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More than half of high-cost Medicaid children use fewer resources over time
More than half of children who are the costliest to cover in the Medicaid program eventually fall out of that category, according to new research.
A retrospective analysis of 48,743 children aged 1-18 years continuously enrolled in Medicaid during 2009-2013 across 10 states who were in the top 5% of all health care spending in 2010 found that from 2011 to 2013, “54.2% fell below the top 5% and did not return to the top 5% in 2011-2013,” Rishi K. Agrawal, MD, of the Ann and Robert Lurie Children’s Hospital, Chicago, and his colleagues wrote in a study published Sept. 15 online in Pediatrics (2016. doi: 10.1542/peds.2016-0682).
Children who were persistently in the top 5% accounted for 32.9% of the cohort and 12.9% of the children who were in the top 5% during 2010 fell out of and returned to the group of highest cost patients in the following 3 years.
“The highest likelihood of subsequent high spending was observed in older children with many chronic conditions, respiratory, or neuromuscular complex chronic conditions, and those who used home health services,” the authors noted. “Decreased likelihood of subsequent high spending was observed with children with hospital or ED [emergency department] use in 2010.”
“Understanding the clinical attributes of children most likely to experience persistent high resource use might help inform clinical approaches to optimize their health,” Dr. Agrawal and associates continued.
They added that previous literature and the authors’ clinical experiences suggest that those with multiple chronic conditions, especially a neuromuscular condition, “are at risk for underuse of primary care,” and without a primary care physician taking charge of overall care coordination, that burden falls on the families.
“Perhaps population health initiatives (e.g., enhanced medical homes or neighborhoods for children with medical complexity, complex care networks) designed to alleviate these specific issues might benefit children who are the most likely to have persistent high resource use,” Dr. Agrawal and his colleagues wrote.
The authors cited no relevant financial disclosures. Jay G. Berry, MD, was supported by the Agency for Healthcare Research and Quality, and Eyal Cohen, MD, was supported as a Harkness Fellow in Health Care Policy and Practice by the Canadian Foundation for Healthcare Improvement and the Commonwealth Fund.
[A] longitudinal analysis of children’s health care utilization and spending while on Medicaid offers fresh insights and raises new questions about how best to provide supportive coordinated care and mitigate rising costs over time.
Understanding specific aspects of complexity – such as the impact of infancy, risks for newly intensified care needs, and the role of mental health comorbidities – will likely enrich our collective understanding of longitudinal trends in spending. Although illness acuity will always demand our clinical attention, there is growing evidence that illness complexity demands our programmatic attention as well.
Matthew Davis, MD, is a pediatrician and researcher at the Ann and Robert H. Lurie Children’s Hospital, Chicago. His observations are excerpted from a commentary published Sept. 15 online in Pediatrics. He said he had no relevant financial disclosures.
[A] longitudinal analysis of children’s health care utilization and spending while on Medicaid offers fresh insights and raises new questions about how best to provide supportive coordinated care and mitigate rising costs over time.
Understanding specific aspects of complexity – such as the impact of infancy, risks for newly intensified care needs, and the role of mental health comorbidities – will likely enrich our collective understanding of longitudinal trends in spending. Although illness acuity will always demand our clinical attention, there is growing evidence that illness complexity demands our programmatic attention as well.
Matthew Davis, MD, is a pediatrician and researcher at the Ann and Robert H. Lurie Children’s Hospital, Chicago. His observations are excerpted from a commentary published Sept. 15 online in Pediatrics. He said he had no relevant financial disclosures.
[A] longitudinal analysis of children’s health care utilization and spending while on Medicaid offers fresh insights and raises new questions about how best to provide supportive coordinated care and mitigate rising costs over time.
Understanding specific aspects of complexity – such as the impact of infancy, risks for newly intensified care needs, and the role of mental health comorbidities – will likely enrich our collective understanding of longitudinal trends in spending. Although illness acuity will always demand our clinical attention, there is growing evidence that illness complexity demands our programmatic attention as well.
Matthew Davis, MD, is a pediatrician and researcher at the Ann and Robert H. Lurie Children’s Hospital, Chicago. His observations are excerpted from a commentary published Sept. 15 online in Pediatrics. He said he had no relevant financial disclosures.
More than half of children who are the costliest to cover in the Medicaid program eventually fall out of that category, according to new research.
A retrospective analysis of 48,743 children aged 1-18 years continuously enrolled in Medicaid during 2009-2013 across 10 states who were in the top 5% of all health care spending in 2010 found that from 2011 to 2013, “54.2% fell below the top 5% and did not return to the top 5% in 2011-2013,” Rishi K. Agrawal, MD, of the Ann and Robert Lurie Children’s Hospital, Chicago, and his colleagues wrote in a study published Sept. 15 online in Pediatrics (2016. doi: 10.1542/peds.2016-0682).
Children who were persistently in the top 5% accounted for 32.9% of the cohort and 12.9% of the children who were in the top 5% during 2010 fell out of and returned to the group of highest cost patients in the following 3 years.
“The highest likelihood of subsequent high spending was observed in older children with many chronic conditions, respiratory, or neuromuscular complex chronic conditions, and those who used home health services,” the authors noted. “Decreased likelihood of subsequent high spending was observed with children with hospital or ED [emergency department] use in 2010.”
“Understanding the clinical attributes of children most likely to experience persistent high resource use might help inform clinical approaches to optimize their health,” Dr. Agrawal and associates continued.
They added that previous literature and the authors’ clinical experiences suggest that those with multiple chronic conditions, especially a neuromuscular condition, “are at risk for underuse of primary care,” and without a primary care physician taking charge of overall care coordination, that burden falls on the families.
“Perhaps population health initiatives (e.g., enhanced medical homes or neighborhoods for children with medical complexity, complex care networks) designed to alleviate these specific issues might benefit children who are the most likely to have persistent high resource use,” Dr. Agrawal and his colleagues wrote.
The authors cited no relevant financial disclosures. Jay G. Berry, MD, was supported by the Agency for Healthcare Research and Quality, and Eyal Cohen, MD, was supported as a Harkness Fellow in Health Care Policy and Practice by the Canadian Foundation for Healthcare Improvement and the Commonwealth Fund.
More than half of children who are the costliest to cover in the Medicaid program eventually fall out of that category, according to new research.
A retrospective analysis of 48,743 children aged 1-18 years continuously enrolled in Medicaid during 2009-2013 across 10 states who were in the top 5% of all health care spending in 2010 found that from 2011 to 2013, “54.2% fell below the top 5% and did not return to the top 5% in 2011-2013,” Rishi K. Agrawal, MD, of the Ann and Robert Lurie Children’s Hospital, Chicago, and his colleagues wrote in a study published Sept. 15 online in Pediatrics (2016. doi: 10.1542/peds.2016-0682).
Children who were persistently in the top 5% accounted for 32.9% of the cohort and 12.9% of the children who were in the top 5% during 2010 fell out of and returned to the group of highest cost patients in the following 3 years.
“The highest likelihood of subsequent high spending was observed in older children with many chronic conditions, respiratory, or neuromuscular complex chronic conditions, and those who used home health services,” the authors noted. “Decreased likelihood of subsequent high spending was observed with children with hospital or ED [emergency department] use in 2010.”
“Understanding the clinical attributes of children most likely to experience persistent high resource use might help inform clinical approaches to optimize their health,” Dr. Agrawal and associates continued.
They added that previous literature and the authors’ clinical experiences suggest that those with multiple chronic conditions, especially a neuromuscular condition, “are at risk for underuse of primary care,” and without a primary care physician taking charge of overall care coordination, that burden falls on the families.
“Perhaps population health initiatives (e.g., enhanced medical homes or neighborhoods for children with medical complexity, complex care networks) designed to alleviate these specific issues might benefit children who are the most likely to have persistent high resource use,” Dr. Agrawal and his colleagues wrote.
The authors cited no relevant financial disclosures. Jay G. Berry, MD, was supported by the Agency for Healthcare Research and Quality, and Eyal Cohen, MD, was supported as a Harkness Fellow in Health Care Policy and Practice by the Canadian Foundation for Healthcare Improvement and the Commonwealth Fund.
FROM PEDIATRICS
White coating on infant’s tongue
The FP diagnosed thrush or candidiasis of the oral mucosa. To make sure it was not just milk, the FP gently drew a tongue blade over the tongue and the white exudate was mostly adherent (milk wipes away rather easily). The tongue blade was then rubbed onto a glass slide and 2 drops of potassium hydroxide (KOH) solution were applied. Microscopic evaluation revealed pseudohyphae and budding yeasts consistent with Candida albicans. (See video on how to perform a KOH preparation.)
Thrush is a common condition in infants with normal immune systems and does not require work-up for immunosuppression if this is the only finding at this age. Of course, thrush is seen in people who are immunosuppressed from various diseases (such as human immunodeficiency virus) and medications (like chemotherapy).
The FP chose to treat the child with oral nystatin suspension 2 mL 4 times a day. The directions were to give 1 mL in each side of the infant’s mouth and to continue this until 48 hours after signs and symptoms resolved. The mother was not having any symptoms or erythema of the nipples, but if she was, a topical antifungal agent (to be washed off before breastfeeding) could be used.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Candidiasis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:777-781.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
The FP diagnosed thrush or candidiasis of the oral mucosa. To make sure it was not just milk, the FP gently drew a tongue blade over the tongue and the white exudate was mostly adherent (milk wipes away rather easily). The tongue blade was then rubbed onto a glass slide and 2 drops of potassium hydroxide (KOH) solution were applied. Microscopic evaluation revealed pseudohyphae and budding yeasts consistent with Candida albicans. (See video on how to perform a KOH preparation.)
Thrush is a common condition in infants with normal immune systems and does not require work-up for immunosuppression if this is the only finding at this age. Of course, thrush is seen in people who are immunosuppressed from various diseases (such as human immunodeficiency virus) and medications (like chemotherapy).
The FP chose to treat the child with oral nystatin suspension 2 mL 4 times a day. The directions were to give 1 mL in each side of the infant’s mouth and to continue this until 48 hours after signs and symptoms resolved. The mother was not having any symptoms or erythema of the nipples, but if she was, a topical antifungal agent (to be washed off before breastfeeding) could be used.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Candidiasis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:777-781.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
The FP diagnosed thrush or candidiasis of the oral mucosa. To make sure it was not just milk, the FP gently drew a tongue blade over the tongue and the white exudate was mostly adherent (milk wipes away rather easily). The tongue blade was then rubbed onto a glass slide and 2 drops of potassium hydroxide (KOH) solution were applied. Microscopic evaluation revealed pseudohyphae and budding yeasts consistent with Candida albicans. (See video on how to perform a KOH preparation.)
Thrush is a common condition in infants with normal immune systems and does not require work-up for immunosuppression if this is the only finding at this age. Of course, thrush is seen in people who are immunosuppressed from various diseases (such as human immunodeficiency virus) and medications (like chemotherapy).
The FP chose to treat the child with oral nystatin suspension 2 mL 4 times a day. The directions were to give 1 mL in each side of the infant’s mouth and to continue this until 48 hours after signs and symptoms resolved. The mother was not having any symptoms or erythema of the nipples, but if she was, a topical antifungal agent (to be washed off before breastfeeding) could be used.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Candidiasis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:777-781.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
It does get better ... with your help: Preventing suicide
Suicide continues to be a major public health problem in the United States. It is the second leading cause of death in young people aged 10-24 years, according to 2010 injury data from the Centers from Disease Control and Prevention.1 This problem disproportionately affects lesbian, gay, bisexual, and transgender (LGBT) youth. Compared to their heterosexual peers, LGBT youth are four times as likely to attempt suicide.2 In addition, almost 50% of transgender youth have attempted suicide.3
Why are LGBT youth at high risk for suicide? Antigay and antitrans stigma and discrimination against LGBT youth create a very stressful environment. For example, LGBT youth are two times more likely than are heterosexual youth to experience bullying4 because of their sexual orientation, and half of transgender youth have reported bullying because of their gender identity.3 LGBT youth tend to perceive lower levels of parental support than do heterosexual youth.5-8 A combination of harassment from peers and decreased perceived support from families increases the risk for suicide in LGBT youth.
However, there are factors that can reduce this risk. LGBT youth whose parents reject their sexual orientation or gender identity are eight times as likely to be suicidal,3,9 while in contrast, LGBT youth whose parents are more accepting are less likely to be suicidal.10 These studies underscore the importance of social support in reducing the stress from antigay and antitrans discrimination, and therefore, play a role in preventing suicide.
Health care providers are another source of support for LGBT youth. They can play a role in providing education and preventing suicide in this population because many victims of suicide have visited a health care provider before attempting to kill themselves.11 It is important for providers to screen for suicide in their patients. Although there is no lab test for suicidal ideation, suicidal adolescents tend to have certain risk factors. In addition to being LGBT, being bullied, and having a lack of social support, other risk factors are psychiatric illness, a history of being impulsive, alcohol and substance abuse, and most important of all, a previous suicide attempt.12
When screening for suicide risk, always remember that at the beginning of any visit with an adolescent, remind them about confidentiality and its limits (e.g., breaking confidentiality if the patient is suicidal). Although this appears counterintuitive, it actually builds rapport between you and the patient. If you don’t discuss the limits of confidentiality beforehand and have to break it because the patient is suicidal, the patient is less likely to tell you again in the future. Once you suspect suicidal ideation based on the above risk factors, you can ask:
• Have you thought about ending your own life or would you rather be dead?
• Have you done something to harm yourself or to end your life?
• Have you considered ways to end your own life?12
Some clinicians have expressed concern over asking about suicide in their adolescent patients, but doing so does not induce suicidal thoughts.13 If a patient does express any of the above, the clinician must then inquire about other risk factors that increase the individual’s chances of completing suicide. The American Association of Suicidology has listed several warning signs of imminent suicide, which can be remembered with the acronym IS PATH WARM. This stands for Ideation, Substance use, Purposelessness, heightened Anxiety, feeling Trapped, feeling Hopeless, Withdrawal from friends and family, uncontrollable Anger, engaging in Reckless behavior, and dramatic Mood changes.14
If a patient threatens to kill him/herself, has a specific plan to do so, or speaks about death and suicide, then the clinician must act immediately. Although sending a patient to the emergency department is the safest option, it is not the only option. If a good support system is present, and the patient lives in an environment where he or she does not have the means to carry out a suicide (e.g., there are no guns in the home), then the clinician can create a safety plan for the patient. A safety plan is different from a “no suicide contract.” A no suicide contract is a written commitment that the patient does not engage in suicidal behavior. Many experts caution against a no suicide contract because it can create a false sense of security for the clinician and does not address the strategies needed to combat feelings of suicidality.15,16
Usually with a safety plan, the clinician and the patient identify several people the patient can contact if the patient feels suicidal. In addition, the clinician and the patient can discuss ways the patient can cope with his/her feelings or distract himself/herself from suicidal thoughts (e.g., going out for a walk, watching a movie, etc.). Finally, if these methods fail, patients are provided with emergency hotlines or directed to the emergency department. The Suicide Prevention Resource Center has a template of a patient safety plan.
Finally, clinicians should be proactive in preventing suicide, especially for LGBT youth. Because bullying is a risk factor for suicide, and because LGBT youth are disproportionately affected by bullying, clinicians should advocate for antibullying school policies and advocate for schools to be more LGBT friendly. Clinicians also should speak to the community about suicide, its warning signs, and how to address it. Just like with any disease, prevention is the most effective form of treatment.
As clinicians, we should always be on the lookout for suicide in our young patients, especially LGBT youth. For many LGBT youth, we may be the only source of support. If patients are suicidal, we should work with them to determine how to keep the them safe. We have a powerful voice in the community. We can advocate for making schools safe for LGBT youth and educate the community in suicide prevention. Such a powerful voice proclaiming that it gets better can save a life.
Resources
• The Trevor Project: A non-profit organization dedicated to prevent suicide in LGBT Youth (www.thetrevorproject.org)
• It Gets Better Project: Another website dedicated to preventing suicide in LGBT youth by promoting the message that life will improve for LGBT teens (www.itgetsbetter.org)
• Patient Safety Plan Template from the Suicide Prevention Resource Center (www.sprc.org)
References
1. CDC. NCIPC. Web-based Injury Statistics Query and Reporting System (WISQARS). 2010.
2. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
3. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
4. J Adolesc Health. 2014 Sep;55(3):432-8.
5. J Youth Adolesc. 2013 Mar;42(3):376-93.
6. J Youth Adolesc. 2010 Oct;39(10):1189-98.
7. School Psychology Review. 2008;37(2):202-16.
8. J Homosex. 2010;57(2):287-309.
9. Pediatrics. 2009 Jan;123(1):346-52.
10. J Child Adolesc Psychiatr Nurs. 2010 Nov;23(4):205-13.
11. Mayo Clin Proc. 2011 Aug;86(8):792-800.
12. Ital J Pediatr. 2015 Jul 7;41:49.
13. Ment Health Fam Med. 2008 Dec;5(4):229-35.
14. Know the Warning Signs of Suicide. American Association of Suicidology.
15. J Psychiatr Ment Health Nurs. 2008 Aug;15(6):512-22.
16. J Amer Acad Psych Law. 1999;27(3):445-50.
Dr. Montano is a physician at Children’s Hospital of Pittsburgh of UPMC and a clinical instructor of pediatrics at the University of Pittsburgh School of Medicine.
Suicide continues to be a major public health problem in the United States. It is the second leading cause of death in young people aged 10-24 years, according to 2010 injury data from the Centers from Disease Control and Prevention.1 This problem disproportionately affects lesbian, gay, bisexual, and transgender (LGBT) youth. Compared to their heterosexual peers, LGBT youth are four times as likely to attempt suicide.2 In addition, almost 50% of transgender youth have attempted suicide.3
Why are LGBT youth at high risk for suicide? Antigay and antitrans stigma and discrimination against LGBT youth create a very stressful environment. For example, LGBT youth are two times more likely than are heterosexual youth to experience bullying4 because of their sexual orientation, and half of transgender youth have reported bullying because of their gender identity.3 LGBT youth tend to perceive lower levels of parental support than do heterosexual youth.5-8 A combination of harassment from peers and decreased perceived support from families increases the risk for suicide in LGBT youth.
However, there are factors that can reduce this risk. LGBT youth whose parents reject their sexual orientation or gender identity are eight times as likely to be suicidal,3,9 while in contrast, LGBT youth whose parents are more accepting are less likely to be suicidal.10 These studies underscore the importance of social support in reducing the stress from antigay and antitrans discrimination, and therefore, play a role in preventing suicide.
Health care providers are another source of support for LGBT youth. They can play a role in providing education and preventing suicide in this population because many victims of suicide have visited a health care provider before attempting to kill themselves.11 It is important for providers to screen for suicide in their patients. Although there is no lab test for suicidal ideation, suicidal adolescents tend to have certain risk factors. In addition to being LGBT, being bullied, and having a lack of social support, other risk factors are psychiatric illness, a history of being impulsive, alcohol and substance abuse, and most important of all, a previous suicide attempt.12
When screening for suicide risk, always remember that at the beginning of any visit with an adolescent, remind them about confidentiality and its limits (e.g., breaking confidentiality if the patient is suicidal). Although this appears counterintuitive, it actually builds rapport between you and the patient. If you don’t discuss the limits of confidentiality beforehand and have to break it because the patient is suicidal, the patient is less likely to tell you again in the future. Once you suspect suicidal ideation based on the above risk factors, you can ask:
• Have you thought about ending your own life or would you rather be dead?
• Have you done something to harm yourself or to end your life?
• Have you considered ways to end your own life?12
Some clinicians have expressed concern over asking about suicide in their adolescent patients, but doing so does not induce suicidal thoughts.13 If a patient does express any of the above, the clinician must then inquire about other risk factors that increase the individual’s chances of completing suicide. The American Association of Suicidology has listed several warning signs of imminent suicide, which can be remembered with the acronym IS PATH WARM. This stands for Ideation, Substance use, Purposelessness, heightened Anxiety, feeling Trapped, feeling Hopeless, Withdrawal from friends and family, uncontrollable Anger, engaging in Reckless behavior, and dramatic Mood changes.14
If a patient threatens to kill him/herself, has a specific plan to do so, or speaks about death and suicide, then the clinician must act immediately. Although sending a patient to the emergency department is the safest option, it is not the only option. If a good support system is present, and the patient lives in an environment where he or she does not have the means to carry out a suicide (e.g., there are no guns in the home), then the clinician can create a safety plan for the patient. A safety plan is different from a “no suicide contract.” A no suicide contract is a written commitment that the patient does not engage in suicidal behavior. Many experts caution against a no suicide contract because it can create a false sense of security for the clinician and does not address the strategies needed to combat feelings of suicidality.15,16
Usually with a safety plan, the clinician and the patient identify several people the patient can contact if the patient feels suicidal. In addition, the clinician and the patient can discuss ways the patient can cope with his/her feelings or distract himself/herself from suicidal thoughts (e.g., going out for a walk, watching a movie, etc.). Finally, if these methods fail, patients are provided with emergency hotlines or directed to the emergency department. The Suicide Prevention Resource Center has a template of a patient safety plan.
Finally, clinicians should be proactive in preventing suicide, especially for LGBT youth. Because bullying is a risk factor for suicide, and because LGBT youth are disproportionately affected by bullying, clinicians should advocate for antibullying school policies and advocate for schools to be more LGBT friendly. Clinicians also should speak to the community about suicide, its warning signs, and how to address it. Just like with any disease, prevention is the most effective form of treatment.
As clinicians, we should always be on the lookout for suicide in our young patients, especially LGBT youth. For many LGBT youth, we may be the only source of support. If patients are suicidal, we should work with them to determine how to keep the them safe. We have a powerful voice in the community. We can advocate for making schools safe for LGBT youth and educate the community in suicide prevention. Such a powerful voice proclaiming that it gets better can save a life.
Resources
• The Trevor Project: A non-profit organization dedicated to prevent suicide in LGBT Youth (www.thetrevorproject.org)
• It Gets Better Project: Another website dedicated to preventing suicide in LGBT youth by promoting the message that life will improve for LGBT teens (www.itgetsbetter.org)
• Patient Safety Plan Template from the Suicide Prevention Resource Center (www.sprc.org)
References
1. CDC. NCIPC. Web-based Injury Statistics Query and Reporting System (WISQARS). 2010.
2. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
3. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
4. J Adolesc Health. 2014 Sep;55(3):432-8.
5. J Youth Adolesc. 2013 Mar;42(3):376-93.
6. J Youth Adolesc. 2010 Oct;39(10):1189-98.
7. School Psychology Review. 2008;37(2):202-16.
8. J Homosex. 2010;57(2):287-309.
9. Pediatrics. 2009 Jan;123(1):346-52.
10. J Child Adolesc Psychiatr Nurs. 2010 Nov;23(4):205-13.
11. Mayo Clin Proc. 2011 Aug;86(8):792-800.
12. Ital J Pediatr. 2015 Jul 7;41:49.
13. Ment Health Fam Med. 2008 Dec;5(4):229-35.
14. Know the Warning Signs of Suicide. American Association of Suicidology.
15. J Psychiatr Ment Health Nurs. 2008 Aug;15(6):512-22.
16. J Amer Acad Psych Law. 1999;27(3):445-50.
Dr. Montano is a physician at Children’s Hospital of Pittsburgh of UPMC and a clinical instructor of pediatrics at the University of Pittsburgh School of Medicine.
Suicide continues to be a major public health problem in the United States. It is the second leading cause of death in young people aged 10-24 years, according to 2010 injury data from the Centers from Disease Control and Prevention.1 This problem disproportionately affects lesbian, gay, bisexual, and transgender (LGBT) youth. Compared to their heterosexual peers, LGBT youth are four times as likely to attempt suicide.2 In addition, almost 50% of transgender youth have attempted suicide.3
Why are LGBT youth at high risk for suicide? Antigay and antitrans stigma and discrimination against LGBT youth create a very stressful environment. For example, LGBT youth are two times more likely than are heterosexual youth to experience bullying4 because of their sexual orientation, and half of transgender youth have reported bullying because of their gender identity.3 LGBT youth tend to perceive lower levels of parental support than do heterosexual youth.5-8 A combination of harassment from peers and decreased perceived support from families increases the risk for suicide in LGBT youth.
However, there are factors that can reduce this risk. LGBT youth whose parents reject their sexual orientation or gender identity are eight times as likely to be suicidal,3,9 while in contrast, LGBT youth whose parents are more accepting are less likely to be suicidal.10 These studies underscore the importance of social support in reducing the stress from antigay and antitrans discrimination, and therefore, play a role in preventing suicide.
Health care providers are another source of support for LGBT youth. They can play a role in providing education and preventing suicide in this population because many victims of suicide have visited a health care provider before attempting to kill themselves.11 It is important for providers to screen for suicide in their patients. Although there is no lab test for suicidal ideation, suicidal adolescents tend to have certain risk factors. In addition to being LGBT, being bullied, and having a lack of social support, other risk factors are psychiatric illness, a history of being impulsive, alcohol and substance abuse, and most important of all, a previous suicide attempt.12
When screening for suicide risk, always remember that at the beginning of any visit with an adolescent, remind them about confidentiality and its limits (e.g., breaking confidentiality if the patient is suicidal). Although this appears counterintuitive, it actually builds rapport between you and the patient. If you don’t discuss the limits of confidentiality beforehand and have to break it because the patient is suicidal, the patient is less likely to tell you again in the future. Once you suspect suicidal ideation based on the above risk factors, you can ask:
• Have you thought about ending your own life or would you rather be dead?
• Have you done something to harm yourself or to end your life?
• Have you considered ways to end your own life?12
Some clinicians have expressed concern over asking about suicide in their adolescent patients, but doing so does not induce suicidal thoughts.13 If a patient does express any of the above, the clinician must then inquire about other risk factors that increase the individual’s chances of completing suicide. The American Association of Suicidology has listed several warning signs of imminent suicide, which can be remembered with the acronym IS PATH WARM. This stands for Ideation, Substance use, Purposelessness, heightened Anxiety, feeling Trapped, feeling Hopeless, Withdrawal from friends and family, uncontrollable Anger, engaging in Reckless behavior, and dramatic Mood changes.14
If a patient threatens to kill him/herself, has a specific plan to do so, or speaks about death and suicide, then the clinician must act immediately. Although sending a patient to the emergency department is the safest option, it is not the only option. If a good support system is present, and the patient lives in an environment where he or she does not have the means to carry out a suicide (e.g., there are no guns in the home), then the clinician can create a safety plan for the patient. A safety plan is different from a “no suicide contract.” A no suicide contract is a written commitment that the patient does not engage in suicidal behavior. Many experts caution against a no suicide contract because it can create a false sense of security for the clinician and does not address the strategies needed to combat feelings of suicidality.15,16
Usually with a safety plan, the clinician and the patient identify several people the patient can contact if the patient feels suicidal. In addition, the clinician and the patient can discuss ways the patient can cope with his/her feelings or distract himself/herself from suicidal thoughts (e.g., going out for a walk, watching a movie, etc.). Finally, if these methods fail, patients are provided with emergency hotlines or directed to the emergency department. The Suicide Prevention Resource Center has a template of a patient safety plan.
Finally, clinicians should be proactive in preventing suicide, especially for LGBT youth. Because bullying is a risk factor for suicide, and because LGBT youth are disproportionately affected by bullying, clinicians should advocate for antibullying school policies and advocate for schools to be more LGBT friendly. Clinicians also should speak to the community about suicide, its warning signs, and how to address it. Just like with any disease, prevention is the most effective form of treatment.
As clinicians, we should always be on the lookout for suicide in our young patients, especially LGBT youth. For many LGBT youth, we may be the only source of support. If patients are suicidal, we should work with them to determine how to keep the them safe. We have a powerful voice in the community. We can advocate for making schools safe for LGBT youth and educate the community in suicide prevention. Such a powerful voice proclaiming that it gets better can save a life.
Resources
• The Trevor Project: A non-profit organization dedicated to prevent suicide in LGBT Youth (www.thetrevorproject.org)
• It Gets Better Project: Another website dedicated to preventing suicide in LGBT youth by promoting the message that life will improve for LGBT teens (www.itgetsbetter.org)
• Patient Safety Plan Template from the Suicide Prevention Resource Center (www.sprc.org)
References
1. CDC. NCIPC. Web-based Injury Statistics Query and Reporting System (WISQARS). 2010.
2. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
3. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
4. J Adolesc Health. 2014 Sep;55(3):432-8.
5. J Youth Adolesc. 2013 Mar;42(3):376-93.
6. J Youth Adolesc. 2010 Oct;39(10):1189-98.
7. School Psychology Review. 2008;37(2):202-16.
8. J Homosex. 2010;57(2):287-309.
9. Pediatrics. 2009 Jan;123(1):346-52.
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12. Ital J Pediatr. 2015 Jul 7;41:49.
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14. Know the Warning Signs of Suicide. American Association of Suicidology.
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16. J Amer Acad Psych Law. 1999;27(3):445-50.
Dr. Montano is a physician at Children’s Hospital of Pittsburgh of UPMC and a clinical instructor of pediatrics at the University of Pittsburgh School of Medicine.
Both prepregnancy and gestational diabetes bode ill for babies
MUNICH – Pregestational maternal diabetes is even riskier for newborns than gestational diabetes, increasing the chance of neonatal hypoglycemia by 36 times over a normal pregnancy.
Baby’s blood sugar isn’t the only thing in danger, though, Basilio Pintaudi, MD, said at the European Association for the Study of Diabetes conference. Women with prepregnancy diabetes are significantly more likely to have babies that are either small or large for gestational age; become jaundiced; have congenital malformations; and experience respiratory distress, hypocalcemia, and hypomagnesemia, said Dr. Pintaudi of Niguarda Ca’ Granda Hospital, Milan.
“Everyone involved in the care of pregnant women should realize there are very real risks for severe neonatal outcomes, for all forms of diabetes – whether it exists before pregnancy or develops during pregnancy,” Dr. Pintaudi said in an interview. “It’s very important to detect both prepregnancy and gestational diabetes early and optimize maternal glucose levels as quickly as possible.”
He and his colleagues studied outcomes in 135,000 pregnancies included in an administrative database in the Italian Puglia region from 2002 to 2012. They found 1,357 singleton pregnancies complicated by gestational diabetes, and 234 by pregestational diabetes. They computed the risks of a number of neonatal outcomes in a multivariate analysis that controlled for hypertensive and thyroid disorders and for several drugs, including antithrombotics, antiplatelets, and ticlopidine. These drugs were chosen as indicators of high-risk pregnancy.
Both gestational and pregestational diabetes were associated with significantly higher risks of neonatal hypoglycemia (odds ratios, 10 and 36, respectively). They were also associated with significantly increased risks of a small for gestational age infant (ORs, 1.7 and 5.8), and large for gestational age infant (ORs, 1.7 and 7.9).
The risk of jaundice was also increased for both gestational and pregestational diabetes (ORs, 1.7 and 2.6).
Fetal malformations were more common in both disorders (ORs, 2.2 and 3.5). The database didn’t include specifics on what type of malformations occurred, but Dr. Pintaudi said prior studies show increases in cardiac and neural tube defects. This problem in particular illustrates the need for early screening and management of pregestational diabetes, he said in an interview.
“The pathophysiology of these malformations is such that they occur in the very early stages of pregnancy, before some women even know they might be pregnant,” he said.
Hypocalcemia and hypomagnesemia of the newborn were more likely in both gestational and pregestational diabetes (ORs, 1.8 and 9.2), as was Cesarean delivery (ORs, 1.9 and 8.5).
Pregestational diabetes alone was also associated with an increased risk of respiratory distress (OR, 2.7) and polyhydramnios (OR, 46.5).
Dr. Pintaudi said that Italy does not recommend universal diabetes screening for women who are or wish to become pregnant. The first evaluation occurs at 16-18 weeks’ gestation, with a repeat evaluation at 24-28 weeks.
He had no financial disclosures.
On Twitter @Alz_Gal
MUNICH – Pregestational maternal diabetes is even riskier for newborns than gestational diabetes, increasing the chance of neonatal hypoglycemia by 36 times over a normal pregnancy.
Baby’s blood sugar isn’t the only thing in danger, though, Basilio Pintaudi, MD, said at the European Association for the Study of Diabetes conference. Women with prepregnancy diabetes are significantly more likely to have babies that are either small or large for gestational age; become jaundiced; have congenital malformations; and experience respiratory distress, hypocalcemia, and hypomagnesemia, said Dr. Pintaudi of Niguarda Ca’ Granda Hospital, Milan.
“Everyone involved in the care of pregnant women should realize there are very real risks for severe neonatal outcomes, for all forms of diabetes – whether it exists before pregnancy or develops during pregnancy,” Dr. Pintaudi said in an interview. “It’s very important to detect both prepregnancy and gestational diabetes early and optimize maternal glucose levels as quickly as possible.”
He and his colleagues studied outcomes in 135,000 pregnancies included in an administrative database in the Italian Puglia region from 2002 to 2012. They found 1,357 singleton pregnancies complicated by gestational diabetes, and 234 by pregestational diabetes. They computed the risks of a number of neonatal outcomes in a multivariate analysis that controlled for hypertensive and thyroid disorders and for several drugs, including antithrombotics, antiplatelets, and ticlopidine. These drugs were chosen as indicators of high-risk pregnancy.
Both gestational and pregestational diabetes were associated with significantly higher risks of neonatal hypoglycemia (odds ratios, 10 and 36, respectively). They were also associated with significantly increased risks of a small for gestational age infant (ORs, 1.7 and 5.8), and large for gestational age infant (ORs, 1.7 and 7.9).
The risk of jaundice was also increased for both gestational and pregestational diabetes (ORs, 1.7 and 2.6).
Fetal malformations were more common in both disorders (ORs, 2.2 and 3.5). The database didn’t include specifics on what type of malformations occurred, but Dr. Pintaudi said prior studies show increases in cardiac and neural tube defects. This problem in particular illustrates the need for early screening and management of pregestational diabetes, he said in an interview.
“The pathophysiology of these malformations is such that they occur in the very early stages of pregnancy, before some women even know they might be pregnant,” he said.
Hypocalcemia and hypomagnesemia of the newborn were more likely in both gestational and pregestational diabetes (ORs, 1.8 and 9.2), as was Cesarean delivery (ORs, 1.9 and 8.5).
Pregestational diabetes alone was also associated with an increased risk of respiratory distress (OR, 2.7) and polyhydramnios (OR, 46.5).
Dr. Pintaudi said that Italy does not recommend universal diabetes screening for women who are or wish to become pregnant. The first evaluation occurs at 16-18 weeks’ gestation, with a repeat evaluation at 24-28 weeks.
He had no financial disclosures.
On Twitter @Alz_Gal
MUNICH – Pregestational maternal diabetes is even riskier for newborns than gestational diabetes, increasing the chance of neonatal hypoglycemia by 36 times over a normal pregnancy.
Baby’s blood sugar isn’t the only thing in danger, though, Basilio Pintaudi, MD, said at the European Association for the Study of Diabetes conference. Women with prepregnancy diabetes are significantly more likely to have babies that are either small or large for gestational age; become jaundiced; have congenital malformations; and experience respiratory distress, hypocalcemia, and hypomagnesemia, said Dr. Pintaudi of Niguarda Ca’ Granda Hospital, Milan.
“Everyone involved in the care of pregnant women should realize there are very real risks for severe neonatal outcomes, for all forms of diabetes – whether it exists before pregnancy or develops during pregnancy,” Dr. Pintaudi said in an interview. “It’s very important to detect both prepregnancy and gestational diabetes early and optimize maternal glucose levels as quickly as possible.”
He and his colleagues studied outcomes in 135,000 pregnancies included in an administrative database in the Italian Puglia region from 2002 to 2012. They found 1,357 singleton pregnancies complicated by gestational diabetes, and 234 by pregestational diabetes. They computed the risks of a number of neonatal outcomes in a multivariate analysis that controlled for hypertensive and thyroid disorders and for several drugs, including antithrombotics, antiplatelets, and ticlopidine. These drugs were chosen as indicators of high-risk pregnancy.
Both gestational and pregestational diabetes were associated with significantly higher risks of neonatal hypoglycemia (odds ratios, 10 and 36, respectively). They were also associated with significantly increased risks of a small for gestational age infant (ORs, 1.7 and 5.8), and large for gestational age infant (ORs, 1.7 and 7.9).
The risk of jaundice was also increased for both gestational and pregestational diabetes (ORs, 1.7 and 2.6).
Fetal malformations were more common in both disorders (ORs, 2.2 and 3.5). The database didn’t include specifics on what type of malformations occurred, but Dr. Pintaudi said prior studies show increases in cardiac and neural tube defects. This problem in particular illustrates the need for early screening and management of pregestational diabetes, he said in an interview.
“The pathophysiology of these malformations is such that they occur in the very early stages of pregnancy, before some women even know they might be pregnant,” he said.
Hypocalcemia and hypomagnesemia of the newborn were more likely in both gestational and pregestational diabetes (ORs, 1.8 and 9.2), as was Cesarean delivery (ORs, 1.9 and 8.5).
Pregestational diabetes alone was also associated with an increased risk of respiratory distress (OR, 2.7) and polyhydramnios (OR, 46.5).
Dr. Pintaudi said that Italy does not recommend universal diabetes screening for women who are or wish to become pregnant. The first evaluation occurs at 16-18 weeks’ gestation, with a repeat evaluation at 24-28 weeks.
He had no financial disclosures.
On Twitter @Alz_Gal
AT EASD 2016
Key clinical point: Pregestational and gestational diabetes increase the risk of a several poor neonatal outcomes.
Major finding: Pregestational diabetes increased the risk of neonatal hypoglycemia by 36 times; gestational diabetes by 10 times.
Data source: The database review comprised 135,000 singleton pregnancies.
Disclosures: Dr. Pintaudi had no financial disclosures.
Soccer injuries up 111% in children
The rate of soccer injuries treated at U.S. emergency departments among patients aged 7-17 years rose by 111%, and that of soccer-related concussions and closed-head injuries increased by 1,595%, during the last 25 years, according to a report published online Sept. 12 in Pediatrics.
These increases underscore the need to improve injury prevention in this patient population. In particular, concussion prevention should focus on reducing player-to-player contact, especially during illegal moves. “Education of players, coaches, referees or officials, and parents about the importance of following the rules of the game, and enforcement of those rules, are critical first steps,” said Nicholas A. Smith of the Center for Injury Research and Policy, the Research Institute at Nationwide Children’s Hospital, Columbus, and his associates.
In what they described as the first study to comprehensively examine the epidemiology of U.S. youth soccer-related injuries treated at EDs, the investigators analyzed data from a nationally representative injury surveillance system between 1990 and 2014. Almost 3 million children were treated during that period for concussions/closed-head injuries, fractures, dislocations, sprains or strains, soft-tissue injuries such as abrasions or hematomas, lacerations, nondental avulsions, or punctures sustained during soccer practice or games.
The annual rate of soccer-related injury per 10,000 participants rose by 111%, and the annual number of such injuries rose by 78%. Much of this increase was attributed to a 1,595% rise in the annual rate of concussions/closed-head injuries and a 1,332% rise in the number of concussions/closed-head injuries. Patients with head injuries were twice as likely to be admitted to the hospital as were those with other types of injury, highlighting the severity of head injuries, the investigators noted.
The majority of injuries (73%) occurred in older children aged 12-17 years; their injury rate was more than three times higher than that in younger children, “probably because of the more aggressive play and the higher-energy impacts associated with the older age group,” Mr. Smith and his associates wrote (Pediatrics. 2016 Sep 12. doi: 10.1542/peds.2016-0346).
The increase in soccer-related injuries was much greater among girls than among boys, paralleling the much larger increase in soccer participation among girls than among boys during the study period.
This study underestimates the actual number of soccer-related injuries because it didn’t include patients who were treated in health care settings other than the ED and patients who were not treated at all, the investigators added.
The rate of soccer injuries treated at U.S. emergency departments among patients aged 7-17 years rose by 111%, and that of soccer-related concussions and closed-head injuries increased by 1,595%, during the last 25 years, according to a report published online Sept. 12 in Pediatrics.
These increases underscore the need to improve injury prevention in this patient population. In particular, concussion prevention should focus on reducing player-to-player contact, especially during illegal moves. “Education of players, coaches, referees or officials, and parents about the importance of following the rules of the game, and enforcement of those rules, are critical first steps,” said Nicholas A. Smith of the Center for Injury Research and Policy, the Research Institute at Nationwide Children’s Hospital, Columbus, and his associates.
In what they described as the first study to comprehensively examine the epidemiology of U.S. youth soccer-related injuries treated at EDs, the investigators analyzed data from a nationally representative injury surveillance system between 1990 and 2014. Almost 3 million children were treated during that period for concussions/closed-head injuries, fractures, dislocations, sprains or strains, soft-tissue injuries such as abrasions or hematomas, lacerations, nondental avulsions, or punctures sustained during soccer practice or games.
The annual rate of soccer-related injury per 10,000 participants rose by 111%, and the annual number of such injuries rose by 78%. Much of this increase was attributed to a 1,595% rise in the annual rate of concussions/closed-head injuries and a 1,332% rise in the number of concussions/closed-head injuries. Patients with head injuries were twice as likely to be admitted to the hospital as were those with other types of injury, highlighting the severity of head injuries, the investigators noted.
The majority of injuries (73%) occurred in older children aged 12-17 years; their injury rate was more than three times higher than that in younger children, “probably because of the more aggressive play and the higher-energy impacts associated with the older age group,” Mr. Smith and his associates wrote (Pediatrics. 2016 Sep 12. doi: 10.1542/peds.2016-0346).
The increase in soccer-related injuries was much greater among girls than among boys, paralleling the much larger increase in soccer participation among girls than among boys during the study period.
This study underestimates the actual number of soccer-related injuries because it didn’t include patients who were treated in health care settings other than the ED and patients who were not treated at all, the investigators added.
The rate of soccer injuries treated at U.S. emergency departments among patients aged 7-17 years rose by 111%, and that of soccer-related concussions and closed-head injuries increased by 1,595%, during the last 25 years, according to a report published online Sept. 12 in Pediatrics.
These increases underscore the need to improve injury prevention in this patient population. In particular, concussion prevention should focus on reducing player-to-player contact, especially during illegal moves. “Education of players, coaches, referees or officials, and parents about the importance of following the rules of the game, and enforcement of those rules, are critical first steps,” said Nicholas A. Smith of the Center for Injury Research and Policy, the Research Institute at Nationwide Children’s Hospital, Columbus, and his associates.
In what they described as the first study to comprehensively examine the epidemiology of U.S. youth soccer-related injuries treated at EDs, the investigators analyzed data from a nationally representative injury surveillance system between 1990 and 2014. Almost 3 million children were treated during that period for concussions/closed-head injuries, fractures, dislocations, sprains or strains, soft-tissue injuries such as abrasions or hematomas, lacerations, nondental avulsions, or punctures sustained during soccer practice or games.
The annual rate of soccer-related injury per 10,000 participants rose by 111%, and the annual number of such injuries rose by 78%. Much of this increase was attributed to a 1,595% rise in the annual rate of concussions/closed-head injuries and a 1,332% rise in the number of concussions/closed-head injuries. Patients with head injuries were twice as likely to be admitted to the hospital as were those with other types of injury, highlighting the severity of head injuries, the investigators noted.
The majority of injuries (73%) occurred in older children aged 12-17 years; their injury rate was more than three times higher than that in younger children, “probably because of the more aggressive play and the higher-energy impacts associated with the older age group,” Mr. Smith and his associates wrote (Pediatrics. 2016 Sep 12. doi: 10.1542/peds.2016-0346).
The increase in soccer-related injuries was much greater among girls than among boys, paralleling the much larger increase in soccer participation among girls than among boys during the study period.
This study underestimates the actual number of soccer-related injuries because it didn’t include patients who were treated in health care settings other than the ED and patients who were not treated at all, the investigators added.
FROM PEDIATRICS
Key clinical point: Soccer injuries treated at U.S. emergency departments rose by 111% during the last 25 years among children aged 7-17 years.
Major finding: Much of the increase in soccer-related injuries was attributed to a 1,595% rise in the annual rate of concussions/closed-head injuries.
Data source: A retrospective analysis of a nationally representative database involving almost 3 million pediatric soccer injuries over a 25-year period.
Disclosures: This study was supported by the Research Institute at Nationwide Children’s Hospital and Ohio State University. Mr. Smith and his associates reported having no relevant financial disclosures.
Antibiotic stewardship lacking at many hospital nurseries
Nearly one-third of hospital newborn nurseries and neonatal ICUs do not have an antibiotic stewardship program, according to a survey of 146 hospital nursery centers across all 50 states.
Researchers randomly selected a level III NICU in each state using the 2014 American Hospital Association annual survey, then selected a level I and level II nursery in the same city. They collected data on the hospital, nursery, and antibiotic stewardship program characteristics and interviewed staff pharmacists and infectious diseases physicians (J Pediatric Infect Dis Soc. 2016 Jul 15. doi: 10.1093/jpids/piw040).
A total of 104 (71%) of responding hospitals had an antibiotic stewardship program in place for their nurseries. Hospitals with a nursery-based antibiotic stewardship programs tended to be larger, have more full-time equivalent staff dedicated to the antibiotic stewardship program, have higher level nurses, and be affiliated with a university, according to Joseph B. Cantey, MD, and his colleagues from the Texas A&M Health Science Center in Temple.
Geographic region and core stewardship strategies did not influence the likelihood of a nursery-based antibiotic stewardship program in place.
From the interviews, the researchers identified several barriers to implementation of antibiotic stewardship programs, and themes such as unwanted coverage, unnecessary coverage, and need for communication.
“Many [antibiotic stewardship program] and nursery representatives stated that nursery [antibiotic stewardship program] coverage was not important, either because antibiotic consumption was perceived as low (theme 1), narrow-spectrum (theme 2), or both,” the authors wrote.
Some nursery providers also argued that participating in stewardship programs was time consuming and not valuable, which the authors said was often related to a lack of pediatric expertise in the program providers. Some of those interviewed also spoke of issues relating to jurisdiction and responsibility for the programs, and there was also a common perception that antibiotic stewardship programs were more concerned with cost savings than patient care.
“Barriers to effective nursery stewardship are exacerbated by lack of communication between stewardship providers and their nursery counterparts,” the authors reported.
No conflicts of interest were declared.
Nearly one-third of hospital newborn nurseries and neonatal ICUs do not have an antibiotic stewardship program, according to a survey of 146 hospital nursery centers across all 50 states.
Researchers randomly selected a level III NICU in each state using the 2014 American Hospital Association annual survey, then selected a level I and level II nursery in the same city. They collected data on the hospital, nursery, and antibiotic stewardship program characteristics and interviewed staff pharmacists and infectious diseases physicians (J Pediatric Infect Dis Soc. 2016 Jul 15. doi: 10.1093/jpids/piw040).
A total of 104 (71%) of responding hospitals had an antibiotic stewardship program in place for their nurseries. Hospitals with a nursery-based antibiotic stewardship programs tended to be larger, have more full-time equivalent staff dedicated to the antibiotic stewardship program, have higher level nurses, and be affiliated with a university, according to Joseph B. Cantey, MD, and his colleagues from the Texas A&M Health Science Center in Temple.
Geographic region and core stewardship strategies did not influence the likelihood of a nursery-based antibiotic stewardship program in place.
From the interviews, the researchers identified several barriers to implementation of antibiotic stewardship programs, and themes such as unwanted coverage, unnecessary coverage, and need for communication.
“Many [antibiotic stewardship program] and nursery representatives stated that nursery [antibiotic stewardship program] coverage was not important, either because antibiotic consumption was perceived as low (theme 1), narrow-spectrum (theme 2), or both,” the authors wrote.
Some nursery providers also argued that participating in stewardship programs was time consuming and not valuable, which the authors said was often related to a lack of pediatric expertise in the program providers. Some of those interviewed also spoke of issues relating to jurisdiction and responsibility for the programs, and there was also a common perception that antibiotic stewardship programs were more concerned with cost savings than patient care.
“Barriers to effective nursery stewardship are exacerbated by lack of communication between stewardship providers and their nursery counterparts,” the authors reported.
No conflicts of interest were declared.
Nearly one-third of hospital newborn nurseries and neonatal ICUs do not have an antibiotic stewardship program, according to a survey of 146 hospital nursery centers across all 50 states.
Researchers randomly selected a level III NICU in each state using the 2014 American Hospital Association annual survey, then selected a level I and level II nursery in the same city. They collected data on the hospital, nursery, and antibiotic stewardship program characteristics and interviewed staff pharmacists and infectious diseases physicians (J Pediatric Infect Dis Soc. 2016 Jul 15. doi: 10.1093/jpids/piw040).
A total of 104 (71%) of responding hospitals had an antibiotic stewardship program in place for their nurseries. Hospitals with a nursery-based antibiotic stewardship programs tended to be larger, have more full-time equivalent staff dedicated to the antibiotic stewardship program, have higher level nurses, and be affiliated with a university, according to Joseph B. Cantey, MD, and his colleagues from the Texas A&M Health Science Center in Temple.
Geographic region and core stewardship strategies did not influence the likelihood of a nursery-based antibiotic stewardship program in place.
From the interviews, the researchers identified several barriers to implementation of antibiotic stewardship programs, and themes such as unwanted coverage, unnecessary coverage, and need for communication.
“Many [antibiotic stewardship program] and nursery representatives stated that nursery [antibiotic stewardship program] coverage was not important, either because antibiotic consumption was perceived as low (theme 1), narrow-spectrum (theme 2), or both,” the authors wrote.
Some nursery providers also argued that participating in stewardship programs was time consuming and not valuable, which the authors said was often related to a lack of pediatric expertise in the program providers. Some of those interviewed also spoke of issues relating to jurisdiction and responsibility for the programs, and there was also a common perception that antibiotic stewardship programs were more concerned with cost savings than patient care.
“Barriers to effective nursery stewardship are exacerbated by lack of communication between stewardship providers and their nursery counterparts,” the authors reported.
No conflicts of interest were declared.
FROM JOURNAL OF THE PEDIATRIC INFECTIOUS DISEASES SOCIETY
Key clinical point: Many hospital newborn nurseries or neonatal ICUs do not have an antibiotic stewardship program in place.
Major finding: 29% of hospital nurseries surveyed did not have an antibiotic stewardship program.
Data source: Survey of 146 hospital nursery centers in 50 states.
Disclosures: No conflicts of interest were declared.
Fourth U.S. case of mcr-1–resistance gene reported
A fourth case of bacterial infection harboring the mcr-1 gene has been reported in a child recently returned from a visit to the Caribbean, according to a case report published Sept. 9 in Morbidity and Mortality Weekly Report.
The mcr-1 gene, which confers resistance to the last-resort antibiotic colistin, was first reported in China and is the first plasmid-mediated colistin-resistance mechanism to be identified. Since its discovery in 2015, cases have been reported in Africa, Asia, Europe, South America, and North America.
In this case report, a young patient developed fever and bloody diarrhea 2 days before returning to the United States from a 2-week visit to the Caribbean. The child were treated with the paromomycin and a stool specimen was collected on June 16, with follow-up cultures on June 18 and June 23.
All revealed Escherichia coli O157 harboring mcr-1. The isolates also carried a plasmid blaCMY-2 gene, which confers resistance to third-generation cephalosporins. Stool cultures taken on June 24 and July 1 were negative for E. coli O157 (MMWR. 2016 Sep 9. http://dx.doi.org/10.15585/mmwr.mm6536e3).
Family members in close contact with the patient also were tested; all were found to be negative. Similarly, 16 environmental samples collected from the kitchen and diaper-changing area of the patient’s home were negative for mcr-1.
Researchers reported that the patient was “typically healthy,” and the child’s diet included fruit, dairy products, and meat. While on vacation in the Caribbean, the child ate meat purchased at a live animal market but did not visit the market personally. The child also had contact with a pet dog and cat.
“At this time, CDC recommends that Enterobacteriaceae isolates with a colistin or polymyxin B MIC plus or minus 4 mcg/mL be tested for the presence of mcr-1; testing is available through CDC,” wrote Dr. Amber M. Vasquez and her colleagues from the Centers for Disease Control and Prevention. “Prompt reporting of mcr-1–carrying isolates to public health officials allows for a rapid response to identify transmission and limit further spread.”
A fourth case of bacterial infection harboring the mcr-1 gene has been reported in a child recently returned from a visit to the Caribbean, according to a case report published Sept. 9 in Morbidity and Mortality Weekly Report.
The mcr-1 gene, which confers resistance to the last-resort antibiotic colistin, was first reported in China and is the first plasmid-mediated colistin-resistance mechanism to be identified. Since its discovery in 2015, cases have been reported in Africa, Asia, Europe, South America, and North America.
In this case report, a young patient developed fever and bloody diarrhea 2 days before returning to the United States from a 2-week visit to the Caribbean. The child were treated with the paromomycin and a stool specimen was collected on June 16, with follow-up cultures on June 18 and June 23.
All revealed Escherichia coli O157 harboring mcr-1. The isolates also carried a plasmid blaCMY-2 gene, which confers resistance to third-generation cephalosporins. Stool cultures taken on June 24 and July 1 were negative for E. coli O157 (MMWR. 2016 Sep 9. http://dx.doi.org/10.15585/mmwr.mm6536e3).
Family members in close contact with the patient also were tested; all were found to be negative. Similarly, 16 environmental samples collected from the kitchen and diaper-changing area of the patient’s home were negative for mcr-1.
Researchers reported that the patient was “typically healthy,” and the child’s diet included fruit, dairy products, and meat. While on vacation in the Caribbean, the child ate meat purchased at a live animal market but did not visit the market personally. The child also had contact with a pet dog and cat.
“At this time, CDC recommends that Enterobacteriaceae isolates with a colistin or polymyxin B MIC plus or minus 4 mcg/mL be tested for the presence of mcr-1; testing is available through CDC,” wrote Dr. Amber M. Vasquez and her colleagues from the Centers for Disease Control and Prevention. “Prompt reporting of mcr-1–carrying isolates to public health officials allows for a rapid response to identify transmission and limit further spread.”
A fourth case of bacterial infection harboring the mcr-1 gene has been reported in a child recently returned from a visit to the Caribbean, according to a case report published Sept. 9 in Morbidity and Mortality Weekly Report.
The mcr-1 gene, which confers resistance to the last-resort antibiotic colistin, was first reported in China and is the first plasmid-mediated colistin-resistance mechanism to be identified. Since its discovery in 2015, cases have been reported in Africa, Asia, Europe, South America, and North America.
In this case report, a young patient developed fever and bloody diarrhea 2 days before returning to the United States from a 2-week visit to the Caribbean. The child were treated with the paromomycin and a stool specimen was collected on June 16, with follow-up cultures on June 18 and June 23.
All revealed Escherichia coli O157 harboring mcr-1. The isolates also carried a plasmid blaCMY-2 gene, which confers resistance to third-generation cephalosporins. Stool cultures taken on June 24 and July 1 were negative for E. coli O157 (MMWR. 2016 Sep 9. http://dx.doi.org/10.15585/mmwr.mm6536e3).
Family members in close contact with the patient also were tested; all were found to be negative. Similarly, 16 environmental samples collected from the kitchen and diaper-changing area of the patient’s home were negative for mcr-1.
Researchers reported that the patient was “typically healthy,” and the child’s diet included fruit, dairy products, and meat. While on vacation in the Caribbean, the child ate meat purchased at a live animal market but did not visit the market personally. The child also had contact with a pet dog and cat.
“At this time, CDC recommends that Enterobacteriaceae isolates with a colistin or polymyxin B MIC plus or minus 4 mcg/mL be tested for the presence of mcr-1; testing is available through CDC,” wrote Dr. Amber M. Vasquez and her colleagues from the Centers for Disease Control and Prevention. “Prompt reporting of mcr-1–carrying isolates to public health officials allows for a rapid response to identify transmission and limit further spread.”
FROM MORBIDITY AND MORTALITY WEEKLY REPORT
AAP report warns against early single-sport specialization
Delaying single-sport specialization until late adolescence not only minimizes the risks of overuse injuries and burnout, but it increases the likelihood of athletic success, according to a new clinical report from the American Academy of Pediatrics.
The new report gives pediatricians a current knowledge base to draw upon in well checks and sports injury visits, author Joel S. Brenner, MD, MPH, of the AAP’s Council on Sports Medicine and Fitness, said in an interview.
Specializing in a single sport at younger ages – and playing intensively year-round – has become increasingly common, and is often driven by aspirations for college scholarships or elite athletic status. Yet evidence suggests that early specialization may actually work against such goals.
Studies of top college athletes and reviews of other elite athletes and their specialization history show that “for the majority of sports, late specialization with early diversification [playing multiple sports early] is most likely to lead to elite status,” the report states (Pediatrics. 2016;138[3]:e20162148).
Youth who participate in a variety of sports until late adolescence (about 15-16 years of age) also have fewer injuries and a higher chance of remaining engaged in sports for the long term than do children who specialize early, according to the guideline. “Unfortunately, 70% of children drop out of organized sports by 13 years of age.”
If a young athlete has decided to specialize in a single sport, you should discuss his or her goals to determine if they are appropriate and realistic. A mere 1% of high school athletes receive athletic scholarships and only 3%-11% go on to compete at college level; of high school athletes, only 0.03%-0.5% proceed to the professional sports level, the report notes.
Having at least 1-2 days off per week from the focal sport can decrease the chance of injury, and taking 1 month off at least 3 times a year “will allow for athletes’ physical and psychological recovery.”
An estimated 50% of athletic injuries are related to overuse. The physiologic and psychological effects of intensive training in young athletes are detailed in other articles by the AAP (Pediatrics. 2007;119[6]:1242-5) and the American Medical Society for Sports Medicine (Clin J Sport Med. 2014;24[1]:3-20).
According to a 2008 report from the National Council of Youth Sports, 27% of the youth active in adult-led organized sports participated in only 1 sport. “There is increased pressure to participate at a high level, to specialize in one sport early, and to play year-round, often on multiple teams,” the guideline notes.
This clinical report replaces the academy’s 2000 policy statement on sports specialization and intensive training and provides “concrete guidance” for pediatricians, said Dr. Brenner, who is medical director of Children’s Hospital of the King’s Daughters’ sports medicine and adolescent medicine programs and the director of CHKD’s sports concussion program, in Norfolk, Va.
There was no external funding for this report and the authors had no relevant financial disclosures.
Delaying single-sport specialization until late adolescence not only minimizes the risks of overuse injuries and burnout, but it increases the likelihood of athletic success, according to a new clinical report from the American Academy of Pediatrics.
The new report gives pediatricians a current knowledge base to draw upon in well checks and sports injury visits, author Joel S. Brenner, MD, MPH, of the AAP’s Council on Sports Medicine and Fitness, said in an interview.
Specializing in a single sport at younger ages – and playing intensively year-round – has become increasingly common, and is often driven by aspirations for college scholarships or elite athletic status. Yet evidence suggests that early specialization may actually work against such goals.
Studies of top college athletes and reviews of other elite athletes and their specialization history show that “for the majority of sports, late specialization with early diversification [playing multiple sports early] is most likely to lead to elite status,” the report states (Pediatrics. 2016;138[3]:e20162148).
Youth who participate in a variety of sports until late adolescence (about 15-16 years of age) also have fewer injuries and a higher chance of remaining engaged in sports for the long term than do children who specialize early, according to the guideline. “Unfortunately, 70% of children drop out of organized sports by 13 years of age.”
If a young athlete has decided to specialize in a single sport, you should discuss his or her goals to determine if they are appropriate and realistic. A mere 1% of high school athletes receive athletic scholarships and only 3%-11% go on to compete at college level; of high school athletes, only 0.03%-0.5% proceed to the professional sports level, the report notes.
Having at least 1-2 days off per week from the focal sport can decrease the chance of injury, and taking 1 month off at least 3 times a year “will allow for athletes’ physical and psychological recovery.”
An estimated 50% of athletic injuries are related to overuse. The physiologic and psychological effects of intensive training in young athletes are detailed in other articles by the AAP (Pediatrics. 2007;119[6]:1242-5) and the American Medical Society for Sports Medicine (Clin J Sport Med. 2014;24[1]:3-20).
According to a 2008 report from the National Council of Youth Sports, 27% of the youth active in adult-led organized sports participated in only 1 sport. “There is increased pressure to participate at a high level, to specialize in one sport early, and to play year-round, often on multiple teams,” the guideline notes.
This clinical report replaces the academy’s 2000 policy statement on sports specialization and intensive training and provides “concrete guidance” for pediatricians, said Dr. Brenner, who is medical director of Children’s Hospital of the King’s Daughters’ sports medicine and adolescent medicine programs and the director of CHKD’s sports concussion program, in Norfolk, Va.
There was no external funding for this report and the authors had no relevant financial disclosures.
Delaying single-sport specialization until late adolescence not only minimizes the risks of overuse injuries and burnout, but it increases the likelihood of athletic success, according to a new clinical report from the American Academy of Pediatrics.
The new report gives pediatricians a current knowledge base to draw upon in well checks and sports injury visits, author Joel S. Brenner, MD, MPH, of the AAP’s Council on Sports Medicine and Fitness, said in an interview.
Specializing in a single sport at younger ages – and playing intensively year-round – has become increasingly common, and is often driven by aspirations for college scholarships or elite athletic status. Yet evidence suggests that early specialization may actually work against such goals.
Studies of top college athletes and reviews of other elite athletes and their specialization history show that “for the majority of sports, late specialization with early diversification [playing multiple sports early] is most likely to lead to elite status,” the report states (Pediatrics. 2016;138[3]:e20162148).
Youth who participate in a variety of sports until late adolescence (about 15-16 years of age) also have fewer injuries and a higher chance of remaining engaged in sports for the long term than do children who specialize early, according to the guideline. “Unfortunately, 70% of children drop out of organized sports by 13 years of age.”
If a young athlete has decided to specialize in a single sport, you should discuss his or her goals to determine if they are appropriate and realistic. A mere 1% of high school athletes receive athletic scholarships and only 3%-11% go on to compete at college level; of high school athletes, only 0.03%-0.5% proceed to the professional sports level, the report notes.
Having at least 1-2 days off per week from the focal sport can decrease the chance of injury, and taking 1 month off at least 3 times a year “will allow for athletes’ physical and psychological recovery.”
An estimated 50% of athletic injuries are related to overuse. The physiologic and psychological effects of intensive training in young athletes are detailed in other articles by the AAP (Pediatrics. 2007;119[6]:1242-5) and the American Medical Society for Sports Medicine (Clin J Sport Med. 2014;24[1]:3-20).
According to a 2008 report from the National Council of Youth Sports, 27% of the youth active in adult-led organized sports participated in only 1 sport. “There is increased pressure to participate at a high level, to specialize in one sport early, and to play year-round, often on multiple teams,” the guideline notes.
This clinical report replaces the academy’s 2000 policy statement on sports specialization and intensive training and provides “concrete guidance” for pediatricians, said Dr. Brenner, who is medical director of Children’s Hospital of the King’s Daughters’ sports medicine and adolescent medicine programs and the director of CHKD’s sports concussion program, in Norfolk, Va.
There was no external funding for this report and the authors had no relevant financial disclosures.
FROM PEDIATRICS
No more popping, swatting, slapping, and spanking
During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.
On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”
As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”
Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.
Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.
Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at pdnews@frontlinemedcom.com.
During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.
On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”
As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”
Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.
Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.
Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at pdnews@frontlinemedcom.com.
During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.
On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”
As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”
Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.
Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.
Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at pdnews@frontlinemedcom.com.
Gluten-free adherence triples while celiac disease prevalence remains stable
The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, despite the fact that the prevalence of celiac disease has remained largely stable over the same period, according to data from the National Health and Nutrition Examination Survey.
Hyun-seok Kim, MD, MPH, and colleagues from Rutgers New Jersey Medical School noted that there is a popular trend of people choosing gluten-free diets, which exceeds the numbers that would be solely attributable to an increasing prevalence of celiac disease.
In a report published online Sept. 6 in JAMA Internal Medicine, the researchers noted that of 22,278 persons aged 6 years or older for whom data were available on celiac disease status and gluten-free diet status, 106 (0.69%) had a diagnosis of celiac disease, and 213 (1.08%) followed a gluten-free diet but did not have celiac disease.
At a U.S. population level, this would correspond to an estimated 1.76 million individuals with celiac disease, and 2.7 million individuals without celiac disease who follow a gluten-free diet.
The prevalence of celiac disease ranged from 0.70% during 2009-2010, to 0.77% during 2011-2012, and 0.58% during 2013-2014 (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5254).
In contrast, the prevalence of a gluten-free diet without celiac disease increased from 0.52% during 2009-2010 to 0.99% during 2011-2012 and 1.69% during 2013-2014, although the increase was even greater among non-Hispanic whites.
“The two trends may be related because gluten consumption has been identified as a risk factor of celiac disease, such that steady or even decreasing gluten consumption may be contributing to a plateau in celiac disease,” they reported.
The authors suggested that there were a number of reasons why individuals without celiac disease might choose to follow a gluten-free diet. “The public perception is that gluten-free diets are healthier and may provide benefits to nonspecific gastrointestinal symptoms,” they wrote, pointing out that gluten-free products are now also more widely available in supermarkets and online.
“There is also an increasing number of individuals with self-diagnosed gluten sensitivity but not the typical enteropathic or serologic features of celiac disease who have improved gastrointestinal health after avoidance of gluten-containing products.”
They stressed that the numbers of individuals in the survey with celiac disease or adhering to a gluten-free diet were relatively small, and that a diagnosis of celiac disease was not confirmed by intestinal biopsy, relying instead on serological tests and prior diagnosis by a health professional.
No conflicts of interest were declared.
Part of what may be driving this gluten-free diet trend is simply a belief, fueled by marketing and media, that these foods are healthier. However, surveys suggest that many individuals who adhere to a gluten-free diet believe that the exclusion of gluten has resulted in subjective health benefits from weight loss to reduced symptoms of inflammation and gastrointestinal distress.
Because a gluten-free diet may have negative social, financial, and health repercussions, it is important for clinicians to understand whether, in most cases, it is the elimination of the protein gluten that is responsible for symptom improvement or whether following a gluten-free diet is simply a marker of other dietary choices that are creating positive effects.
Although the choice to be gluten free may be driven in part by marketing and a misperception that gluten free is healthier, it is important that this choice not be dismissed as an unfounded trend except for those with celiac disease and wheat allergy.
Dr. Daphne Miller is from the department of family and community medicine at the University of California, San Francisco. The comments are taken from an editorial (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5271). No conflicts of interest were declared.
Part of what may be driving this gluten-free diet trend is simply a belief, fueled by marketing and media, that these foods are healthier. However, surveys suggest that many individuals who adhere to a gluten-free diet believe that the exclusion of gluten has resulted in subjective health benefits from weight loss to reduced symptoms of inflammation and gastrointestinal distress.
Because a gluten-free diet may have negative social, financial, and health repercussions, it is important for clinicians to understand whether, in most cases, it is the elimination of the protein gluten that is responsible for symptom improvement or whether following a gluten-free diet is simply a marker of other dietary choices that are creating positive effects.
Although the choice to be gluten free may be driven in part by marketing and a misperception that gluten free is healthier, it is important that this choice not be dismissed as an unfounded trend except for those with celiac disease and wheat allergy.
Dr. Daphne Miller is from the department of family and community medicine at the University of California, San Francisco. The comments are taken from an editorial (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5271). No conflicts of interest were declared.
Part of what may be driving this gluten-free diet trend is simply a belief, fueled by marketing and media, that these foods are healthier. However, surveys suggest that many individuals who adhere to a gluten-free diet believe that the exclusion of gluten has resulted in subjective health benefits from weight loss to reduced symptoms of inflammation and gastrointestinal distress.
Because a gluten-free diet may have negative social, financial, and health repercussions, it is important for clinicians to understand whether, in most cases, it is the elimination of the protein gluten that is responsible for symptom improvement or whether following a gluten-free diet is simply a marker of other dietary choices that are creating positive effects.
Although the choice to be gluten free may be driven in part by marketing and a misperception that gluten free is healthier, it is important that this choice not be dismissed as an unfounded trend except for those with celiac disease and wheat allergy.
Dr. Daphne Miller is from the department of family and community medicine at the University of California, San Francisco. The comments are taken from an editorial (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5271). No conflicts of interest were declared.
The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, despite the fact that the prevalence of celiac disease has remained largely stable over the same period, according to data from the National Health and Nutrition Examination Survey.
Hyun-seok Kim, MD, MPH, and colleagues from Rutgers New Jersey Medical School noted that there is a popular trend of people choosing gluten-free diets, which exceeds the numbers that would be solely attributable to an increasing prevalence of celiac disease.
In a report published online Sept. 6 in JAMA Internal Medicine, the researchers noted that of 22,278 persons aged 6 years or older for whom data were available on celiac disease status and gluten-free diet status, 106 (0.69%) had a diagnosis of celiac disease, and 213 (1.08%) followed a gluten-free diet but did not have celiac disease.
At a U.S. population level, this would correspond to an estimated 1.76 million individuals with celiac disease, and 2.7 million individuals without celiac disease who follow a gluten-free diet.
The prevalence of celiac disease ranged from 0.70% during 2009-2010, to 0.77% during 2011-2012, and 0.58% during 2013-2014 (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5254).
In contrast, the prevalence of a gluten-free diet without celiac disease increased from 0.52% during 2009-2010 to 0.99% during 2011-2012 and 1.69% during 2013-2014, although the increase was even greater among non-Hispanic whites.
“The two trends may be related because gluten consumption has been identified as a risk factor of celiac disease, such that steady or even decreasing gluten consumption may be contributing to a plateau in celiac disease,” they reported.
The authors suggested that there were a number of reasons why individuals without celiac disease might choose to follow a gluten-free diet. “The public perception is that gluten-free diets are healthier and may provide benefits to nonspecific gastrointestinal symptoms,” they wrote, pointing out that gluten-free products are now also more widely available in supermarkets and online.
“There is also an increasing number of individuals with self-diagnosed gluten sensitivity but not the typical enteropathic or serologic features of celiac disease who have improved gastrointestinal health after avoidance of gluten-containing products.”
They stressed that the numbers of individuals in the survey with celiac disease or adhering to a gluten-free diet were relatively small, and that a diagnosis of celiac disease was not confirmed by intestinal biopsy, relying instead on serological tests and prior diagnosis by a health professional.
No conflicts of interest were declared.
The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, despite the fact that the prevalence of celiac disease has remained largely stable over the same period, according to data from the National Health and Nutrition Examination Survey.
Hyun-seok Kim, MD, MPH, and colleagues from Rutgers New Jersey Medical School noted that there is a popular trend of people choosing gluten-free diets, which exceeds the numbers that would be solely attributable to an increasing prevalence of celiac disease.
In a report published online Sept. 6 in JAMA Internal Medicine, the researchers noted that of 22,278 persons aged 6 years or older for whom data were available on celiac disease status and gluten-free diet status, 106 (0.69%) had a diagnosis of celiac disease, and 213 (1.08%) followed a gluten-free diet but did not have celiac disease.
At a U.S. population level, this would correspond to an estimated 1.76 million individuals with celiac disease, and 2.7 million individuals without celiac disease who follow a gluten-free diet.
The prevalence of celiac disease ranged from 0.70% during 2009-2010, to 0.77% during 2011-2012, and 0.58% during 2013-2014 (JAMA Intern Med. 2016 Sept 6. doi: 10.1001/jamainternmed.2016.5254).
In contrast, the prevalence of a gluten-free diet without celiac disease increased from 0.52% during 2009-2010 to 0.99% during 2011-2012 and 1.69% during 2013-2014, although the increase was even greater among non-Hispanic whites.
“The two trends may be related because gluten consumption has been identified as a risk factor of celiac disease, such that steady or even decreasing gluten consumption may be contributing to a plateau in celiac disease,” they reported.
The authors suggested that there were a number of reasons why individuals without celiac disease might choose to follow a gluten-free diet. “The public perception is that gluten-free diets are healthier and may provide benefits to nonspecific gastrointestinal symptoms,” they wrote, pointing out that gluten-free products are now also more widely available in supermarkets and online.
“There is also an increasing number of individuals with self-diagnosed gluten sensitivity but not the typical enteropathic or serologic features of celiac disease who have improved gastrointestinal health after avoidance of gluten-containing products.”
They stressed that the numbers of individuals in the survey with celiac disease or adhering to a gluten-free diet were relatively small, and that a diagnosis of celiac disease was not confirmed by intestinal biopsy, relying instead on serological tests and prior diagnosis by a health professional.
No conflicts of interest were declared.
FROM JAMA INTERNAL MEDICINE
Key clinical point: The number of people adhering to a gluten-free diet more than tripled between 2009 and 2014, while the prevalence of celiac disease has remained largely stable over the same period.
Major finding: The prevalence of celiac disease ranged from 0.70% during 2009-2010 to 0.58% in 2013-2014, while the prevalence of a gluten-free diet without celiac disease increased from 0.52% in 2009-2010 to 1.69% during 2013-2014.
Data source: Analysis of data from 22,278 participants in the National Health and Nutrition Examination Survey.
Disclosures: No conflicts of interest were disclosed.
