monitoring with an ambulatory device, and when they returned to her office the next day, she performed an office-based measurement using meticulous technique: Each child was seated and calm, measured on the right arm, with four measurements taken sequentially at about 1 minute intervals with the first reading discarded and the remaining three averaged.
Over the course of several months, she collected 173 paired ambulatory and office-based systolic blood pressure readings from individual patients. Substantial differences between the two forms of measurement were remarkably common. In 20% of the pairs, the ambulatory systolic reading was at least 10 mm Hg higher than the office-based reading, and for some pairs the differences ran as high as 30 mm Hg. In an additional 32% of the paired readings, office-based systolic pressure ran at least 10 mm Hg higher and in some cases as much as 35 mm Hg higher than the ambulatory reading.
Dr. Samuel also analyzed her findings a different way to assess the clinical consequences of these differences based on whether a child’s systolic pressure identified the patient as normotensive, hypertensive, or prehypertensive (a systolic pressure at the 90-94th percentile for the child’s age, sex and height). She found that the diagnoses matched for only 49% of the paired measurements. In 24% of the paired readings, ABPM identified children with hypertension that was not seen with concurrent office-based measurement, cases of masked hypertension. In 17% of the pairs, office-based measurement diagnosed hypertension that was not confirmed by ABPM, cases of white-coat hypertension. The remaining 10% of pairs were mismatched by showing normotensive with one method and prehypertensive with the other method. Dr. Samuel searched for any consistent patterns in these differences and found none. The disparate results with ambulatory and office-based measurements seemed almost random, with no correlation with age, sex, race, the medications patients received, or how many times a patient had already undergone dual blood-pressure monitoring. Individual patients had no meaningful differences between some of their paired measurements but had a meaningful disparity for others.
“We were unable to predict discrepancies,” said Dr. Samuels.
“You can’t get around it, you need ambulatory blood pressure monitoring to make the best diagnosis” of hypertension, she told me. “We need to push to make ambulatory monitoring more available. I am moving toward believing that ambulatory blood pressure monitoring must be routinely done on everyone. This is what the data suggest.”
It’s also where medicine is headed. In 2015, the U.S. Preventative Services Task Force (USPSTF) issued new recommendations for hypertension screening in adults aged 18 years or older, indicating that there was “convincing evidence that ABPM is the best method for diagnosing hypertension,” and the agency further recommended that ABPM is “the reference standard for confirming the diagnosis of hypertension.” Another endorsement of ambulatory blood pressure monitoring came out last year from the International Society for Chronobiology.
Recommendations are not yet as evolved for children. The USPSTF last weighed in on screening kids for hypertension in 2013, and said the evidence as of then was “insufficient” to assess the benefits and harms of screening for hypertension in children and adolescents. That document endorsed careful office-based blood pressure measurement, which highlights how recently expert sentiment has shifted on the issue of measurement. In response to the USPSTF 2013 statement, the American Academy of Pediatrics noted that it continued to back recommendations that are more than a decade old from the National High Blood Pressure Education Program that called for hypertension screening in children starting when they are 3 years old. Neither of these two groups has made any recent statement about the preferred method to measure blood pressure.
On Twitter @mitchelzoler
VIDEO: Transgender care becoming an increasingly important component of pediatric care
BALTIMORE – With a growing number of youth coming out as transgender, it’s becoming increasingly important for both the current and upcoming generation of pediatricians to know how to provide the best possible health care to this population.
“It’s now very common for pediatricians to be approached by parents or teens, and asked for help or support with a transition,” explained Dr. Daniel E. Shumer of the University of Michigan in Ann Arbor. He added, “I think it’s incumbent upon pediatricians to figure out how to provide that education to trainees so that the next generation of pediatricians is able to provide excellent care for transgender kids and their families.”
In an interview at the annual meeting of the Pediatric Academic Societies, Dr. Shumer elaborated on the importance of training new pediatricians on how to handle LGBT patients, exactly what such training should entail, and why it’s equally important for current pediatricians to educate themselves on this very issue.
Dr. Shumer did not report any relevant financial disclosures.
Go to LGBT Youth Consult on our site for articles on the nature of sexuality and gender identity and how they affect health, advice on how to talk with your patients about these topics, and how to make your office a safe place for LGBT youth.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
BALTIMORE – With a growing number of youth coming out as transgender, it’s becoming increasingly important for both the current and upcoming generation of pediatricians to know how to provide the best possible health care to this population.
“It’s now very common for pediatricians to be approached by parents or teens, and asked for help or support with a transition,” explained Dr. Daniel E. Shumer of the University of Michigan in Ann Arbor. He added, “I think it’s incumbent upon pediatricians to figure out how to provide that education to trainees so that the next generation of pediatricians is able to provide excellent care for transgender kids and their families.”
In an interview at the annual meeting of the Pediatric Academic Societies, Dr. Shumer elaborated on the importance of training new pediatricians on how to handle LGBT patients, exactly what such training should entail, and why it’s equally important for current pediatricians to educate themselves on this very issue.
Dr. Shumer did not report any relevant financial disclosures.
Go to LGBT Youth Consult on our site for articles on the nature of sexuality and gender identity and how they affect health, advice on how to talk with your patients about these topics, and how to make your office a safe place for LGBT youth.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
BALTIMORE – With a growing number of youth coming out as transgender, it’s becoming increasingly important for both the current and upcoming generation of pediatricians to know how to provide the best possible health care to this population.
“It’s now very common for pediatricians to be approached by parents or teens, and asked for help or support with a transition,” explained Dr. Daniel E. Shumer of the University of Michigan in Ann Arbor. He added, “I think it’s incumbent upon pediatricians to figure out how to provide that education to trainees so that the next generation of pediatricians is able to provide excellent care for transgender kids and their families.”
In an interview at the annual meeting of the Pediatric Academic Societies, Dr. Shumer elaborated on the importance of training new pediatricians on how to handle LGBT patients, exactly what such training should entail, and why it’s equally important for current pediatricians to educate themselves on this very issue.
Dr. Shumer did not report any relevant financial disclosures.
Go to LGBT Youth Consult on our site for articles on the nature of sexuality and gender identity and how they affect health, advice on how to talk with your patients about these topics, and how to make your office a safe place for LGBT youth.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
EXPERT ANALYSIS FROM THE PAS ANNUAL MEETING
Target Fortification of Breast Milk Boosts Preemie Growth
BALTIMORE – For a premature infant, breast milk straight from Mom or a donor may not be the ideal meal.
The problem is that breast milk is often unbalanced in its content of protein, fat, and carbohydrates, and for a premature neonate fed by a nasogastric tube, unfortified breast milk can provide too little of one nutrient or too much of another. Conventional fortification of breast milk adds a standardized cocktail of nutrients that doesn’t provide an ideal balance for optimal growth.
Frequent analysis of breast milk’s nutrient content and target fortification to tweak the milk to a more ideal nutrient balance may be a way around this problem, and results from a single-center, randomized trial with 85 premature infants showed that this approach led to significantly better infant weights when measured at 36 weeks postmenstrual age, Dr. Christoph Fusch reported at the annual meeting of the Pediatric Academic Societies.
Target fortification of breast milk resulted in an average weight at 36 weeks postmenstrual age of 2,510 g among 42 infants in the intervention group, compared with an average weight of 2,280 g among 43 control infants who received breast milk that underwent routine fortification with a commercial product – a statistically significant difference for the study’s primary endpoint, said Dr. Fusch, professor of pediatrics at McMaster University and director of the neonatal intensive care unit at McMaster Children’s Hospital, both in Hamilton, Ont.
Baseline weights in the two groups of premature infants, who were born at an average of 27 weeks’ gestation and began the study at an average age of about 30 weeks’ postmenstrual age, were 970 g in the controls and 960 g in the infants who received target fortification.
The benefit from target fortification was even more dramatic in the 50% of infants fed on breast milk with the lowest protein content. In this subgroup, the 21 infants on target fortification weighed an average of 2,540 g at 36 weeks postmenstrual age, compared with an average weight of 2,170 g among 21 control infants.
“If you use standard fortification you never get [the nutrients] right. Too many nutrients will be outside [the ideal range] and those babies have a high risk of not growing,” Dr. Fusch noted in an interview.
One of the key steps in the study was measuring the protein, fat, and carbohydrate content of the breast milk that each infant received 3 days a week and using those data to guide fortification. Assessment of each breast milk specimen takes about 2 minutes, after which a technician adds the required levels of freshly prepared nutrient supplements to produce a final protein content of 3 g/dL, fat at 4.3 g/dL, and carbohydrate at 8.5 g/dL. The researchers set these levels based on an assumed daily intake of 150 mL/kg of fortified breast milk.
Dr. Fusch and his associates plan additional analyses of the data they collected in this study to look at the impact of target fortification on infant length and head circumference, metabolic responses, body composition, and neurodevelopment out to 18 months of age. They also have launched a larger, multicenter study with a similar design at 10 sites in Europe and 8 sites in North America.
The infants who stand to gain the most from target fortification are those fed donor breast milk, an increasingly popular option when breast milk from the infant’s mother is not available, but also a flawed option because this milk is usually low in protein, said Dr. Fusch, who also holds the Jack Sinclair Chair in Neonatology at the university. Target fortification is not an issue for term infants who feed normally because they usually cry to demand more milk when they lack specific nutrients. Premature infants are much more vulnerable when fed by a nasogastric tube because they will become sated simply by milk volume and then stop eating, even when they ingest an unbalanced nutrient supply.
BALTIMORE – For a premature infant, breast milk straight from Mom or a donor may not be the ideal meal.
The problem is that breast milk is often unbalanced in its content of protein, fat, and carbohydrates, and for a premature neonate fed by a nasogastric tube, unfortified breast milk can provide too little of one nutrient or too much of another. Conventional fortification of breast milk adds a standardized cocktail of nutrients that doesn’t provide an ideal balance for optimal growth.
Frequent analysis of breast milk’s nutrient content and target fortification to tweak the milk to a more ideal nutrient balance may be a way around this problem, and results from a single-center, randomized trial with 85 premature infants showed that this approach led to significantly better infant weights when measured at 36 weeks postmenstrual age, Dr. Christoph Fusch reported at the annual meeting of the Pediatric Academic Societies.
Target fortification of breast milk resulted in an average weight at 36 weeks postmenstrual age of 2,510 g among 42 infants in the intervention group, compared with an average weight of 2,280 g among 43 control infants who received breast milk that underwent routine fortification with a commercial product – a statistically significant difference for the study’s primary endpoint, said Dr. Fusch, professor of pediatrics at McMaster University and director of the neonatal intensive care unit at McMaster Children’s Hospital, both in Hamilton, Ont.
Baseline weights in the two groups of premature infants, who were born at an average of 27 weeks’ gestation and began the study at an average age of about 30 weeks’ postmenstrual age, were 970 g in the controls and 960 g in the infants who received target fortification.
The benefit from target fortification was even more dramatic in the 50% of infants fed on breast milk with the lowest protein content. In this subgroup, the 21 infants on target fortification weighed an average of 2,540 g at 36 weeks postmenstrual age, compared with an average weight of 2,170 g among 21 control infants.
“If you use standard fortification you never get [the nutrients] right. Too many nutrients will be outside [the ideal range] and those babies have a high risk of not growing,” Dr. Fusch noted in an interview.
One of the key steps in the study was measuring the protein, fat, and carbohydrate content of the breast milk that each infant received 3 days a week and using those data to guide fortification. Assessment of each breast milk specimen takes about 2 minutes, after which a technician adds the required levels of freshly prepared nutrient supplements to produce a final protein content of 3 g/dL, fat at 4.3 g/dL, and carbohydrate at 8.5 g/dL. The researchers set these levels based on an assumed daily intake of 150 mL/kg of fortified breast milk.
Dr. Fusch and his associates plan additional analyses of the data they collected in this study to look at the impact of target fortification on infant length and head circumference, metabolic responses, body composition, and neurodevelopment out to 18 months of age. They also have launched a larger, multicenter study with a similar design at 10 sites in Europe and 8 sites in North America.
The infants who stand to gain the most from target fortification are those fed donor breast milk, an increasingly popular option when breast milk from the infant’s mother is not available, but also a flawed option because this milk is usually low in protein, said Dr. Fusch, who also holds the Jack Sinclair Chair in Neonatology at the university. Target fortification is not an issue for term infants who feed normally because they usually cry to demand more milk when they lack specific nutrients. Premature infants are much more vulnerable when fed by a nasogastric tube because they will become sated simply by milk volume and then stop eating, even when they ingest an unbalanced nutrient supply.
BALTIMORE – For a premature infant, breast milk straight from Mom or a donor may not be the ideal meal.
The problem is that breast milk is often unbalanced in its content of protein, fat, and carbohydrates, and for a premature neonate fed by a nasogastric tube, unfortified breast milk can provide too little of one nutrient or too much of another. Conventional fortification of breast milk adds a standardized cocktail of nutrients that doesn’t provide an ideal balance for optimal growth.
Frequent analysis of breast milk’s nutrient content and target fortification to tweak the milk to a more ideal nutrient balance may be a way around this problem, and results from a single-center, randomized trial with 85 premature infants showed that this approach led to significantly better infant weights when measured at 36 weeks postmenstrual age, Dr. Christoph Fusch reported at the annual meeting of the Pediatric Academic Societies.
Target fortification of breast milk resulted in an average weight at 36 weeks postmenstrual age of 2,510 g among 42 infants in the intervention group, compared with an average weight of 2,280 g among 43 control infants who received breast milk that underwent routine fortification with a commercial product – a statistically significant difference for the study’s primary endpoint, said Dr. Fusch, professor of pediatrics at McMaster University and director of the neonatal intensive care unit at McMaster Children’s Hospital, both in Hamilton, Ont.
Baseline weights in the two groups of premature infants, who were born at an average of 27 weeks’ gestation and began the study at an average age of about 30 weeks’ postmenstrual age, were 970 g in the controls and 960 g in the infants who received target fortification.
The benefit from target fortification was even more dramatic in the 50% of infants fed on breast milk with the lowest protein content. In this subgroup, the 21 infants on target fortification weighed an average of 2,540 g at 36 weeks postmenstrual age, compared with an average weight of 2,170 g among 21 control infants.
“If you use standard fortification you never get [the nutrients] right. Too many nutrients will be outside [the ideal range] and those babies have a high risk of not growing,” Dr. Fusch noted in an interview.
One of the key steps in the study was measuring the protein, fat, and carbohydrate content of the breast milk that each infant received 3 days a week and using those data to guide fortification. Assessment of each breast milk specimen takes about 2 minutes, after which a technician adds the required levels of freshly prepared nutrient supplements to produce a final protein content of 3 g/dL, fat at 4.3 g/dL, and carbohydrate at 8.5 g/dL. The researchers set these levels based on an assumed daily intake of 150 mL/kg of fortified breast milk.
Dr. Fusch and his associates plan additional analyses of the data they collected in this study to look at the impact of target fortification on infant length and head circumference, metabolic responses, body composition, and neurodevelopment out to 18 months of age. They also have launched a larger, multicenter study with a similar design at 10 sites in Europe and 8 sites in North America.
The infants who stand to gain the most from target fortification are those fed donor breast milk, an increasingly popular option when breast milk from the infant’s mother is not available, but also a flawed option because this milk is usually low in protein, said Dr. Fusch, who also holds the Jack Sinclair Chair in Neonatology at the university. Target fortification is not an issue for term infants who feed normally because they usually cry to demand more milk when they lack specific nutrients. Premature infants are much more vulnerable when fed by a nasogastric tube because they will become sated simply by milk volume and then stop eating, even when they ingest an unbalanced nutrient supply.
AT THE PAS ANNUAL MEETING
Target fortification of breast milk boosts preemie growth
BALTIMORE – For a premature infant, breast milk straight from Mom or a donor may not be the ideal meal.
The problem is that breast milk is often unbalanced in its content of protein, fat, and carbohydrates, and for a premature neonate fed by a nasogastric tube, unfortified breast milk can provide too little of one nutrient or too much of another. Conventional fortification of breast milk adds a standardized cocktail of nutrients that doesn’t provide an ideal balance for optimal growth.
Frequent analysis of breast milk’s nutrient content and target fortification to tweak the milk to a more ideal nutrient balance may be a way around this problem, and results from a single-center, randomized trial with 85 premature infants showed that this approach led to significantly better infant weights when measured at 36 weeks postmenstrual age, Dr. Christoph Fusch reported at the annual meeting of the Pediatric Academic Societies.
Target fortification of breast milk resulted in an average weight at 36 weeks postmenstrual age of 2,510 g among 42 infants in the intervention group, compared with an average weight of 2,280 g among 43 control infants who received breast milk that underwent routine fortification with a commercial product – a statistically significant difference for the study’s primary endpoint, said Dr. Fusch, professor of pediatrics at McMaster University and director of the neonatal intensive care unit at McMaster Children’s Hospital, both in Hamilton, Ont.
Baseline weights in the two groups of premature infants, who were born at an average of 27 weeks’ gestation and began the study at an average age of about 30 weeks’ postmenstrual age, were 970 g in the controls and 960 g in the infants who received target fortification.
The benefit from target fortification was even more dramatic in the 50% of infants fed on breast milk with the lowest protein content. In this subgroup, the 21 infants on target fortification weighed an average of 2,540 g at 36 weeks postmenstrual age, compared with an average weight of 2,170 g among 21 control infants.
“If you use standard fortification you never get [the nutrients] right. Too many nutrients will be outside [the ideal range] and those babies have a high risk of not growing,” Dr. Fusch noted in an interview.
One of the key steps in the study was measuring the protein, fat, and carbohydrate content of the breast milk that each infant received 3 days a week and using those data to guide fortification. Assessment of each breast milk specimen takes about 2 minutes, after which a technician adds the required levels of freshly prepared nutrient supplements to produce a final protein content of 3 g/dL, fat at 4.3 g/dL, and carbohydrate at 8.5 g/dL. The researchers set these levels based on an assumed daily intake of 150 mL/kg of fortified breast milk.
Dr. Fusch and his associates plan additional analyses of the data they collected in this study to look at the impact of target fortification on infant length and head circumference, metabolic responses, body composition, and neurodevelopment out to 18 months of age. They also have launched a larger, multicenter study with a similar design at 10 sites in Europe and 8 sites in North America.
The infants who stand to gain the most from target fortification are those fed donor breast milk, an increasingly popular option when breast milk from the infant’s mother is not available, but also a flawed option because this milk is usually low in protein, said Dr. Fusch, who also holds the Jack Sinclair Chair in Neonatology at the university. Target fortification is not an issue for term infants who feed normally because they usually cry to demand more milk when they lack specific nutrients. Premature infants are much more vulnerable when fed by a nasogastric tube because they will become sated simply by milk volume and then stop eating, even when they ingest an unbalanced nutrient supply.
On Twitter @mitchelzoler
BALTIMORE – For a premature infant, breast milk straight from Mom or a donor may not be the ideal meal.
The problem is that breast milk is often unbalanced in its content of protein, fat, and carbohydrates, and for a premature neonate fed by a nasogastric tube, unfortified breast milk can provide too little of one nutrient or too much of another. Conventional fortification of breast milk adds a standardized cocktail of nutrients that doesn’t provide an ideal balance for optimal growth.
Frequent analysis of breast milk’s nutrient content and target fortification to tweak the milk to a more ideal nutrient balance may be a way around this problem, and results from a single-center, randomized trial with 85 premature infants showed that this approach led to significantly better infant weights when measured at 36 weeks postmenstrual age, Dr. Christoph Fusch reported at the annual meeting of the Pediatric Academic Societies.
Target fortification of breast milk resulted in an average weight at 36 weeks postmenstrual age of 2,510 g among 42 infants in the intervention group, compared with an average weight of 2,280 g among 43 control infants who received breast milk that underwent routine fortification with a commercial product – a statistically significant difference for the study’s primary endpoint, said Dr. Fusch, professor of pediatrics at McMaster University and director of the neonatal intensive care unit at McMaster Children’s Hospital, both in Hamilton, Ont.
Baseline weights in the two groups of premature infants, who were born at an average of 27 weeks’ gestation and began the study at an average age of about 30 weeks’ postmenstrual age, were 970 g in the controls and 960 g in the infants who received target fortification.
The benefit from target fortification was even more dramatic in the 50% of infants fed on breast milk with the lowest protein content. In this subgroup, the 21 infants on target fortification weighed an average of 2,540 g at 36 weeks postmenstrual age, compared with an average weight of 2,170 g among 21 control infants.
“If you use standard fortification you never get [the nutrients] right. Too many nutrients will be outside [the ideal range] and those babies have a high risk of not growing,” Dr. Fusch noted in an interview.
One of the key steps in the study was measuring the protein, fat, and carbohydrate content of the breast milk that each infant received 3 days a week and using those data to guide fortification. Assessment of each breast milk specimen takes about 2 minutes, after which a technician adds the required levels of freshly prepared nutrient supplements to produce a final protein content of 3 g/dL, fat at 4.3 g/dL, and carbohydrate at 8.5 g/dL. The researchers set these levels based on an assumed daily intake of 150 mL/kg of fortified breast milk.
Dr. Fusch and his associates plan additional analyses of the data they collected in this study to look at the impact of target fortification on infant length and head circumference, metabolic responses, body composition, and neurodevelopment out to 18 months of age. They also have launched a larger, multicenter study with a similar design at 10 sites in Europe and 8 sites in North America.
The infants who stand to gain the most from target fortification are those fed donor breast milk, an increasingly popular option when breast milk from the infant’s mother is not available, but also a flawed option because this milk is usually low in protein, said Dr. Fusch, who also holds the Jack Sinclair Chair in Neonatology at the university. Target fortification is not an issue for term infants who feed normally because they usually cry to demand more milk when they lack specific nutrients. Premature infants are much more vulnerable when fed by a nasogastric tube because they will become sated simply by milk volume and then stop eating, even when they ingest an unbalanced nutrient supply.
On Twitter @mitchelzoler
BALTIMORE – For a premature infant, breast milk straight from Mom or a donor may not be the ideal meal.
The problem is that breast milk is often unbalanced in its content of protein, fat, and carbohydrates, and for a premature neonate fed by a nasogastric tube, unfortified breast milk can provide too little of one nutrient or too much of another. Conventional fortification of breast milk adds a standardized cocktail of nutrients that doesn’t provide an ideal balance for optimal growth.
Frequent analysis of breast milk’s nutrient content and target fortification to tweak the milk to a more ideal nutrient balance may be a way around this problem, and results from a single-center, randomized trial with 85 premature infants showed that this approach led to significantly better infant weights when measured at 36 weeks postmenstrual age, Dr. Christoph Fusch reported at the annual meeting of the Pediatric Academic Societies.
Target fortification of breast milk resulted in an average weight at 36 weeks postmenstrual age of 2,510 g among 42 infants in the intervention group, compared with an average weight of 2,280 g among 43 control infants who received breast milk that underwent routine fortification with a commercial product – a statistically significant difference for the study’s primary endpoint, said Dr. Fusch, professor of pediatrics at McMaster University and director of the neonatal intensive care unit at McMaster Children’s Hospital, both in Hamilton, Ont.
Baseline weights in the two groups of premature infants, who were born at an average of 27 weeks’ gestation and began the study at an average age of about 30 weeks’ postmenstrual age, were 970 g in the controls and 960 g in the infants who received target fortification.
The benefit from target fortification was even more dramatic in the 50% of infants fed on breast milk with the lowest protein content. In this subgroup, the 21 infants on target fortification weighed an average of 2,540 g at 36 weeks postmenstrual age, compared with an average weight of 2,170 g among 21 control infants.
“If you use standard fortification you never get [the nutrients] right. Too many nutrients will be outside [the ideal range] and those babies have a high risk of not growing,” Dr. Fusch noted in an interview.
One of the key steps in the study was measuring the protein, fat, and carbohydrate content of the breast milk that each infant received 3 days a week and using those data to guide fortification. Assessment of each breast milk specimen takes about 2 minutes, after which a technician adds the required levels of freshly prepared nutrient supplements to produce a final protein content of 3 g/dL, fat at 4.3 g/dL, and carbohydrate at 8.5 g/dL. The researchers set these levels based on an assumed daily intake of 150 mL/kg of fortified breast milk.
Dr. Fusch and his associates plan additional analyses of the data they collected in this study to look at the impact of target fortification on infant length and head circumference, metabolic responses, body composition, and neurodevelopment out to 18 months of age. They also have launched a larger, multicenter study with a similar design at 10 sites in Europe and 8 sites in North America.
The infants who stand to gain the most from target fortification are those fed donor breast milk, an increasingly popular option when breast milk from the infant’s mother is not available, but also a flawed option because this milk is usually low in protein, said Dr. Fusch, who also holds the Jack Sinclair Chair in Neonatology at the university. Target fortification is not an issue for term infants who feed normally because they usually cry to demand more milk when they lack specific nutrients. Premature infants are much more vulnerable when fed by a nasogastric tube because they will become sated simply by milk volume and then stop eating, even when they ingest an unbalanced nutrient supply.
On Twitter @mitchelzoler
AT THE PAS ANNUAL MEETING
Key clinical point: Premature infants fed breast milk that had undergone target fortification showed significantly better growth to 36 weeks postmenstrual age, compared with control infants fed with conventionally fortified breast milk.
Major finding: Average weight after intervention was 2,510 g in infants fed target-fortified breast milk and 2,280 g in controls.
Data source: Single-center, randomized controlled study with 85 premature infants.
Disclosures: Dr. Fusch had no disclosures.
VIDEO: Preemies on early caffeine not benefited, possibly harmed
BALTIMORE – Early initiation of caffeine treatment in premature neonates on mechanical ventilation did not cut the time to when these babies could successfully wean off the ventilator, according to findings of a single-center, randomized controlled study of 83 children.
The results also showed an “unexpected” trend toward increased mortality among the neonates who received early caffeine treatment, Dr. Cynthia M. Amaro reported at the annual meeting of the Pediatric Academic Societies. This signal of elevated mortality with caffeine treatment prompted the study’s data and safety monitoring board to prematurely stop the trial, limiting enrollment to just 75% of the number originally planned in the study’s design, thereby raising questions about the reliability of the primary-endpoint finding that early caffeine treatment did not result in the benefit of a reduced time to extubation.
Dr. Amaro said that she and her associates ran the study to address what had emerged as a significant area of doubt in routine U.S. practice on how to best use caffeine treatment in this neonatal population following publication of findings from the landmark Caffeine for Apnea of Prematurity (CAP) Trial (N Engl J Med. 2006 May 18;354[20]:2112-21). Results from the CAP Trial had shown in nearly 2,000 randomized, premature infants that treatment with caffeine led to significantly fewer episodes of bronchopulmonary dysplasia as well as quicker time to extubation of mechanical ventilation. Caffeine or other methylxanthines stimulate an infant’s respiratory center to allow faster extubation.
Ever since that publication a decade ago, “clinicians have been using caffeine earlier and more liberally, without really good data to support its early use in mechanically-ventilated preterm babies,” explained Dr. Amaro, a neonatologist at the University of Miami and Holtz Children’s Hospital in Miami.
Based on the new findings from the study she reported, “we are now not routinely initiating caffeine in mechanically ventilated preterm babies and just using caffeine immediately before extubation to treat apnea of prematurity. This returns caffeine treatment to the way it was used in the CAP Trial,” she said. “Further studies are needed before we can say what is best for early treatment of these preterm babies,” Dr. Amaro said in a video interview.
Her report led to a flurry of comments during the question period, with several pediatricians voicing concern about the reliability of results from a study that followed only 83 patients because of its premature termination.
“The data and safety monitoring board’s decision is a big issue,” said Dr. Carl E. Hunt, a pediatrician at the Uniformed Services University of the Health Sciences in Bethesda, Md. “There is a literature that shows results of studies can be very different when they stop early. It’s unfortunate because we don’t have other prospective data, and it may now be hard to do a large randomized, controlled trial” of early caffeine treatment, Dr. Hunt said.
While Dr. Amaro conceded that premature termination limited her study’s size, she also asserted that her analyses confirmed the validity of the finding of no benefit from early caffeine treatment. “We projected to full enrollment, and there still was no difference in the time to first successful extubation,” she said.
Her study enrolled preterm infants during January 2013–December 2015 born at 23-30 weeks’ gestation who required mechanical ventilation during their first 5 days. Randomization assigned 41 infants to receive a 20-mg/kg bolus of caffeine, followed by a maintenance dosage of 5 mg/kg that continued until extubation, while 42 patients received placebo and did not get caffeine until just before attempted extubation. The bolus and maintenance caffeine dosages tested were identical to those used in the CAP Trial.
The researchers defined successful extubation as keeping a child off restart of mechanical ventilation for more than 24 hours. The average gestational age of the enrolled neonates was 26 weeks, their average weight was 700 g, and intubation started an average of 3 hours after delivery.
The study’s primary endpoint, age at first successful extubation, was an average of 24 days among the neonates treated with caffeine and 20 days in those on placebo, Dr. Amaro reported. Mortality occurred at an average of 30 days after delivery in the caffeine recipients and after an average of 10 days in the controls. The incidence of death was 22% in those on early caffeine and 12% among those in the placebo group, an excess of four deaths in the intervention arm that was not statically significant.
A recent review of more than 29,000 matched very-low-birth-weight infants managed in routine practice showed that neonates who received early caffeine had an adjusted mortality risk that was 23% higher than that of matched infants not receiving early caffeine, Dr. Amaro noted (J Pediatrics. 2014 May;164[5]:992-8).
The incidence of bronchopulmonary dysplasia also did not show a statistically significant difference between the two study arms, 46% among those on early caffeine and 53% in the placebo group. Patients on early caffeine also had higher rates of necrotizing enterocolitis, more episodes of necrotizing enterocolitis requiring surgery, and more intraventricular hemorrhages, but none of these differences reached statistical significance.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @mitchelzoler
Clinicians need to be very cautious starting caffeine to treat premature neonates on mechanical ventilation with the goal of reducing the time to extubation. The findings from Dr. Amaro and her associates show that we do not really know whether starting caffeine treatment early is the right thing to do.
Because their study stopped sooner than planned, I don’t believe the number of enrolled patients was large enough to provide clear guidance on when to start treatment with caffeine or another methylxanthine. We still don’t know the answer. In addition, the suggestion of excess mortality with caffeine treatment gives us no reassurance that caffeine is safe in this setting. However, as was clear in the questions and comments from some members of the audience that heard this report, some people continue to believe that early treatment with caffeine of premature infants on mechanical ventilation is appropriate.
As a result of the equivocal results in Dr. Amaro’s study, the best option is probably to go back to using the protocol tested and shown safe and effective in the 2006 report from the Caffeine for Apnea of Prematurity Trial (N Engl J Med. 2006 May 18;354[20]:2112-21). Ideally, researchers will soon run a large, randomized trial that can better address the questions that Dr. Amaro and her associates attempted to answer with their study.
Dr. Clifford W. Bogue is professor of pediatrics at Yale University, New Haven, Conn., and chaired the session where Dr. Amaro presented her report. He had no relevant disclosures. He made these comments in an interview.
Clinicians need to be very cautious starting caffeine to treat premature neonates on mechanical ventilation with the goal of reducing the time to extubation. The findings from Dr. Amaro and her associates show that we do not really know whether starting caffeine treatment early is the right thing to do.
Because their study stopped sooner than planned, I don’t believe the number of enrolled patients was large enough to provide clear guidance on when to start treatment with caffeine or another methylxanthine. We still don’t know the answer. In addition, the suggestion of excess mortality with caffeine treatment gives us no reassurance that caffeine is safe in this setting. However, as was clear in the questions and comments from some members of the audience that heard this report, some people continue to believe that early treatment with caffeine of premature infants on mechanical ventilation is appropriate.
As a result of the equivocal results in Dr. Amaro’s study, the best option is probably to go back to using the protocol tested and shown safe and effective in the 2006 report from the Caffeine for Apnea of Prematurity Trial (N Engl J Med. 2006 May 18;354[20]:2112-21). Ideally, researchers will soon run a large, randomized trial that can better address the questions that Dr. Amaro and her associates attempted to answer with their study.
Dr. Clifford W. Bogue is professor of pediatrics at Yale University, New Haven, Conn., and chaired the session where Dr. Amaro presented her report. He had no relevant disclosures. He made these comments in an interview.
Clinicians need to be very cautious starting caffeine to treat premature neonates on mechanical ventilation with the goal of reducing the time to extubation. The findings from Dr. Amaro and her associates show that we do not really know whether starting caffeine treatment early is the right thing to do.
Because their study stopped sooner than planned, I don’t believe the number of enrolled patients was large enough to provide clear guidance on when to start treatment with caffeine or another methylxanthine. We still don’t know the answer. In addition, the suggestion of excess mortality with caffeine treatment gives us no reassurance that caffeine is safe in this setting. However, as was clear in the questions and comments from some members of the audience that heard this report, some people continue to believe that early treatment with caffeine of premature infants on mechanical ventilation is appropriate.
As a result of the equivocal results in Dr. Amaro’s study, the best option is probably to go back to using the protocol tested and shown safe and effective in the 2006 report from the Caffeine for Apnea of Prematurity Trial (N Engl J Med. 2006 May 18;354[20]:2112-21). Ideally, researchers will soon run a large, randomized trial that can better address the questions that Dr. Amaro and her associates attempted to answer with their study.
Dr. Clifford W. Bogue is professor of pediatrics at Yale University, New Haven, Conn., and chaired the session where Dr. Amaro presented her report. He had no relevant disclosures. He made these comments in an interview.
BALTIMORE – Early initiation of caffeine treatment in premature neonates on mechanical ventilation did not cut the time to when these babies could successfully wean off the ventilator, according to findings of a single-center, randomized controlled study of 83 children.
The results also showed an “unexpected” trend toward increased mortality among the neonates who received early caffeine treatment, Dr. Cynthia M. Amaro reported at the annual meeting of the Pediatric Academic Societies. This signal of elevated mortality with caffeine treatment prompted the study’s data and safety monitoring board to prematurely stop the trial, limiting enrollment to just 75% of the number originally planned in the study’s design, thereby raising questions about the reliability of the primary-endpoint finding that early caffeine treatment did not result in the benefit of a reduced time to extubation.
Dr. Amaro said that she and her associates ran the study to address what had emerged as a significant area of doubt in routine U.S. practice on how to best use caffeine treatment in this neonatal population following publication of findings from the landmark Caffeine for Apnea of Prematurity (CAP) Trial (N Engl J Med. 2006 May 18;354[20]:2112-21). Results from the CAP Trial had shown in nearly 2,000 randomized, premature infants that treatment with caffeine led to significantly fewer episodes of bronchopulmonary dysplasia as well as quicker time to extubation of mechanical ventilation. Caffeine or other methylxanthines stimulate an infant’s respiratory center to allow faster extubation.
Ever since that publication a decade ago, “clinicians have been using caffeine earlier and more liberally, without really good data to support its early use in mechanically-ventilated preterm babies,” explained Dr. Amaro, a neonatologist at the University of Miami and Holtz Children’s Hospital in Miami.
Based on the new findings from the study she reported, “we are now not routinely initiating caffeine in mechanically ventilated preterm babies and just using caffeine immediately before extubation to treat apnea of prematurity. This returns caffeine treatment to the way it was used in the CAP Trial,” she said. “Further studies are needed before we can say what is best for early treatment of these preterm babies,” Dr. Amaro said in a video interview.
Her report led to a flurry of comments during the question period, with several pediatricians voicing concern about the reliability of results from a study that followed only 83 patients because of its premature termination.
“The data and safety monitoring board’s decision is a big issue,” said Dr. Carl E. Hunt, a pediatrician at the Uniformed Services University of the Health Sciences in Bethesda, Md. “There is a literature that shows results of studies can be very different when they stop early. It’s unfortunate because we don’t have other prospective data, and it may now be hard to do a large randomized, controlled trial” of early caffeine treatment, Dr. Hunt said.
While Dr. Amaro conceded that premature termination limited her study’s size, she also asserted that her analyses confirmed the validity of the finding of no benefit from early caffeine treatment. “We projected to full enrollment, and there still was no difference in the time to first successful extubation,” she said.
Her study enrolled preterm infants during January 2013–December 2015 born at 23-30 weeks’ gestation who required mechanical ventilation during their first 5 days. Randomization assigned 41 infants to receive a 20-mg/kg bolus of caffeine, followed by a maintenance dosage of 5 mg/kg that continued until extubation, while 42 patients received placebo and did not get caffeine until just before attempted extubation. The bolus and maintenance caffeine dosages tested were identical to those used in the CAP Trial.
The researchers defined successful extubation as keeping a child off restart of mechanical ventilation for more than 24 hours. The average gestational age of the enrolled neonates was 26 weeks, their average weight was 700 g, and intubation started an average of 3 hours after delivery.
The study’s primary endpoint, age at first successful extubation, was an average of 24 days among the neonates treated with caffeine and 20 days in those on placebo, Dr. Amaro reported. Mortality occurred at an average of 30 days after delivery in the caffeine recipients and after an average of 10 days in the controls. The incidence of death was 22% in those on early caffeine and 12% among those in the placebo group, an excess of four deaths in the intervention arm that was not statically significant.
A recent review of more than 29,000 matched very-low-birth-weight infants managed in routine practice showed that neonates who received early caffeine had an adjusted mortality risk that was 23% higher than that of matched infants not receiving early caffeine, Dr. Amaro noted (J Pediatrics. 2014 May;164[5]:992-8).
The incidence of bronchopulmonary dysplasia also did not show a statistically significant difference between the two study arms, 46% among those on early caffeine and 53% in the placebo group. Patients on early caffeine also had higher rates of necrotizing enterocolitis, more episodes of necrotizing enterocolitis requiring surgery, and more intraventricular hemorrhages, but none of these differences reached statistical significance.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @mitchelzoler
BALTIMORE – Early initiation of caffeine treatment in premature neonates on mechanical ventilation did not cut the time to when these babies could successfully wean off the ventilator, according to findings of a single-center, randomized controlled study of 83 children.
The results also showed an “unexpected” trend toward increased mortality among the neonates who received early caffeine treatment, Dr. Cynthia M. Amaro reported at the annual meeting of the Pediatric Academic Societies. This signal of elevated mortality with caffeine treatment prompted the study’s data and safety monitoring board to prematurely stop the trial, limiting enrollment to just 75% of the number originally planned in the study’s design, thereby raising questions about the reliability of the primary-endpoint finding that early caffeine treatment did not result in the benefit of a reduced time to extubation.
Dr. Amaro said that she and her associates ran the study to address what had emerged as a significant area of doubt in routine U.S. practice on how to best use caffeine treatment in this neonatal population following publication of findings from the landmark Caffeine for Apnea of Prematurity (CAP) Trial (N Engl J Med. 2006 May 18;354[20]:2112-21). Results from the CAP Trial had shown in nearly 2,000 randomized, premature infants that treatment with caffeine led to significantly fewer episodes of bronchopulmonary dysplasia as well as quicker time to extubation of mechanical ventilation. Caffeine or other methylxanthines stimulate an infant’s respiratory center to allow faster extubation.
Ever since that publication a decade ago, “clinicians have been using caffeine earlier and more liberally, without really good data to support its early use in mechanically-ventilated preterm babies,” explained Dr. Amaro, a neonatologist at the University of Miami and Holtz Children’s Hospital in Miami.
Based on the new findings from the study she reported, “we are now not routinely initiating caffeine in mechanically ventilated preterm babies and just using caffeine immediately before extubation to treat apnea of prematurity. This returns caffeine treatment to the way it was used in the CAP Trial,” she said. “Further studies are needed before we can say what is best for early treatment of these preterm babies,” Dr. Amaro said in a video interview.
Her report led to a flurry of comments during the question period, with several pediatricians voicing concern about the reliability of results from a study that followed only 83 patients because of its premature termination.
“The data and safety monitoring board’s decision is a big issue,” said Dr. Carl E. Hunt, a pediatrician at the Uniformed Services University of the Health Sciences in Bethesda, Md. “There is a literature that shows results of studies can be very different when they stop early. It’s unfortunate because we don’t have other prospective data, and it may now be hard to do a large randomized, controlled trial” of early caffeine treatment, Dr. Hunt said.
While Dr. Amaro conceded that premature termination limited her study’s size, she also asserted that her analyses confirmed the validity of the finding of no benefit from early caffeine treatment. “We projected to full enrollment, and there still was no difference in the time to first successful extubation,” she said.
Her study enrolled preterm infants during January 2013–December 2015 born at 23-30 weeks’ gestation who required mechanical ventilation during their first 5 days. Randomization assigned 41 infants to receive a 20-mg/kg bolus of caffeine, followed by a maintenance dosage of 5 mg/kg that continued until extubation, while 42 patients received placebo and did not get caffeine until just before attempted extubation. The bolus and maintenance caffeine dosages tested were identical to those used in the CAP Trial.
The researchers defined successful extubation as keeping a child off restart of mechanical ventilation for more than 24 hours. The average gestational age of the enrolled neonates was 26 weeks, their average weight was 700 g, and intubation started an average of 3 hours after delivery.
The study’s primary endpoint, age at first successful extubation, was an average of 24 days among the neonates treated with caffeine and 20 days in those on placebo, Dr. Amaro reported. Mortality occurred at an average of 30 days after delivery in the caffeine recipients and after an average of 10 days in the controls. The incidence of death was 22% in those on early caffeine and 12% among those in the placebo group, an excess of four deaths in the intervention arm that was not statically significant.
A recent review of more than 29,000 matched very-low-birth-weight infants managed in routine practice showed that neonates who received early caffeine had an adjusted mortality risk that was 23% higher than that of matched infants not receiving early caffeine, Dr. Amaro noted (J Pediatrics. 2014 May;164[5]:992-8).
The incidence of bronchopulmonary dysplasia also did not show a statistically significant difference between the two study arms, 46% among those on early caffeine and 53% in the placebo group. Patients on early caffeine also had higher rates of necrotizing enterocolitis, more episodes of necrotizing enterocolitis requiring surgery, and more intraventricular hemorrhages, but none of these differences reached statistical significance.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @mitchelzoler
AT THE PAS ANNUAL MEETING
Key clinical point: Early caffeine treatment of premature neonates on mechanical ventilation did not reduce the time to extubation and produced a trend toward increased mortality.
Major finding: The age of first successful extubation averaged 24 days in infants receiving caffeine and 20 days among controls.
Data source: Single-center, randomized, controlled study of 83 premature neonates.
Disclosures: Dr. Amaro had no disclosures.
Vaccination Rates High at Kindergarten Entry, but Gaps Remain
BALTIMORE – Most families’ kindergarteners met the full vaccination requirements of their state in a 2013 national survey, although 17% of parents were notified that their children still needed vaccines to comply with state requirements.
Of those 17% of families, however, 7.5% claimed exemptions from their states’ vaccination requirements at school entry, according to a study conducted by Philip Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention.
Using data from the 1,465 parents who participated in the 2013 National Immunization Survey–Kindergarten (NIS-K,), Dr. Smith and his colleagues found that among the required vaccines, full coverage (five or more doses) was lowest for the DTaP vaccine, at 88.5% of 5- to 7-year-olds. Next was the varicella vaccine, with 89.4% of children having received at least two doses. For the inactivated polio vaccine, 90.9% of children had received at least four doses. The highest rate of full coverage – 91.8% – was for the MMR vaccine.
Whether children attended public or private school didn’t make a difference in vaccination rates. However, for children who had not entered kindergarten, “vaccination coverage was significantly lower than coverage for children who had entered kindergarten,” at least in part because those children were younger than those who had entered kindergarten, said Dr. Smith.
Health insurance status did not make a difference in the likelihood that a family would receive notification that their kindergartener needed vaccinations, implying that the differences “may not be attributable to access to primary care,” wrote Dr. Smith, presenting his work at a poster session of the annual meeting of the Pediatric Academic Societies.
The number of parents overall who claimed an exemption was “really, really small,” said Dr. Smith, just 1.9% of all families surveyed. He noted that his work shows that most of the children who have not met their state’s full immunization requirements for school entry do not come from families who seek exemption from the requirements.
Limitations of the survey, said Dr. Smith and his colleagues, included the inability to determine vaccination rates at the precise time of kindergarten entry. “As a consequence, our estimates of differences in vaccination coverage that is associated with notification as of the date of school entry may underestimate the true differences,” they wrote. Also, the small sample size made it difficult to ascertain the proportion of parents who took exemptions from vaccination of their child for medical, religious, or philosophical reasons.
“While our findings show that national vaccination coverage at school entry was high and exemption levels were low, some children remained undervaccinated after the start of the school year despite efforts of school vaccination programs to notify parents about needed vaccines,” wrote Dr. Smith and his coauthors.
The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
BALTIMORE – Most families’ kindergarteners met the full vaccination requirements of their state in a 2013 national survey, although 17% of parents were notified that their children still needed vaccines to comply with state requirements.
Of those 17% of families, however, 7.5% claimed exemptions from their states’ vaccination requirements at school entry, according to a study conducted by Philip Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention.
Using data from the 1,465 parents who participated in the 2013 National Immunization Survey–Kindergarten (NIS-K,), Dr. Smith and his colleagues found that among the required vaccines, full coverage (five or more doses) was lowest for the DTaP vaccine, at 88.5% of 5- to 7-year-olds. Next was the varicella vaccine, with 89.4% of children having received at least two doses. For the inactivated polio vaccine, 90.9% of children had received at least four doses. The highest rate of full coverage – 91.8% – was for the MMR vaccine.
Whether children attended public or private school didn’t make a difference in vaccination rates. However, for children who had not entered kindergarten, “vaccination coverage was significantly lower than coverage for children who had entered kindergarten,” at least in part because those children were younger than those who had entered kindergarten, said Dr. Smith.
Health insurance status did not make a difference in the likelihood that a family would receive notification that their kindergartener needed vaccinations, implying that the differences “may not be attributable to access to primary care,” wrote Dr. Smith, presenting his work at a poster session of the annual meeting of the Pediatric Academic Societies.
The number of parents overall who claimed an exemption was “really, really small,” said Dr. Smith, just 1.9% of all families surveyed. He noted that his work shows that most of the children who have not met their state’s full immunization requirements for school entry do not come from families who seek exemption from the requirements.
Limitations of the survey, said Dr. Smith and his colleagues, included the inability to determine vaccination rates at the precise time of kindergarten entry. “As a consequence, our estimates of differences in vaccination coverage that is associated with notification as of the date of school entry may underestimate the true differences,” they wrote. Also, the small sample size made it difficult to ascertain the proportion of parents who took exemptions from vaccination of their child for medical, religious, or philosophical reasons.
“While our findings show that national vaccination coverage at school entry was high and exemption levels were low, some children remained undervaccinated after the start of the school year despite efforts of school vaccination programs to notify parents about needed vaccines,” wrote Dr. Smith and his coauthors.
The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
BALTIMORE – Most families’ kindergarteners met the full vaccination requirements of their state in a 2013 national survey, although 17% of parents were notified that their children still needed vaccines to comply with state requirements.
Of those 17% of families, however, 7.5% claimed exemptions from their states’ vaccination requirements at school entry, according to a study conducted by Philip Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention.
Using data from the 1,465 parents who participated in the 2013 National Immunization Survey–Kindergarten (NIS-K,), Dr. Smith and his colleagues found that among the required vaccines, full coverage (five or more doses) was lowest for the DTaP vaccine, at 88.5% of 5- to 7-year-olds. Next was the varicella vaccine, with 89.4% of children having received at least two doses. For the inactivated polio vaccine, 90.9% of children had received at least four doses. The highest rate of full coverage – 91.8% – was for the MMR vaccine.
Whether children attended public or private school didn’t make a difference in vaccination rates. However, for children who had not entered kindergarten, “vaccination coverage was significantly lower than coverage for children who had entered kindergarten,” at least in part because those children were younger than those who had entered kindergarten, said Dr. Smith.
Health insurance status did not make a difference in the likelihood that a family would receive notification that their kindergartener needed vaccinations, implying that the differences “may not be attributable to access to primary care,” wrote Dr. Smith, presenting his work at a poster session of the annual meeting of the Pediatric Academic Societies.
The number of parents overall who claimed an exemption was “really, really small,” said Dr. Smith, just 1.9% of all families surveyed. He noted that his work shows that most of the children who have not met their state’s full immunization requirements for school entry do not come from families who seek exemption from the requirements.
Limitations of the survey, said Dr. Smith and his colleagues, included the inability to determine vaccination rates at the precise time of kindergarten entry. “As a consequence, our estimates of differences in vaccination coverage that is associated with notification as of the date of school entry may underestimate the true differences,” they wrote. Also, the small sample size made it difficult to ascertain the proportion of parents who took exemptions from vaccination of their child for medical, religious, or philosophical reasons.
“While our findings show that national vaccination coverage at school entry was high and exemption levels were low, some children remained undervaccinated after the start of the school year despite efforts of school vaccination programs to notify parents about needed vaccines,” wrote Dr. Smith and his coauthors.
The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
AT THE PAS ANNUAL MEETING
Vaccination rates high at kindergarten entry, but gaps remain
BALTIMORE – Most families’ kindergarteners met the full vaccination requirements of their state in a 2013 national survey, although 17% of parents were notified that their children still needed vaccines to comply with state requirements.
Of those 17% of families, however, 7.5% claimed exemptions from their states’ vaccination requirements at school entry, according to a study conducted by Philip Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention.
Using data from the 1,465 parents who participated in the 2013 National Immunization Survey–Kindergarten (NIS-K,), Dr. Smith and his colleagues found that among the required vaccines, full coverage (five or more doses) was lowest for the DTaP vaccine, at 88.5% of 5- to 7-year-olds. Next was the varicella vaccine, with 89.4% of children having received at least two doses. For the inactivated polio vaccine, 90.9% of children had received at least four doses. The highest rate of full coverage – 91.8% – was for the MMR vaccine.
Whether children attended public or private school didn’t make a difference in vaccination rates. However, for children who had not entered kindergarten, “vaccination coverage was significantly lower than coverage for children who had entered kindergarten,” at least in part because those children were younger than those who had entered kindergarten, said Dr. Smith.
Health insurance status did not make a difference in the likelihood that a family would receive notification that their kindergartener needed vaccinations, implying that the differences “may not be attributable to access to primary care,” wrote Dr. Smith, presenting his work at a poster session of the annual meeting of the Pediatric Academic Societies.
The number of parents overall who claimed an exemption was “really, really small,” said Dr. Smith, just 1.9% of all families surveyed. He noted that his work shows that most of the children who have not met their state’s full immunization requirements for school entry do not come from families who seek exemption from the requirements.
Limitations of the survey, said Dr. Smith and his colleagues, included the inability to determine vaccination rates at the precise time of kindergarten entry. “As a consequence, our estimates of differences in vaccination coverage that is associated with notification as of the date of school entry may underestimate the true differences,” they wrote. Also, the small sample size made it difficult to ascertain the proportion of parents who took exemptions from vaccination of their child for medical, religious, or philosophical reasons.
“While our findings show that national vaccination coverage at school entry was high and exemption levels were low, some children remained undervaccinated after the start of the school year despite efforts of school vaccination programs to notify parents about needed vaccines,” wrote Dr. Smith and his coauthors.
The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
On Twitter @karioakes
BALTIMORE – Most families’ kindergarteners met the full vaccination requirements of their state in a 2013 national survey, although 17% of parents were notified that their children still needed vaccines to comply with state requirements.
Of those 17% of families, however, 7.5% claimed exemptions from their states’ vaccination requirements at school entry, according to a study conducted by Philip Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention.
Using data from the 1,465 parents who participated in the 2013 National Immunization Survey–Kindergarten (NIS-K,), Dr. Smith and his colleagues found that among the required vaccines, full coverage (five or more doses) was lowest for the DTaP vaccine, at 88.5% of 5- to 7-year-olds. Next was the varicella vaccine, with 89.4% of children having received at least two doses. For the inactivated polio vaccine, 90.9% of children had received at least four doses. The highest rate of full coverage – 91.8% – was for the MMR vaccine.
Whether children attended public or private school didn’t make a difference in vaccination rates. However, for children who had not entered kindergarten, “vaccination coverage was significantly lower than coverage for children who had entered kindergarten,” at least in part because those children were younger than those who had entered kindergarten, said Dr. Smith.
Health insurance status did not make a difference in the likelihood that a family would receive notification that their kindergartener needed vaccinations, implying that the differences “may not be attributable to access to primary care,” wrote Dr. Smith, presenting his work at a poster session of the annual meeting of the Pediatric Academic Societies.
The number of parents overall who claimed an exemption was “really, really small,” said Dr. Smith, just 1.9% of all families surveyed. He noted that his work shows that most of the children who have not met their state’s full immunization requirements for school entry do not come from families who seek exemption from the requirements.
Limitations of the survey, said Dr. Smith and his colleagues, included the inability to determine vaccination rates at the precise time of kindergarten entry. “As a consequence, our estimates of differences in vaccination coverage that is associated with notification as of the date of school entry may underestimate the true differences,” they wrote. Also, the small sample size made it difficult to ascertain the proportion of parents who took exemptions from vaccination of their child for medical, religious, or philosophical reasons.
“While our findings show that national vaccination coverage at school entry was high and exemption levels were low, some children remained undervaccinated after the start of the school year despite efforts of school vaccination programs to notify parents about needed vaccines,” wrote Dr. Smith and his coauthors.
The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
On Twitter @karioakes
BALTIMORE – Most families’ kindergarteners met the full vaccination requirements of their state in a 2013 national survey, although 17% of parents were notified that their children still needed vaccines to comply with state requirements.
Of those 17% of families, however, 7.5% claimed exemptions from their states’ vaccination requirements at school entry, according to a study conducted by Philip Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention.
Using data from the 1,465 parents who participated in the 2013 National Immunization Survey–Kindergarten (NIS-K,), Dr. Smith and his colleagues found that among the required vaccines, full coverage (five or more doses) was lowest for the DTaP vaccine, at 88.5% of 5- to 7-year-olds. Next was the varicella vaccine, with 89.4% of children having received at least two doses. For the inactivated polio vaccine, 90.9% of children had received at least four doses. The highest rate of full coverage – 91.8% – was for the MMR vaccine.
Whether children attended public or private school didn’t make a difference in vaccination rates. However, for children who had not entered kindergarten, “vaccination coverage was significantly lower than coverage for children who had entered kindergarten,” at least in part because those children were younger than those who had entered kindergarten, said Dr. Smith.
Health insurance status did not make a difference in the likelihood that a family would receive notification that their kindergartener needed vaccinations, implying that the differences “may not be attributable to access to primary care,” wrote Dr. Smith, presenting his work at a poster session of the annual meeting of the Pediatric Academic Societies.
The number of parents overall who claimed an exemption was “really, really small,” said Dr. Smith, just 1.9% of all families surveyed. He noted that his work shows that most of the children who have not met their state’s full immunization requirements for school entry do not come from families who seek exemption from the requirements.
Limitations of the survey, said Dr. Smith and his colleagues, included the inability to determine vaccination rates at the precise time of kindergarten entry. “As a consequence, our estimates of differences in vaccination coverage that is associated with notification as of the date of school entry may underestimate the true differences,” they wrote. Also, the small sample size made it difficult to ascertain the proportion of parents who took exemptions from vaccination of their child for medical, religious, or philosophical reasons.
“While our findings show that national vaccination coverage at school entry was high and exemption levels were low, some children remained undervaccinated after the start of the school year despite efforts of school vaccination programs to notify parents about needed vaccines,” wrote Dr. Smith and his coauthors.
The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
On Twitter @karioakes
AT THE PAS ANNUAL MEETING
Key clinical point: All but 17% of 5- to 7-year-olds received their full complement of childhood immunizations in a 2013 study.
Major finding: Of the 17% of 1,465 who were notified of missing immunizations, 7.5% claimed an exemption from vaccination. This is just 1.9% of the total.
Data source: The 2013 National Immunization Survey–Kindergarten (NIS-K), a physician record–verified phone survey of 1,465 parents.
Disclosures: The NIS-K is conducted by the Centers for Disease Control and Prevention, where Dr. Smith is employed. Dr. Smith reported no relevant financial disclosures.
Congenital Heart Disease Screening Cuts Infant Mortality
BALTIMORE – The mandate to screen all U.S.-born neonates for critical congenital heart disease that started in 2011 has had an apparent effect on infant mortality.
By 2013, national U.S. data showed that the number of U.S. infants who died attributable to congenital heart disease had dropped by a small but statistically significant percentage, compared with a reference year prior to initiation of the mandate, 2006, Dr. Jagjit S. Teji reported in a poster at the annual meeting of the Pediatric Academic Societies.
“This is the first report on the impact of newborn screening for critical congenital heart disease,” said Dr. Teji, a neonatologist at Northwestern University in Chicago.
He analyzed birth and death records from the U.S. National Center for Health Statistics and calculated that infant mortality in 2013, compared with 2006, included roughly 100 fewer infants deaths attributable to congenital heart disease, a statistically significant difference, after adjusting for differences in variables between the 2 years that could affect mortality, including gestational ages at delivery, birth weight, maternal age, race, ethnicity, and marital status. The decrease occurred despite an overall increase in U.S. births of about 8% from 2006 to 2013.
In 2013, the rate of infant mortality was 0.027%, while in 2006 it was 0.032%, Dr. Teji reported. The decrease that appeared attributable to early screening for critical congenital heart disease was especially notable because by 2013 only two-thirds of states had a rule in place mandating newborn screening following the 2011 recommendation from the Department of Health & Human Services to U.S. clinicians to noninvasively measure blood oxygenation levels in the upper and lower limbs of newborns, using pulse oximetry, Dr. Teji said. By April 2016, this had grown to 48 states with mandates for newborn screening of critical congenital heart disease, usually performed just before newborns are discharged or after they are 24 hours old. Idaho and Wyoming are the exceptions.
Dr. Teji had no relevant financial disclosures.
BALTIMORE – The mandate to screen all U.S.-born neonates for critical congenital heart disease that started in 2011 has had an apparent effect on infant mortality.
By 2013, national U.S. data showed that the number of U.S. infants who died attributable to congenital heart disease had dropped by a small but statistically significant percentage, compared with a reference year prior to initiation of the mandate, 2006, Dr. Jagjit S. Teji reported in a poster at the annual meeting of the Pediatric Academic Societies.
“This is the first report on the impact of newborn screening for critical congenital heart disease,” said Dr. Teji, a neonatologist at Northwestern University in Chicago.
He analyzed birth and death records from the U.S. National Center for Health Statistics and calculated that infant mortality in 2013, compared with 2006, included roughly 100 fewer infants deaths attributable to congenital heart disease, a statistically significant difference, after adjusting for differences in variables between the 2 years that could affect mortality, including gestational ages at delivery, birth weight, maternal age, race, ethnicity, and marital status. The decrease occurred despite an overall increase in U.S. births of about 8% from 2006 to 2013.
In 2013, the rate of infant mortality was 0.027%, while in 2006 it was 0.032%, Dr. Teji reported. The decrease that appeared attributable to early screening for critical congenital heart disease was especially notable because by 2013 only two-thirds of states had a rule in place mandating newborn screening following the 2011 recommendation from the Department of Health & Human Services to U.S. clinicians to noninvasively measure blood oxygenation levels in the upper and lower limbs of newborns, using pulse oximetry, Dr. Teji said. By April 2016, this had grown to 48 states with mandates for newborn screening of critical congenital heart disease, usually performed just before newborns are discharged or after they are 24 hours old. Idaho and Wyoming are the exceptions.
Dr. Teji had no relevant financial disclosures.
BALTIMORE – The mandate to screen all U.S.-born neonates for critical congenital heart disease that started in 2011 has had an apparent effect on infant mortality.
By 2013, national U.S. data showed that the number of U.S. infants who died attributable to congenital heart disease had dropped by a small but statistically significant percentage, compared with a reference year prior to initiation of the mandate, 2006, Dr. Jagjit S. Teji reported in a poster at the annual meeting of the Pediatric Academic Societies.
“This is the first report on the impact of newborn screening for critical congenital heart disease,” said Dr. Teji, a neonatologist at Northwestern University in Chicago.
He analyzed birth and death records from the U.S. National Center for Health Statistics and calculated that infant mortality in 2013, compared with 2006, included roughly 100 fewer infants deaths attributable to congenital heart disease, a statistically significant difference, after adjusting for differences in variables between the 2 years that could affect mortality, including gestational ages at delivery, birth weight, maternal age, race, ethnicity, and marital status. The decrease occurred despite an overall increase in U.S. births of about 8% from 2006 to 2013.
In 2013, the rate of infant mortality was 0.027%, while in 2006 it was 0.032%, Dr. Teji reported. The decrease that appeared attributable to early screening for critical congenital heart disease was especially notable because by 2013 only two-thirds of states had a rule in place mandating newborn screening following the 2011 recommendation from the Department of Health & Human Services to U.S. clinicians to noninvasively measure blood oxygenation levels in the upper and lower limbs of newborns, using pulse oximetry, Dr. Teji said. By April 2016, this had grown to 48 states with mandates for newborn screening of critical congenital heart disease, usually performed just before newborns are discharged or after they are 24 hours old. Idaho and Wyoming are the exceptions.
Dr. Teji had no relevant financial disclosures.
AT THE PAS ANNUAL MEETING
