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AYA cancer survivors struggle with social functioning
New research suggests young cancer survivors struggle to get their social lives “back to normal” within the first 2 years of their diagnosis.
The study showed that adolescents and young adults (AYAs) with cancer had significantly worse social functioning than the general population around the time of cancer diagnosis as well as 1 year and 2 years later.
These findings were published in Cancer.
“The research is important to help these young survivors better reintegrate into society,” said study author Brad Zebrack, PhD, of the University of Michigan in Ann Arbor.
He and his colleagues collected data from 141 AYA cancer patients (ages 14 to 39) who visited 1 of 5 US medical facilities between March 2008 and April 2010.
The patients completed a self-report measure of social functioning within the first 4 months of diagnosis, then again at 12 months and 24 months.
Compared to the general population, the AYA cancer patients had significantly worse social functioning scores at all time points:
- Around the time of diagnosis—52.0 vs 85.1 (P<0.001)
- At 12 months—73.1 vs 85.1 (P<0.001)
- At 24 months—69.2 vs 85.1 (P<0.001).
Overall, the patients did experience improvements in social functioning from baseline to the 12-month time point, but their scores remained stable after that.
The researchers noted that 9% of patients had consistently high/normal social functioning, 47% had improvements in social functioning over time, 13% had worsening social functioning over time, and 32% had consistently low social functioning.
“This finding highlights the need to screen, identify, and respond to the needs of high-risk young adult-adolescent patients at the time of diagnosis and then monitor them over time,” Dr Zebrack said.
“They are likely the ones most in need of help in managing work, school, and potentially problematic relationships with family members and friends.”
New research suggests young cancer survivors struggle to get their social lives “back to normal” within the first 2 years of their diagnosis.
The study showed that adolescents and young adults (AYAs) with cancer had significantly worse social functioning than the general population around the time of cancer diagnosis as well as 1 year and 2 years later.
These findings were published in Cancer.
“The research is important to help these young survivors better reintegrate into society,” said study author Brad Zebrack, PhD, of the University of Michigan in Ann Arbor.
He and his colleagues collected data from 141 AYA cancer patients (ages 14 to 39) who visited 1 of 5 US medical facilities between March 2008 and April 2010.
The patients completed a self-report measure of social functioning within the first 4 months of diagnosis, then again at 12 months and 24 months.
Compared to the general population, the AYA cancer patients had significantly worse social functioning scores at all time points:
- Around the time of diagnosis—52.0 vs 85.1 (P<0.001)
- At 12 months—73.1 vs 85.1 (P<0.001)
- At 24 months—69.2 vs 85.1 (P<0.001).
Overall, the patients did experience improvements in social functioning from baseline to the 12-month time point, but their scores remained stable after that.
The researchers noted that 9% of patients had consistently high/normal social functioning, 47% had improvements in social functioning over time, 13% had worsening social functioning over time, and 32% had consistently low social functioning.
“This finding highlights the need to screen, identify, and respond to the needs of high-risk young adult-adolescent patients at the time of diagnosis and then monitor them over time,” Dr Zebrack said.
“They are likely the ones most in need of help in managing work, school, and potentially problematic relationships with family members and friends.”
New research suggests young cancer survivors struggle to get their social lives “back to normal” within the first 2 years of their diagnosis.
The study showed that adolescents and young adults (AYAs) with cancer had significantly worse social functioning than the general population around the time of cancer diagnosis as well as 1 year and 2 years later.
These findings were published in Cancer.
“The research is important to help these young survivors better reintegrate into society,” said study author Brad Zebrack, PhD, of the University of Michigan in Ann Arbor.
He and his colleagues collected data from 141 AYA cancer patients (ages 14 to 39) who visited 1 of 5 US medical facilities between March 2008 and April 2010.
The patients completed a self-report measure of social functioning within the first 4 months of diagnosis, then again at 12 months and 24 months.
Compared to the general population, the AYA cancer patients had significantly worse social functioning scores at all time points:
- Around the time of diagnosis—52.0 vs 85.1 (P<0.001)
- At 12 months—73.1 vs 85.1 (P<0.001)
- At 24 months—69.2 vs 85.1 (P<0.001).
Overall, the patients did experience improvements in social functioning from baseline to the 12-month time point, but their scores remained stable after that.
The researchers noted that 9% of patients had consistently high/normal social functioning, 47% had improvements in social functioning over time, 13% had worsening social functioning over time, and 32% had consistently low social functioning.
“This finding highlights the need to screen, identify, and respond to the needs of high-risk young adult-adolescent patients at the time of diagnosis and then monitor them over time,” Dr Zebrack said.
“They are likely the ones most in need of help in managing work, school, and potentially problematic relationships with family members and friends.”
Statewide QI learning collaboratives improve asthma care
Care of children with asthma can be improved using statewide quality improvement (QI) learning collaboratives, said Judith C. Dolins, of the American Academy of Pediatrics (AAP), Elk Grove Village, Ill., and her associates.
AAP chapters demonstrated this through their implementation of the Chapter Quality Network (CQN) project, which was supported by the national organization. This project sought to encourage practice changes in asthma care in a number of states using statewide QI learning collaboratives and lead practices to implement the National Heart, Lung, and Blood Institute’s (NHLBI) 2007 asthma guidelines over the course of four time periods, which the researchers referred to as waves. In nine states, 19 AAP chapters engaged 180 practices to participate, and involved 749 pediatricians treating 45,431 patients (Pediatrics. 2017. doi: 10.1542/peds.2016-1612).
Across all waves, practices had reasonably high baseline use of the stepwise approach (81%-89%) and a controller medication for patients with persistent asthma (74%-88%). The patients with a current written asthma action plan increased from 49%-57% to 75%-91%. Physicians’ and parents’ ratings of asthma in children as “well controlled” rose modestly from 58%-63% to 71%-74% and from 67%-73% to 78%-87%, respectively. Patients receiving self-management materials increased from 57%-62% to 62%-88%.
Here’s how the project worked. The CQN had three linked frameworks.: One provided a methodology for spreading practice changes, another outlined the elements of care, and a third provided a framework so the practices could test, implement, and adapt changes.
A national AAP leadership team of experts in asthma care, QI, and primary care practice systems developed a set of key drivers and interventions, and an implementation guide that included resources, tools and methods, and a set of measures for the chapters. They also designed reporting tools and a curriculum fostering QI learning by chapter leaders. Then, in a state chapter leadership learning network and a practice collaborative model in each state, there were “multiple in-person learning sessions and defined action periods, best practices, and tests of change that were spread and incorporated” for the chapters to use, according to the study report.
Chapters in each state had monthly webinars and two in-person learning sessions for participating practices. They also reviewed data reports at the state and practice level and provided coaching for practices.
Practices were asked to “incorporate optimal NHLBI asthma care practices, including assessment of control, a stepwise approach to treatment, appropriate use of controller medication, and an updated asthma action plan for self-management.” Other interventions included use of an asthma encounter form (which collected 16 measures, including outcome and process measures that were entered into a national database at least monthly); introduction of population registries; workflow assessment; motivational interviews; plan-do-study-act cycles for QI; and review of data for QI.
All the physicians were eligible to earn MOC part 4 credit and continuing medical education credit, and 80% of the physicians did get MOC credit across the 4 waves.
“Our findings are notable for achieving improvement in asthma care through training multiple state coordinating entities instead of directly leading the learning collaborative itself. Few other projects have achieved this level of results in pediatric practice improvement in asthma care on such a widespread scale across multiple states. This project may serve as a model for other statewide and national organizations attempting to achieve improvements in population health through support and training for statewide organizations that, in turn, support individual health care providers and practices,” Ms. Dolins and her associates said. “Although none of the waves achieved the preset goal of 90%, all showed substantial improvement and remarkable consistency in the rate of improvement. We, therefore, regarded the project as an overall success.”
The study was funded by the Merck Childhood Asthma Network, American Board of Pediatrics Foundation, American Academy of Pediatrics Friends of Children Fund, the JPB Foundation, and GlaxoSmithKline. Ms. Dolins and Mr. Wise received salary support. Ms. Powell and Dr. Stemmler received consulting fees.
We can do a better job of taking care of our patients. And in no other area is there more room for quality improvement (QI) than in ambulatory care. In the article by Dolins et al., substantial improvements were reported in outpatient management meeting the standard of care for asthma. In my experience, doing so not only gives children a better functional outcome but also saves costs by avoiding unnecessary ED visits and hospitalization and generates new dollars for pediatric offices through the additional services they provide. We have seen similar improvements in our own work in South Carolina and Tennessee. The practices that have wanted to become involved in our asthma QI are those that are already doing a better than average job. Yet, they still generate substantial additional improvements.
The AAP study relied heavily on national experts and standards. Although their input is valued, the true advantage of QI is the opportunity for pediatricians and their staff at the service delivery level to generate their own changes within the context of a learning collaborative. True improvement and innovation is facilitated by allowing flexibility at the local level and sharing the ideas that result. Those that design the QI efforts of the future need to make sure they allow for local expertise rather than leaning too heavily on centrally predetermined change concepts.
Part IV Maintenance of Certification requirements from the American Board of Pediatrics help provide momentum for successful pediatric QI. The National Improvement Partnership Network has formed pediatric outpatient learning collaboratives to share ideas. As we identify more successes with ambulatory care QI, as more and more organizations like AAP state chapters become involved, as all practices – rather than just the best – recognize the obligation to promote quality, we have a tremendous opportunity to improve the developmental and health outcomes of the children. QI can promote work and cost efficiencies that facilitate our work as pediatricians, making our lives more productive and rewarding.
Francis E. Rushton Jr, MD, is a pediatrician and medical director of South Carolina’s QTIP (Quality Through Innovation in Pediatrics) network and the Quality Director for PHIIT (Pediatric Health Improvement In Tennessee). He reported not having any relevant financial disclosures.
We can do a better job of taking care of our patients. And in no other area is there more room for quality improvement (QI) than in ambulatory care. In the article by Dolins et al., substantial improvements were reported in outpatient management meeting the standard of care for asthma. In my experience, doing so not only gives children a better functional outcome but also saves costs by avoiding unnecessary ED visits and hospitalization and generates new dollars for pediatric offices through the additional services they provide. We have seen similar improvements in our own work in South Carolina and Tennessee. The practices that have wanted to become involved in our asthma QI are those that are already doing a better than average job. Yet, they still generate substantial additional improvements.
The AAP study relied heavily on national experts and standards. Although their input is valued, the true advantage of QI is the opportunity for pediatricians and their staff at the service delivery level to generate their own changes within the context of a learning collaborative. True improvement and innovation is facilitated by allowing flexibility at the local level and sharing the ideas that result. Those that design the QI efforts of the future need to make sure they allow for local expertise rather than leaning too heavily on centrally predetermined change concepts.
Part IV Maintenance of Certification requirements from the American Board of Pediatrics help provide momentum for successful pediatric QI. The National Improvement Partnership Network has formed pediatric outpatient learning collaboratives to share ideas. As we identify more successes with ambulatory care QI, as more and more organizations like AAP state chapters become involved, as all practices – rather than just the best – recognize the obligation to promote quality, we have a tremendous opportunity to improve the developmental and health outcomes of the children. QI can promote work and cost efficiencies that facilitate our work as pediatricians, making our lives more productive and rewarding.
Francis E. Rushton Jr, MD, is a pediatrician and medical director of South Carolina’s QTIP (Quality Through Innovation in Pediatrics) network and the Quality Director for PHIIT (Pediatric Health Improvement In Tennessee). He reported not having any relevant financial disclosures.
We can do a better job of taking care of our patients. And in no other area is there more room for quality improvement (QI) than in ambulatory care. In the article by Dolins et al., substantial improvements were reported in outpatient management meeting the standard of care for asthma. In my experience, doing so not only gives children a better functional outcome but also saves costs by avoiding unnecessary ED visits and hospitalization and generates new dollars for pediatric offices through the additional services they provide. We have seen similar improvements in our own work in South Carolina and Tennessee. The practices that have wanted to become involved in our asthma QI are those that are already doing a better than average job. Yet, they still generate substantial additional improvements.
The AAP study relied heavily on national experts and standards. Although their input is valued, the true advantage of QI is the opportunity for pediatricians and their staff at the service delivery level to generate their own changes within the context of a learning collaborative. True improvement and innovation is facilitated by allowing flexibility at the local level and sharing the ideas that result. Those that design the QI efforts of the future need to make sure they allow for local expertise rather than leaning too heavily on centrally predetermined change concepts.
Part IV Maintenance of Certification requirements from the American Board of Pediatrics help provide momentum for successful pediatric QI. The National Improvement Partnership Network has formed pediatric outpatient learning collaboratives to share ideas. As we identify more successes with ambulatory care QI, as more and more organizations like AAP state chapters become involved, as all practices – rather than just the best – recognize the obligation to promote quality, we have a tremendous opportunity to improve the developmental and health outcomes of the children. QI can promote work and cost efficiencies that facilitate our work as pediatricians, making our lives more productive and rewarding.
Francis E. Rushton Jr, MD, is a pediatrician and medical director of South Carolina’s QTIP (Quality Through Innovation in Pediatrics) network and the Quality Director for PHIIT (Pediatric Health Improvement In Tennessee). He reported not having any relevant financial disclosures.
Care of children with asthma can be improved using statewide quality improvement (QI) learning collaboratives, said Judith C. Dolins, of the American Academy of Pediatrics (AAP), Elk Grove Village, Ill., and her associates.
AAP chapters demonstrated this through their implementation of the Chapter Quality Network (CQN) project, which was supported by the national organization. This project sought to encourage practice changes in asthma care in a number of states using statewide QI learning collaboratives and lead practices to implement the National Heart, Lung, and Blood Institute’s (NHLBI) 2007 asthma guidelines over the course of four time periods, which the researchers referred to as waves. In nine states, 19 AAP chapters engaged 180 practices to participate, and involved 749 pediatricians treating 45,431 patients (Pediatrics. 2017. doi: 10.1542/peds.2016-1612).
Across all waves, practices had reasonably high baseline use of the stepwise approach (81%-89%) and a controller medication for patients with persistent asthma (74%-88%). The patients with a current written asthma action plan increased from 49%-57% to 75%-91%. Physicians’ and parents’ ratings of asthma in children as “well controlled” rose modestly from 58%-63% to 71%-74% and from 67%-73% to 78%-87%, respectively. Patients receiving self-management materials increased from 57%-62% to 62%-88%.
Here’s how the project worked. The CQN had three linked frameworks.: One provided a methodology for spreading practice changes, another outlined the elements of care, and a third provided a framework so the practices could test, implement, and adapt changes.
A national AAP leadership team of experts in asthma care, QI, and primary care practice systems developed a set of key drivers and interventions, and an implementation guide that included resources, tools and methods, and a set of measures for the chapters. They also designed reporting tools and a curriculum fostering QI learning by chapter leaders. Then, in a state chapter leadership learning network and a practice collaborative model in each state, there were “multiple in-person learning sessions and defined action periods, best practices, and tests of change that were spread and incorporated” for the chapters to use, according to the study report.
Chapters in each state had monthly webinars and two in-person learning sessions for participating practices. They also reviewed data reports at the state and practice level and provided coaching for practices.
Practices were asked to “incorporate optimal NHLBI asthma care practices, including assessment of control, a stepwise approach to treatment, appropriate use of controller medication, and an updated asthma action plan for self-management.” Other interventions included use of an asthma encounter form (which collected 16 measures, including outcome and process measures that were entered into a national database at least monthly); introduction of population registries; workflow assessment; motivational interviews; plan-do-study-act cycles for QI; and review of data for QI.
All the physicians were eligible to earn MOC part 4 credit and continuing medical education credit, and 80% of the physicians did get MOC credit across the 4 waves.
“Our findings are notable for achieving improvement in asthma care through training multiple state coordinating entities instead of directly leading the learning collaborative itself. Few other projects have achieved this level of results in pediatric practice improvement in asthma care on such a widespread scale across multiple states. This project may serve as a model for other statewide and national organizations attempting to achieve improvements in population health through support and training for statewide organizations that, in turn, support individual health care providers and practices,” Ms. Dolins and her associates said. “Although none of the waves achieved the preset goal of 90%, all showed substantial improvement and remarkable consistency in the rate of improvement. We, therefore, regarded the project as an overall success.”
The study was funded by the Merck Childhood Asthma Network, American Board of Pediatrics Foundation, American Academy of Pediatrics Friends of Children Fund, the JPB Foundation, and GlaxoSmithKline. Ms. Dolins and Mr. Wise received salary support. Ms. Powell and Dr. Stemmler received consulting fees.
Care of children with asthma can be improved using statewide quality improvement (QI) learning collaboratives, said Judith C. Dolins, of the American Academy of Pediatrics (AAP), Elk Grove Village, Ill., and her associates.
AAP chapters demonstrated this through their implementation of the Chapter Quality Network (CQN) project, which was supported by the national organization. This project sought to encourage practice changes in asthma care in a number of states using statewide QI learning collaboratives and lead practices to implement the National Heart, Lung, and Blood Institute’s (NHLBI) 2007 asthma guidelines over the course of four time periods, which the researchers referred to as waves. In nine states, 19 AAP chapters engaged 180 practices to participate, and involved 749 pediatricians treating 45,431 patients (Pediatrics. 2017. doi: 10.1542/peds.2016-1612).
Across all waves, practices had reasonably high baseline use of the stepwise approach (81%-89%) and a controller medication for patients with persistent asthma (74%-88%). The patients with a current written asthma action plan increased from 49%-57% to 75%-91%. Physicians’ and parents’ ratings of asthma in children as “well controlled” rose modestly from 58%-63% to 71%-74% and from 67%-73% to 78%-87%, respectively. Patients receiving self-management materials increased from 57%-62% to 62%-88%.
Here’s how the project worked. The CQN had three linked frameworks.: One provided a methodology for spreading practice changes, another outlined the elements of care, and a third provided a framework so the practices could test, implement, and adapt changes.
A national AAP leadership team of experts in asthma care, QI, and primary care practice systems developed a set of key drivers and interventions, and an implementation guide that included resources, tools and methods, and a set of measures for the chapters. They also designed reporting tools and a curriculum fostering QI learning by chapter leaders. Then, in a state chapter leadership learning network and a practice collaborative model in each state, there were “multiple in-person learning sessions and defined action periods, best practices, and tests of change that were spread and incorporated” for the chapters to use, according to the study report.
Chapters in each state had monthly webinars and two in-person learning sessions for participating practices. They also reviewed data reports at the state and practice level and provided coaching for practices.
Practices were asked to “incorporate optimal NHLBI asthma care practices, including assessment of control, a stepwise approach to treatment, appropriate use of controller medication, and an updated asthma action plan for self-management.” Other interventions included use of an asthma encounter form (which collected 16 measures, including outcome and process measures that were entered into a national database at least monthly); introduction of population registries; workflow assessment; motivational interviews; plan-do-study-act cycles for QI; and review of data for QI.
All the physicians were eligible to earn MOC part 4 credit and continuing medical education credit, and 80% of the physicians did get MOC credit across the 4 waves.
“Our findings are notable for achieving improvement in asthma care through training multiple state coordinating entities instead of directly leading the learning collaborative itself. Few other projects have achieved this level of results in pediatric practice improvement in asthma care on such a widespread scale across multiple states. This project may serve as a model for other statewide and national organizations attempting to achieve improvements in population health through support and training for statewide organizations that, in turn, support individual health care providers and practices,” Ms. Dolins and her associates said. “Although none of the waves achieved the preset goal of 90%, all showed substantial improvement and remarkable consistency in the rate of improvement. We, therefore, regarded the project as an overall success.”
The study was funded by the Merck Childhood Asthma Network, American Board of Pediatrics Foundation, American Academy of Pediatrics Friends of Children Fund, the JPB Foundation, and GlaxoSmithKline. Ms. Dolins and Mr. Wise received salary support. Ms. Powell and Dr. Stemmler received consulting fees.
FROM PEDIATRICS
Key clinical point:
Major finding: In wave 4, during which data were collected for 9 months, the rate of optimal asthma care at each encounter improved from 38% to 72%.
Data source: In nine states, 19 AAP chapters engaged 180 practices to participate in quality improvement learning collaboratives, which involved 749 pediatricians treating 45,431 patients.
Disclosures: The study was funded by the Merck Childhood Asthma Network, American Board of Pediatrics Foundation, American Academy of Pediatrics Friends of Children Fund, the JPB Foundation, and GlaxoSmithKline. Ms. Dolins and Mr. Wise received salary support. Ms. Powell and Dr. Stemmler received consulting fees.
Prenatal SSRI exposure’s effect on development
Unfortunately, the bottom line for most of these important questions is that we really don’t know as much as we probably should.
Just when we’ve read a convincing finding from a reputable journal that establishes a link between prenatal SSRI use and an untoward outcome, we see it disputed the next month. Why is this always happening, and why can’t we really know anything with certainty? Much of the confusion can be attributed to research methods and the obvious difficulty of using randomized, controlled trials to control for potential confounding factors. While statistical techniques have become increasingly sophisticated in addressing these confounding factors, they remain imperfect. For example, one of the most difficult challenges that remains is separating any effects of a medication from any effects caused by the condition it was designed to treat. Comparing women with the same underlying condition, some of whom are treated with a medication and some of whom are not, is a step forward, but there may be important reasons that one group decides to seek treatment and the other doesn’t. One clever research design that was employed to look at congenital anomalies in the offspring of women taking SSRIs accounted for siblings of these children who were born when their mother was not taking an SSRI. This study demonstrated that these women were more likely to have children with congenital malformations even when they weren’t taking the SSRIs.1 Other factors that render this literature difficult to interpret include small sample sizes when looking at specific SSRIs (many studies cluster them all), dose effects, timing (which trimester), duration of treatment, and method of recording compliance.
The potential link between SSRIs and autism has received a fair amount of attention lately, especially after a very well-designed study in 2016 suggested a significantly increased risk.10 However, as with many of the findings, this study was quickly disputed by other high-quality, well-powered research that found no increased risk after controlling for maternal illness.11,12
ADHD generally has not been found to be related to maternal SSRI use, although one study did find a link between ADHD and tricyclic antidepressants.12,13
In terms of other neurodevelopmental outcomes, there have been many negative studies examining IQ, nonverbal communication, as well as speech and motor skills.14,15,16 However, as with so many other outcomes, some other studies contradict these negative results. According to a recent, large cohort study, there may be some concern regarding SSRI exposure prenatally and an increase in speech disorders by age 14 years, as well as lower language competence at age 3 years.17,18 Likewise, mild motor abnormalities have been observed, with maternal depression severity as an independent but contributing factor.19
Several studies demonstrate a connection between prenatal SSRI exposure and childhood internalizing symptoms, such as depression and anxiety, independent of maternal depression.12,20 These findings must be balanced with our knowledge of the serious mental health conditions in offspring that are associated with untreated maternal illness, including both internalizing and externalizing disorders.21,22
How does one come to any firm conclusions to guide a primary care clinician’s practice and recommendations? Hopefully, the evidence will become clearer over time as we adopt more sophisticated designs and accumulate observations. A larger number of observations would allow us to decrease heterogeneity by studying subgroups according to type of SSRI and duration of exposure. Enhanced understanding of the role of genetic factors also may shed some light on individual variation as the serotonin transporter gene has been suggested as a potential moderator of sensitivity.23
Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont Robert Larner College of Medicine, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.
References
1. BMJ. 2015 Apr 17;350:h1798.
2. Can J Clin Pharmacol. 2009 Winter;16(1):e66-7.
3. J Matern Fetal Neonatal Med. 2008 Oct;21(10):745-51.
4. PLoS ONE. 2014 Nov; 9(11): e111327.
5. Pediatr Res. 2017 Jun 30. doi: 10.1038/pr.2017.156. [Epub ahead of print].
6. J Clin Psychiatry. 2017 May;78(5):605-11.
7. Acta Psychiatr Scand. 2010 Jun;121(6):471-9.
8. Am J Psychiatry. 2016 Feb 1;173(2):147-57.
9. J Perinatol. 2011 Sep;31(9):615-20.
10. JAMA Pediatr. 2016 Feb;170(2):117-24.
11. JAMA. 2017 Apr 18;317(15):1544-52.
12. J Am Acad Child Adolesc Psychiatry. 2016 May;55(5):359-66.
13. Paediatr Perinat Epidemiol. 2017 Jul;31(4):363-73.
14. Acta Obstet Gynecol Scand. 2015 May;94(5):501-7.
15. J Psychopharmacol. 2017 Mar;31(3):346-55.
16. CNS Drugs. 2005;19(7):623-33.
17. JAMA Psychiatry. 2016 Nov 1;73(11):1163-70.
18. BJOG. 2014. doi: 10.1111/1471-0528.12821.
19. BJOG. 2016 Nov;123(12):1908-17.
20. Pediatr Res. 2015 Aug;78(2):174-80.
21. Neuroscience. 2017 Feb 7;342:154-66.
22. Depress Anxiety. 2014 Jan;31(1):9-18.
23. Neuroscience. 2017 Feb 7;342:212-31.
Unfortunately, the bottom line for most of these important questions is that we really don’t know as much as we probably should.
Just when we’ve read a convincing finding from a reputable journal that establishes a link between prenatal SSRI use and an untoward outcome, we see it disputed the next month. Why is this always happening, and why can’t we really know anything with certainty? Much of the confusion can be attributed to research methods and the obvious difficulty of using randomized, controlled trials to control for potential confounding factors. While statistical techniques have become increasingly sophisticated in addressing these confounding factors, they remain imperfect. For example, one of the most difficult challenges that remains is separating any effects of a medication from any effects caused by the condition it was designed to treat. Comparing women with the same underlying condition, some of whom are treated with a medication and some of whom are not, is a step forward, but there may be important reasons that one group decides to seek treatment and the other doesn’t. One clever research design that was employed to look at congenital anomalies in the offspring of women taking SSRIs accounted for siblings of these children who were born when their mother was not taking an SSRI. This study demonstrated that these women were more likely to have children with congenital malformations even when they weren’t taking the SSRIs.1 Other factors that render this literature difficult to interpret include small sample sizes when looking at specific SSRIs (many studies cluster them all), dose effects, timing (which trimester), duration of treatment, and method of recording compliance.
The potential link between SSRIs and autism has received a fair amount of attention lately, especially after a very well-designed study in 2016 suggested a significantly increased risk.10 However, as with many of the findings, this study was quickly disputed by other high-quality, well-powered research that found no increased risk after controlling for maternal illness.11,12
ADHD generally has not been found to be related to maternal SSRI use, although one study did find a link between ADHD and tricyclic antidepressants.12,13
In terms of other neurodevelopmental outcomes, there have been many negative studies examining IQ, nonverbal communication, as well as speech and motor skills.14,15,16 However, as with so many other outcomes, some other studies contradict these negative results. According to a recent, large cohort study, there may be some concern regarding SSRI exposure prenatally and an increase in speech disorders by age 14 years, as well as lower language competence at age 3 years.17,18 Likewise, mild motor abnormalities have been observed, with maternal depression severity as an independent but contributing factor.19
Several studies demonstrate a connection between prenatal SSRI exposure and childhood internalizing symptoms, such as depression and anxiety, independent of maternal depression.12,20 These findings must be balanced with our knowledge of the serious mental health conditions in offspring that are associated with untreated maternal illness, including both internalizing and externalizing disorders.21,22
How does one come to any firm conclusions to guide a primary care clinician’s practice and recommendations? Hopefully, the evidence will become clearer over time as we adopt more sophisticated designs and accumulate observations. A larger number of observations would allow us to decrease heterogeneity by studying subgroups according to type of SSRI and duration of exposure. Enhanced understanding of the role of genetic factors also may shed some light on individual variation as the serotonin transporter gene has been suggested as a potential moderator of sensitivity.23
Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont Robert Larner College of Medicine, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.
References
1. BMJ. 2015 Apr 17;350:h1798.
2. Can J Clin Pharmacol. 2009 Winter;16(1):e66-7.
3. J Matern Fetal Neonatal Med. 2008 Oct;21(10):745-51.
4. PLoS ONE. 2014 Nov; 9(11): e111327.
5. Pediatr Res. 2017 Jun 30. doi: 10.1038/pr.2017.156. [Epub ahead of print].
6. J Clin Psychiatry. 2017 May;78(5):605-11.
7. Acta Psychiatr Scand. 2010 Jun;121(6):471-9.
8. Am J Psychiatry. 2016 Feb 1;173(2):147-57.
9. J Perinatol. 2011 Sep;31(9):615-20.
10. JAMA Pediatr. 2016 Feb;170(2):117-24.
11. JAMA. 2017 Apr 18;317(15):1544-52.
12. J Am Acad Child Adolesc Psychiatry. 2016 May;55(5):359-66.
13. Paediatr Perinat Epidemiol. 2017 Jul;31(4):363-73.
14. Acta Obstet Gynecol Scand. 2015 May;94(5):501-7.
15. J Psychopharmacol. 2017 Mar;31(3):346-55.
16. CNS Drugs. 2005;19(7):623-33.
17. JAMA Psychiatry. 2016 Nov 1;73(11):1163-70.
18. BJOG. 2014. doi: 10.1111/1471-0528.12821.
19. BJOG. 2016 Nov;123(12):1908-17.
20. Pediatr Res. 2015 Aug;78(2):174-80.
21. Neuroscience. 2017 Feb 7;342:154-66.
22. Depress Anxiety. 2014 Jan;31(1):9-18.
23. Neuroscience. 2017 Feb 7;342:212-31.
Unfortunately, the bottom line for most of these important questions is that we really don’t know as much as we probably should.
Just when we’ve read a convincing finding from a reputable journal that establishes a link between prenatal SSRI use and an untoward outcome, we see it disputed the next month. Why is this always happening, and why can’t we really know anything with certainty? Much of the confusion can be attributed to research methods and the obvious difficulty of using randomized, controlled trials to control for potential confounding factors. While statistical techniques have become increasingly sophisticated in addressing these confounding factors, they remain imperfect. For example, one of the most difficult challenges that remains is separating any effects of a medication from any effects caused by the condition it was designed to treat. Comparing women with the same underlying condition, some of whom are treated with a medication and some of whom are not, is a step forward, but there may be important reasons that one group decides to seek treatment and the other doesn’t. One clever research design that was employed to look at congenital anomalies in the offspring of women taking SSRIs accounted for siblings of these children who were born when their mother was not taking an SSRI. This study demonstrated that these women were more likely to have children with congenital malformations even when they weren’t taking the SSRIs.1 Other factors that render this literature difficult to interpret include small sample sizes when looking at specific SSRIs (many studies cluster them all), dose effects, timing (which trimester), duration of treatment, and method of recording compliance.
The potential link between SSRIs and autism has received a fair amount of attention lately, especially after a very well-designed study in 2016 suggested a significantly increased risk.10 However, as with many of the findings, this study was quickly disputed by other high-quality, well-powered research that found no increased risk after controlling for maternal illness.11,12
ADHD generally has not been found to be related to maternal SSRI use, although one study did find a link between ADHD and tricyclic antidepressants.12,13
In terms of other neurodevelopmental outcomes, there have been many negative studies examining IQ, nonverbal communication, as well as speech and motor skills.14,15,16 However, as with so many other outcomes, some other studies contradict these negative results. According to a recent, large cohort study, there may be some concern regarding SSRI exposure prenatally and an increase in speech disorders by age 14 years, as well as lower language competence at age 3 years.17,18 Likewise, mild motor abnormalities have been observed, with maternal depression severity as an independent but contributing factor.19
Several studies demonstrate a connection between prenatal SSRI exposure and childhood internalizing symptoms, such as depression and anxiety, independent of maternal depression.12,20 These findings must be balanced with our knowledge of the serious mental health conditions in offspring that are associated with untreated maternal illness, including both internalizing and externalizing disorders.21,22
How does one come to any firm conclusions to guide a primary care clinician’s practice and recommendations? Hopefully, the evidence will become clearer over time as we adopt more sophisticated designs and accumulate observations. A larger number of observations would allow us to decrease heterogeneity by studying subgroups according to type of SSRI and duration of exposure. Enhanced understanding of the role of genetic factors also may shed some light on individual variation as the serotonin transporter gene has been suggested as a potential moderator of sensitivity.23
Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont Robert Larner College of Medicine, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.
References
1. BMJ. 2015 Apr 17;350:h1798.
2. Can J Clin Pharmacol. 2009 Winter;16(1):e66-7.
3. J Matern Fetal Neonatal Med. 2008 Oct;21(10):745-51.
4. PLoS ONE. 2014 Nov; 9(11): e111327.
5. Pediatr Res. 2017 Jun 30. doi: 10.1038/pr.2017.156. [Epub ahead of print].
6. J Clin Psychiatry. 2017 May;78(5):605-11.
7. Acta Psychiatr Scand. 2010 Jun;121(6):471-9.
8. Am J Psychiatry. 2016 Feb 1;173(2):147-57.
9. J Perinatol. 2011 Sep;31(9):615-20.
10. JAMA Pediatr. 2016 Feb;170(2):117-24.
11. JAMA. 2017 Apr 18;317(15):1544-52.
12. J Am Acad Child Adolesc Psychiatry. 2016 May;55(5):359-66.
13. Paediatr Perinat Epidemiol. 2017 Jul;31(4):363-73.
14. Acta Obstet Gynecol Scand. 2015 May;94(5):501-7.
15. J Psychopharmacol. 2017 Mar;31(3):346-55.
16. CNS Drugs. 2005;19(7):623-33.
17. JAMA Psychiatry. 2016 Nov 1;73(11):1163-70.
18. BJOG. 2014. doi: 10.1111/1471-0528.12821.
19. BJOG. 2016 Nov;123(12):1908-17.
20. Pediatr Res. 2015 Aug;78(2):174-80.
21. Neuroscience. 2017 Feb 7;342:154-66.
22. Depress Anxiety. 2014 Jan;31(1):9-18.
23. Neuroscience. 2017 Feb 7;342:212-31.
Corticosteroid therapy in Kawasaki disease
Clinical Question
What is the efficacy of corticosteroid therapy in Kawasaki disease?
Background
First described in 1967 in Japan, Kawasaki disease (KD), or mucocutaneous lymph node syndrome, is an acute systemic vasculitis of unclear etiology which primarily affects infants and children. Of significant clinical concern, 30%-50% of untreated patients develop acute coronary artery dilatation, and about one fourth progress to serious coronary artery abnormalities (CAA) such as aneurysm and ectasia.1,2 These patients have a higher risk of long-term complications, such as coronary artery thrombus, myocardial infarction, and sudden death.3 KD is typically treated with a combination of intravenous immunoglobulin (IVIG) and aspirin, which reduces the risk of CAA.1 However, more than 20% of cases are resistant to this conventional therapy and have higher risk of CAA than nonresistant patients.4 Corticosteroids have been suggested as therapy in KD, as the anti-inflammatory effect is useful for many other vasculitides, but studies to date have had conflicting results. This study was performed to comprehensively evaluate the effect of corticosteroids in KD as initial or rescue therapy (after failure to respond to IVIG).
Study design
Systematic review and meta-analysis.
Synopsis
The population of interest was children diagnosed with KD. The intervention of interest was treatment with adjunctive corticosteroids either as initial or rescue therapy. Comparisons were made between the corticosteroids group and the conventional therapy (IVIG) group. Outcome measurements included the incidence of CAA (primary outcome), duration until defervescence, and adverse events. IVIG resistance was defined as persistent or recurrent fever lasting (or relapsed within) 24-48 hours after the initial IVIG treatment.
A total of 681 articles were initially retrieved, and after exclusions, 16 comparative studies were enrolled for meta-analysis. In these studies, a total of 2,746 cases were involved, with 861 in the corticosteroid group and 1,885 in the IVIG group. Ten studies used corticosteroids as initial treatment (comparing this plus IVIG versus IVIG therapy alone), and six used steroids as rescue treatment after initial IVIG failure (comparing corticosteroids with additional IVIG therapy). Four studies enrolled patients with KD who were predicted to have high risk of IVIG resistance, based on published scoring systems. All patients in the studies received oral aspirin.
Overall, this meta-analysis found that adding corticosteroid therapy was associated with a relative risk reduction of 58% in CAA (odds ratio, 0.424; 95% confidence interval, 0.270-0.665; P less than .001). Further analysis showed that the longer the duration of illness prior to corticosteroids, the less of a treatment effect was noticed. The studies using steroids as initial adjunctive therapy had duration of illness 4.7 days prior to treatment, and showed an advantage, compared with IVIG alone, while studies using steroids as rescue therapy had a longer duration of illness prior to steroid therapy (7.2 days), and did not show significant benefit, compared with additional IVIG. In analyzing patients predicted to be at high risk of IVIG resistance at baseline, addition of corticosteroids with IVIG as initial therapy showed a significantly lower risk of CAA development (relative risk reduction of 76%) versus IVIG alone (OR, 0.240; 95% CI, 0.123-0.467; P less than .001). As a secondary outcome, the use of adjunctive corticosteroid therapy was associated with a quicker resolution of fever, compared with IVIG alone (0.66 days vs. 2.18 days). There was no significant difference in adverse events between the two groups.
Although this is the most comprehensive study of corticosteroids in KD, there are some limitations. High-risk patients were found to receive the greatest benefit, but the predictive ability of published scoring systems have not been optimized or generalized to all populations. Most of the studies included in this review were conducted in Japan, so it is uncertain if the results are applicable to other regions. Also, the selection of corticosteroids and treatment regimens were not consistent between studies.
Bottom line
This study suggests that corticosteroids combined with IVIG as initial therapy for KD showed a more protective effect against CAA, compared with conventional IVIG therapy, and the efficacy was more pronounced in the high-risk patient group.
Citation
Chen S, Dong Y, Kiuchi MG, et al. Coronary Artery Complication in Kawasaki Disease and the Importance of Early Intervention: A Systematic Review and Meta-analysis. JAMA Pediatr. 2016;170(12):1156-1163.
References
1. Newburger JW, Takahashi M, Gerber MA, et al. Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease. Council on Cardiovascular Disease in the Young; American Heart Association; American Academy of Pediatrics: diagnosis, treatment, and long-term management of Kawasaki disease. Circulation. 2004;110:2747-71.
2. Daniels LB, Tjajadi MS, Walford HH, et al. Prevalence of Kawasaki disease in young adults with suspected myocardial ischemia. Circulation. 2012;125(20):2447-53.
3. Gordon JB, Kahn AM, Burns JC. When children with Kawasaki disease grow up: myocardial and vascular complications in adulthood. J Am Coll Cardiol. 2009;54(21):1911-20.
4. Tremoulet AH, Best BM, Song S, et al. Resistance to intravenous immunoglobulin in children with Kawasaki disease. J Pediatr. 2008;153(1):117-21.
Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.
Clinical Question
What is the efficacy of corticosteroid therapy in Kawasaki disease?
Background
First described in 1967 in Japan, Kawasaki disease (KD), or mucocutaneous lymph node syndrome, is an acute systemic vasculitis of unclear etiology which primarily affects infants and children. Of significant clinical concern, 30%-50% of untreated patients develop acute coronary artery dilatation, and about one fourth progress to serious coronary artery abnormalities (CAA) such as aneurysm and ectasia.1,2 These patients have a higher risk of long-term complications, such as coronary artery thrombus, myocardial infarction, and sudden death.3 KD is typically treated with a combination of intravenous immunoglobulin (IVIG) and aspirin, which reduces the risk of CAA.1 However, more than 20% of cases are resistant to this conventional therapy and have higher risk of CAA than nonresistant patients.4 Corticosteroids have been suggested as therapy in KD, as the anti-inflammatory effect is useful for many other vasculitides, but studies to date have had conflicting results. This study was performed to comprehensively evaluate the effect of corticosteroids in KD as initial or rescue therapy (after failure to respond to IVIG).
Study design
Systematic review and meta-analysis.
Synopsis
The population of interest was children diagnosed with KD. The intervention of interest was treatment with adjunctive corticosteroids either as initial or rescue therapy. Comparisons were made between the corticosteroids group and the conventional therapy (IVIG) group. Outcome measurements included the incidence of CAA (primary outcome), duration until defervescence, and adverse events. IVIG resistance was defined as persistent or recurrent fever lasting (or relapsed within) 24-48 hours after the initial IVIG treatment.
A total of 681 articles were initially retrieved, and after exclusions, 16 comparative studies were enrolled for meta-analysis. In these studies, a total of 2,746 cases were involved, with 861 in the corticosteroid group and 1,885 in the IVIG group. Ten studies used corticosteroids as initial treatment (comparing this plus IVIG versus IVIG therapy alone), and six used steroids as rescue treatment after initial IVIG failure (comparing corticosteroids with additional IVIG therapy). Four studies enrolled patients with KD who were predicted to have high risk of IVIG resistance, based on published scoring systems. All patients in the studies received oral aspirin.
Overall, this meta-analysis found that adding corticosteroid therapy was associated with a relative risk reduction of 58% in CAA (odds ratio, 0.424; 95% confidence interval, 0.270-0.665; P less than .001). Further analysis showed that the longer the duration of illness prior to corticosteroids, the less of a treatment effect was noticed. The studies using steroids as initial adjunctive therapy had duration of illness 4.7 days prior to treatment, and showed an advantage, compared with IVIG alone, while studies using steroids as rescue therapy had a longer duration of illness prior to steroid therapy (7.2 days), and did not show significant benefit, compared with additional IVIG. In analyzing patients predicted to be at high risk of IVIG resistance at baseline, addition of corticosteroids with IVIG as initial therapy showed a significantly lower risk of CAA development (relative risk reduction of 76%) versus IVIG alone (OR, 0.240; 95% CI, 0.123-0.467; P less than .001). As a secondary outcome, the use of adjunctive corticosteroid therapy was associated with a quicker resolution of fever, compared with IVIG alone (0.66 days vs. 2.18 days). There was no significant difference in adverse events between the two groups.
Although this is the most comprehensive study of corticosteroids in KD, there are some limitations. High-risk patients were found to receive the greatest benefit, but the predictive ability of published scoring systems have not been optimized or generalized to all populations. Most of the studies included in this review were conducted in Japan, so it is uncertain if the results are applicable to other regions. Also, the selection of corticosteroids and treatment regimens were not consistent between studies.
Bottom line
This study suggests that corticosteroids combined with IVIG as initial therapy for KD showed a more protective effect against CAA, compared with conventional IVIG therapy, and the efficacy was more pronounced in the high-risk patient group.
Citation
Chen S, Dong Y, Kiuchi MG, et al. Coronary Artery Complication in Kawasaki Disease and the Importance of Early Intervention: A Systematic Review and Meta-analysis. JAMA Pediatr. 2016;170(12):1156-1163.
References
1. Newburger JW, Takahashi M, Gerber MA, et al. Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease. Council on Cardiovascular Disease in the Young; American Heart Association; American Academy of Pediatrics: diagnosis, treatment, and long-term management of Kawasaki disease. Circulation. 2004;110:2747-71.
2. Daniels LB, Tjajadi MS, Walford HH, et al. Prevalence of Kawasaki disease in young adults with suspected myocardial ischemia. Circulation. 2012;125(20):2447-53.
3. Gordon JB, Kahn AM, Burns JC. When children with Kawasaki disease grow up: myocardial and vascular complications in adulthood. J Am Coll Cardiol. 2009;54(21):1911-20.
4. Tremoulet AH, Best BM, Song S, et al. Resistance to intravenous immunoglobulin in children with Kawasaki disease. J Pediatr. 2008;153(1):117-21.
Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.
Clinical Question
What is the efficacy of corticosteroid therapy in Kawasaki disease?
Background
First described in 1967 in Japan, Kawasaki disease (KD), or mucocutaneous lymph node syndrome, is an acute systemic vasculitis of unclear etiology which primarily affects infants and children. Of significant clinical concern, 30%-50% of untreated patients develop acute coronary artery dilatation, and about one fourth progress to serious coronary artery abnormalities (CAA) such as aneurysm and ectasia.1,2 These patients have a higher risk of long-term complications, such as coronary artery thrombus, myocardial infarction, and sudden death.3 KD is typically treated with a combination of intravenous immunoglobulin (IVIG) and aspirin, which reduces the risk of CAA.1 However, more than 20% of cases are resistant to this conventional therapy and have higher risk of CAA than nonresistant patients.4 Corticosteroids have been suggested as therapy in KD, as the anti-inflammatory effect is useful for many other vasculitides, but studies to date have had conflicting results. This study was performed to comprehensively evaluate the effect of corticosteroids in KD as initial or rescue therapy (after failure to respond to IVIG).
Study design
Systematic review and meta-analysis.
Synopsis
The population of interest was children diagnosed with KD. The intervention of interest was treatment with adjunctive corticosteroids either as initial or rescue therapy. Comparisons were made between the corticosteroids group and the conventional therapy (IVIG) group. Outcome measurements included the incidence of CAA (primary outcome), duration until defervescence, and adverse events. IVIG resistance was defined as persistent or recurrent fever lasting (or relapsed within) 24-48 hours after the initial IVIG treatment.
A total of 681 articles were initially retrieved, and after exclusions, 16 comparative studies were enrolled for meta-analysis. In these studies, a total of 2,746 cases were involved, with 861 in the corticosteroid group and 1,885 in the IVIG group. Ten studies used corticosteroids as initial treatment (comparing this plus IVIG versus IVIG therapy alone), and six used steroids as rescue treatment after initial IVIG failure (comparing corticosteroids with additional IVIG therapy). Four studies enrolled patients with KD who were predicted to have high risk of IVIG resistance, based on published scoring systems. All patients in the studies received oral aspirin.
Overall, this meta-analysis found that adding corticosteroid therapy was associated with a relative risk reduction of 58% in CAA (odds ratio, 0.424; 95% confidence interval, 0.270-0.665; P less than .001). Further analysis showed that the longer the duration of illness prior to corticosteroids, the less of a treatment effect was noticed. The studies using steroids as initial adjunctive therapy had duration of illness 4.7 days prior to treatment, and showed an advantage, compared with IVIG alone, while studies using steroids as rescue therapy had a longer duration of illness prior to steroid therapy (7.2 days), and did not show significant benefit, compared with additional IVIG. In analyzing patients predicted to be at high risk of IVIG resistance at baseline, addition of corticosteroids with IVIG as initial therapy showed a significantly lower risk of CAA development (relative risk reduction of 76%) versus IVIG alone (OR, 0.240; 95% CI, 0.123-0.467; P less than .001). As a secondary outcome, the use of adjunctive corticosteroid therapy was associated with a quicker resolution of fever, compared with IVIG alone (0.66 days vs. 2.18 days). There was no significant difference in adverse events between the two groups.
Although this is the most comprehensive study of corticosteroids in KD, there are some limitations. High-risk patients were found to receive the greatest benefit, but the predictive ability of published scoring systems have not been optimized or generalized to all populations. Most of the studies included in this review were conducted in Japan, so it is uncertain if the results are applicable to other regions. Also, the selection of corticosteroids and treatment regimens were not consistent between studies.
Bottom line
This study suggests that corticosteroids combined with IVIG as initial therapy for KD showed a more protective effect against CAA, compared with conventional IVIG therapy, and the efficacy was more pronounced in the high-risk patient group.
Citation
Chen S, Dong Y, Kiuchi MG, et al. Coronary Artery Complication in Kawasaki Disease and the Importance of Early Intervention: A Systematic Review and Meta-analysis. JAMA Pediatr. 2016;170(12):1156-1163.
References
1. Newburger JW, Takahashi M, Gerber MA, et al. Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease. Council on Cardiovascular Disease in the Young; American Heart Association; American Academy of Pediatrics: diagnosis, treatment, and long-term management of Kawasaki disease. Circulation. 2004;110:2747-71.
2. Daniels LB, Tjajadi MS, Walford HH, et al. Prevalence of Kawasaki disease in young adults with suspected myocardial ischemia. Circulation. 2012;125(20):2447-53.
3. Gordon JB, Kahn AM, Burns JC. When children with Kawasaki disease grow up: myocardial and vascular complications in adulthood. J Am Coll Cardiol. 2009;54(21):1911-20.
4. Tremoulet AH, Best BM, Song S, et al. Resistance to intravenous immunoglobulin in children with Kawasaki disease. J Pediatr. 2008;153(1):117-21.
Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.
Depression in adolescence
As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And 
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
Supportive care alone linked to worse outcomes in mucocutaneous reactions
CHICAGO – , compared with other treatment modalities, a systematic review suggested.
Although rare in the pediatric population – with an incidence of approximately 1 case in 2 million – Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are both life-threatening mucocutaneous reactions.
Because reliable and validated data in the management of these conditions are lacking, he and his associates performed a systematic review to evaluate the effectiveness of reported treatment modalities using specific outcome measures.
“This study is unique in that it aims to not only capture more commonly employed interventions such as supportive care, surgical debridement, intravenous immunoglobulin [IVIG], and corticosteroids but also newer modalities that coincide with our improved understanding of the pathogenesis of the disease, such as the use of cyclosporine and biologics,” said Mr. Mansour, a third-year medical student at the University of Toronto.
The researchers systematically reviewed English and non-English articles using EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the NHS Economic Evaluation Database, and the Health Technology Assessment Database. They excluded nonpediatric cases and those in which specific treatment modalities and outcome measures of interest were missing. In all, 302 articles were included in the study – 197 that examined mortality and 105 that examined time for arrest of progression of blistering, re-epithelialization, and length of hospital stay.
The main treatment modalities included supportive care alone, IVIG, corticosteroids, cyclosporine, surgical debridement, and biologics. The average time for arrest of progression of blistering was 8.4 days for supportive care, 4 days for IVIG, 6 days for corticosteroids, 2.5 days for cyclosporine, and 1 for infliximab. No data were available for time to arrest of progression for surgical debridement alone.
The average time for re-epithelialization was 24 days for supportive care, 18 days for surgical debridement, 8.7 days for IVIG, 12.2 days for corticosteroids, 10.6 days for cyclosporine, and 13 days for infliximab. Average length of hospital stay varied from 15.6 days for supportive care, 24.3 days for surgical debridement, 17.4 days for IVIG, 11.5 for corticosteroids, 15.5 for cyclosporine, and 26.3 for biologics.
The overall mortality was 4.6% among those who received supportive care alone, 8.3% among those who received IVIG, 4.5% among those who received corticosteroids, and 0.9% among those who received IVIG plus corticosteroids. Specifically, the rates of mortality for SJS and TEN cases treated with supportive care alone were 2% for SJS cases and 15.3% for TEN cases, respectively. The rates for other treatment modalities were 3.1% and 11% for IVIG, 1.7% and 9.3% for corticosteroids, and 0% and 2.1% for IVIG plus corticosteroids.
“While it was not surprising that mortality rates in pediatric SJS and TEN are low, the rates were slightly higher than anticipated,” Mr. Mansour said. “In addition, our data show that, although mortality is not influenced by certain therapeutic interventions in SJS patients, it may play a role in the management of the more severe disease, TEN.”
He acknowledged certain limitations of the study, including the fact that many of the data were derived from small-cohort retrospective studies and isolated case reports, giving rise to data heterogeneity and publication bias. “In addition, the mortality data we gathered may not necessarily represent patient survival, as many studies had variable follow-up duration,” he said. “Lastly, the additive effect of combination treatment and variable dosing was not captured in the present analysis, and further statistical analysis is required for re-epithelialization–based outcome measures and length of stay to ascertain significance.”
Mr. Mansour reported having no financial disclosures.
CHICAGO – , compared with other treatment modalities, a systematic review suggested.
Although rare in the pediatric population – with an incidence of approximately 1 case in 2 million – Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are both life-threatening mucocutaneous reactions.
Because reliable and validated data in the management of these conditions are lacking, he and his associates performed a systematic review to evaluate the effectiveness of reported treatment modalities using specific outcome measures.
“This study is unique in that it aims to not only capture more commonly employed interventions such as supportive care, surgical debridement, intravenous immunoglobulin [IVIG], and corticosteroids but also newer modalities that coincide with our improved understanding of the pathogenesis of the disease, such as the use of cyclosporine and biologics,” said Mr. Mansour, a third-year medical student at the University of Toronto.
The researchers systematically reviewed English and non-English articles using EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the NHS Economic Evaluation Database, and the Health Technology Assessment Database. They excluded nonpediatric cases and those in which specific treatment modalities and outcome measures of interest were missing. In all, 302 articles were included in the study – 197 that examined mortality and 105 that examined time for arrest of progression of blistering, re-epithelialization, and length of hospital stay.
The main treatment modalities included supportive care alone, IVIG, corticosteroids, cyclosporine, surgical debridement, and biologics. The average time for arrest of progression of blistering was 8.4 days for supportive care, 4 days for IVIG, 6 days for corticosteroids, 2.5 days for cyclosporine, and 1 for infliximab. No data were available for time to arrest of progression for surgical debridement alone.
The average time for re-epithelialization was 24 days for supportive care, 18 days for surgical debridement, 8.7 days for IVIG, 12.2 days for corticosteroids, 10.6 days for cyclosporine, and 13 days for infliximab. Average length of hospital stay varied from 15.6 days for supportive care, 24.3 days for surgical debridement, 17.4 days for IVIG, 11.5 for corticosteroids, 15.5 for cyclosporine, and 26.3 for biologics.
The overall mortality was 4.6% among those who received supportive care alone, 8.3% among those who received IVIG, 4.5% among those who received corticosteroids, and 0.9% among those who received IVIG plus corticosteroids. Specifically, the rates of mortality for SJS and TEN cases treated with supportive care alone were 2% for SJS cases and 15.3% for TEN cases, respectively. The rates for other treatment modalities were 3.1% and 11% for IVIG, 1.7% and 9.3% for corticosteroids, and 0% and 2.1% for IVIG plus corticosteroids.
“While it was not surprising that mortality rates in pediatric SJS and TEN are low, the rates were slightly higher than anticipated,” Mr. Mansour said. “In addition, our data show that, although mortality is not influenced by certain therapeutic interventions in SJS patients, it may play a role in the management of the more severe disease, TEN.”
He acknowledged certain limitations of the study, including the fact that many of the data were derived from small-cohort retrospective studies and isolated case reports, giving rise to data heterogeneity and publication bias. “In addition, the mortality data we gathered may not necessarily represent patient survival, as many studies had variable follow-up duration,” he said. “Lastly, the additive effect of combination treatment and variable dosing was not captured in the present analysis, and further statistical analysis is required for re-epithelialization–based outcome measures and length of stay to ascertain significance.”
Mr. Mansour reported having no financial disclosures.
CHICAGO – , compared with other treatment modalities, a systematic review suggested.
Although rare in the pediatric population – with an incidence of approximately 1 case in 2 million – Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are both life-threatening mucocutaneous reactions.
Because reliable and validated data in the management of these conditions are lacking, he and his associates performed a systematic review to evaluate the effectiveness of reported treatment modalities using specific outcome measures.
“This study is unique in that it aims to not only capture more commonly employed interventions such as supportive care, surgical debridement, intravenous immunoglobulin [IVIG], and corticosteroids but also newer modalities that coincide with our improved understanding of the pathogenesis of the disease, such as the use of cyclosporine and biologics,” said Mr. Mansour, a third-year medical student at the University of Toronto.
The researchers systematically reviewed English and non-English articles using EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the NHS Economic Evaluation Database, and the Health Technology Assessment Database. They excluded nonpediatric cases and those in which specific treatment modalities and outcome measures of interest were missing. In all, 302 articles were included in the study – 197 that examined mortality and 105 that examined time for arrest of progression of blistering, re-epithelialization, and length of hospital stay.
The main treatment modalities included supportive care alone, IVIG, corticosteroids, cyclosporine, surgical debridement, and biologics. The average time for arrest of progression of blistering was 8.4 days for supportive care, 4 days for IVIG, 6 days for corticosteroids, 2.5 days for cyclosporine, and 1 for infliximab. No data were available for time to arrest of progression for surgical debridement alone.
The average time for re-epithelialization was 24 days for supportive care, 18 days for surgical debridement, 8.7 days for IVIG, 12.2 days for corticosteroids, 10.6 days for cyclosporine, and 13 days for infliximab. Average length of hospital stay varied from 15.6 days for supportive care, 24.3 days for surgical debridement, 17.4 days for IVIG, 11.5 for corticosteroids, 15.5 for cyclosporine, and 26.3 for biologics.
The overall mortality was 4.6% among those who received supportive care alone, 8.3% among those who received IVIG, 4.5% among those who received corticosteroids, and 0.9% among those who received IVIG plus corticosteroids. Specifically, the rates of mortality for SJS and TEN cases treated with supportive care alone were 2% for SJS cases and 15.3% for TEN cases, respectively. The rates for other treatment modalities were 3.1% and 11% for IVIG, 1.7% and 9.3% for corticosteroids, and 0% and 2.1% for IVIG plus corticosteroids.
“While it was not surprising that mortality rates in pediatric SJS and TEN are low, the rates were slightly higher than anticipated,” Mr. Mansour said. “In addition, our data show that, although mortality is not influenced by certain therapeutic interventions in SJS patients, it may play a role in the management of the more severe disease, TEN.”
He acknowledged certain limitations of the study, including the fact that many of the data were derived from small-cohort retrospective studies and isolated case reports, giving rise to data heterogeneity and publication bias. “In addition, the mortality data we gathered may not necessarily represent patient survival, as many studies had variable follow-up duration,” he said. “Lastly, the additive effect of combination treatment and variable dosing was not captured in the present analysis, and further statistical analysis is required for re-epithelialization–based outcome measures and length of stay to ascertain significance.”
Mr. Mansour reported having no financial disclosures.
AT WCPD 2017
Key clinical point: Reliable and validated data informing the best treatment intervention for Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are lacking.
Major finding: The overall mortality was 4.6% among those who received supportive care alone, 8.3% among those who received IVIG, 4.5% among those who received corticosteroids, and 0.9% among those who received IVIG plus corticosteroids.
Data source: A systematic review of 302 studies that evaluated the effectiveness of reported treatment modalities for SJS/TEN using specific outcome measures.
Disclosures: Mr. Mansour reported having no financial disclosures.
Pediatric hospital medicine marches toward subspecialty recognition
Pediatric hospital medicine is moving quickly toward recognition as a board-certified, fellowship-trained medical subspecialty, joining 14 other pediatric subspecialties now certified by the American Board of Pediatrics (ABP).
It was approved as a subspecialty by the American Board of Medical Specialties (ABMS) at its October 2016 board meeting in Chicago in response to a petition from the ABP. Following years of discussion within the field,1 it will take 2 more years to describe pediatric hospital medicine’s specialized knowledge base and write test questions for biannual board exams that are projected to commence in the fall of 2019.
Eventually, starting in 2025, pediatric hospitalists will need to complete a fellowship of 2 years or more if they wish to sit for the exam and become board-certified in the field. But for the next 7 years, hospitalists in current practice will be able to qualify based on their work experience. Maintenance of certification requirements likely will be similar to those in other subspecialties, and doctors certified in pediatric hospital medicine won’t be required to maintain general pediatric certification, Dr. Rauch said.
Formal eligibility criteria have not been set, but likely will include working half-time overall in pediatric-related activities, and quarter-time in clinical practice in pediatric hospital medicine for 4 years prior to qualifying for the exam. How the hours might break down between clinical and other hospital responsibilities, and between pediatric or adult patients, still needs to be determined, Dr. Rauch said. He added that the experiential pathway is likely to be defined broadly, with latitude for determinations based on percentages of time worked, rather than absolute number of hours worked. Local pediatric institutions will be granted latitude to determine how that “plays out” in real world situations, he said, “and an ABP credentialing committee will be available to hear appeals for people who have complicated life circumstances.”
“I was part of a committee that explored these issues. We were an independent group of hospitalists who decided that board certification was a good way to advance the field,” Dr. Quinonez said. “We’ve seen what subspecialty certification has done, for example, for pediatric emergency medicine and pediatric critical care medicine – advancing them tremendously from a research standpoint and helping to develop a distinct body of knowledge reflecting increased severity of illness in hospitalized children.”
Discrepancy between practicing hospitalists, fellowships
An estimated 4,000 pediatric hospitalists now practice in the United States, and 2,100 of those belong to the American Academy of Pediatrics’ Section on Hospital Medicine. There are 40 pediatric hospital medicine fellowship programs listed on the website of AAP’s Section on Hospital Medicine (http://phmfellows.org/phm-programs/), although formal training assessment criteria will be needed for the American College of Graduate Medical Education to recognize programs that qualify their fellows to sit for the PHM exam. A wide gap is anticipated between the demand for pediatric hospitalists and currently available fellowship training slots to generate new candidates for board certification, although Dr. Rauch projects that fellowship slots will double in coming years.
“My message to the field is that historically, board certification has been the launching point for further development of the field,” Dr. Rauch said. “It leads to standardization of who is a subspecialist. Right now, who is a pediatric hospitalist is subject to wide variation. We need to standardize training and to create for this field the same distinction and stature as other medical subspecialties,” he said, noting that subspecialty status also has ramifications for academic settings, and for career advancement and career satisfaction for the individuals who choose to pursue it.
“I know there has been some hue and cry about this in the field, but in most cases certification will not change a pediatric hospitalist’s ability to obtain a job,” he said. “Already, you can’t become a division leader at a children’s hospital without additional training. This isn’t going to change that reality. But for people who don’t want to follow an academic career path, there will never be enough board-certified or fellowship-trained pediatric hospitalists to fill all of the pediatric positions in all the hospitals in the country. Community hospitals aren’t going to say: We won’t hire you unless you are board certified.”
Is the fellowship good for the field?
The subspecialty development process clearly is moving forward. Those in favor believe it will increase scholarship, research, and recognition for the subspecialty by the public for its specialized body of knowledge. But not everyone in the field agrees. Last fall The Hospitalist published3 an opinion piece questioning the need for fellowship-based board certification in pediatric hospital medicine. The author recommended instead retaining the current voluntary approach to fellowships and establishing a pediatric “focused practice” incorporated into residency training, much as the American Board of Internal Medicine and the American Board of Family Medicine have done for hospitalists in adult medicine.
“Will it lead to uncertainty among those currently in residency programs? If you are a pediatric resident and you want to become a board-certified pediatric hospitalist, you’ll need at least 2 years more of training. Is that going to deter qualified individuals?” Dr. Chang said. “The people this decision will impact the most are med-peds doctors – who complete a combined internal medicine and pediatrics residency – and part-timers. They may find themselves in a difficult position if the number of hours don’t add up for them to sit for the boards. For the most part, we’ll have to wait and see for answers to these questions.”
Brian Alverson, MD, FAAP, current chair of the AAP’s Section on Hospital Medicine and associate professor of pediatrics at Brown University, Providence, R.I., says he can see both sides of the debate.
But at the same time, there is a significant opportunity cost for doing 2 more years of fellowship training, Dr. Alverson said.
“We don’t know how much the board certification test will improve actual care,” he noted. “Does it truly identify higher quality doctors, or just doctors who are good at taking multiple choice exams? There are a number of people in pediatrics who do a lot of different things in their jobs, and it’s important that they not lose their ability to practice in the field. Two-thirds of our work force is in community hospitals, not academic medical centers. They work hard to provide the backbone of hospital care for young patients, and many of them are unlikely to ever do a fellowship.”
Nonetheless, Dr. Alverson believes pediatric hospitalists needn’t worry. “You still have plenty of time to figure out what’s going to happen in your hospital,” he said.
References
1. Section on Hospital Medicine. Guiding principles for pediatric hospital medicine program. Pediatrics; 2013; 132:782-786.
2. Stucky E. The Pediatric Hospital Medicine Core Competencies. Wiley-Blackwell; 2010.
3. Feldman LS, Monash B, Eniasivam A. Why required pediatric hospital medicine fellowships are unnecessary. The Hospitalist Magazine, October 8, 2016.
Pediatric hospital medicine is moving quickly toward recognition as a board-certified, fellowship-trained medical subspecialty, joining 14 other pediatric subspecialties now certified by the American Board of Pediatrics (ABP).
It was approved as a subspecialty by the American Board of Medical Specialties (ABMS) at its October 2016 board meeting in Chicago in response to a petition from the ABP. Following years of discussion within the field,1 it will take 2 more years to describe pediatric hospital medicine’s specialized knowledge base and write test questions for biannual board exams that are projected to commence in the fall of 2019.
Eventually, starting in 2025, pediatric hospitalists will need to complete a fellowship of 2 years or more if they wish to sit for the exam and become board-certified in the field. But for the next 7 years, hospitalists in current practice will be able to qualify based on their work experience. Maintenance of certification requirements likely will be similar to those in other subspecialties, and doctors certified in pediatric hospital medicine won’t be required to maintain general pediatric certification, Dr. Rauch said.
Formal eligibility criteria have not been set, but likely will include working half-time overall in pediatric-related activities, and quarter-time in clinical practice in pediatric hospital medicine for 4 years prior to qualifying for the exam. How the hours might break down between clinical and other hospital responsibilities, and between pediatric or adult patients, still needs to be determined, Dr. Rauch said. He added that the experiential pathway is likely to be defined broadly, with latitude for determinations based on percentages of time worked, rather than absolute number of hours worked. Local pediatric institutions will be granted latitude to determine how that “plays out” in real world situations, he said, “and an ABP credentialing committee will be available to hear appeals for people who have complicated life circumstances.”
“I was part of a committee that explored these issues. We were an independent group of hospitalists who decided that board certification was a good way to advance the field,” Dr. Quinonez said. “We’ve seen what subspecialty certification has done, for example, for pediatric emergency medicine and pediatric critical care medicine – advancing them tremendously from a research standpoint and helping to develop a distinct body of knowledge reflecting increased severity of illness in hospitalized children.”
Discrepancy between practicing hospitalists, fellowships
An estimated 4,000 pediatric hospitalists now practice in the United States, and 2,100 of those belong to the American Academy of Pediatrics’ Section on Hospital Medicine. There are 40 pediatric hospital medicine fellowship programs listed on the website of AAP’s Section on Hospital Medicine (http://phmfellows.org/phm-programs/), although formal training assessment criteria will be needed for the American College of Graduate Medical Education to recognize programs that qualify their fellows to sit for the PHM exam. A wide gap is anticipated between the demand for pediatric hospitalists and currently available fellowship training slots to generate new candidates for board certification, although Dr. Rauch projects that fellowship slots will double in coming years.
“My message to the field is that historically, board certification has been the launching point for further development of the field,” Dr. Rauch said. “It leads to standardization of who is a subspecialist. Right now, who is a pediatric hospitalist is subject to wide variation. We need to standardize training and to create for this field the same distinction and stature as other medical subspecialties,” he said, noting that subspecialty status also has ramifications for academic settings, and for career advancement and career satisfaction for the individuals who choose to pursue it.
“I know there has been some hue and cry about this in the field, but in most cases certification will not change a pediatric hospitalist’s ability to obtain a job,” he said. “Already, you can’t become a division leader at a children’s hospital without additional training. This isn’t going to change that reality. But for people who don’t want to follow an academic career path, there will never be enough board-certified or fellowship-trained pediatric hospitalists to fill all of the pediatric positions in all the hospitals in the country. Community hospitals aren’t going to say: We won’t hire you unless you are board certified.”
Is the fellowship good for the field?
The subspecialty development process clearly is moving forward. Those in favor believe it will increase scholarship, research, and recognition for the subspecialty by the public for its specialized body of knowledge. But not everyone in the field agrees. Last fall The Hospitalist published3 an opinion piece questioning the need for fellowship-based board certification in pediatric hospital medicine. The author recommended instead retaining the current voluntary approach to fellowships and establishing a pediatric “focused practice” incorporated into residency training, much as the American Board of Internal Medicine and the American Board of Family Medicine have done for hospitalists in adult medicine.
“Will it lead to uncertainty among those currently in residency programs? If you are a pediatric resident and you want to become a board-certified pediatric hospitalist, you’ll need at least 2 years more of training. Is that going to deter qualified individuals?” Dr. Chang said. “The people this decision will impact the most are med-peds doctors – who complete a combined internal medicine and pediatrics residency – and part-timers. They may find themselves in a difficult position if the number of hours don’t add up for them to sit for the boards. For the most part, we’ll have to wait and see for answers to these questions.”
Brian Alverson, MD, FAAP, current chair of the AAP’s Section on Hospital Medicine and associate professor of pediatrics at Brown University, Providence, R.I., says he can see both sides of the debate.
But at the same time, there is a significant opportunity cost for doing 2 more years of fellowship training, Dr. Alverson said.
“We don’t know how much the board certification test will improve actual care,” he noted. “Does it truly identify higher quality doctors, or just doctors who are good at taking multiple choice exams? There are a number of people in pediatrics who do a lot of different things in their jobs, and it’s important that they not lose their ability to practice in the field. Two-thirds of our work force is in community hospitals, not academic medical centers. They work hard to provide the backbone of hospital care for young patients, and many of them are unlikely to ever do a fellowship.”
Nonetheless, Dr. Alverson believes pediatric hospitalists needn’t worry. “You still have plenty of time to figure out what’s going to happen in your hospital,” he said.
References
1. Section on Hospital Medicine. Guiding principles for pediatric hospital medicine program. Pediatrics; 2013; 132:782-786.
2. Stucky E. The Pediatric Hospital Medicine Core Competencies. Wiley-Blackwell; 2010.
3. Feldman LS, Monash B, Eniasivam A. Why required pediatric hospital medicine fellowships are unnecessary. The Hospitalist Magazine, October 8, 2016.
Pediatric hospital medicine is moving quickly toward recognition as a board-certified, fellowship-trained medical subspecialty, joining 14 other pediatric subspecialties now certified by the American Board of Pediatrics (ABP).
It was approved as a subspecialty by the American Board of Medical Specialties (ABMS) at its October 2016 board meeting in Chicago in response to a petition from the ABP. Following years of discussion within the field,1 it will take 2 more years to describe pediatric hospital medicine’s specialized knowledge base and write test questions for biannual board exams that are projected to commence in the fall of 2019.
Eventually, starting in 2025, pediatric hospitalists will need to complete a fellowship of 2 years or more if they wish to sit for the exam and become board-certified in the field. But for the next 7 years, hospitalists in current practice will be able to qualify based on their work experience. Maintenance of certification requirements likely will be similar to those in other subspecialties, and doctors certified in pediatric hospital medicine won’t be required to maintain general pediatric certification, Dr. Rauch said.
Formal eligibility criteria have not been set, but likely will include working half-time overall in pediatric-related activities, and quarter-time in clinical practice in pediatric hospital medicine for 4 years prior to qualifying for the exam. How the hours might break down between clinical and other hospital responsibilities, and between pediatric or adult patients, still needs to be determined, Dr. Rauch said. He added that the experiential pathway is likely to be defined broadly, with latitude for determinations based on percentages of time worked, rather than absolute number of hours worked. Local pediatric institutions will be granted latitude to determine how that “plays out” in real world situations, he said, “and an ABP credentialing committee will be available to hear appeals for people who have complicated life circumstances.”
“I was part of a committee that explored these issues. We were an independent group of hospitalists who decided that board certification was a good way to advance the field,” Dr. Quinonez said. “We’ve seen what subspecialty certification has done, for example, for pediatric emergency medicine and pediatric critical care medicine – advancing them tremendously from a research standpoint and helping to develop a distinct body of knowledge reflecting increased severity of illness in hospitalized children.”
Discrepancy between practicing hospitalists, fellowships
An estimated 4,000 pediatric hospitalists now practice in the United States, and 2,100 of those belong to the American Academy of Pediatrics’ Section on Hospital Medicine. There are 40 pediatric hospital medicine fellowship programs listed on the website of AAP’s Section on Hospital Medicine (http://phmfellows.org/phm-programs/), although formal training assessment criteria will be needed for the American College of Graduate Medical Education to recognize programs that qualify their fellows to sit for the PHM exam. A wide gap is anticipated between the demand for pediatric hospitalists and currently available fellowship training slots to generate new candidates for board certification, although Dr. Rauch projects that fellowship slots will double in coming years.
“My message to the field is that historically, board certification has been the launching point for further development of the field,” Dr. Rauch said. “It leads to standardization of who is a subspecialist. Right now, who is a pediatric hospitalist is subject to wide variation. We need to standardize training and to create for this field the same distinction and stature as other medical subspecialties,” he said, noting that subspecialty status also has ramifications for academic settings, and for career advancement and career satisfaction for the individuals who choose to pursue it.
“I know there has been some hue and cry about this in the field, but in most cases certification will not change a pediatric hospitalist’s ability to obtain a job,” he said. “Already, you can’t become a division leader at a children’s hospital without additional training. This isn’t going to change that reality. But for people who don’t want to follow an academic career path, there will never be enough board-certified or fellowship-trained pediatric hospitalists to fill all of the pediatric positions in all the hospitals in the country. Community hospitals aren’t going to say: We won’t hire you unless you are board certified.”
Is the fellowship good for the field?
The subspecialty development process clearly is moving forward. Those in favor believe it will increase scholarship, research, and recognition for the subspecialty by the public for its specialized body of knowledge. But not everyone in the field agrees. Last fall The Hospitalist published3 an opinion piece questioning the need for fellowship-based board certification in pediatric hospital medicine. The author recommended instead retaining the current voluntary approach to fellowships and establishing a pediatric “focused practice” incorporated into residency training, much as the American Board of Internal Medicine and the American Board of Family Medicine have done for hospitalists in adult medicine.
“Will it lead to uncertainty among those currently in residency programs? If you are a pediatric resident and you want to become a board-certified pediatric hospitalist, you’ll need at least 2 years more of training. Is that going to deter qualified individuals?” Dr. Chang said. “The people this decision will impact the most are med-peds doctors – who complete a combined internal medicine and pediatrics residency – and part-timers. They may find themselves in a difficult position if the number of hours don’t add up for them to sit for the boards. For the most part, we’ll have to wait and see for answers to these questions.”
Brian Alverson, MD, FAAP, current chair of the AAP’s Section on Hospital Medicine and associate professor of pediatrics at Brown University, Providence, R.I., says he can see both sides of the debate.
But at the same time, there is a significant opportunity cost for doing 2 more years of fellowship training, Dr. Alverson said.
“We don’t know how much the board certification test will improve actual care,” he noted. “Does it truly identify higher quality doctors, or just doctors who are good at taking multiple choice exams? There are a number of people in pediatrics who do a lot of different things in their jobs, and it’s important that they not lose their ability to practice in the field. Two-thirds of our work force is in community hospitals, not academic medical centers. They work hard to provide the backbone of hospital care for young patients, and many of them are unlikely to ever do a fellowship.”
Nonetheless, Dr. Alverson believes pediatric hospitalists needn’t worry. “You still have plenty of time to figure out what’s going to happen in your hospital,” he said.
References
1. Section on Hospital Medicine. Guiding principles for pediatric hospital medicine program. Pediatrics; 2013; 132:782-786.
2. Stucky E. The Pediatric Hospital Medicine Core Competencies. Wiley-Blackwell; 2010.
3. Feldman LS, Monash B, Eniasivam A. Why required pediatric hospital medicine fellowships are unnecessary. The Hospitalist Magazine, October 8, 2016.
Early neuroimaging essential for Zika-exposed neonates
DENVER – The experience gleaned at ground zero of the Brazilian Zika virus epidemic drives home a clinical imperative: every neonate whose pregnant mother has presumed or confirmed Zika infection needs to undergo prompt neuroimaging, even if head circumference at birth is normal, Vanessa van der Linden, MD, said at the annual meeting of the Teratology Society.
Dr. van der Linden, a pediatric neurologist at the Association for Assistance of Disabled Children in Recife, Brazil, has done pioneering work in characterizing the recently recognized congenital Zika syndrome. She was the lead author of the first report of infants who had laboratory evidence of congenital Zika infection and normal head circumference at birth but who developed poor head growth and microcephaly later in infancy.
Comprehensive multispecialty medical and developmental follow-up documented that 10 of 13 infants had dysphagia, 7 had epilepsy, 3 had chorioretinal abnormalities, all 13 had hypertonia, and 12 had pyramidal and extrapyramidal signs with dystonia (MMWR. 2016 Dec 2;65[47]:1343-8).
In another recent publication, Dr. van der Linden and her coinvestigators described classic congenital Zika syndrome with microcephaly at birth as simply the tip of the Zika virus iceberg. In their retrospective review of 77 infants exposed to Zika in utero, 9 had microcephaly at birth, 7 developed microcephaly postnatally, and 3 didn’t have microcephaly at all. Those with microcephaly at birth showed the traditional neuroimaging findings of congenital Zika syndrome, including reduced brain volume, ventriculomegaly, subcortical calcifications, corpus callosum abnormalities, and an enlarged extra-axial space.
Those who subsequently developed microcephaly later in infancy showed most of the same neuroimaging abnormalities. The three infants who remained normocephalic displayed calcifications in the cortico-subcortical junction, asymmetric frontal polymicrogyria, delayed myelination, and milder ventriculomegaly than in the other two groups (AJNR Am J Neuroradiol. 2017 Jul;38[7]:1427-34).
The rehabilitation center where Dr. van der Linden and her colleagues are currently following roughly 200 children with congenital Zika syndrome is in the state of Pernambuco, which was particularly hard hit by the Zika epidemic.
She reported having no relevant financial disclosures.
DENVER – The experience gleaned at ground zero of the Brazilian Zika virus epidemic drives home a clinical imperative: every neonate whose pregnant mother has presumed or confirmed Zika infection needs to undergo prompt neuroimaging, even if head circumference at birth is normal, Vanessa van der Linden, MD, said at the annual meeting of the Teratology Society.
Dr. van der Linden, a pediatric neurologist at the Association for Assistance of Disabled Children in Recife, Brazil, has done pioneering work in characterizing the recently recognized congenital Zika syndrome. She was the lead author of the first report of infants who had laboratory evidence of congenital Zika infection and normal head circumference at birth but who developed poor head growth and microcephaly later in infancy.
Comprehensive multispecialty medical and developmental follow-up documented that 10 of 13 infants had dysphagia, 7 had epilepsy, 3 had chorioretinal abnormalities, all 13 had hypertonia, and 12 had pyramidal and extrapyramidal signs with dystonia (MMWR. 2016 Dec 2;65[47]:1343-8).
In another recent publication, Dr. van der Linden and her coinvestigators described classic congenital Zika syndrome with microcephaly at birth as simply the tip of the Zika virus iceberg. In their retrospective review of 77 infants exposed to Zika in utero, 9 had microcephaly at birth, 7 developed microcephaly postnatally, and 3 didn’t have microcephaly at all. Those with microcephaly at birth showed the traditional neuroimaging findings of congenital Zika syndrome, including reduced brain volume, ventriculomegaly, subcortical calcifications, corpus callosum abnormalities, and an enlarged extra-axial space.
Those who subsequently developed microcephaly later in infancy showed most of the same neuroimaging abnormalities. The three infants who remained normocephalic displayed calcifications in the cortico-subcortical junction, asymmetric frontal polymicrogyria, delayed myelination, and milder ventriculomegaly than in the other two groups (AJNR Am J Neuroradiol. 2017 Jul;38[7]:1427-34).
The rehabilitation center where Dr. van der Linden and her colleagues are currently following roughly 200 children with congenital Zika syndrome is in the state of Pernambuco, which was particularly hard hit by the Zika epidemic.
She reported having no relevant financial disclosures.
DENVER – The experience gleaned at ground zero of the Brazilian Zika virus epidemic drives home a clinical imperative: every neonate whose pregnant mother has presumed or confirmed Zika infection needs to undergo prompt neuroimaging, even if head circumference at birth is normal, Vanessa van der Linden, MD, said at the annual meeting of the Teratology Society.
Dr. van der Linden, a pediatric neurologist at the Association for Assistance of Disabled Children in Recife, Brazil, has done pioneering work in characterizing the recently recognized congenital Zika syndrome. She was the lead author of the first report of infants who had laboratory evidence of congenital Zika infection and normal head circumference at birth but who developed poor head growth and microcephaly later in infancy.
Comprehensive multispecialty medical and developmental follow-up documented that 10 of 13 infants had dysphagia, 7 had epilepsy, 3 had chorioretinal abnormalities, all 13 had hypertonia, and 12 had pyramidal and extrapyramidal signs with dystonia (MMWR. 2016 Dec 2;65[47]:1343-8).
In another recent publication, Dr. van der Linden and her coinvestigators described classic congenital Zika syndrome with microcephaly at birth as simply the tip of the Zika virus iceberg. In their retrospective review of 77 infants exposed to Zika in utero, 9 had microcephaly at birth, 7 developed microcephaly postnatally, and 3 didn’t have microcephaly at all. Those with microcephaly at birth showed the traditional neuroimaging findings of congenital Zika syndrome, including reduced brain volume, ventriculomegaly, subcortical calcifications, corpus callosum abnormalities, and an enlarged extra-axial space.
Those who subsequently developed microcephaly later in infancy showed most of the same neuroimaging abnormalities. The three infants who remained normocephalic displayed calcifications in the cortico-subcortical junction, asymmetric frontal polymicrogyria, delayed myelination, and milder ventriculomegaly than in the other two groups (AJNR Am J Neuroradiol. 2017 Jul;38[7]:1427-34).
The rehabilitation center where Dr. van der Linden and her colleagues are currently following roughly 200 children with congenital Zika syndrome is in the state of Pernambuco, which was particularly hard hit by the Zika epidemic.
She reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM TERATOLOGY SOCIETY 2017
Maternal protection against measles steadily declines prior to vaccination
, and for coxsackievirus (CoxA16), for which there currently is no vaccine.
EV71 and CoxA16 are enteroviruses that are common agents of hand-foot-and-mouth disease. Some patients infected with EV71 or CoxA16 develop neurological and systemic complications that can kill them. An EV71 vaccine, which is initially administered at 6 months, has been licensed in China since December 2015.
In a longitudinally designed study conducted by Chuanxi Fu and Jichuan Shen of Guangzhou (China) Center for Disease Control and Prevention, and their associates, sera was collected from 717 infants ages 0, 3, and 6 months, and examined for levels of measles IgG antibodies, and neutralizing antibodies for EV71 and CoxA16. Measles IgG antibody concentration from 717, 233, and 75 sera were assessed in infants of 0 month, 3 months, and 6 months, and 225, 217, and 72 sera were assessed for EV71 and CoxA16 at these time periods.
This study provides evidence of the rapid declining of measles antibodies in infants prior to vaccination under the Expanded Program on Immunization schedule in China, and confirms the rapid decrease of measles antibody levels suggested by prior cross-sectional studies in China. “Further modifications of vaccination strategies for measles, earlier vaccination for EV71 infection, and development and provision of a CoxA16 vaccine should be investigated and considered in the future,” concluded the researchers.
, and for coxsackievirus (CoxA16), for which there currently is no vaccine.
EV71 and CoxA16 are enteroviruses that are common agents of hand-foot-and-mouth disease. Some patients infected with EV71 or CoxA16 develop neurological and systemic complications that can kill them. An EV71 vaccine, which is initially administered at 6 months, has been licensed in China since December 2015.
In a longitudinally designed study conducted by Chuanxi Fu and Jichuan Shen of Guangzhou (China) Center for Disease Control and Prevention, and their associates, sera was collected from 717 infants ages 0, 3, and 6 months, and examined for levels of measles IgG antibodies, and neutralizing antibodies for EV71 and CoxA16. Measles IgG antibody concentration from 717, 233, and 75 sera were assessed in infants of 0 month, 3 months, and 6 months, and 225, 217, and 72 sera were assessed for EV71 and CoxA16 at these time periods.
This study provides evidence of the rapid declining of measles antibodies in infants prior to vaccination under the Expanded Program on Immunization schedule in China, and confirms the rapid decrease of measles antibody levels suggested by prior cross-sectional studies in China. “Further modifications of vaccination strategies for measles, earlier vaccination for EV71 infection, and development and provision of a CoxA16 vaccine should be investigated and considered in the future,” concluded the researchers.
, and for coxsackievirus (CoxA16), for which there currently is no vaccine.
EV71 and CoxA16 are enteroviruses that are common agents of hand-foot-and-mouth disease. Some patients infected with EV71 or CoxA16 develop neurological and systemic complications that can kill them. An EV71 vaccine, which is initially administered at 6 months, has been licensed in China since December 2015.
In a longitudinally designed study conducted by Chuanxi Fu and Jichuan Shen of Guangzhou (China) Center for Disease Control and Prevention, and their associates, sera was collected from 717 infants ages 0, 3, and 6 months, and examined for levels of measles IgG antibodies, and neutralizing antibodies for EV71 and CoxA16. Measles IgG antibody concentration from 717, 233, and 75 sera were assessed in infants of 0 month, 3 months, and 6 months, and 225, 217, and 72 sera were assessed for EV71 and CoxA16 at these time periods.
This study provides evidence of the rapid declining of measles antibodies in infants prior to vaccination under the Expanded Program on Immunization schedule in China, and confirms the rapid decrease of measles antibody levels suggested by prior cross-sectional studies in China. “Further modifications of vaccination strategies for measles, earlier vaccination for EV71 infection, and development and provision of a CoxA16 vaccine should be investigated and considered in the future,” concluded the researchers.
FROM VACCINE
High-dose vitamin D fails against young children’s upper respiratory infections
A daily dose of 2,000 IU of vitamin D had no impact on reducing wintertime upper respiratory tract infections in young children, compared with a 400 IU dose, based on a study of 703 children aged 1-5 years. The report was published July 18 in JAMA.
“Vitamin D increases the synthesis of the antimicrobial peptide cathelicidin in respiratory epithelium, which has been shown to reduce disease severity and replication of the influenza virus in vitro,” but studies on the effect of vitamin D on upper respiratory infections have been limited, wrote Mary Aglipay of St. Michael’s Hospital, Toronto, and her colleagues.
The average number of laboratory-confirmed cases of upper respiratory tract infections per child was not significantly different between the high-dose and low-dose groups (1.05 vs. 1.03).
The median time to the first laboratory-confirmed infection was similar between the groups: 3.95 months in the high-dose group and 3.29 months in the low-dose group. In addition, the number of parent-reported upper respiratory tract infections was similar between the high-dose and low-dose groups (625 vs. 600).
Serum 25-hydroxyvitamin D levels also remained comparable between the high-dose and low-dose groups at the study’s end (48.7 ng/mL vs. 36.8 ng/mL).
The results were limited by several factors, including the lack of a placebo group and the high baseline vitamin D levels in the children at the end of the summer, the researchers noted.
However, “these findings do not support the routine use of high-dose vitamin D supplementation in children for the prevention of viral upper respiratory tract infection,” they said.
The study was supported by the Canadian Institutes of Health Research, Institute of Human Development, Child and Youth Health, and Institute of Nutrition, Metabolism and Diabetes, and the Thrasher Research Fund. The vitamin D formulations were donated by Ddrops. Ms. Aglipay had no financial conflicts to disclose. One coauthor, Muhammad Mamdani, MPH, had ties to a number of pharmaceutical companies.
A daily dose of 2,000 IU of vitamin D had no impact on reducing wintertime upper respiratory tract infections in young children, compared with a 400 IU dose, based on a study of 703 children aged 1-5 years. The report was published July 18 in JAMA.
“Vitamin D increases the synthesis of the antimicrobial peptide cathelicidin in respiratory epithelium, which has been shown to reduce disease severity and replication of the influenza virus in vitro,” but studies on the effect of vitamin D on upper respiratory infections have been limited, wrote Mary Aglipay of St. Michael’s Hospital, Toronto, and her colleagues.
The average number of laboratory-confirmed cases of upper respiratory tract infections per child was not significantly different between the high-dose and low-dose groups (1.05 vs. 1.03).
The median time to the first laboratory-confirmed infection was similar between the groups: 3.95 months in the high-dose group and 3.29 months in the low-dose group. In addition, the number of parent-reported upper respiratory tract infections was similar between the high-dose and low-dose groups (625 vs. 600).
Serum 25-hydroxyvitamin D levels also remained comparable between the high-dose and low-dose groups at the study’s end (48.7 ng/mL vs. 36.8 ng/mL).
The results were limited by several factors, including the lack of a placebo group and the high baseline vitamin D levels in the children at the end of the summer, the researchers noted.
However, “these findings do not support the routine use of high-dose vitamin D supplementation in children for the prevention of viral upper respiratory tract infection,” they said.
The study was supported by the Canadian Institutes of Health Research, Institute of Human Development, Child and Youth Health, and Institute of Nutrition, Metabolism and Diabetes, and the Thrasher Research Fund. The vitamin D formulations were donated by Ddrops. Ms. Aglipay had no financial conflicts to disclose. One coauthor, Muhammad Mamdani, MPH, had ties to a number of pharmaceutical companies.
A daily dose of 2,000 IU of vitamin D had no impact on reducing wintertime upper respiratory tract infections in young children, compared with a 400 IU dose, based on a study of 703 children aged 1-5 years. The report was published July 18 in JAMA.
“Vitamin D increases the synthesis of the antimicrobial peptide cathelicidin in respiratory epithelium, which has been shown to reduce disease severity and replication of the influenza virus in vitro,” but studies on the effect of vitamin D on upper respiratory infections have been limited, wrote Mary Aglipay of St. Michael’s Hospital, Toronto, and her colleagues.
The average number of laboratory-confirmed cases of upper respiratory tract infections per child was not significantly different between the high-dose and low-dose groups (1.05 vs. 1.03).
The median time to the first laboratory-confirmed infection was similar between the groups: 3.95 months in the high-dose group and 3.29 months in the low-dose group. In addition, the number of parent-reported upper respiratory tract infections was similar between the high-dose and low-dose groups (625 vs. 600).
Serum 25-hydroxyvitamin D levels also remained comparable between the high-dose and low-dose groups at the study’s end (48.7 ng/mL vs. 36.8 ng/mL).
The results were limited by several factors, including the lack of a placebo group and the high baseline vitamin D levels in the children at the end of the summer, the researchers noted.
However, “these findings do not support the routine use of high-dose vitamin D supplementation in children for the prevention of viral upper respiratory tract infection,” they said.
The study was supported by the Canadian Institutes of Health Research, Institute of Human Development, Child and Youth Health, and Institute of Nutrition, Metabolism and Diabetes, and the Thrasher Research Fund. The vitamin D formulations were donated by Ddrops. Ms. Aglipay had no financial conflicts to disclose. One coauthor, Muhammad Mamdani, MPH, had ties to a number of pharmaceutical companies.
FROM JAMA
Key clinical point:
Major finding: The average number of laboratory-confirmed upper respiratory tract infections per child was not significantly different between the high-dose and low-dose groups (1.05 vs. 1.03).
Data source: A study of 703 healthy children aged 1-5 years randomized to 2,000 IU or 400 IU of vitamin D.
Disclosures: The study was supported by the Canadian Institutes of Health Research, Institute of Human Development, Child and Youth Health, and Institute of Nutrition, Metabolism and Diabetes, and the Thrasher Research Fund. The vitamin D formulations were donated by Ddrops. Ms. Aglipay had no financial conflicts to disclose. One coauthor, Muhammad Mamdani, MPH, had ties to a number of pharmaceutical companies.
