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Most children’s hypertension goes undiagnosed and untreated
Twenty-three percent of children with hypertension and 10% of those with prehypertension were diagnosed by clinicians, based on data from a retrospective study of more than 398,000 children in the United States.
In addition, only 6% of children who met criteria for hypertension received treatment within a year of their diagnosis.
The researchers reviewed data from 398,079 children and adolescents aged 3-18 years who were part of the Comparative Effectiveness Research Through Collaborative Electronic Reporting Consortium. The patients had at least three visits with blood pressure and height measured.
The final study population included 12,138 children with hypertension at 44 sites and 38,874 children with prehypertension at 77 sites. Of the children with hypertension, 23% had hypertension or abnormal blood pressure diagnosis in their electronic health record (EHR). In addition, 32% of 4,996 children with stage 2 hypertension had an EHR diagnosis. A diagnosis was more likely in children who were male, taller, older, heavier, had at least one blood pressure measurement in the stage 2 range, or who had additional measurements beyond the three needed for a diagnosis.
Of the children with prehypertension, 10% had a diagnosis of hypertension or abnormal blood pressure in their EHRs. Diagnosis was more common among males and those who were older, heavier, taller, had more than one blood pressure measurement in the stage 2 range or had additional readings beyond those needed for diagnosis, the investigators said.
Of 2,813 pediatric patients who met criteria for hypertension and continued to have high blood pressure readings, only 6% were prescribed medication within 12 months of diagnosis. The average age for medication initiation was almost 14 years, and the most commonly prescribed medications were angiotensin-converting-enzyme inhibitors or angiotensin-II-receptor blockers for 35% of children, diuretics for 22%, calcium channel blockers for 17%, and beta blockers for 10%, Dr. Kaelber and his associates reported.
The study results were limited by several factors, among them the reliance on ICD-9 codes for identification of abnormal blood pressure and inclusion of all reasons (preventive care and nonpreventive care) for visits to primary care pediatric providers. The findings, however, suggest that “intervention is needed to help pediatric primary care clinicians recognize and treat hypertension and prehypertension,” they wrote.
Funding was provided by U.S. Department of Health & Human Services grants and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers had no relevant financial disclosures.
“Childhood hypertension is associated with increased carotid intima media thickness, increased left ventricular mass, and increased arterial stiffness, all precursors to adverse cardiovascular outcomes in adulthood,” wrote Kevin D. Hill, MD, and Jennifer S. Li., MD, in an accompanying editorial (Pediatrics 2016 Nov 22;138:e20162857. doi: 10.1542/peds.2016-2857).
Although some may question the study findings, “there are compelling reasons to believe the results,” in part because the study’s definition of hypertension and reported 3.3% hypertension rate are consistent with current guidelines and previous studies, they noted.
“Hypertension is indeed more challenging to diagnose in children because of age, sex, and height-related variability in blood pressure norms,” they said. Evaluation of blood pressure percentiles, however, should be routine in pediatric practice.
More research is needed, including head-to-head comparisons of drugs and assessments of lifestyle interventions, the editorialists said. However, “it is clear that childhood hypertension is a major public health concern. The clinical manifestations may be silent during childhood, but this should not deter early diagnosis and treatment.”
Dr. Hill and Dr. Li are with Duke University in Durham, N.C. They had no financial conflicts to disclose. Their work was supported in part by the National Institutes of Health.
“Childhood hypertension is associated with increased carotid intima media thickness, increased left ventricular mass, and increased arterial stiffness, all precursors to adverse cardiovascular outcomes in adulthood,” wrote Kevin D. Hill, MD, and Jennifer S. Li., MD, in an accompanying editorial (Pediatrics 2016 Nov 22;138:e20162857. doi: 10.1542/peds.2016-2857).
Although some may question the study findings, “there are compelling reasons to believe the results,” in part because the study’s definition of hypertension and reported 3.3% hypertension rate are consistent with current guidelines and previous studies, they noted.
“Hypertension is indeed more challenging to diagnose in children because of age, sex, and height-related variability in blood pressure norms,” they said. Evaluation of blood pressure percentiles, however, should be routine in pediatric practice.
More research is needed, including head-to-head comparisons of drugs and assessments of lifestyle interventions, the editorialists said. However, “it is clear that childhood hypertension is a major public health concern. The clinical manifestations may be silent during childhood, but this should not deter early diagnosis and treatment.”
Dr. Hill and Dr. Li are with Duke University in Durham, N.C. They had no financial conflicts to disclose. Their work was supported in part by the National Institutes of Health.
“Childhood hypertension is associated with increased carotid intima media thickness, increased left ventricular mass, and increased arterial stiffness, all precursors to adverse cardiovascular outcomes in adulthood,” wrote Kevin D. Hill, MD, and Jennifer S. Li., MD, in an accompanying editorial (Pediatrics 2016 Nov 22;138:e20162857. doi: 10.1542/peds.2016-2857).
Although some may question the study findings, “there are compelling reasons to believe the results,” in part because the study’s definition of hypertension and reported 3.3% hypertension rate are consistent with current guidelines and previous studies, they noted.
“Hypertension is indeed more challenging to diagnose in children because of age, sex, and height-related variability in blood pressure norms,” they said. Evaluation of blood pressure percentiles, however, should be routine in pediatric practice.
More research is needed, including head-to-head comparisons of drugs and assessments of lifestyle interventions, the editorialists said. However, “it is clear that childhood hypertension is a major public health concern. The clinical manifestations may be silent during childhood, but this should not deter early diagnosis and treatment.”
Dr. Hill and Dr. Li are with Duke University in Durham, N.C. They had no financial conflicts to disclose. Their work was supported in part by the National Institutes of Health.
Twenty-three percent of children with hypertension and 10% of those with prehypertension were diagnosed by clinicians, based on data from a retrospective study of more than 398,000 children in the United States.
In addition, only 6% of children who met criteria for hypertension received treatment within a year of their diagnosis.
The researchers reviewed data from 398,079 children and adolescents aged 3-18 years who were part of the Comparative Effectiveness Research Through Collaborative Electronic Reporting Consortium. The patients had at least three visits with blood pressure and height measured.
The final study population included 12,138 children with hypertension at 44 sites and 38,874 children with prehypertension at 77 sites. Of the children with hypertension, 23% had hypertension or abnormal blood pressure diagnosis in their electronic health record (EHR). In addition, 32% of 4,996 children with stage 2 hypertension had an EHR diagnosis. A diagnosis was more likely in children who were male, taller, older, heavier, had at least one blood pressure measurement in the stage 2 range, or who had additional measurements beyond the three needed for a diagnosis.
Of the children with prehypertension, 10% had a diagnosis of hypertension or abnormal blood pressure in their EHRs. Diagnosis was more common among males and those who were older, heavier, taller, had more than one blood pressure measurement in the stage 2 range or had additional readings beyond those needed for diagnosis, the investigators said.
Of 2,813 pediatric patients who met criteria for hypertension and continued to have high blood pressure readings, only 6% were prescribed medication within 12 months of diagnosis. The average age for medication initiation was almost 14 years, and the most commonly prescribed medications were angiotensin-converting-enzyme inhibitors or angiotensin-II-receptor blockers for 35% of children, diuretics for 22%, calcium channel blockers for 17%, and beta blockers for 10%, Dr. Kaelber and his associates reported.
The study results were limited by several factors, among them the reliance on ICD-9 codes for identification of abnormal blood pressure and inclusion of all reasons (preventive care and nonpreventive care) for visits to primary care pediatric providers. The findings, however, suggest that “intervention is needed to help pediatric primary care clinicians recognize and treat hypertension and prehypertension,” they wrote.
Funding was provided by U.S. Department of Health & Human Services grants and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers had no relevant financial disclosures.
Twenty-three percent of children with hypertension and 10% of those with prehypertension were diagnosed by clinicians, based on data from a retrospective study of more than 398,000 children in the United States.
In addition, only 6% of children who met criteria for hypertension received treatment within a year of their diagnosis.
The researchers reviewed data from 398,079 children and adolescents aged 3-18 years who were part of the Comparative Effectiveness Research Through Collaborative Electronic Reporting Consortium. The patients had at least three visits with blood pressure and height measured.
The final study population included 12,138 children with hypertension at 44 sites and 38,874 children with prehypertension at 77 sites. Of the children with hypertension, 23% had hypertension or abnormal blood pressure diagnosis in their electronic health record (EHR). In addition, 32% of 4,996 children with stage 2 hypertension had an EHR diagnosis. A diagnosis was more likely in children who were male, taller, older, heavier, had at least one blood pressure measurement in the stage 2 range, or who had additional measurements beyond the three needed for a diagnosis.
Of the children with prehypertension, 10% had a diagnosis of hypertension or abnormal blood pressure in their EHRs. Diagnosis was more common among males and those who were older, heavier, taller, had more than one blood pressure measurement in the stage 2 range or had additional readings beyond those needed for diagnosis, the investigators said.
Of 2,813 pediatric patients who met criteria for hypertension and continued to have high blood pressure readings, only 6% were prescribed medication within 12 months of diagnosis. The average age for medication initiation was almost 14 years, and the most commonly prescribed medications were angiotensin-converting-enzyme inhibitors or angiotensin-II-receptor blockers for 35% of children, diuretics for 22%, calcium channel blockers for 17%, and beta blockers for 10%, Dr. Kaelber and his associates reported.
The study results were limited by several factors, among them the reliance on ICD-9 codes for identification of abnormal blood pressure and inclusion of all reasons (preventive care and nonpreventive care) for visits to primary care pediatric providers. The findings, however, suggest that “intervention is needed to help pediatric primary care clinicians recognize and treat hypertension and prehypertension,” they wrote.
Funding was provided by U.S. Department of Health & Human Services grants and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers had no relevant financial disclosures.
FROM PEDIATRICS
Key clinical point: Pediatric hypertension is underdiagnosed, and medication guidelines are inconsistently followed.
Major finding: Only 23% of children with hypertension and 10% of those with prehypertension were diagnosed by clinicians; 6% of those with hypertension were prescribed medication.
Data source: A retrospective cohort study including 398,079 pediatric patients from 196 clinics in 27 states.
Disclosures: Funding was provided by U.S. Department of Health & Human Services grants and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers had no relevant financial disclosures.
Two doses of HPV vaccine may be noninferior to three
A two-dose schedule of the 9-valent human papillomavirus (HPV) vaccine in children aged 9-14 years is noninferior to a three-dose schedule in adolescent girls and women (aged 16-26 years), based on immunogenicity measurements.
Many countries have poor HPV vaccination rates, in part because the current regimen requires three doses over a 6-month span, and it can be challenging in some areas for children to make three health care visits in the required time span. “Using an effective two-dose regimen entailing fewer visits could improve adherence to HPV vaccination programs. Coadministration of the 9-valent HPV vaccine with diphtheria, tetanus, pertussis, polio, and meningococcal vaccines could also be completed at the same visit,” reported Ole-Erik Iversen, MD, PhD, of the University of Bergen (Norway) and his colleagues (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.17615).
The researchers measured serum anti-HPV antibodies 1 month after the final dose. At least 98% of the participants in each group seroconverted to a response against all 9 HPV subtypes, and analysis of the antibody geometric mean titers revealed that the groups who received two doses had noninferior responses to the control group of adolescent girls and young women who received three doses.
Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses. “These observations suggest that the overall results of the primary immunogenicity analyses may be applicable across the entire studied age range of girls and boys,” Dr. Iversen and his associates wrote.
The study cannot prove that the two-dose regimen has equal efficacy to the three-dose regimen in preventing HPV infection, only that the immunogenicity is noninferior, they said.
The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
Evidence now supports a two-dose schedule in adolescents (aged 9-14 years) for all three licensed HPV vaccines. When the vaccination series is initiated before the age of 15 years, two doses administered at a 0- and 6-month interval or at a 0- and 12-month interval were found to be just as immunogenic as (or even better than) three doses.
The coverage of HPV vaccination in the United States is lower than that for other vaccines recommended for adolescents, such as quadrivalent meningococcal conjugate vaccine and tetanus, diphtheria, and acellular pertussis vaccine. In 2015, three-dose HPV vaccination coverage among 13- to 17-year-olds was only 41.9% for girls and 28.1% for boys; at least one-dose coverage was 62.8% for girls and 49.8% for boys.
Going forward, a two-dose schedule should make it easier to complete the recommended vaccination series. A two-dose schedule (at 0 and 6-12 months) will decrease health care appointments needed for HPV vaccination and facilitate clinicians’ ability to deliver vaccine at preventive health visits. Nevertheless, efforts will be needed to increase vaccine initiation and ensure delivery of the second dose.
Lauri E. Markowitz, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Elizabeth R. Unger, MD, MPH, is at the division of high-consequence pathogens and pathology, National Center for Emerging and Zoonotic Infectious Diseases at the CDC. Elissa Meites, PhD, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the CDC. Their comments were excerpted from an editorial accompanying the article by Iversen et al. (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.16393). The authors declared no financial conflicts of interest.
Evidence now supports a two-dose schedule in adolescents (aged 9-14 years) for all three licensed HPV vaccines. When the vaccination series is initiated before the age of 15 years, two doses administered at a 0- and 6-month interval or at a 0- and 12-month interval were found to be just as immunogenic as (or even better than) three doses.
The coverage of HPV vaccination in the United States is lower than that for other vaccines recommended for adolescents, such as quadrivalent meningococcal conjugate vaccine and tetanus, diphtheria, and acellular pertussis vaccine. In 2015, three-dose HPV vaccination coverage among 13- to 17-year-olds was only 41.9% for girls and 28.1% for boys; at least one-dose coverage was 62.8% for girls and 49.8% for boys.
Going forward, a two-dose schedule should make it easier to complete the recommended vaccination series. A two-dose schedule (at 0 and 6-12 months) will decrease health care appointments needed for HPV vaccination and facilitate clinicians’ ability to deliver vaccine at preventive health visits. Nevertheless, efforts will be needed to increase vaccine initiation and ensure delivery of the second dose.
Lauri E. Markowitz, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Elizabeth R. Unger, MD, MPH, is at the division of high-consequence pathogens and pathology, National Center for Emerging and Zoonotic Infectious Diseases at the CDC. Elissa Meites, PhD, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the CDC. Their comments were excerpted from an editorial accompanying the article by Iversen et al. (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.16393). The authors declared no financial conflicts of interest.
Evidence now supports a two-dose schedule in adolescents (aged 9-14 years) for all three licensed HPV vaccines. When the vaccination series is initiated before the age of 15 years, two doses administered at a 0- and 6-month interval or at a 0- and 12-month interval were found to be just as immunogenic as (or even better than) three doses.
The coverage of HPV vaccination in the United States is lower than that for other vaccines recommended for adolescents, such as quadrivalent meningococcal conjugate vaccine and tetanus, diphtheria, and acellular pertussis vaccine. In 2015, three-dose HPV vaccination coverage among 13- to 17-year-olds was only 41.9% for girls and 28.1% for boys; at least one-dose coverage was 62.8% for girls and 49.8% for boys.
Going forward, a two-dose schedule should make it easier to complete the recommended vaccination series. A two-dose schedule (at 0 and 6-12 months) will decrease health care appointments needed for HPV vaccination and facilitate clinicians’ ability to deliver vaccine at preventive health visits. Nevertheless, efforts will be needed to increase vaccine initiation and ensure delivery of the second dose.
Lauri E. Markowitz, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Elizabeth R. Unger, MD, MPH, is at the division of high-consequence pathogens and pathology, National Center for Emerging and Zoonotic Infectious Diseases at the CDC. Elissa Meites, PhD, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the CDC. Their comments were excerpted from an editorial accompanying the article by Iversen et al. (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.16393). The authors declared no financial conflicts of interest.
A two-dose schedule of the 9-valent human papillomavirus (HPV) vaccine in children aged 9-14 years is noninferior to a three-dose schedule in adolescent girls and women (aged 16-26 years), based on immunogenicity measurements.
Many countries have poor HPV vaccination rates, in part because the current regimen requires three doses over a 6-month span, and it can be challenging in some areas for children to make three health care visits in the required time span. “Using an effective two-dose regimen entailing fewer visits could improve adherence to HPV vaccination programs. Coadministration of the 9-valent HPV vaccine with diphtheria, tetanus, pertussis, polio, and meningococcal vaccines could also be completed at the same visit,” reported Ole-Erik Iversen, MD, PhD, of the University of Bergen (Norway) and his colleagues (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.17615).
The researchers measured serum anti-HPV antibodies 1 month after the final dose. At least 98% of the participants in each group seroconverted to a response against all 9 HPV subtypes, and analysis of the antibody geometric mean titers revealed that the groups who received two doses had noninferior responses to the control group of adolescent girls and young women who received three doses.
Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses. “These observations suggest that the overall results of the primary immunogenicity analyses may be applicable across the entire studied age range of girls and boys,” Dr. Iversen and his associates wrote.
The study cannot prove that the two-dose regimen has equal efficacy to the three-dose regimen in preventing HPV infection, only that the immunogenicity is noninferior, they said.
The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
A two-dose schedule of the 9-valent human papillomavirus (HPV) vaccine in children aged 9-14 years is noninferior to a three-dose schedule in adolescent girls and women (aged 16-26 years), based on immunogenicity measurements.
Many countries have poor HPV vaccination rates, in part because the current regimen requires three doses over a 6-month span, and it can be challenging in some areas for children to make three health care visits in the required time span. “Using an effective two-dose regimen entailing fewer visits could improve adherence to HPV vaccination programs. Coadministration of the 9-valent HPV vaccine with diphtheria, tetanus, pertussis, polio, and meningococcal vaccines could also be completed at the same visit,” reported Ole-Erik Iversen, MD, PhD, of the University of Bergen (Norway) and his colleagues (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.17615).
The researchers measured serum anti-HPV antibodies 1 month after the final dose. At least 98% of the participants in each group seroconverted to a response against all 9 HPV subtypes, and analysis of the antibody geometric mean titers revealed that the groups who received two doses had noninferior responses to the control group of adolescent girls and young women who received three doses.
Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses. “These observations suggest that the overall results of the primary immunogenicity analyses may be applicable across the entire studied age range of girls and boys,” Dr. Iversen and his associates wrote.
The study cannot prove that the two-dose regimen has equal efficacy to the three-dose regimen in preventing HPV infection, only that the immunogenicity is noninferior, they said.
The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
FROM JAMA
Key clinical point:
Major finding: Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses.
Data source: Prospective, randomized trial of 1,377 children and young adults.
Disclosures: The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
Adjustment for fluid balance improved detection of AKI in critically ill children
CHICAGO – Adjustment for fluid balance increased the detection rate of acute kidney injury, more accurately staged the kidney damage, and distinguished false-positive cases in critically ill children, based on a secondary analysis of the Study of the Prediction of Acute Kidney Injury in Children Using Risk Stratification and Biomarkers (AKI-CHERUB).
Fluid overload can mask acute kidney injury (AKI) in critically ill children. “The failure to correct serum creatinine measure for fluid overload dilutes the impact of AKI on outcomes,” David T. Selewski, MD, of the University of Michigan, Ann Arbor, said at the annual meeting sponsored by the American Society for Nephrology.
The primary outcome was ICU mortality. Secondary outcomes were length of mechanical ventilation, and length of stay in the ICU and the hospital.
The original study documented an ICU mortality rate of 7.1%. AKI was identified in 77 (41.8%) of the 184 patients. The median peak fluid overload during ICU admission was 12.9 (interquartile range, 7.4-20.8).
The serum creatinine data were corrected for fluid balance and these rates were reassessed. Following the adjustment, the rate of AKI increased from 41.8% to 53.4%, with 30 new cases identified according to standard defined criteria. The mean fluid overload was now 11.2 (interquartile range, 5.7-17.7).
In the original cohort, there were 40 cases of severe AKI (stage 2 and 3). Following the creatinine correction, 13 more cases were judged to be severe. Of these, five cases were associated with a worse outcome in terms of ICU mortality. Additionally, 10 cases that had been diagnosed as AKI were found to be false positives.
The results need to be studied in larger studies and in other populations, such as neonates, Dr. Selewski said.
CHICAGO – Adjustment for fluid balance increased the detection rate of acute kidney injury, more accurately staged the kidney damage, and distinguished false-positive cases in critically ill children, based on a secondary analysis of the Study of the Prediction of Acute Kidney Injury in Children Using Risk Stratification and Biomarkers (AKI-CHERUB).
Fluid overload can mask acute kidney injury (AKI) in critically ill children. “The failure to correct serum creatinine measure for fluid overload dilutes the impact of AKI on outcomes,” David T. Selewski, MD, of the University of Michigan, Ann Arbor, said at the annual meeting sponsored by the American Society for Nephrology.
The primary outcome was ICU mortality. Secondary outcomes were length of mechanical ventilation, and length of stay in the ICU and the hospital.
The original study documented an ICU mortality rate of 7.1%. AKI was identified in 77 (41.8%) of the 184 patients. The median peak fluid overload during ICU admission was 12.9 (interquartile range, 7.4-20.8).
The serum creatinine data were corrected for fluid balance and these rates were reassessed. Following the adjustment, the rate of AKI increased from 41.8% to 53.4%, with 30 new cases identified according to standard defined criteria. The mean fluid overload was now 11.2 (interquartile range, 5.7-17.7).
In the original cohort, there were 40 cases of severe AKI (stage 2 and 3). Following the creatinine correction, 13 more cases were judged to be severe. Of these, five cases were associated with a worse outcome in terms of ICU mortality. Additionally, 10 cases that had been diagnosed as AKI were found to be false positives.
The results need to be studied in larger studies and in other populations, such as neonates, Dr. Selewski said.
CHICAGO – Adjustment for fluid balance increased the detection rate of acute kidney injury, more accurately staged the kidney damage, and distinguished false-positive cases in critically ill children, based on a secondary analysis of the Study of the Prediction of Acute Kidney Injury in Children Using Risk Stratification and Biomarkers (AKI-CHERUB).
Fluid overload can mask acute kidney injury (AKI) in critically ill children. “The failure to correct serum creatinine measure for fluid overload dilutes the impact of AKI on outcomes,” David T. Selewski, MD, of the University of Michigan, Ann Arbor, said at the annual meeting sponsored by the American Society for Nephrology.
The primary outcome was ICU mortality. Secondary outcomes were length of mechanical ventilation, and length of stay in the ICU and the hospital.
The original study documented an ICU mortality rate of 7.1%. AKI was identified in 77 (41.8%) of the 184 patients. The median peak fluid overload during ICU admission was 12.9 (interquartile range, 7.4-20.8).
The serum creatinine data were corrected for fluid balance and these rates were reassessed. Following the adjustment, the rate of AKI increased from 41.8% to 53.4%, with 30 new cases identified according to standard defined criteria. The mean fluid overload was now 11.2 (interquartile range, 5.7-17.7).
In the original cohort, there were 40 cases of severe AKI (stage 2 and 3). Following the creatinine correction, 13 more cases were judged to be severe. Of these, five cases were associated with a worse outcome in terms of ICU mortality. Additionally, 10 cases that had been diagnosed as AKI were found to be false positives.
The results need to be studied in larger studies and in other populations, such as neonates, Dr. Selewski said.
AT KIDNEY WEEK 2016
Key clinical point: Acute kidney injury can be detected more accurately in critically ill children by correcting for fluid overload.
Major finding: Fluid overload masked diagnosis of over 40% of patients with acute kidney injury in an observational study.
Data source: Secondary analysis of AKI-CHERUB single-center observational study involving 181 critically ill children.
Disclosures: The AKI-CHERUB study was funded by NIH. Dr. Selewski reported having no financial disclosures.
Acute kidney injury common in children, young adults in ICU
Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.
The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.
Ahmad Kaddourah, MD, from the Center for Acute Care Nephrology at the Cincinnati Children’s Hospital Medical Center, and his coauthors found that 27% of the participants developed acute kidney injury and 12% developed severe acute kidney injury – defined as stage 2 or 3 acute kidney injury – within the first 7 days after admission.
The risk of death within 28 days was 77% higher among individuals with severe acute kidney injury, even after accounting for their original diagnosis when they were admitted to the ICU. Mortality among these individuals was 11%, compared with 2.5% among patients without severe acute kidney injury. These patients also had an increased use of renal replacement therapy and mechanical ventilation, and were more likely to have longer stays in hospital.
Researchers also saw a stepwise increase in 28-day mortality associated with maximum stage of acute kidney injury.
“The common and early occurrence of acute kidney injury reinforces the need for systematic surveillance for acute kidney injury at the time of admission to the ICU,” Dr. Kaddourah and his associates wrote. “Early identification of modifiable risk factors for acute kidney injury (e.g., nephrotoxic medications) or adverse sequelae (e.g., fluid overload) has the potential to decrease morbidity and mortality.”
Of particular note was the observation that 67% of the patients who met the urine-output criteria for acute kidney injury would not have been diagnosed using the plasma creatinine criteria alone. Furthermore, “mortality was higher among patients diagnosed with stage 3 acute kidney injury according to urine output than among those diagnosed according to plasma creatinine levels,” the authors reported.
There was a steady increase in the daily prevalence of acute kidney disease, from 15% on day 1 after admission to 20% by day 7. Patients with stage 1 acute kidney injury on day 1 also were more likely to progress to stage 2 or 3 by day 7, compared with patients who did not have acute kidney injury on admission.
However, around three-quarters of this increase in stage occurred within the first 4 days after admission, which the authors suggested would support a 4-day time frame for future studies on acute kidney injury in children. They also stressed that as their assessments for acute kidney injury stopped at day 7 after admission, there may have been incidents that were missed.
Dr. Kaddourah and his associates noted that although the rates of severe and acute kidney injury seen in the study were slightly lower than those observed in studies in adults, the associations with morbidity and mortality were similar.
“The presence of chronic systemic diseases contributes to residual confounding in studies of acute kidney injury in adults,” they wrote. “Children have a low prevalence of such chronic diseases; thus, although the incremental association between acute kidney injury and risk of death mirrors that seen in adults, our study suggests that acute kidney injury itself may be key to the associated morbidity and mortality.”
The study was supported by the Pediatric Nephrology Center for Excellence at Cincinnati Children’s Hospital Medical Center. The authors declared grants, consultancies, speaking engagements, and other support from private industry, some related to and some outside of the submitted work.
A strength of this study is the definition of acute kidney injury, with the use of precise and validated criteria. Limitations of the study, beyond its observational nature, include the lack of data about diuretic and other treatment that may have influenced urine output, and the requirement for just a single baseline plasma creatinine level for study entry.
However, the study results indicate that acute injury is not only common among critically ill children and young adults, but is associated with adverse outcomes, implying that we should look more carefully for markers of acute kidney injury. Given the link between acute kidney injury and subsequent chronic kidney disease, it possible that identifying and treating acute kidney injury promptly might reduce the prevalence of chronic kidney disease, now estimated as roughly one in eight adults in the United States.
Julie R. Ingelfinger, MD, is a pediatric nephrologist at Massachusetts General Hospital and deputy editor of the New England Journal of Medicine. These comments are excerpted from an accompanying editorial (N Eng J Med. 2016 Nov 18. doi: 10.1056/NEJMe613456). No conflicts of interest were declared.
A strength of this study is the definition of acute kidney injury, with the use of precise and validated criteria. Limitations of the study, beyond its observational nature, include the lack of data about diuretic and other treatment that may have influenced urine output, and the requirement for just a single baseline plasma creatinine level for study entry.
However, the study results indicate that acute injury is not only common among critically ill children and young adults, but is associated with adverse outcomes, implying that we should look more carefully for markers of acute kidney injury. Given the link between acute kidney injury and subsequent chronic kidney disease, it possible that identifying and treating acute kidney injury promptly might reduce the prevalence of chronic kidney disease, now estimated as roughly one in eight adults in the United States.
Julie R. Ingelfinger, MD, is a pediatric nephrologist at Massachusetts General Hospital and deputy editor of the New England Journal of Medicine. These comments are excerpted from an accompanying editorial (N Eng J Med. 2016 Nov 18. doi: 10.1056/NEJMe613456). No conflicts of interest were declared.
A strength of this study is the definition of acute kidney injury, with the use of precise and validated criteria. Limitations of the study, beyond its observational nature, include the lack of data about diuretic and other treatment that may have influenced urine output, and the requirement for just a single baseline plasma creatinine level for study entry.
However, the study results indicate that acute injury is not only common among critically ill children and young adults, but is associated with adverse outcomes, implying that we should look more carefully for markers of acute kidney injury. Given the link between acute kidney injury and subsequent chronic kidney disease, it possible that identifying and treating acute kidney injury promptly might reduce the prevalence of chronic kidney disease, now estimated as roughly one in eight adults in the United States.
Julie R. Ingelfinger, MD, is a pediatric nephrologist at Massachusetts General Hospital and deputy editor of the New England Journal of Medicine. These comments are excerpted from an accompanying editorial (N Eng J Med. 2016 Nov 18. doi: 10.1056/NEJMe613456). No conflicts of interest were declared.
Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.
The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.
Ahmad Kaddourah, MD, from the Center for Acute Care Nephrology at the Cincinnati Children’s Hospital Medical Center, and his coauthors found that 27% of the participants developed acute kidney injury and 12% developed severe acute kidney injury – defined as stage 2 or 3 acute kidney injury – within the first 7 days after admission.
The risk of death within 28 days was 77% higher among individuals with severe acute kidney injury, even after accounting for their original diagnosis when they were admitted to the ICU. Mortality among these individuals was 11%, compared with 2.5% among patients without severe acute kidney injury. These patients also had an increased use of renal replacement therapy and mechanical ventilation, and were more likely to have longer stays in hospital.
Researchers also saw a stepwise increase in 28-day mortality associated with maximum stage of acute kidney injury.
“The common and early occurrence of acute kidney injury reinforces the need for systematic surveillance for acute kidney injury at the time of admission to the ICU,” Dr. Kaddourah and his associates wrote. “Early identification of modifiable risk factors for acute kidney injury (e.g., nephrotoxic medications) or adverse sequelae (e.g., fluid overload) has the potential to decrease morbidity and mortality.”
Of particular note was the observation that 67% of the patients who met the urine-output criteria for acute kidney injury would not have been diagnosed using the plasma creatinine criteria alone. Furthermore, “mortality was higher among patients diagnosed with stage 3 acute kidney injury according to urine output than among those diagnosed according to plasma creatinine levels,” the authors reported.
There was a steady increase in the daily prevalence of acute kidney disease, from 15% on day 1 after admission to 20% by day 7. Patients with stage 1 acute kidney injury on day 1 also were more likely to progress to stage 2 or 3 by day 7, compared with patients who did not have acute kidney injury on admission.
However, around three-quarters of this increase in stage occurred within the first 4 days after admission, which the authors suggested would support a 4-day time frame for future studies on acute kidney injury in children. They also stressed that as their assessments for acute kidney injury stopped at day 7 after admission, there may have been incidents that were missed.
Dr. Kaddourah and his associates noted that although the rates of severe and acute kidney injury seen in the study were slightly lower than those observed in studies in adults, the associations with morbidity and mortality were similar.
“The presence of chronic systemic diseases contributes to residual confounding in studies of acute kidney injury in adults,” they wrote. “Children have a low prevalence of such chronic diseases; thus, although the incremental association between acute kidney injury and risk of death mirrors that seen in adults, our study suggests that acute kidney injury itself may be key to the associated morbidity and mortality.”
The study was supported by the Pediatric Nephrology Center for Excellence at Cincinnati Children’s Hospital Medical Center. The authors declared grants, consultancies, speaking engagements, and other support from private industry, some related to and some outside of the submitted work.
Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.
The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.
Ahmad Kaddourah, MD, from the Center for Acute Care Nephrology at the Cincinnati Children’s Hospital Medical Center, and his coauthors found that 27% of the participants developed acute kidney injury and 12% developed severe acute kidney injury – defined as stage 2 or 3 acute kidney injury – within the first 7 days after admission.
The risk of death within 28 days was 77% higher among individuals with severe acute kidney injury, even after accounting for their original diagnosis when they were admitted to the ICU. Mortality among these individuals was 11%, compared with 2.5% among patients without severe acute kidney injury. These patients also had an increased use of renal replacement therapy and mechanical ventilation, and were more likely to have longer stays in hospital.
Researchers also saw a stepwise increase in 28-day mortality associated with maximum stage of acute kidney injury.
“The common and early occurrence of acute kidney injury reinforces the need for systematic surveillance for acute kidney injury at the time of admission to the ICU,” Dr. Kaddourah and his associates wrote. “Early identification of modifiable risk factors for acute kidney injury (e.g., nephrotoxic medications) or adverse sequelae (e.g., fluid overload) has the potential to decrease morbidity and mortality.”
Of particular note was the observation that 67% of the patients who met the urine-output criteria for acute kidney injury would not have been diagnosed using the plasma creatinine criteria alone. Furthermore, “mortality was higher among patients diagnosed with stage 3 acute kidney injury according to urine output than among those diagnosed according to plasma creatinine levels,” the authors reported.
There was a steady increase in the daily prevalence of acute kidney disease, from 15% on day 1 after admission to 20% by day 7. Patients with stage 1 acute kidney injury on day 1 also were more likely to progress to stage 2 or 3 by day 7, compared with patients who did not have acute kidney injury on admission.
However, around three-quarters of this increase in stage occurred within the first 4 days after admission, which the authors suggested would support a 4-day time frame for future studies on acute kidney injury in children. They also stressed that as their assessments for acute kidney injury stopped at day 7 after admission, there may have been incidents that were missed.
Dr. Kaddourah and his associates noted that although the rates of severe and acute kidney injury seen in the study were slightly lower than those observed in studies in adults, the associations with morbidity and mortality were similar.
“The presence of chronic systemic diseases contributes to residual confounding in studies of acute kidney injury in adults,” they wrote. “Children have a low prevalence of such chronic diseases; thus, although the incremental association between acute kidney injury and risk of death mirrors that seen in adults, our study suggests that acute kidney injury itself may be key to the associated morbidity and mortality.”
The study was supported by the Pediatric Nephrology Center for Excellence at Cincinnati Children’s Hospital Medical Center. The authors declared grants, consultancies, speaking engagements, and other support from private industry, some related to and some outside of the submitted work.
FROM KIDNEY WEEK 2016
Key clinical point: Acute kidney injury is common in children and young adults admitted to ICU, but many cases may be missed using plasma creatinine criteria alone.
Major finding: Among children and young adults admitted to intensive care, as many as 1 in 4 may have acute kidney injury and 1 in 10 may have severe acute kidney injury.
Data source: Prospective observational study in 4,683 patients aged 3 months to 25 years admitted to pediatric intensive care.
Disclosures: The study was supported by the Pediatric Nephrology Center for Excellence at Cincinnati Children’s Hospital Medical Center. The authors declared grants, consultancies, speaking engagements and other support from private industry, some related to and some outside of the submitted work.
Distinguishing early puberty from pathology
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
AT AAP 16
Confront youth opioid misuse head on
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
EXPERT ANALYSIS FROM AAP 16
It’s in the nose
There is a lot more going on in the nose besides air going in and out. The nose is where it all begins for pathogenesis for all respiratory infections. The interplay between the commensal microbes, the potential pathogens, innate immunity, and adaptive immunity is much more complex than was previously understood. So what is new?
In our research on acute otitis media, we swab and wash out noses of children aged 6-36 months to isolate the potential pathogens Streptococcus pneumoniae, nontypeable Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Group A streptococci. We isolate one or more of these bacteria from most of the children even though they are well. We observe perhaps a half-dozen other species of bacteria on the culture plate. Mostly, we isolate S. pneumoniae, nontypeable H. influenza, or M. catarrhalis and alpha-hemolytic streptococci and corynebacterium species.
We have recently begun to investigate the other microbiota in the nose and found they are indeed plentiful. In a recent screening of a half-dozen children, we found hundreds of different microbes in their noses, so cultures and standard molecular detection methods were just touching the surface. I was asked recently at a medical conference – the American Academy of Pediatrics– Orange County, California, annual CME course – at which I spoke on this topic what I thought would be the most-important area of research in the next decade. I responded, the microbiome. The microbiome is indeed a hot topic. Research over the last decade suggests that 90% of all diseases can be traced in some way to disturbances in the microbiome. What I mean by microbiome is “the totality of microorganisms and their collective genetic material present in or on the human body.” The term is often used interchangeably with “microbiota,” although the former refers to genes of microbes and the latter refers to the microbes themselves. What I mean by “disturbance” is excessive use of antibiotics.
How many microbes are in the nose? We don’t know. But if the gut is any indication, there are thousands of microbes in the nose because the gut has more than 10,000 different microbes. Recognizing that there are hundreds of microbes in the nose and from time to time children get colonized by potential pathogens that can cause otitis media, sinusitis, or pneumonia, how does pathogenesis get started? It starts with a respiratory virus infection. The bacteria need help from the viruses to cause disease. The viruses cause damage to the epithelial cells of the nose, and this gives the bacteria more places to attach when they divide so the amount of bacteria increases exponentially. As the viruses replicate, they more effectively slow down cilia beating, and the nasal mucus thickens. This, too, helps the bacteria and viruses attach to and penetrate epithelial cells in the nose and increase in density on the surface of the cells and inside the cells. The viruses divert and/or suppress the innate immune system, represented by neutrophils that migrate to the nose and discharge their intracellular contents to turn nasal mucus yellow and green. The viruses even down-modulate the adaptive immune system in clever ways that result in fewer potentially protective cytotoxic lymphocytes that kill viruses making their way to the nose, and fewer T cells that discharge cytokines that promote a necessary inflammatory response to clear both bacteria and viruses from the nose and fewer B cells that become plasma cells and release antibodies into the nose.
When the bacteria with potential to cause diseases reach a “pathogenic threshold,” they move, along with mucus, into the middle ear, the sinuses, or down the throat to the lungs, usually with the accompanying respiratory virus. There pathogenesis continues in the otherwise sterile and protected sanctuary of these interconnected respiratory sites. A few days later, we as clinicians observe the symptoms and signs of otitis media, sinusitis, or pneumonia.
What can we do to help the nose? Mostly, we should do no harm, and that has been our failing for decades since the introduction of antibiotics. The allure of antibiotics is great because they have indeed saved many lives and shortened many illnesses when appropriately used. However, too often clinicians have seen patients with yellow and green nasal mucus (or any increased nasal mucus) and diagnosed “a bacterial infection” and prescribed antibiotics. And too often clinicians have seen patients with an annoying cough (or any cough) and diagnosed “a bacterial chest infection” and prescribed antibiotics. The clinicians thought it was the right thing to do because they wanted to help their patient. And they did not want them to come back in a few days with persistence or worsening of symptoms, or worse, seek care from other health care providers elsewhere. So they gave antibiotics.
Well, the paradigm has changed. It is now clearly known that antibiotics can be harmful mainly by damaging the normal, healthy microbiome. The change in healthy homeostasis of the microbiome wrought by antibiotics is greatest in newborns, especially premature newborns, then next worst for infants, and then next worst for young children. These are the age groups where antibiotics are prescribed most frequently! And everyone needs to stop writing those prescriptions for runny noses, yellow and green mucus in the nose, and coughs. All of us need to prescribe antibiotics only when there is an accurate diagnosis of otitis media or sinusitis or bronchopneumonia or lobar pneumonia. And when we do prescribe the antibiotics ,we need to give them for as short a time as possible. But that is a topic for another column.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he has no relevant financial disclosures, and that his research is supported by a grant from the National Institutes of Health National Institute of Deafness and Communication Disorders. Email him at pdnews@frontlinemedcom.com.
There is a lot more going on in the nose besides air going in and out. The nose is where it all begins for pathogenesis for all respiratory infections. The interplay between the commensal microbes, the potential pathogens, innate immunity, and adaptive immunity is much more complex than was previously understood. So what is new?
In our research on acute otitis media, we swab and wash out noses of children aged 6-36 months to isolate the potential pathogens Streptococcus pneumoniae, nontypeable Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Group A streptococci. We isolate one or more of these bacteria from most of the children even though they are well. We observe perhaps a half-dozen other species of bacteria on the culture plate. Mostly, we isolate S. pneumoniae, nontypeable H. influenza, or M. catarrhalis and alpha-hemolytic streptococci and corynebacterium species.
We have recently begun to investigate the other microbiota in the nose and found they are indeed plentiful. In a recent screening of a half-dozen children, we found hundreds of different microbes in their noses, so cultures and standard molecular detection methods were just touching the surface. I was asked recently at a medical conference – the American Academy of Pediatrics– Orange County, California, annual CME course – at which I spoke on this topic what I thought would be the most-important area of research in the next decade. I responded, the microbiome. The microbiome is indeed a hot topic. Research over the last decade suggests that 90% of all diseases can be traced in some way to disturbances in the microbiome. What I mean by microbiome is “the totality of microorganisms and their collective genetic material present in or on the human body.” The term is often used interchangeably with “microbiota,” although the former refers to genes of microbes and the latter refers to the microbes themselves. What I mean by “disturbance” is excessive use of antibiotics.
How many microbes are in the nose? We don’t know. But if the gut is any indication, there are thousands of microbes in the nose because the gut has more than 10,000 different microbes. Recognizing that there are hundreds of microbes in the nose and from time to time children get colonized by potential pathogens that can cause otitis media, sinusitis, or pneumonia, how does pathogenesis get started? It starts with a respiratory virus infection. The bacteria need help from the viruses to cause disease. The viruses cause damage to the epithelial cells of the nose, and this gives the bacteria more places to attach when they divide so the amount of bacteria increases exponentially. As the viruses replicate, they more effectively slow down cilia beating, and the nasal mucus thickens. This, too, helps the bacteria and viruses attach to and penetrate epithelial cells in the nose and increase in density on the surface of the cells and inside the cells. The viruses divert and/or suppress the innate immune system, represented by neutrophils that migrate to the nose and discharge their intracellular contents to turn nasal mucus yellow and green. The viruses even down-modulate the adaptive immune system in clever ways that result in fewer potentially protective cytotoxic lymphocytes that kill viruses making their way to the nose, and fewer T cells that discharge cytokines that promote a necessary inflammatory response to clear both bacteria and viruses from the nose and fewer B cells that become plasma cells and release antibodies into the nose.
When the bacteria with potential to cause diseases reach a “pathogenic threshold,” they move, along with mucus, into the middle ear, the sinuses, or down the throat to the lungs, usually with the accompanying respiratory virus. There pathogenesis continues in the otherwise sterile and protected sanctuary of these interconnected respiratory sites. A few days later, we as clinicians observe the symptoms and signs of otitis media, sinusitis, or pneumonia.
What can we do to help the nose? Mostly, we should do no harm, and that has been our failing for decades since the introduction of antibiotics. The allure of antibiotics is great because they have indeed saved many lives and shortened many illnesses when appropriately used. However, too often clinicians have seen patients with yellow and green nasal mucus (or any increased nasal mucus) and diagnosed “a bacterial infection” and prescribed antibiotics. And too often clinicians have seen patients with an annoying cough (or any cough) and diagnosed “a bacterial chest infection” and prescribed antibiotics. The clinicians thought it was the right thing to do because they wanted to help their patient. And they did not want them to come back in a few days with persistence or worsening of symptoms, or worse, seek care from other health care providers elsewhere. So they gave antibiotics.
Well, the paradigm has changed. It is now clearly known that antibiotics can be harmful mainly by damaging the normal, healthy microbiome. The change in healthy homeostasis of the microbiome wrought by antibiotics is greatest in newborns, especially premature newborns, then next worst for infants, and then next worst for young children. These are the age groups where antibiotics are prescribed most frequently! And everyone needs to stop writing those prescriptions for runny noses, yellow and green mucus in the nose, and coughs. All of us need to prescribe antibiotics only when there is an accurate diagnosis of otitis media or sinusitis or bronchopneumonia or lobar pneumonia. And when we do prescribe the antibiotics ,we need to give them for as short a time as possible. But that is a topic for another column.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he has no relevant financial disclosures, and that his research is supported by a grant from the National Institutes of Health National Institute of Deafness and Communication Disorders. Email him at pdnews@frontlinemedcom.com.
There is a lot more going on in the nose besides air going in and out. The nose is where it all begins for pathogenesis for all respiratory infections. The interplay between the commensal microbes, the potential pathogens, innate immunity, and adaptive immunity is much more complex than was previously understood. So what is new?
In our research on acute otitis media, we swab and wash out noses of children aged 6-36 months to isolate the potential pathogens Streptococcus pneumoniae, nontypeable Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Group A streptococci. We isolate one or more of these bacteria from most of the children even though they are well. We observe perhaps a half-dozen other species of bacteria on the culture plate. Mostly, we isolate S. pneumoniae, nontypeable H. influenza, or M. catarrhalis and alpha-hemolytic streptococci and corynebacterium species.
We have recently begun to investigate the other microbiota in the nose and found they are indeed plentiful. In a recent screening of a half-dozen children, we found hundreds of different microbes in their noses, so cultures and standard molecular detection methods were just touching the surface. I was asked recently at a medical conference – the American Academy of Pediatrics– Orange County, California, annual CME course – at which I spoke on this topic what I thought would be the most-important area of research in the next decade. I responded, the microbiome. The microbiome is indeed a hot topic. Research over the last decade suggests that 90% of all diseases can be traced in some way to disturbances in the microbiome. What I mean by microbiome is “the totality of microorganisms and their collective genetic material present in or on the human body.” The term is often used interchangeably with “microbiota,” although the former refers to genes of microbes and the latter refers to the microbes themselves. What I mean by “disturbance” is excessive use of antibiotics.
How many microbes are in the nose? We don’t know. But if the gut is any indication, there are thousands of microbes in the nose because the gut has more than 10,000 different microbes. Recognizing that there are hundreds of microbes in the nose and from time to time children get colonized by potential pathogens that can cause otitis media, sinusitis, or pneumonia, how does pathogenesis get started? It starts with a respiratory virus infection. The bacteria need help from the viruses to cause disease. The viruses cause damage to the epithelial cells of the nose, and this gives the bacteria more places to attach when they divide so the amount of bacteria increases exponentially. As the viruses replicate, they more effectively slow down cilia beating, and the nasal mucus thickens. This, too, helps the bacteria and viruses attach to and penetrate epithelial cells in the nose and increase in density on the surface of the cells and inside the cells. The viruses divert and/or suppress the innate immune system, represented by neutrophils that migrate to the nose and discharge their intracellular contents to turn nasal mucus yellow and green. The viruses even down-modulate the adaptive immune system in clever ways that result in fewer potentially protective cytotoxic lymphocytes that kill viruses making their way to the nose, and fewer T cells that discharge cytokines that promote a necessary inflammatory response to clear both bacteria and viruses from the nose and fewer B cells that become plasma cells and release antibodies into the nose.
When the bacteria with potential to cause diseases reach a “pathogenic threshold,” they move, along with mucus, into the middle ear, the sinuses, or down the throat to the lungs, usually with the accompanying respiratory virus. There pathogenesis continues in the otherwise sterile and protected sanctuary of these interconnected respiratory sites. A few days later, we as clinicians observe the symptoms and signs of otitis media, sinusitis, or pneumonia.
What can we do to help the nose? Mostly, we should do no harm, and that has been our failing for decades since the introduction of antibiotics. The allure of antibiotics is great because they have indeed saved many lives and shortened many illnesses when appropriately used. However, too often clinicians have seen patients with yellow and green nasal mucus (or any increased nasal mucus) and diagnosed “a bacterial infection” and prescribed antibiotics. And too often clinicians have seen patients with an annoying cough (or any cough) and diagnosed “a bacterial chest infection” and prescribed antibiotics. The clinicians thought it was the right thing to do because they wanted to help their patient. And they did not want them to come back in a few days with persistence or worsening of symptoms, or worse, seek care from other health care providers elsewhere. So they gave antibiotics.
Well, the paradigm has changed. It is now clearly known that antibiotics can be harmful mainly by damaging the normal, healthy microbiome. The change in healthy homeostasis of the microbiome wrought by antibiotics is greatest in newborns, especially premature newborns, then next worst for infants, and then next worst for young children. These are the age groups where antibiotics are prescribed most frequently! And everyone needs to stop writing those prescriptions for runny noses, yellow and green mucus in the nose, and coughs. All of us need to prescribe antibiotics only when there is an accurate diagnosis of otitis media or sinusitis or bronchopneumonia or lobar pneumonia. And when we do prescribe the antibiotics ,we need to give them for as short a time as possible. But that is a topic for another column.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he has no relevant financial disclosures, and that his research is supported by a grant from the National Institutes of Health National Institute of Deafness and Communication Disorders. Email him at pdnews@frontlinemedcom.com.
VIDEO: TNF inhibitors don’t boost cancer risk in JIA
WASHINGTON – Tumor necrosis factor inhibitors don’t appear to confer any additional cancer risk upon children with juvenile idiopathic arthritis above the increased incidence of cancer that comes hand in hand with the disease itself.
In 2009, the drugs came under suspicion of boosting the already-known increased cancer risk in these patients, Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology. But the large database review that he conducted with his colleagues doesn’t validate those fears.
“I feel fairly confident now that I can stand in front of parents and say that we can treat their child effectively without putting that child at an even higher risk of a malignancy,” he said in a video interview.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Thomas J.A. Lehman, MD, chief of pediatric rheumatology at the Hospital for Special Surgery, New York, and professor of clinical pediatrics at Weill Cornell Medical College in New York, agreed.
“This study again indicates that anti-TNF therapy does not increase the risk of cancer for children with arthritis,” he said in an interview. “Although children with rheumatic diseases have a small increased background risk of malignancies, this is independent of the use of anti-TNF therapies. For physicians who have cared for children in the era when we did not have anti-TNF therapies available, it is clear that any minor risks associated with these medications are far outweighed by their dramatic benefits.”
In the last few years, five large studies have found that children with juvenile idiopathic arthritis (JIA) have a two- to sixfold increased malignancy risk, compared with the general pediatric population. However, only two of those studies included children taking TNF inhibitors, who comprised just 2% and 9% of those study populations.
In 2009, based on voluntary adverse event reporting, the Food and Drug Administration issued a black box warning on TNF inhibitors, citing a possibly increased risk of cancer in children and adolescents who received the drugs for JIA, inflammatory bowel diseases, and other inflammatory diseases.
Shortly thereafter, a report identified a fivefold increase in the risk of childhood lymphoma associated with the medications (Arthritis Rheum. 2010 Aug;62[8]:2517-24). Other studies have not borne this out, but the boxed warning stands.
To further explore the association, Dr. Beukelman of the University of Alabama, Birmingham, and his associates examined billing data from two large national billing databases: the National U.S. Truven MarketScan claims database and Medicaid billing records. Together, the databases contained information on 27,000 children with JIA who received a prescription for a TNF inhibitor any time during 2000-2014. Cancer rates in this population were compared with those seen in a cohort of 2.64 million children with attention-deficit/hyperactivity disorder who were included in the national Surveillance, Epidemiology, and End Results (SEER) database. The investigators chose individuals with ADHD as a control group because of ADHD’s chronicity and lack of any association with cancer risk.
Dr. Beukelman also performed a within-group analysis on the JIA patients, comparing cancer rates among those treated with a TNF inhibitor and with methotrexate. The mean follow-up for patients who took TNF inhibitors was 4 years (median of 1.4 years), but there were a full 14 years of data for some patients.
Among the controls, with more than 4 million person-years of follow-up, there were 727 cases of any malignancy – a standardized incident rate (SIR) of 1.03. Among all children with JIA, with more than 52,000 person-years of follow-up, there were 20 malignancies. The SEER database predicted eight among a sex- and age-matched cohort of healthy children. This translated to an SIR of 2.4. This represents the baseline increased risk of cancer conferred by JIA alone.
Nine malignancies occurred in the subgroup of children with JIA who took no medications. The SEER expectation among this group was 3.8 cancers, also translating to an SIR of 2.4
One malignancy occurred in the group treated with methotrexate only. Among these children, the SEER expected number was 1.9; the SIR in this group was 0.53.
Seven malignancies occurred among children who took TNF inhibitors, translating to an SIR of 2.9. Six occurred in children who took a TNF inhibitor in combination with or without methotrexate – an SIR of 3.0.
A final group consisted of children who took a wide range of other medications used in JIA (abatacept, anakinra, canakinumab, rilonacept, rituximab, tocilizumab, ustekinumab, tofacitinib, azathioprine, cyclosporine, gold, leflunomide, mycophenolate mofetil, tacrolimus, thalidomide, lenalidomide). This group also included patients who may or may not have taken methotrexate or a TNF inhibitor. Among these, there were four cancers when the SEER expected number was 0.7. This translated to an SIR of almost 6 – a surprising finding, Dr. Beukelman said. But since there were only four cancers and the group was exposed to so many different medications, it’s tough to know what that means, if anything, Dr. Beukelman said.
“There’s a lot to unpack here. The treatment paradigm for JIA is methotrexate followed by a TNF inhibitor if that’s ineffective. So these kids were on all of these more uncommon drugs,” suggesting that neither TNF inhibition nor methotrexate worked. “Some of these patients might actually have had systemic arthritis, Still’s disease, which is a completely separate thing, and we don’t know anything about the risk of malignancy in that. They might have an even higher rate of malignancies at baseline due to having worse disease, or uncontrolled inflammation. It is concerning, but I think it probably speaks to the fact that these patients are difficult to treat and probably at higher risk.”
Dr. Beukelman didn’t specifically break out the types and numbers of cancer, except to say that 3 of the 20 were lymphomas. The rest were leukemias and brain cancers – a finding that reflects the general pattern of childhood malignancies.
“Unfortunately, the most common childhood cancers are lymphomas, leukemias, and brain cancers, and that is what we saw in this study as well,” he said.
The study was supported by the U.S. Agency for Healthcare Research and Quality. Dr. Beukelman noted that he has received consulting fees from Novartis, Genetech/Roche, and UCB.
msullivan@frontlinemedcom.com
On Twitter @alz_gal
WASHINGTON – Tumor necrosis factor inhibitors don’t appear to confer any additional cancer risk upon children with juvenile idiopathic arthritis above the increased incidence of cancer that comes hand in hand with the disease itself.
In 2009, the drugs came under suspicion of boosting the already-known increased cancer risk in these patients, Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology. But the large database review that he conducted with his colleagues doesn’t validate those fears.
“I feel fairly confident now that I can stand in front of parents and say that we can treat their child effectively without putting that child at an even higher risk of a malignancy,” he said in a video interview.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Thomas J.A. Lehman, MD, chief of pediatric rheumatology at the Hospital for Special Surgery, New York, and professor of clinical pediatrics at Weill Cornell Medical College in New York, agreed.
“This study again indicates that anti-TNF therapy does not increase the risk of cancer for children with arthritis,” he said in an interview. “Although children with rheumatic diseases have a small increased background risk of malignancies, this is independent of the use of anti-TNF therapies. For physicians who have cared for children in the era when we did not have anti-TNF therapies available, it is clear that any minor risks associated with these medications are far outweighed by their dramatic benefits.”
In the last few years, five large studies have found that children with juvenile idiopathic arthritis (JIA) have a two- to sixfold increased malignancy risk, compared with the general pediatric population. However, only two of those studies included children taking TNF inhibitors, who comprised just 2% and 9% of those study populations.
In 2009, based on voluntary adverse event reporting, the Food and Drug Administration issued a black box warning on TNF inhibitors, citing a possibly increased risk of cancer in children and adolescents who received the drugs for JIA, inflammatory bowel diseases, and other inflammatory diseases.
Shortly thereafter, a report identified a fivefold increase in the risk of childhood lymphoma associated with the medications (Arthritis Rheum. 2010 Aug;62[8]:2517-24). Other studies have not borne this out, but the boxed warning stands.
To further explore the association, Dr. Beukelman of the University of Alabama, Birmingham, and his associates examined billing data from two large national billing databases: the National U.S. Truven MarketScan claims database and Medicaid billing records. Together, the databases contained information on 27,000 children with JIA who received a prescription for a TNF inhibitor any time during 2000-2014. Cancer rates in this population were compared with those seen in a cohort of 2.64 million children with attention-deficit/hyperactivity disorder who were included in the national Surveillance, Epidemiology, and End Results (SEER) database. The investigators chose individuals with ADHD as a control group because of ADHD’s chronicity and lack of any association with cancer risk.
Dr. Beukelman also performed a within-group analysis on the JIA patients, comparing cancer rates among those treated with a TNF inhibitor and with methotrexate. The mean follow-up for patients who took TNF inhibitors was 4 years (median of 1.4 years), but there were a full 14 years of data for some patients.
Among the controls, with more than 4 million person-years of follow-up, there were 727 cases of any malignancy – a standardized incident rate (SIR) of 1.03. Among all children with JIA, with more than 52,000 person-years of follow-up, there were 20 malignancies. The SEER database predicted eight among a sex- and age-matched cohort of healthy children. This translated to an SIR of 2.4. This represents the baseline increased risk of cancer conferred by JIA alone.
Nine malignancies occurred in the subgroup of children with JIA who took no medications. The SEER expectation among this group was 3.8 cancers, also translating to an SIR of 2.4
One malignancy occurred in the group treated with methotrexate only. Among these children, the SEER expected number was 1.9; the SIR in this group was 0.53.
Seven malignancies occurred among children who took TNF inhibitors, translating to an SIR of 2.9. Six occurred in children who took a TNF inhibitor in combination with or without methotrexate – an SIR of 3.0.
A final group consisted of children who took a wide range of other medications used in JIA (abatacept, anakinra, canakinumab, rilonacept, rituximab, tocilizumab, ustekinumab, tofacitinib, azathioprine, cyclosporine, gold, leflunomide, mycophenolate mofetil, tacrolimus, thalidomide, lenalidomide). This group also included patients who may or may not have taken methotrexate or a TNF inhibitor. Among these, there were four cancers when the SEER expected number was 0.7. This translated to an SIR of almost 6 – a surprising finding, Dr. Beukelman said. But since there were only four cancers and the group was exposed to so many different medications, it’s tough to know what that means, if anything, Dr. Beukelman said.
“There’s a lot to unpack here. The treatment paradigm for JIA is methotrexate followed by a TNF inhibitor if that’s ineffective. So these kids were on all of these more uncommon drugs,” suggesting that neither TNF inhibition nor methotrexate worked. “Some of these patients might actually have had systemic arthritis, Still’s disease, which is a completely separate thing, and we don’t know anything about the risk of malignancy in that. They might have an even higher rate of malignancies at baseline due to having worse disease, or uncontrolled inflammation. It is concerning, but I think it probably speaks to the fact that these patients are difficult to treat and probably at higher risk.”
Dr. Beukelman didn’t specifically break out the types and numbers of cancer, except to say that 3 of the 20 were lymphomas. The rest were leukemias and brain cancers – a finding that reflects the general pattern of childhood malignancies.
“Unfortunately, the most common childhood cancers are lymphomas, leukemias, and brain cancers, and that is what we saw in this study as well,” he said.
The study was supported by the U.S. Agency for Healthcare Research and Quality. Dr. Beukelman noted that he has received consulting fees from Novartis, Genetech/Roche, and UCB.
msullivan@frontlinemedcom.com
On Twitter @alz_gal
WASHINGTON – Tumor necrosis factor inhibitors don’t appear to confer any additional cancer risk upon children with juvenile idiopathic arthritis above the increased incidence of cancer that comes hand in hand with the disease itself.
In 2009, the drugs came under suspicion of boosting the already-known increased cancer risk in these patients, Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology. But the large database review that he conducted with his colleagues doesn’t validate those fears.
“I feel fairly confident now that I can stand in front of parents and say that we can treat their child effectively without putting that child at an even higher risk of a malignancy,” he said in a video interview.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Thomas J.A. Lehman, MD, chief of pediatric rheumatology at the Hospital for Special Surgery, New York, and professor of clinical pediatrics at Weill Cornell Medical College in New York, agreed.
“This study again indicates that anti-TNF therapy does not increase the risk of cancer for children with arthritis,” he said in an interview. “Although children with rheumatic diseases have a small increased background risk of malignancies, this is independent of the use of anti-TNF therapies. For physicians who have cared for children in the era when we did not have anti-TNF therapies available, it is clear that any minor risks associated with these medications are far outweighed by their dramatic benefits.”
In the last few years, five large studies have found that children with juvenile idiopathic arthritis (JIA) have a two- to sixfold increased malignancy risk, compared with the general pediatric population. However, only two of those studies included children taking TNF inhibitors, who comprised just 2% and 9% of those study populations.
In 2009, based on voluntary adverse event reporting, the Food and Drug Administration issued a black box warning on TNF inhibitors, citing a possibly increased risk of cancer in children and adolescents who received the drugs for JIA, inflammatory bowel diseases, and other inflammatory diseases.
Shortly thereafter, a report identified a fivefold increase in the risk of childhood lymphoma associated with the medications (Arthritis Rheum. 2010 Aug;62[8]:2517-24). Other studies have not borne this out, but the boxed warning stands.
To further explore the association, Dr. Beukelman of the University of Alabama, Birmingham, and his associates examined billing data from two large national billing databases: the National U.S. Truven MarketScan claims database and Medicaid billing records. Together, the databases contained information on 27,000 children with JIA who received a prescription for a TNF inhibitor any time during 2000-2014. Cancer rates in this population were compared with those seen in a cohort of 2.64 million children with attention-deficit/hyperactivity disorder who were included in the national Surveillance, Epidemiology, and End Results (SEER) database. The investigators chose individuals with ADHD as a control group because of ADHD’s chronicity and lack of any association with cancer risk.
Dr. Beukelman also performed a within-group analysis on the JIA patients, comparing cancer rates among those treated with a TNF inhibitor and with methotrexate. The mean follow-up for patients who took TNF inhibitors was 4 years (median of 1.4 years), but there were a full 14 years of data for some patients.
Among the controls, with more than 4 million person-years of follow-up, there were 727 cases of any malignancy – a standardized incident rate (SIR) of 1.03. Among all children with JIA, with more than 52,000 person-years of follow-up, there were 20 malignancies. The SEER database predicted eight among a sex- and age-matched cohort of healthy children. This translated to an SIR of 2.4. This represents the baseline increased risk of cancer conferred by JIA alone.
Nine malignancies occurred in the subgroup of children with JIA who took no medications. The SEER expectation among this group was 3.8 cancers, also translating to an SIR of 2.4
One malignancy occurred in the group treated with methotrexate only. Among these children, the SEER expected number was 1.9; the SIR in this group was 0.53.
Seven malignancies occurred among children who took TNF inhibitors, translating to an SIR of 2.9. Six occurred in children who took a TNF inhibitor in combination with or without methotrexate – an SIR of 3.0.
A final group consisted of children who took a wide range of other medications used in JIA (abatacept, anakinra, canakinumab, rilonacept, rituximab, tocilizumab, ustekinumab, tofacitinib, azathioprine, cyclosporine, gold, leflunomide, mycophenolate mofetil, tacrolimus, thalidomide, lenalidomide). This group also included patients who may or may not have taken methotrexate or a TNF inhibitor. Among these, there were four cancers when the SEER expected number was 0.7. This translated to an SIR of almost 6 – a surprising finding, Dr. Beukelman said. But since there were only four cancers and the group was exposed to so many different medications, it’s tough to know what that means, if anything, Dr. Beukelman said.
“There’s a lot to unpack here. The treatment paradigm for JIA is methotrexate followed by a TNF inhibitor if that’s ineffective. So these kids were on all of these more uncommon drugs,” suggesting that neither TNF inhibition nor methotrexate worked. “Some of these patients might actually have had systemic arthritis, Still’s disease, which is a completely separate thing, and we don’t know anything about the risk of malignancy in that. They might have an even higher rate of malignancies at baseline due to having worse disease, or uncontrolled inflammation. It is concerning, but I think it probably speaks to the fact that these patients are difficult to treat and probably at higher risk.”
Dr. Beukelman didn’t specifically break out the types and numbers of cancer, except to say that 3 of the 20 were lymphomas. The rest were leukemias and brain cancers – a finding that reflects the general pattern of childhood malignancies.
“Unfortunately, the most common childhood cancers are lymphomas, leukemias, and brain cancers, and that is what we saw in this study as well,” he said.
The study was supported by the U.S. Agency for Healthcare Research and Quality. Dr. Beukelman noted that he has received consulting fees from Novartis, Genetech/Roche, and UCB.
msullivan@frontlinemedcom.com
On Twitter @alz_gal
AT THE ACR ANNUAL MEETING
Key clinical point:
Major finding: Children with JIA were about twice as likely to get cancer as the general population, regardless of whether they took a TNF inhibitor.
Data source: A database review comprising 27,000 patients and 2.5 million controls.
Disclosures: The study was supported by the U.S. Agency for Healthcare Research and Quality. Dr. Beukelman noted that he has received consulting fees from Novartis, Genetech/Roche, and UCB.
STUDY: More children have access to care, insurance
Children’s access to pediatricians has improved since 2000 with markedly more patients carrying health insurance, according to a new study.
An analysis showed the rate of uninsured children dropped from 12% in 2000 to 5% in 2014, while children’s access rose for physician visits and regular care.
Kandyce Larson, PhD, of the American Academy of Pediatrics and her colleagues reviewed trends for 178,038 children in the Centers for Disease Control & Prevention’ National Health Interview Survey from 2000 to 2014. Researchers examined statistics for health insurance and trends across five access indicators: well-child visits, doctor office visits, dental visits, usual source of care, and unmet health needs. Results showed the uninsured rate declined by more than 50% from 12% of children in 2000 to 5% in 2014. Findings showed an accompanying increase in public health insurance coverage (19% to 39%), while private coverage decreased (69% to 56%) during the same time period (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2176).
Uninsured rates for minority and poor children showed the largest decreases, the study found. The uninsured rate for Hispanic children decreased from 26% in 2000 to 9% in 2014, while uninsured black children dropped from 12% to 3%, according to the study. Significant declines in the uninsured rate also were seen for children in poor families (22% to 6%) and near-poor families (21% to 9%).
Health care access improved across all five indicators. Rates for no well-child visit declined from 29% in 2000 to 16% in 2014, while no doctor office visit went from 13% to 9%, and no dental visit decreased from 30% to 21%. No usual source of care dropped from 7% to 4%, and unmet health care needs decreased from 8% to 6%. The results amounted to an additional 9 million children receiving a well-child visit in 2014, compared with 2000. Improvements in access were generally greater for black and Hispanic children and those in poor and near-poor families, according to the study.
“It’s critical for our nation’s future health that we provide children at all income levels access to quality health care,” he said in a statement.
The rise in children who have a usual source of care and are undergoing regular well-child visits is especially heartening, added pediatrician Andrew D. Racine, MD, PhD, coauthor of the study and a member of the AAP Committee on Child Health Financing.
“When children see providers who know their medical history and can monitor their physical and socio-emotional development, they are more likely to have better overall health, be up to date on immunizations, perform better in school, and receive care in the most cost-effective way,” he said in a statement. Dr. Racine is a professor of clinical pediatrics at Albert Einstein College of Medicine, Bronx, N.Y.
agallegos@frontlinemedcom.com
On Twitter @legal_med
The findings of the current study have important implications for future child health care policy decisions.
First, children should have coverage, and strong efforts must be made to reach the 5.3% of children who remain uninsured. Second, the reauthorization and continued funding of the Children’s Health Insurance Plan, due to terminate in 2019, is essential and should be addressed sooner rather than later.
In addition, while this study focuses attention on health care access measures, advocates and policy makers need to address having meaningful health outcomes. Because health care only contributes 10% to 20% to maximizing population health, a new child health policy should focus on addressing the social determinants of health and the reduction of behaviors that compromise health, such as smoking, excessive alcohol intake, substance abuse, and poor nutrition.
Stephen Berman, MD, is a professor of pediatrics at the University of Colorado at Denver, holds an endowed chair in academic general pediatrics at the Children’s Hospital Colorado, and is the director of the Center for Global Health in the Colorado School of Public Health, all in Aurora. These remarks are excerpted from an accompanying editorial (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2823). He reported having no relevant financial disclosures.
The findings of the current study have important implications for future child health care policy decisions.
First, children should have coverage, and strong efforts must be made to reach the 5.3% of children who remain uninsured. Second, the reauthorization and continued funding of the Children’s Health Insurance Plan, due to terminate in 2019, is essential and should be addressed sooner rather than later.
In addition, while this study focuses attention on health care access measures, advocates and policy makers need to address having meaningful health outcomes. Because health care only contributes 10% to 20% to maximizing population health, a new child health policy should focus on addressing the social determinants of health and the reduction of behaviors that compromise health, such as smoking, excessive alcohol intake, substance abuse, and poor nutrition.
Stephen Berman, MD, is a professor of pediatrics at the University of Colorado at Denver, holds an endowed chair in academic general pediatrics at the Children’s Hospital Colorado, and is the director of the Center for Global Health in the Colorado School of Public Health, all in Aurora. These remarks are excerpted from an accompanying editorial (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2823). He reported having no relevant financial disclosures.
The findings of the current study have important implications for future child health care policy decisions.
First, children should have coverage, and strong efforts must be made to reach the 5.3% of children who remain uninsured. Second, the reauthorization and continued funding of the Children’s Health Insurance Plan, due to terminate in 2019, is essential and should be addressed sooner rather than later.
In addition, while this study focuses attention on health care access measures, advocates and policy makers need to address having meaningful health outcomes. Because health care only contributes 10% to 20% to maximizing population health, a new child health policy should focus on addressing the social determinants of health and the reduction of behaviors that compromise health, such as smoking, excessive alcohol intake, substance abuse, and poor nutrition.
Stephen Berman, MD, is a professor of pediatrics at the University of Colorado at Denver, holds an endowed chair in academic general pediatrics at the Children’s Hospital Colorado, and is the director of the Center for Global Health in the Colorado School of Public Health, all in Aurora. These remarks are excerpted from an accompanying editorial (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2823). He reported having no relevant financial disclosures.
Children’s access to pediatricians has improved since 2000 with markedly more patients carrying health insurance, according to a new study.
An analysis showed the rate of uninsured children dropped from 12% in 2000 to 5% in 2014, while children’s access rose for physician visits and regular care.
Kandyce Larson, PhD, of the American Academy of Pediatrics and her colleagues reviewed trends for 178,038 children in the Centers for Disease Control & Prevention’ National Health Interview Survey from 2000 to 2014. Researchers examined statistics for health insurance and trends across five access indicators: well-child visits, doctor office visits, dental visits, usual source of care, and unmet health needs. Results showed the uninsured rate declined by more than 50% from 12% of children in 2000 to 5% in 2014. Findings showed an accompanying increase in public health insurance coverage (19% to 39%), while private coverage decreased (69% to 56%) during the same time period (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2176).
Uninsured rates for minority and poor children showed the largest decreases, the study found. The uninsured rate for Hispanic children decreased from 26% in 2000 to 9% in 2014, while uninsured black children dropped from 12% to 3%, according to the study. Significant declines in the uninsured rate also were seen for children in poor families (22% to 6%) and near-poor families (21% to 9%).
Health care access improved across all five indicators. Rates for no well-child visit declined from 29% in 2000 to 16% in 2014, while no doctor office visit went from 13% to 9%, and no dental visit decreased from 30% to 21%. No usual source of care dropped from 7% to 4%, and unmet health care needs decreased from 8% to 6%. The results amounted to an additional 9 million children receiving a well-child visit in 2014, compared with 2000. Improvements in access were generally greater for black and Hispanic children and those in poor and near-poor families, according to the study.
“It’s critical for our nation’s future health that we provide children at all income levels access to quality health care,” he said in a statement.
The rise in children who have a usual source of care and are undergoing regular well-child visits is especially heartening, added pediatrician Andrew D. Racine, MD, PhD, coauthor of the study and a member of the AAP Committee on Child Health Financing.
“When children see providers who know their medical history and can monitor their physical and socio-emotional development, they are more likely to have better overall health, be up to date on immunizations, perform better in school, and receive care in the most cost-effective way,” he said in a statement. Dr. Racine is a professor of clinical pediatrics at Albert Einstein College of Medicine, Bronx, N.Y.
agallegos@frontlinemedcom.com
On Twitter @legal_med
Children’s access to pediatricians has improved since 2000 with markedly more patients carrying health insurance, according to a new study.
An analysis showed the rate of uninsured children dropped from 12% in 2000 to 5% in 2014, while children’s access rose for physician visits and regular care.
Kandyce Larson, PhD, of the American Academy of Pediatrics and her colleagues reviewed trends for 178,038 children in the Centers for Disease Control & Prevention’ National Health Interview Survey from 2000 to 2014. Researchers examined statistics for health insurance and trends across five access indicators: well-child visits, doctor office visits, dental visits, usual source of care, and unmet health needs. Results showed the uninsured rate declined by more than 50% from 12% of children in 2000 to 5% in 2014. Findings showed an accompanying increase in public health insurance coverage (19% to 39%), while private coverage decreased (69% to 56%) during the same time period (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2176).
Uninsured rates for minority and poor children showed the largest decreases, the study found. The uninsured rate for Hispanic children decreased from 26% in 2000 to 9% in 2014, while uninsured black children dropped from 12% to 3%, according to the study. Significant declines in the uninsured rate also were seen for children in poor families (22% to 6%) and near-poor families (21% to 9%).
Health care access improved across all five indicators. Rates for no well-child visit declined from 29% in 2000 to 16% in 2014, while no doctor office visit went from 13% to 9%, and no dental visit decreased from 30% to 21%. No usual source of care dropped from 7% to 4%, and unmet health care needs decreased from 8% to 6%. The results amounted to an additional 9 million children receiving a well-child visit in 2014, compared with 2000. Improvements in access were generally greater for black and Hispanic children and those in poor and near-poor families, according to the study.
“It’s critical for our nation’s future health that we provide children at all income levels access to quality health care,” he said in a statement.
The rise in children who have a usual source of care and are undergoing regular well-child visits is especially heartening, added pediatrician Andrew D. Racine, MD, PhD, coauthor of the study and a member of the AAP Committee on Child Health Financing.
“When children see providers who know their medical history and can monitor their physical and socio-emotional development, they are more likely to have better overall health, be up to date on immunizations, perform better in school, and receive care in the most cost-effective way,” he said in a statement. Dr. Racine is a professor of clinical pediatrics at Albert Einstein College of Medicine, Bronx, N.Y.
agallegos@frontlinemedcom.com
On Twitter @legal_med
Key clinical point:
Major finding: The rate of uninsured children dropped from 12% in 2000 to 5% in 2014.
Data source: Study of survey data of 178,038 children.
Disclosures: The authors have indicated they have no relevant financial disclosures.
VIDEO: Biologics: Proposed guideline addresses perioperative management
WASHINGTON – Biologic agents should be stopped prior to elective total knee or hip arthroplasty in patients with rheumatic diseases, according to a draft guideline developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons.
The guideline, which address the perioperative management of antirheumatic medications in patients with rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, juvenile idiopathic arthritis (JIA), or lupus who are undergoing such surgery, is currently under review, Dr. Susan Goodman, MD, coprincipal investigator, reported at the annual meeting of the American College of Rheumatology.
The draft guideline was created because “guidance was needed for common clinical situations, even where data were sparse. We didn’t want to configure treatment mandates – that’s not what these are,” Dr. Goodman of Cornell University, New York, said.
The recommendations are conditional, she said, meaning that the benefits probably outweigh the harms, that the recommendations apply to most but not all patients, and that future research may lead to changes.
“They’re also preference sensitive,” she said, explaining that patients’ values and preferences should be carefully considered, as they might differ from those of the patient panel consulted during guideline development; the panel expressed greater concern about the risk of infection following surgery than about perioperative flares resulting from medication discontinuation.
Based on agreement by at least 80% of a voting panel which considered available evidence in the context of their clinical experience along with the input from the patient panel, the draft guideline states that:
• Current doses of methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine should be continued in patients with rheumatic diseases undergoing elective hip and knee replacement. This recommendation is based on an extensive literature review that showed the infection rate is decreased in patients who continue these medications, Dr. Goodman said.
• All biologics should be withheld prior to surgery in patients with inflammatory arthritis, and surgery should be planned for the end of the dosing cycle. This matter wasn’t specifically addressed in the literature; however, numerous randomized controlled trials outside of the surgical setting demonstrate an increased risk of infection associated with their use, she noted.
“All of the biologic medications were found to be associated with an increased risk of infection,” she said. “Because of this and the level of importance patients place on minimizing infection risk, we’ve recommended that biologics be withheld prior to surgery.”
• Tofacitinib, which was considered in a separate oral, targeted therapy category, should be withheld for at least 7 days prior to surgery in patients with RA, spondyloarthritis, and JIA. Data from systematic reviews and meta-analyses showed an increased risk of infection with tofacitinib, although more research is needed in order to “firm up” this recommendation, Dr. Goodman said.
• In lupus patients, rituximab and belimumab should be withheld prior to surgery, and surgery should be planned for the end of the dosing period.
“Again, this was not answered in the literature. We depended on observational studies that we reviewed that did show that patients with severe active lupus were at much higher risk for adverse events. But since rituximab isn’t approved by the [Food and Drug Administration] for use in lupus, and belimumab isn’t approved for use in severe lupus – and those seem to be the high-risk patients – we thought withholding them was more prudent,” she said.
• Patients with severe lupus should continue on current doses of methotrexate, mycophenolic acid, azathioprine, mizoribine, cyclosporine, and tacrolimus through surgery. This recommendation is based on indirect data from experience in organ transplant patients.
• All medications should be discontinued in patients whose lupus is not severe.
“Our recommendation is to withhold for 7 days to 2-5 days after surgery in the absence of any wound healing complications or any other complications,” she said, noting that the literature does not directly address this; the recommendation is based on indirect evidence in patients with either active infection or who are at risk for infection.
“We thought that careful monitoring of the patient would permit us to identify flare and intervene quickly. … and that, for mild cases of lupus, the morbidity associated with infection might not be greater than the morbidity associated with the disease flare,” she said.
• Biologics should be restarted once surgical wounds show evidence of healing and there is no clinical evidence of infection. The literature does not directly address this; the recommendation is based on the rationale for use of these medications in patients with either active infection or risk for infection.
• Current daily doses of glucocorticoids, rather than supraphysiologic doses, should be continued in adults with RA, lupus, or inflammatory arthritis. A meta-analysis and systematic review of randomized controlled trial data and observational data showed no hemodynamic difference between daily doses and stress doses.
“In addition, there are abundant observational data demonstrating an increase in infection in patients on chronic steroids greater than 15 mg, and we thought that part of the optimization of the patient would be getting them on the lowest possible steroid dose,” she said, stressing that this refers only to adults receiving glucocorticoids for their rheumatic disease, and not to those with a history of JIA who may have received steroids during development, or to those receiving glucocorticoids for primary, adrenal, or hypothalamic disease.
According to Dr. Goodman, the time is right for the introduction of these recommendations, because the increased use of disease-modifying drugs and biologics means that most patients coming in for these surgeries will be taking these medications.
Further, despite the widespread use of the medications, the rate of total knee and hip arthroplasty surgeries among patients with rheumatic diseases is about the same as it was 20 or 30 years ago – and their risk for devastating complications, including infections, remains high, she said, noting that appropriate medication management provides an opportunity to mitigate risk.
Coprincipal investigator, Bryan Springer, MD, further emphasized the importance of the guideline, noting that the 5-year survival among rheumatic disease patients who develop certain perioperative complications is lower than for many common cancers, and that the literature offers little guidance on managing medications in the perioperative period.
“We now have a document that’s based on the available evidence, and also based on expert opinion, to help us manage these patients much more thoroughly in the perioperative period,” Dr. Springer, an orthopedic surgeon in Charlotte, N.C., said during a press briefing on the guideline.
Dr. Springer highlighted the value of the unique collaboration between the ACR and the AAHKS, calling the effort a win both for patients, and for “collaborative efforts, collaborative research, which we just really don’t do enough of,” he said. “I hope this is a huge step towards that direction.”
This guideline development process was funded by the ACR and AAHKS.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WASHINGTON – Biologic agents should be stopped prior to elective total knee or hip arthroplasty in patients with rheumatic diseases, according to a draft guideline developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons.
The guideline, which address the perioperative management of antirheumatic medications in patients with rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, juvenile idiopathic arthritis (JIA), or lupus who are undergoing such surgery, is currently under review, Dr. Susan Goodman, MD, coprincipal investigator, reported at the annual meeting of the American College of Rheumatology.
The draft guideline was created because “guidance was needed for common clinical situations, even where data were sparse. We didn’t want to configure treatment mandates – that’s not what these are,” Dr. Goodman of Cornell University, New York, said.
The recommendations are conditional, she said, meaning that the benefits probably outweigh the harms, that the recommendations apply to most but not all patients, and that future research may lead to changes.
“They’re also preference sensitive,” she said, explaining that patients’ values and preferences should be carefully considered, as they might differ from those of the patient panel consulted during guideline development; the panel expressed greater concern about the risk of infection following surgery than about perioperative flares resulting from medication discontinuation.
Based on agreement by at least 80% of a voting panel which considered available evidence in the context of their clinical experience along with the input from the patient panel, the draft guideline states that:
• Current doses of methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine should be continued in patients with rheumatic diseases undergoing elective hip and knee replacement. This recommendation is based on an extensive literature review that showed the infection rate is decreased in patients who continue these medications, Dr. Goodman said.
• All biologics should be withheld prior to surgery in patients with inflammatory arthritis, and surgery should be planned for the end of the dosing cycle. This matter wasn’t specifically addressed in the literature; however, numerous randomized controlled trials outside of the surgical setting demonstrate an increased risk of infection associated with their use, she noted.
“All of the biologic medications were found to be associated with an increased risk of infection,” she said. “Because of this and the level of importance patients place on minimizing infection risk, we’ve recommended that biologics be withheld prior to surgery.”
• Tofacitinib, which was considered in a separate oral, targeted therapy category, should be withheld for at least 7 days prior to surgery in patients with RA, spondyloarthritis, and JIA. Data from systematic reviews and meta-analyses showed an increased risk of infection with tofacitinib, although more research is needed in order to “firm up” this recommendation, Dr. Goodman said.
• In lupus patients, rituximab and belimumab should be withheld prior to surgery, and surgery should be planned for the end of the dosing period.
“Again, this was not answered in the literature. We depended on observational studies that we reviewed that did show that patients with severe active lupus were at much higher risk for adverse events. But since rituximab isn’t approved by the [Food and Drug Administration] for use in lupus, and belimumab isn’t approved for use in severe lupus – and those seem to be the high-risk patients – we thought withholding them was more prudent,” she said.
• Patients with severe lupus should continue on current doses of methotrexate, mycophenolic acid, azathioprine, mizoribine, cyclosporine, and tacrolimus through surgery. This recommendation is based on indirect data from experience in organ transplant patients.
• All medications should be discontinued in patients whose lupus is not severe.
“Our recommendation is to withhold for 7 days to 2-5 days after surgery in the absence of any wound healing complications or any other complications,” she said, noting that the literature does not directly address this; the recommendation is based on indirect evidence in patients with either active infection or who are at risk for infection.
“We thought that careful monitoring of the patient would permit us to identify flare and intervene quickly. … and that, for mild cases of lupus, the morbidity associated with infection might not be greater than the morbidity associated with the disease flare,” she said.
• Biologics should be restarted once surgical wounds show evidence of healing and there is no clinical evidence of infection. The literature does not directly address this; the recommendation is based on the rationale for use of these medications in patients with either active infection or risk for infection.
• Current daily doses of glucocorticoids, rather than supraphysiologic doses, should be continued in adults with RA, lupus, or inflammatory arthritis. A meta-analysis and systematic review of randomized controlled trial data and observational data showed no hemodynamic difference between daily doses and stress doses.
“In addition, there are abundant observational data demonstrating an increase in infection in patients on chronic steroids greater than 15 mg, and we thought that part of the optimization of the patient would be getting them on the lowest possible steroid dose,” she said, stressing that this refers only to adults receiving glucocorticoids for their rheumatic disease, and not to those with a history of JIA who may have received steroids during development, or to those receiving glucocorticoids for primary, adrenal, or hypothalamic disease.
According to Dr. Goodman, the time is right for the introduction of these recommendations, because the increased use of disease-modifying drugs and biologics means that most patients coming in for these surgeries will be taking these medications.
Further, despite the widespread use of the medications, the rate of total knee and hip arthroplasty surgeries among patients with rheumatic diseases is about the same as it was 20 or 30 years ago – and their risk for devastating complications, including infections, remains high, she said, noting that appropriate medication management provides an opportunity to mitigate risk.
Coprincipal investigator, Bryan Springer, MD, further emphasized the importance of the guideline, noting that the 5-year survival among rheumatic disease patients who develop certain perioperative complications is lower than for many common cancers, and that the literature offers little guidance on managing medications in the perioperative period.
“We now have a document that’s based on the available evidence, and also based on expert opinion, to help us manage these patients much more thoroughly in the perioperative period,” Dr. Springer, an orthopedic surgeon in Charlotte, N.C., said during a press briefing on the guideline.
Dr. Springer highlighted the value of the unique collaboration between the ACR and the AAHKS, calling the effort a win both for patients, and for “collaborative efforts, collaborative research, which we just really don’t do enough of,” he said. “I hope this is a huge step towards that direction.”
This guideline development process was funded by the ACR and AAHKS.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WASHINGTON – Biologic agents should be stopped prior to elective total knee or hip arthroplasty in patients with rheumatic diseases, according to a draft guideline developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons.
The guideline, which address the perioperative management of antirheumatic medications in patients with rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, juvenile idiopathic arthritis (JIA), or lupus who are undergoing such surgery, is currently under review, Dr. Susan Goodman, MD, coprincipal investigator, reported at the annual meeting of the American College of Rheumatology.
The draft guideline was created because “guidance was needed for common clinical situations, even where data were sparse. We didn’t want to configure treatment mandates – that’s not what these are,” Dr. Goodman of Cornell University, New York, said.
The recommendations are conditional, she said, meaning that the benefits probably outweigh the harms, that the recommendations apply to most but not all patients, and that future research may lead to changes.
“They’re also preference sensitive,” she said, explaining that patients’ values and preferences should be carefully considered, as they might differ from those of the patient panel consulted during guideline development; the panel expressed greater concern about the risk of infection following surgery than about perioperative flares resulting from medication discontinuation.
Based on agreement by at least 80% of a voting panel which considered available evidence in the context of their clinical experience along with the input from the patient panel, the draft guideline states that:
• Current doses of methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine should be continued in patients with rheumatic diseases undergoing elective hip and knee replacement. This recommendation is based on an extensive literature review that showed the infection rate is decreased in patients who continue these medications, Dr. Goodman said.
• All biologics should be withheld prior to surgery in patients with inflammatory arthritis, and surgery should be planned for the end of the dosing cycle. This matter wasn’t specifically addressed in the literature; however, numerous randomized controlled trials outside of the surgical setting demonstrate an increased risk of infection associated with their use, she noted.
“All of the biologic medications were found to be associated with an increased risk of infection,” she said. “Because of this and the level of importance patients place on minimizing infection risk, we’ve recommended that biologics be withheld prior to surgery.”
• Tofacitinib, which was considered in a separate oral, targeted therapy category, should be withheld for at least 7 days prior to surgery in patients with RA, spondyloarthritis, and JIA. Data from systematic reviews and meta-analyses showed an increased risk of infection with tofacitinib, although more research is needed in order to “firm up” this recommendation, Dr. Goodman said.
• In lupus patients, rituximab and belimumab should be withheld prior to surgery, and surgery should be planned for the end of the dosing period.
“Again, this was not answered in the literature. We depended on observational studies that we reviewed that did show that patients with severe active lupus were at much higher risk for adverse events. But since rituximab isn’t approved by the [Food and Drug Administration] for use in lupus, and belimumab isn’t approved for use in severe lupus – and those seem to be the high-risk patients – we thought withholding them was more prudent,” she said.
• Patients with severe lupus should continue on current doses of methotrexate, mycophenolic acid, azathioprine, mizoribine, cyclosporine, and tacrolimus through surgery. This recommendation is based on indirect data from experience in organ transplant patients.
• All medications should be discontinued in patients whose lupus is not severe.
“Our recommendation is to withhold for 7 days to 2-5 days after surgery in the absence of any wound healing complications or any other complications,” she said, noting that the literature does not directly address this; the recommendation is based on indirect evidence in patients with either active infection or who are at risk for infection.
“We thought that careful monitoring of the patient would permit us to identify flare and intervene quickly. … and that, for mild cases of lupus, the morbidity associated with infection might not be greater than the morbidity associated with the disease flare,” she said.
• Biologics should be restarted once surgical wounds show evidence of healing and there is no clinical evidence of infection. The literature does not directly address this; the recommendation is based on the rationale for use of these medications in patients with either active infection or risk for infection.
• Current daily doses of glucocorticoids, rather than supraphysiologic doses, should be continued in adults with RA, lupus, or inflammatory arthritis. A meta-analysis and systematic review of randomized controlled trial data and observational data showed no hemodynamic difference between daily doses and stress doses.
“In addition, there are abundant observational data demonstrating an increase in infection in patients on chronic steroids greater than 15 mg, and we thought that part of the optimization of the patient would be getting them on the lowest possible steroid dose,” she said, stressing that this refers only to adults receiving glucocorticoids for their rheumatic disease, and not to those with a history of JIA who may have received steroids during development, or to those receiving glucocorticoids for primary, adrenal, or hypothalamic disease.
According to Dr. Goodman, the time is right for the introduction of these recommendations, because the increased use of disease-modifying drugs and biologics means that most patients coming in for these surgeries will be taking these medications.
Further, despite the widespread use of the medications, the rate of total knee and hip arthroplasty surgeries among patients with rheumatic diseases is about the same as it was 20 or 30 years ago – and their risk for devastating complications, including infections, remains high, she said, noting that appropriate medication management provides an opportunity to mitigate risk.
Coprincipal investigator, Bryan Springer, MD, further emphasized the importance of the guideline, noting that the 5-year survival among rheumatic disease patients who develop certain perioperative complications is lower than for many common cancers, and that the literature offers little guidance on managing medications in the perioperative period.
“We now have a document that’s based on the available evidence, and also based on expert opinion, to help us manage these patients much more thoroughly in the perioperative period,” Dr. Springer, an orthopedic surgeon in Charlotte, N.C., said during a press briefing on the guideline.
Dr. Springer highlighted the value of the unique collaboration between the ACR and the AAHKS, calling the effort a win both for patients, and for “collaborative efforts, collaborative research, which we just really don’t do enough of,” he said. “I hope this is a huge step towards that direction.”
This guideline development process was funded by the ACR and AAHKS.
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