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Modifying our behavior
“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.
While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.
However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.
I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.
Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”
What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.
I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.
At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.
While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.
However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.
I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.
Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”
What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.
I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.
At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.
While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.
However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.
I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.
Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”
What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.
I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.
At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
Pertussis vaccines effective against pertactin-deficient strains
Current pertussis vaccines were as effective against the rapidly evolving pertactin-deficient strains of the organism as they have been against other strains, according to a report published online April 13 in Pediatrics.
The proportion of pertussis strains lacking pertactin increased markedly in the United States, from 14% in 2010 to 85% in 2012. Pertactin, an autotransporter thought to be “involved in bacterial adhesion to the respiratory tract and resistance to neutrophil-induced bacterial clearance,” is a component of acellular pertussis vaccines. Some have speculated that pertactin deficiency evolved to give the bacteria an advantage in response to vaccine-related selection pressure, and that this evolution has contributed to the recent resurgence of pertussis disease, said Lucy Breakwell, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, Atlanta, and her associates.
To assess vaccine efficacy in the setting of pertactin deficiency, the investigators studied 820 cases and 2,369 matched control subjects treated in Vermont during a 3-year period encompassing a recent pertussis outbreak there. The study included children aged 4-10 years given the five-dose DTaP childhood series and adolescents aged 11-19 years given the adolescent Tdap dose. Specimens from these cases had been cultured routinely by the state department of health laboratory, and more than 90% of the available isolates were found to be pertactin deficient.
The overall vaccine efficacy of the DTap series was 84%, and of the Tdap booster, 70%. “Remarkably,” these rates are comparable to the 89% efficacy of DTap reported in a 2010 California outbreak and the 64% efficacy of Tdap reported in a 2012 Washington state outbreak, the investigators said. “Our findings suggest that both acellular pertussis vaccines remain protective against pertussis disease in the setting of high pertactin deficiency,” and therefore remain the best method for protecting against severe disease, Dr. Breakwell and her associates said (Pediatr. 2016 April 12. doi: 10.1542/peds.2015-3973).
Nevertheless, further study is warranted “to better understand the implications of pertactin deficiency on pertussis pathogenesis and host immunologic response, which could provide insight into the development of novel pertussis vaccines,” they wrote.
This study was supported by the Centers for Disease Control and Prevention. Dr. Breakwell and her associates reported having no relevant financial disclosures.
Immunity to pertussis from either natural infection or vaccination, is not lifelong. Two acellular pertussis vaccines are in widespread use in the United States, and they differ in the number and amounts of purified proteins and method of being chemically inactivated. A vaccine made by GlaxoSmithKline includes three proteins: pertussis toxin (PT), filamentous hemagglutinin (FHA), and pertactin (PRN). A vaccine made by Sanofi Pasteur includes the same three proteins (PT, FHA, and PRN) plus two types of fimbriae (FIM), for a total of five ingredients. PT causes virtually all the symptoms of pertussis disease. The other proteins included in the two acellular vaccines are principally there to prevent the Bordetella pertussis bacteria from attaching to the nasopharynx and lung because prevention of attachment is a prevention of pathogenesis.
Although both acellular pertussis vaccines provide good protection, many reports support that acellular pertussis vaccines have shown waning immunity. One hypothesis among experts is that waning immunity might be related to changes in the protein structure of one or more of the targets for acellular vaccines. The protein that has been shown to have changed since introduction of acellular vaccines is PRN.
In the current study from Vermont, we learn that acellular pertussis vaccine efficacy remained high in that state despite the presence of over 90% of the B. pertussis strains lacking a PRN protein on the bacteria surface that would serve as an antibody target following vaccination. In other words, the lack of PRN as a vaccine target did not reduce vaccine efficacy nor did it impact the waning immunity following vaccination.
The result is reassuring and expected. All bacteria that seek to attach themselves to our respiratory tract in the nose or lungs or both have many different proteins to accomplish that attachment task. The redundancy of those proteins fits easily in a biologic necessity framework because pathogenesis cannot begin for any of the respiratory pathogenic bacteria unless they can attach themselves to the host in the nose or lungs or both. The addition of FHA as well as PRN in the GlaxoSmithKline vaccine and FHA plus two types of FIM antigen as ingredients in the Sanofi Pasteur vaccine was to raise antibody to multiple “adhesion” proteins. That way if “escape mutants” occurred, as we are now observing for PRN-deficient strains, the vaccines would still work. The study from Vermont tells us that they still do work.
Michael E. Pichichero, M.D., a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero commented in an interview. He said he had no relevant financial disclosures.
Immunity to pertussis from either natural infection or vaccination, is not lifelong. Two acellular pertussis vaccines are in widespread use in the United States, and they differ in the number and amounts of purified proteins and method of being chemically inactivated. A vaccine made by GlaxoSmithKline includes three proteins: pertussis toxin (PT), filamentous hemagglutinin (FHA), and pertactin (PRN). A vaccine made by Sanofi Pasteur includes the same three proteins (PT, FHA, and PRN) plus two types of fimbriae (FIM), for a total of five ingredients. PT causes virtually all the symptoms of pertussis disease. The other proteins included in the two acellular vaccines are principally there to prevent the Bordetella pertussis bacteria from attaching to the nasopharynx and lung because prevention of attachment is a prevention of pathogenesis.
Although both acellular pertussis vaccines provide good protection, many reports support that acellular pertussis vaccines have shown waning immunity. One hypothesis among experts is that waning immunity might be related to changes in the protein structure of one or more of the targets for acellular vaccines. The protein that has been shown to have changed since introduction of acellular vaccines is PRN.
In the current study from Vermont, we learn that acellular pertussis vaccine efficacy remained high in that state despite the presence of over 90% of the B. pertussis strains lacking a PRN protein on the bacteria surface that would serve as an antibody target following vaccination. In other words, the lack of PRN as a vaccine target did not reduce vaccine efficacy nor did it impact the waning immunity following vaccination.
The result is reassuring and expected. All bacteria that seek to attach themselves to our respiratory tract in the nose or lungs or both have many different proteins to accomplish that attachment task. The redundancy of those proteins fits easily in a biologic necessity framework because pathogenesis cannot begin for any of the respiratory pathogenic bacteria unless they can attach themselves to the host in the nose or lungs or both. The addition of FHA as well as PRN in the GlaxoSmithKline vaccine and FHA plus two types of FIM antigen as ingredients in the Sanofi Pasteur vaccine was to raise antibody to multiple “adhesion” proteins. That way if “escape mutants” occurred, as we are now observing for PRN-deficient strains, the vaccines would still work. The study from Vermont tells us that they still do work.
Michael E. Pichichero, M.D., a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero commented in an interview. He said he had no relevant financial disclosures.
Immunity to pertussis from either natural infection or vaccination, is not lifelong. Two acellular pertussis vaccines are in widespread use in the United States, and they differ in the number and amounts of purified proteins and method of being chemically inactivated. A vaccine made by GlaxoSmithKline includes three proteins: pertussis toxin (PT), filamentous hemagglutinin (FHA), and pertactin (PRN). A vaccine made by Sanofi Pasteur includes the same three proteins (PT, FHA, and PRN) plus two types of fimbriae (FIM), for a total of five ingredients. PT causes virtually all the symptoms of pertussis disease. The other proteins included in the two acellular vaccines are principally there to prevent the Bordetella pertussis bacteria from attaching to the nasopharynx and lung because prevention of attachment is a prevention of pathogenesis.
Although both acellular pertussis vaccines provide good protection, many reports support that acellular pertussis vaccines have shown waning immunity. One hypothesis among experts is that waning immunity might be related to changes in the protein structure of one or more of the targets for acellular vaccines. The protein that has been shown to have changed since introduction of acellular vaccines is PRN.
In the current study from Vermont, we learn that acellular pertussis vaccine efficacy remained high in that state despite the presence of over 90% of the B. pertussis strains lacking a PRN protein on the bacteria surface that would serve as an antibody target following vaccination. In other words, the lack of PRN as a vaccine target did not reduce vaccine efficacy nor did it impact the waning immunity following vaccination.
The result is reassuring and expected. All bacteria that seek to attach themselves to our respiratory tract in the nose or lungs or both have many different proteins to accomplish that attachment task. The redundancy of those proteins fits easily in a biologic necessity framework because pathogenesis cannot begin for any of the respiratory pathogenic bacteria unless they can attach themselves to the host in the nose or lungs or both. The addition of FHA as well as PRN in the GlaxoSmithKline vaccine and FHA plus two types of FIM antigen as ingredients in the Sanofi Pasteur vaccine was to raise antibody to multiple “adhesion” proteins. That way if “escape mutants” occurred, as we are now observing for PRN-deficient strains, the vaccines would still work. The study from Vermont tells us that they still do work.
Michael E. Pichichero, M.D., a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero commented in an interview. He said he had no relevant financial disclosures.
Current pertussis vaccines were as effective against the rapidly evolving pertactin-deficient strains of the organism as they have been against other strains, according to a report published online April 13 in Pediatrics.
The proportion of pertussis strains lacking pertactin increased markedly in the United States, from 14% in 2010 to 85% in 2012. Pertactin, an autotransporter thought to be “involved in bacterial adhesion to the respiratory tract and resistance to neutrophil-induced bacterial clearance,” is a component of acellular pertussis vaccines. Some have speculated that pertactin deficiency evolved to give the bacteria an advantage in response to vaccine-related selection pressure, and that this evolution has contributed to the recent resurgence of pertussis disease, said Lucy Breakwell, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, Atlanta, and her associates.
To assess vaccine efficacy in the setting of pertactin deficiency, the investigators studied 820 cases and 2,369 matched control subjects treated in Vermont during a 3-year period encompassing a recent pertussis outbreak there. The study included children aged 4-10 years given the five-dose DTaP childhood series and adolescents aged 11-19 years given the adolescent Tdap dose. Specimens from these cases had been cultured routinely by the state department of health laboratory, and more than 90% of the available isolates were found to be pertactin deficient.
The overall vaccine efficacy of the DTap series was 84%, and of the Tdap booster, 70%. “Remarkably,” these rates are comparable to the 89% efficacy of DTap reported in a 2010 California outbreak and the 64% efficacy of Tdap reported in a 2012 Washington state outbreak, the investigators said. “Our findings suggest that both acellular pertussis vaccines remain protective against pertussis disease in the setting of high pertactin deficiency,” and therefore remain the best method for protecting against severe disease, Dr. Breakwell and her associates said (Pediatr. 2016 April 12. doi: 10.1542/peds.2015-3973).
Nevertheless, further study is warranted “to better understand the implications of pertactin deficiency on pertussis pathogenesis and host immunologic response, which could provide insight into the development of novel pertussis vaccines,” they wrote.
This study was supported by the Centers for Disease Control and Prevention. Dr. Breakwell and her associates reported having no relevant financial disclosures.
Current pertussis vaccines were as effective against the rapidly evolving pertactin-deficient strains of the organism as they have been against other strains, according to a report published online April 13 in Pediatrics.
The proportion of pertussis strains lacking pertactin increased markedly in the United States, from 14% in 2010 to 85% in 2012. Pertactin, an autotransporter thought to be “involved in bacterial adhesion to the respiratory tract and resistance to neutrophil-induced bacterial clearance,” is a component of acellular pertussis vaccines. Some have speculated that pertactin deficiency evolved to give the bacteria an advantage in response to vaccine-related selection pressure, and that this evolution has contributed to the recent resurgence of pertussis disease, said Lucy Breakwell, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, Atlanta, and her associates.
To assess vaccine efficacy in the setting of pertactin deficiency, the investigators studied 820 cases and 2,369 matched control subjects treated in Vermont during a 3-year period encompassing a recent pertussis outbreak there. The study included children aged 4-10 years given the five-dose DTaP childhood series and adolescents aged 11-19 years given the adolescent Tdap dose. Specimens from these cases had been cultured routinely by the state department of health laboratory, and more than 90% of the available isolates were found to be pertactin deficient.
The overall vaccine efficacy of the DTap series was 84%, and of the Tdap booster, 70%. “Remarkably,” these rates are comparable to the 89% efficacy of DTap reported in a 2010 California outbreak and the 64% efficacy of Tdap reported in a 2012 Washington state outbreak, the investigators said. “Our findings suggest that both acellular pertussis vaccines remain protective against pertussis disease in the setting of high pertactin deficiency,” and therefore remain the best method for protecting against severe disease, Dr. Breakwell and her associates said (Pediatr. 2016 April 12. doi: 10.1542/peds.2015-3973).
Nevertheless, further study is warranted “to better understand the implications of pertactin deficiency on pertussis pathogenesis and host immunologic response, which could provide insight into the development of novel pertussis vaccines,” they wrote.
This study was supported by the Centers for Disease Control and Prevention. Dr. Breakwell and her associates reported having no relevant financial disclosures.
FROM PEDIATRICS
Key clinical point: Current pertussis vaccines remain effective against rapidly evolving pertactin-deficient strains of the organism.
Major finding: The overall vaccine efficacy of the DTap series was 84%, and of the Tdap booster, 70%.
Data source: A case-control study assessing vaccine efficacy in 820 patients and 2,369 controls involved in the recent Vermont outbreak of pertussis.
Disclosures: This study was supported by the Centers for Disease Control and Prevention. Dr. Breakwell and her associates reported having no relevant financial disclosures.
Students’ hours of physical education fall short of national recommendations
Few states follow the national recommendations for weekly time in physical education at the elementary and middle school levels, and no state follows the recommended rate of physical education participation at the high school level, according to the 2016 update to the Shape of the Nation report.
The report, which is sponsored by Voices for Healthy Kids – a joint initiative of the American Heart Association and Robert Wood Johnson Foundation, and SHAPE, the Society of Health and Physical Educators – was formulated from responses of physical education coordinators in the 50 state education agencies and the District of Columbia to a questionnaire on kindergarten through 12th grade physical education and physical activity requirements. The education coordinators were queried during the winter of 2015-2016.
At the elementary school level, five states – Alabama, Florida, Louisiana, New Jersey, and Oregon – and the District of Columbia require students to participate in physical education for 150 minutes per week, the nationally recommended rate. For middle schoolers, the nationally recommended rate of participation in physical education is 225 minutes per week, which is followed in even fewer parts of the country; Montana, Oregon, and the District of Columbia are its sole adopters. California and Hawaii are the only two states who come close to satisfying the national recommendation of providing high school students with 225 minutes per week of physical education. In California, students in grades 7-12 receive 400 minutes of physical education per 10 school days and, in Hawaii, ninth graders receive 200 minutes of physical education per week.
While most states do not require their schools to follow the nationally recommended hours of weekly physical education for schools, the majority of states require students to participate in some amount of physical education during elementary school, middle school, and high school. State physical education requirements are undermined, though, by the majority of states offering ways for students to get out of participating in a physical education course, the report said. Specifically, more than 31 states allow students to substitute participating – in activities such as Junior Reserve Officer Training Corps, interscholastic sports, marching band, and cheerleading – with earning their required physical education credit. In addition, 15 states allow schools or school districts to apply for a waiver from the state physical education requirements, with “medical purposes” having been the most common reason for granting such an exemption.
“There is a large disparity in state requirements and implementation, affecting children’s ability to engage in and benefit from these [physical education] programs,” the report said. “Physical education improves student wellness and academic outcomes, develops life skills that shape the whole person, encourages smart choices, and cultivates a healthful lifestyle.”
The full report is available for download at www.shapeamerica.org/shapeofthenation.
Few states follow the national recommendations for weekly time in physical education at the elementary and middle school levels, and no state follows the recommended rate of physical education participation at the high school level, according to the 2016 update to the Shape of the Nation report.
The report, which is sponsored by Voices for Healthy Kids – a joint initiative of the American Heart Association and Robert Wood Johnson Foundation, and SHAPE, the Society of Health and Physical Educators – was formulated from responses of physical education coordinators in the 50 state education agencies and the District of Columbia to a questionnaire on kindergarten through 12th grade physical education and physical activity requirements. The education coordinators were queried during the winter of 2015-2016.
At the elementary school level, five states – Alabama, Florida, Louisiana, New Jersey, and Oregon – and the District of Columbia require students to participate in physical education for 150 minutes per week, the nationally recommended rate. For middle schoolers, the nationally recommended rate of participation in physical education is 225 minutes per week, which is followed in even fewer parts of the country; Montana, Oregon, and the District of Columbia are its sole adopters. California and Hawaii are the only two states who come close to satisfying the national recommendation of providing high school students with 225 minutes per week of physical education. In California, students in grades 7-12 receive 400 minutes of physical education per 10 school days and, in Hawaii, ninth graders receive 200 minutes of physical education per week.
While most states do not require their schools to follow the nationally recommended hours of weekly physical education for schools, the majority of states require students to participate in some amount of physical education during elementary school, middle school, and high school. State physical education requirements are undermined, though, by the majority of states offering ways for students to get out of participating in a physical education course, the report said. Specifically, more than 31 states allow students to substitute participating – in activities such as Junior Reserve Officer Training Corps, interscholastic sports, marching band, and cheerleading – with earning their required physical education credit. In addition, 15 states allow schools or school districts to apply for a waiver from the state physical education requirements, with “medical purposes” having been the most common reason for granting such an exemption.
“There is a large disparity in state requirements and implementation, affecting children’s ability to engage in and benefit from these [physical education] programs,” the report said. “Physical education improves student wellness and academic outcomes, develops life skills that shape the whole person, encourages smart choices, and cultivates a healthful lifestyle.”
The full report is available for download at www.shapeamerica.org/shapeofthenation.
Few states follow the national recommendations for weekly time in physical education at the elementary and middle school levels, and no state follows the recommended rate of physical education participation at the high school level, according to the 2016 update to the Shape of the Nation report.
The report, which is sponsored by Voices for Healthy Kids – a joint initiative of the American Heart Association and Robert Wood Johnson Foundation, and SHAPE, the Society of Health and Physical Educators – was formulated from responses of physical education coordinators in the 50 state education agencies and the District of Columbia to a questionnaire on kindergarten through 12th grade physical education and physical activity requirements. The education coordinators were queried during the winter of 2015-2016.
At the elementary school level, five states – Alabama, Florida, Louisiana, New Jersey, and Oregon – and the District of Columbia require students to participate in physical education for 150 minutes per week, the nationally recommended rate. For middle schoolers, the nationally recommended rate of participation in physical education is 225 minutes per week, which is followed in even fewer parts of the country; Montana, Oregon, and the District of Columbia are its sole adopters. California and Hawaii are the only two states who come close to satisfying the national recommendation of providing high school students with 225 minutes per week of physical education. In California, students in grades 7-12 receive 400 minutes of physical education per 10 school days and, in Hawaii, ninth graders receive 200 minutes of physical education per week.
While most states do not require their schools to follow the nationally recommended hours of weekly physical education for schools, the majority of states require students to participate in some amount of physical education during elementary school, middle school, and high school. State physical education requirements are undermined, though, by the majority of states offering ways for students to get out of participating in a physical education course, the report said. Specifically, more than 31 states allow students to substitute participating – in activities such as Junior Reserve Officer Training Corps, interscholastic sports, marching band, and cheerleading – with earning their required physical education credit. In addition, 15 states allow schools or school districts to apply for a waiver from the state physical education requirements, with “medical purposes” having been the most common reason for granting such an exemption.
“There is a large disparity in state requirements and implementation, affecting children’s ability to engage in and benefit from these [physical education] programs,” the report said. “Physical education improves student wellness and academic outcomes, develops life skills that shape the whole person, encourages smart choices, and cultivates a healthful lifestyle.”
The full report is available for download at www.shapeamerica.org/shapeofthenation.
Sickle cell anemia: Stroke screening still underused
Children and adolescents with sickle cell anemia still are not being screened for stroke risk using transcranial Doppler, despite clinical guidelines that strongly recommend annual screening and despite these patients’ frequent health care encounters, according to a report published online April 11 in JAMA Pediatrics.
Approximately 10% of children and adolescents with sickle cell anemia experience stroke before the age of 20 years, unless those at high risk are identified and treated preemptively with blood transfusions, which reduces stroke risk by 92%. The National Heart, Lung, and Blood Institute clinical practice guideline on treating sickle cell disease calls for patients aged 2-16 years to undergo transcranial Doppler every year to detect any elevated velocity of cerebral blood flow, which indicates high stroke risk, said Sarah L. Reeves, Ph.D., of the Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, and her associates.
To assess screening rates, the investigators performed a retrospective cross-sectional analysis of administrative claims data for 4,775 affected children and adolescents treated during a 5-year period in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. This yielded 10,787 person-years of data.
Overall, screening rates increased somewhat across all six states during the study period – from 22% to 44% – but “even the highest rates we report are suboptimal,” Dr. Reeves and her associates noted (JAMA Ped. 2016 Apr 11. doi: 10.1001/jamapediatrics.2015.4859).
This is especially true given that the average patient had 20.0 disease-related outpatient visits, 2.1 disease-related hospitalizations, 3.7 emergency department visits, and 1 well-child visit each year – numerous missed opportunities when they could have been referred for screening.
One way to improve screening rates would be to integrate transcranial Doppler exams into comprehensive sickle-cell healthcare, rather than requiring separate scheduled appointments at imaging facilities, they added.
This study was funded by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. Dr. Reeves and her associates reported having no relevant financial disclosures.
Children and adolescents with sickle cell anemia still are not being screened for stroke risk using transcranial Doppler, despite clinical guidelines that strongly recommend annual screening and despite these patients’ frequent health care encounters, according to a report published online April 11 in JAMA Pediatrics.
Approximately 10% of children and adolescents with sickle cell anemia experience stroke before the age of 20 years, unless those at high risk are identified and treated preemptively with blood transfusions, which reduces stroke risk by 92%. The National Heart, Lung, and Blood Institute clinical practice guideline on treating sickle cell disease calls for patients aged 2-16 years to undergo transcranial Doppler every year to detect any elevated velocity of cerebral blood flow, which indicates high stroke risk, said Sarah L. Reeves, Ph.D., of the Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, and her associates.
To assess screening rates, the investigators performed a retrospective cross-sectional analysis of administrative claims data for 4,775 affected children and adolescents treated during a 5-year period in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. This yielded 10,787 person-years of data.
Overall, screening rates increased somewhat across all six states during the study period – from 22% to 44% – but “even the highest rates we report are suboptimal,” Dr. Reeves and her associates noted (JAMA Ped. 2016 Apr 11. doi: 10.1001/jamapediatrics.2015.4859).
This is especially true given that the average patient had 20.0 disease-related outpatient visits, 2.1 disease-related hospitalizations, 3.7 emergency department visits, and 1 well-child visit each year – numerous missed opportunities when they could have been referred for screening.
One way to improve screening rates would be to integrate transcranial Doppler exams into comprehensive sickle-cell healthcare, rather than requiring separate scheduled appointments at imaging facilities, they added.
This study was funded by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. Dr. Reeves and her associates reported having no relevant financial disclosures.
Children and adolescents with sickle cell anemia still are not being screened for stroke risk using transcranial Doppler, despite clinical guidelines that strongly recommend annual screening and despite these patients’ frequent health care encounters, according to a report published online April 11 in JAMA Pediatrics.
Approximately 10% of children and adolescents with sickle cell anemia experience stroke before the age of 20 years, unless those at high risk are identified and treated preemptively with blood transfusions, which reduces stroke risk by 92%. The National Heart, Lung, and Blood Institute clinical practice guideline on treating sickle cell disease calls for patients aged 2-16 years to undergo transcranial Doppler every year to detect any elevated velocity of cerebral blood flow, which indicates high stroke risk, said Sarah L. Reeves, Ph.D., of the Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, and her associates.
To assess screening rates, the investigators performed a retrospective cross-sectional analysis of administrative claims data for 4,775 affected children and adolescents treated during a 5-year period in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. This yielded 10,787 person-years of data.
Overall, screening rates increased somewhat across all six states during the study period – from 22% to 44% – but “even the highest rates we report are suboptimal,” Dr. Reeves and her associates noted (JAMA Ped. 2016 Apr 11. doi: 10.1001/jamapediatrics.2015.4859).
This is especially true given that the average patient had 20.0 disease-related outpatient visits, 2.1 disease-related hospitalizations, 3.7 emergency department visits, and 1 well-child visit each year – numerous missed opportunities when they could have been referred for screening.
One way to improve screening rates would be to integrate transcranial Doppler exams into comprehensive sickle-cell healthcare, rather than requiring separate scheduled appointments at imaging facilities, they added.
This study was funded by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. Dr. Reeves and her associates reported having no relevant financial disclosures.
FROM JAMA PEDIATRICS
Key clinical point: Transcranial Doppler screening for stroke risk is still underused among children and adolescents with sickle cell anemia, despite clinical guidelines that strongly recommend annual screening.
Major finding: Screening rates increased somewhat across all six states studied, from 22% to 44%, but even the highest rates were suboptimal.
Data source: A retrospective cross-sectional analysis of administrative claims data for 4,775 pediatric patients treated in a 5-year period.
Disclosures: This study was funded by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. Dr. Reeves and her associates reported having no relevant financial disclosures.
Proactive Endocrine Screening Urged for Pediatric Brain Tumor Survivors
BOSTON – More than a third of 419 children treated for brain tumors at Cincinnati Children’s Hospital Medical Center later developed endocrine problems, according to a review presented at the Endocrine Society annual meeting.
Over 60% of the 96 suprasellar tumor patients developed endocrine dysfunction, which isn’t surprising considering the location of the tumor, but wide-ranging endocrine problems were also common in the 145 posterior fossa, 158 supratentorial, and 20 spinal cord cases, ranging from 14% in the spinal cord group to 42% in the posterior fossa group, after some combination of radiation, chemotherapy, and surgery based on tumor location and other factors.
“Even with tumors that aren’t supposed to be high risk, there was a high risk of endocrinopathies. We need yearly screening of these patients” for about 6 years, after which symptom-based screening may be sufficient. The clock should be restarted if there’s a recurrence. “Not everyone does this” at Cincinnati Children’s and probably most other institutions, said investigator and endocrinology fellow Dr. Vincent Horne.
The findings are “changing how our oncology department is thinking about [screening]; there’s a concentrated effort to increase proactive screening and follow these patients long term,” he said.
“Even within our specialized, multidisciplinary center,” endocrinopathy screening referrals were low, about 61% overall and only 80% in the suprasellar group. “Patients at highest risk” – those with craniopharyngioma – “are being seen early by us,” but others aren’t being referred. It’s possible that the extent of endocrine problems after pediatric brain tumor treatment is simply unrecognized, he said.
Endocrine abnormalities were found in 114 (45%) of the 254 patients evaluated, which translated to problems in more than a third of all patients.
More than half of the children had more than one problem, and most of the issues occurred within 6 years of treatment. Central hypothyroidism was found in 53% of the children, probably because Cincinnati Children’s already has thyroid screening in place.
About 40% were growth hormone deficient, and almost a third had precocious puberty. About 30% were gonadotropin-releasing hormone deficient, over 20% had primary hypothyroidism, and about the same had diabetes insipidus. Just over 6% were hyperprolactinemic.
Of the 151 patients who completed adrenocorticotropic hormone (ACTH) testing, 14.6% were deficient. ACTH deficient children were about evenly split between the suprasellar and supratentorial groups, with the remaining in the posterior fossa cohort.
“We are probably not thinking about” the risk of radiation “to locations like the posterior fossa. That group actually had the highest risk of primary hypothyroidism [20%] because of the spinal radiation. The supratentorial group is also receiving radiation; even though we think we are missing the hypothalamus, obviously that’s not necessarily the case,” Dr. Horne said.
His team looked into endocrine screening because previous studies “were limited and done years ago.” People are living longer now after treatment, “so we need to think about how to screen for endocrine disease. This is an attempt to clarify how we should do it,” he said.
Children were a median of 8 years old at diagnosis, and the median radiation dose was 54 Gy.
There was no industry funding for the work, and the investigators had no disclosures.
BOSTON – More than a third of 419 children treated for brain tumors at Cincinnati Children’s Hospital Medical Center later developed endocrine problems, according to a review presented at the Endocrine Society annual meeting.
Over 60% of the 96 suprasellar tumor patients developed endocrine dysfunction, which isn’t surprising considering the location of the tumor, but wide-ranging endocrine problems were also common in the 145 posterior fossa, 158 supratentorial, and 20 spinal cord cases, ranging from 14% in the spinal cord group to 42% in the posterior fossa group, after some combination of radiation, chemotherapy, and surgery based on tumor location and other factors.
“Even with tumors that aren’t supposed to be high risk, there was a high risk of endocrinopathies. We need yearly screening of these patients” for about 6 years, after which symptom-based screening may be sufficient. The clock should be restarted if there’s a recurrence. “Not everyone does this” at Cincinnati Children’s and probably most other institutions, said investigator and endocrinology fellow Dr. Vincent Horne.
The findings are “changing how our oncology department is thinking about [screening]; there’s a concentrated effort to increase proactive screening and follow these patients long term,” he said.
“Even within our specialized, multidisciplinary center,” endocrinopathy screening referrals were low, about 61% overall and only 80% in the suprasellar group. “Patients at highest risk” – those with craniopharyngioma – “are being seen early by us,” but others aren’t being referred. It’s possible that the extent of endocrine problems after pediatric brain tumor treatment is simply unrecognized, he said.
Endocrine abnormalities were found in 114 (45%) of the 254 patients evaluated, which translated to problems in more than a third of all patients.
More than half of the children had more than one problem, and most of the issues occurred within 6 years of treatment. Central hypothyroidism was found in 53% of the children, probably because Cincinnati Children’s already has thyroid screening in place.
About 40% were growth hormone deficient, and almost a third had precocious puberty. About 30% were gonadotropin-releasing hormone deficient, over 20% had primary hypothyroidism, and about the same had diabetes insipidus. Just over 6% were hyperprolactinemic.
Of the 151 patients who completed adrenocorticotropic hormone (ACTH) testing, 14.6% were deficient. ACTH deficient children were about evenly split between the suprasellar and supratentorial groups, with the remaining in the posterior fossa cohort.
“We are probably not thinking about” the risk of radiation “to locations like the posterior fossa. That group actually had the highest risk of primary hypothyroidism [20%] because of the spinal radiation. The supratentorial group is also receiving radiation; even though we think we are missing the hypothalamus, obviously that’s not necessarily the case,” Dr. Horne said.
His team looked into endocrine screening because previous studies “were limited and done years ago.” People are living longer now after treatment, “so we need to think about how to screen for endocrine disease. This is an attempt to clarify how we should do it,” he said.
Children were a median of 8 years old at diagnosis, and the median radiation dose was 54 Gy.
There was no industry funding for the work, and the investigators had no disclosures.
BOSTON – More than a third of 419 children treated for brain tumors at Cincinnati Children’s Hospital Medical Center later developed endocrine problems, according to a review presented at the Endocrine Society annual meeting.
Over 60% of the 96 suprasellar tumor patients developed endocrine dysfunction, which isn’t surprising considering the location of the tumor, but wide-ranging endocrine problems were also common in the 145 posterior fossa, 158 supratentorial, and 20 spinal cord cases, ranging from 14% in the spinal cord group to 42% in the posterior fossa group, after some combination of radiation, chemotherapy, and surgery based on tumor location and other factors.
“Even with tumors that aren’t supposed to be high risk, there was a high risk of endocrinopathies. We need yearly screening of these patients” for about 6 years, after which symptom-based screening may be sufficient. The clock should be restarted if there’s a recurrence. “Not everyone does this” at Cincinnati Children’s and probably most other institutions, said investigator and endocrinology fellow Dr. Vincent Horne.
The findings are “changing how our oncology department is thinking about [screening]; there’s a concentrated effort to increase proactive screening and follow these patients long term,” he said.
“Even within our specialized, multidisciplinary center,” endocrinopathy screening referrals were low, about 61% overall and only 80% in the suprasellar group. “Patients at highest risk” – those with craniopharyngioma – “are being seen early by us,” but others aren’t being referred. It’s possible that the extent of endocrine problems after pediatric brain tumor treatment is simply unrecognized, he said.
Endocrine abnormalities were found in 114 (45%) of the 254 patients evaluated, which translated to problems in more than a third of all patients.
More than half of the children had more than one problem, and most of the issues occurred within 6 years of treatment. Central hypothyroidism was found in 53% of the children, probably because Cincinnati Children’s already has thyroid screening in place.
About 40% were growth hormone deficient, and almost a third had precocious puberty. About 30% were gonadotropin-releasing hormone deficient, over 20% had primary hypothyroidism, and about the same had diabetes insipidus. Just over 6% were hyperprolactinemic.
Of the 151 patients who completed adrenocorticotropic hormone (ACTH) testing, 14.6% were deficient. ACTH deficient children were about evenly split between the suprasellar and supratentorial groups, with the remaining in the posterior fossa cohort.
“We are probably not thinking about” the risk of radiation “to locations like the posterior fossa. That group actually had the highest risk of primary hypothyroidism [20%] because of the spinal radiation. The supratentorial group is also receiving radiation; even though we think we are missing the hypothalamus, obviously that’s not necessarily the case,” Dr. Horne said.
His team looked into endocrine screening because previous studies “were limited and done years ago.” People are living longer now after treatment, “so we need to think about how to screen for endocrine disease. This is an attempt to clarify how we should do it,” he said.
Children were a median of 8 years old at diagnosis, and the median radiation dose was 54 Gy.
There was no industry funding for the work, and the investigators had no disclosures.
AT ENDO 2016
Proactive endocrine screening urged for pediatric brain tumor survivors
BOSTON – More than a third of 419 children treated for brain tumors at Cincinnati Children’s Hospital Medical Center later developed endocrine problems, according to a review presented at the Endocrine Society annual meeting.
Over 60% of the 96 suprasellar tumor patients developed endocrine dysfunction, which isn’t surprising considering the location of the tumor, but wide-ranging endocrine problems were also common in the 145 posterior fossa, 158 supratentorial, and 20 spinal cord cases, ranging from 14% in the spinal cord group to 42% in the posterior fossa group, after some combination of radiation, chemotherapy, and surgery based on tumor location and other factors.
“Even with tumors that aren’t supposed to be high risk, there was a high risk of endocrinopathies. We need yearly screening of these patients” for about 6 years, after which symptom-based screening may be sufficient. The clock should be restarted if there’s a recurrence. “Not everyone does this” at Cincinnati Children’s and probably most other institutions, said investigator and endocrinology fellow Dr. Vincent Horne.
The findings are “changing how our oncology department is thinking about [screening]; there’s a concentrated effort to increase proactive screening and follow these patients long term,” he said.
“Even within our specialized, multidisciplinary center,” endocrinopathy screening referrals were low, about 61% overall and only 80% in the suprasellar group. “Patients at highest risk” – those with craniopharyngioma – “are being seen early by us,” but others aren’t being referred. It’s possible that the extent of endocrine problems after pediatric brain tumor treatment is simply unrecognized, he said.
Endocrine abnormalities were found in 114 (45%) of the 254 patients evaluated, which translated to problems in more than a third of all patients.
More than half of the children had more than one problem, and most of the issues occurred within 6 years of treatment. Central hypothyroidism was found in 53% of the children, probably because Cincinnati Children’s already has thyroid screening in place.
About 40% were growth hormone deficient, and almost a third had precocious puberty. About 30% were gonadotropin-releasing hormone deficient, over 20% had primary hypothyroidism, and about the same had diabetes insipidus. Just over 6% were hyperprolactinemic.
Of the 151 patients who completed adrenocorticotropic hormone (ACTH) testing, 14.6% were deficient. ACTH deficient children were about evenly split between the suprasellar and supratentorial groups, with the remaining in the posterior fossa cohort.
“We are probably not thinking about” the risk of radiation “to locations like the posterior fossa. That group actually had the highest risk of primary hypothyroidism [20%] because of the spinal radiation. The supratentorial group is also receiving radiation; even though we think we are missing the hypothalamus, obviously that’s not necessarily the case,” Dr. Horne said.
His team looked into endocrine screening because previous studies “were limited and done years ago.” People are living longer now after treatment, “so we need to think about how to screen for endocrine disease. This is an attempt to clarify how we should do it,” he said.
Children were a median of 8 years old at diagnosis, and the median radiation dose was 54 Gy.
There was no industry funding for the work, and the investigators had no disclosures.
BOSTON – More than a third of 419 children treated for brain tumors at Cincinnati Children’s Hospital Medical Center later developed endocrine problems, according to a review presented at the Endocrine Society annual meeting.
Over 60% of the 96 suprasellar tumor patients developed endocrine dysfunction, which isn’t surprising considering the location of the tumor, but wide-ranging endocrine problems were also common in the 145 posterior fossa, 158 supratentorial, and 20 spinal cord cases, ranging from 14% in the spinal cord group to 42% in the posterior fossa group, after some combination of radiation, chemotherapy, and surgery based on tumor location and other factors.
“Even with tumors that aren’t supposed to be high risk, there was a high risk of endocrinopathies. We need yearly screening of these patients” for about 6 years, after which symptom-based screening may be sufficient. The clock should be restarted if there’s a recurrence. “Not everyone does this” at Cincinnati Children’s and probably most other institutions, said investigator and endocrinology fellow Dr. Vincent Horne.
The findings are “changing how our oncology department is thinking about [screening]; there’s a concentrated effort to increase proactive screening and follow these patients long term,” he said.
“Even within our specialized, multidisciplinary center,” endocrinopathy screening referrals were low, about 61% overall and only 80% in the suprasellar group. “Patients at highest risk” – those with craniopharyngioma – “are being seen early by us,” but others aren’t being referred. It’s possible that the extent of endocrine problems after pediatric brain tumor treatment is simply unrecognized, he said.
Endocrine abnormalities were found in 114 (45%) of the 254 patients evaluated, which translated to problems in more than a third of all patients.
More than half of the children had more than one problem, and most of the issues occurred within 6 years of treatment. Central hypothyroidism was found in 53% of the children, probably because Cincinnati Children’s already has thyroid screening in place.
About 40% were growth hormone deficient, and almost a third had precocious puberty. About 30% were gonadotropin-releasing hormone deficient, over 20% had primary hypothyroidism, and about the same had diabetes insipidus. Just over 6% were hyperprolactinemic.
Of the 151 patients who completed adrenocorticotropic hormone (ACTH) testing, 14.6% were deficient. ACTH deficient children were about evenly split between the suprasellar and supratentorial groups, with the remaining in the posterior fossa cohort.
“We are probably not thinking about” the risk of radiation “to locations like the posterior fossa. That group actually had the highest risk of primary hypothyroidism [20%] because of the spinal radiation. The supratentorial group is also receiving radiation; even though we think we are missing the hypothalamus, obviously that’s not necessarily the case,” Dr. Horne said.
His team looked into endocrine screening because previous studies “were limited and done years ago.” People are living longer now after treatment, “so we need to think about how to screen for endocrine disease. This is an attempt to clarify how we should do it,” he said.
Children were a median of 8 years old at diagnosis, and the median radiation dose was 54 Gy.
There was no industry funding for the work, and the investigators had no disclosures.
BOSTON – More than a third of 419 children treated for brain tumors at Cincinnati Children’s Hospital Medical Center later developed endocrine problems, according to a review presented at the Endocrine Society annual meeting.
Over 60% of the 96 suprasellar tumor patients developed endocrine dysfunction, which isn’t surprising considering the location of the tumor, but wide-ranging endocrine problems were also common in the 145 posterior fossa, 158 supratentorial, and 20 spinal cord cases, ranging from 14% in the spinal cord group to 42% in the posterior fossa group, after some combination of radiation, chemotherapy, and surgery based on tumor location and other factors.
“Even with tumors that aren’t supposed to be high risk, there was a high risk of endocrinopathies. We need yearly screening of these patients” for about 6 years, after which symptom-based screening may be sufficient. The clock should be restarted if there’s a recurrence. “Not everyone does this” at Cincinnati Children’s and probably most other institutions, said investigator and endocrinology fellow Dr. Vincent Horne.
The findings are “changing how our oncology department is thinking about [screening]; there’s a concentrated effort to increase proactive screening and follow these patients long term,” he said.
“Even within our specialized, multidisciplinary center,” endocrinopathy screening referrals were low, about 61% overall and only 80% in the suprasellar group. “Patients at highest risk” – those with craniopharyngioma – “are being seen early by us,” but others aren’t being referred. It’s possible that the extent of endocrine problems after pediatric brain tumor treatment is simply unrecognized, he said.
Endocrine abnormalities were found in 114 (45%) of the 254 patients evaluated, which translated to problems in more than a third of all patients.
More than half of the children had more than one problem, and most of the issues occurred within 6 years of treatment. Central hypothyroidism was found in 53% of the children, probably because Cincinnati Children’s already has thyroid screening in place.
About 40% were growth hormone deficient, and almost a third had precocious puberty. About 30% were gonadotropin-releasing hormone deficient, over 20% had primary hypothyroidism, and about the same had diabetes insipidus. Just over 6% were hyperprolactinemic.
Of the 151 patients who completed adrenocorticotropic hormone (ACTH) testing, 14.6% were deficient. ACTH deficient children were about evenly split between the suprasellar and supratentorial groups, with the remaining in the posterior fossa cohort.
“We are probably not thinking about” the risk of radiation “to locations like the posterior fossa. That group actually had the highest risk of primary hypothyroidism [20%] because of the spinal radiation. The supratentorial group is also receiving radiation; even though we think we are missing the hypothalamus, obviously that’s not necessarily the case,” Dr. Horne said.
His team looked into endocrine screening because previous studies “were limited and done years ago.” People are living longer now after treatment, “so we need to think about how to screen for endocrine disease. This is an attempt to clarify how we should do it,” he said.
Children were a median of 8 years old at diagnosis, and the median radiation dose was 54 Gy.
There was no industry funding for the work, and the investigators had no disclosures.
AT ENDO 2016
Key clinical point: Screen for endocrine dysfunction for 6 years after pediatric brain tumor treatment.
Major finding: Endocrine abnormalities were found in 114 of 254 patients (45%) evaluated, which translated to problems in more than a third of all patients.
Data source: Single-center review of 419 pediatric brain tumor cases.
Disclosures: There was no industry funding for the work, and the investigators had no disclosures.
Immunization need not be delayed in most preterm infants with BPD
Despite concerns that preterm infants with bronchopulmonary dysplasia (BPD) are more likely to experience respiratory decompensation after immunization than those without BPD, no difference in the incidence of respiratory decompensation within 72 hours after immunization was found between these groups in a cohort study at a tertiary care facility, according to a report published April 11 in Pediatrics.
These results demonstrate the safety of immunizing preterm infants with BPD, and that the findings should negate delays in immunizations in these patients based on safety concerns described in previous studies, Dr. Edwin Clark Montague of Emory University, Atlanta, and his colleagues assert.
In a retrospective observational study, Dr. Clark and his associates assessed a cohort of infants admitted to the NICU at a level 4, nonbirthing referral hospital, Children’s Healthcare of Atlanta at Egleston, who received any immunizations while hospitalized between Jan. 1, 2008, and Aug. 1, 2014. Inclusion criteria were birth at less than 32 weeks’ estimated gestational age and the availability of data for 72 hours before and 72 hours after immunization. The incidence of respiratory decompensation and cardiorespiratory events (apnea, bradycardia, desaturations) after immunization was compared between infants with and without BPD after immunization (Pediatrics. 2016 doi: 10.1542/peds.2015-4225).
Of the 403 patients assessed, 240 met the inclusion criteria. Of these, 170 were identified as having BPD and were compared with the 70 patients without BPD. The study results revealed no statistically significant difference in respiratory decompensation between patients with and without BPD. In addition, both groups showed an increased incidence of cardiorespiratory events, but there was no statistically significant difference between those with and without BPD.
In addition to BPD, the authors assessed risk factors that may predispose preterm infants to respiratory decompensation after immunization, such as a history of necrotizing enterocolitis or spontaneous intestinal perforation, grade III or IV intraventricular hemorrhage, or periventricular leukomalacia. Results from these analyses indicated that severe intraventricular hemorrhage was a predictor of respiratory decompensation after immunization, and that a positive blood culture within 72 hours of immunization was predictive as well. The authors said that decompensation was likely secondary to the underlying infection in those with positive blood cultures, but that additional research would be required to better understand this finding.
The authors reported no external funding sources and no financial relationships relevant to this article.
Despite concerns that preterm infants with bronchopulmonary dysplasia (BPD) are more likely to experience respiratory decompensation after immunization than those without BPD, no difference in the incidence of respiratory decompensation within 72 hours after immunization was found between these groups in a cohort study at a tertiary care facility, according to a report published April 11 in Pediatrics.
These results demonstrate the safety of immunizing preterm infants with BPD, and that the findings should negate delays in immunizations in these patients based on safety concerns described in previous studies, Dr. Edwin Clark Montague of Emory University, Atlanta, and his colleagues assert.
In a retrospective observational study, Dr. Clark and his associates assessed a cohort of infants admitted to the NICU at a level 4, nonbirthing referral hospital, Children’s Healthcare of Atlanta at Egleston, who received any immunizations while hospitalized between Jan. 1, 2008, and Aug. 1, 2014. Inclusion criteria were birth at less than 32 weeks’ estimated gestational age and the availability of data for 72 hours before and 72 hours after immunization. The incidence of respiratory decompensation and cardiorespiratory events (apnea, bradycardia, desaturations) after immunization was compared between infants with and without BPD after immunization (Pediatrics. 2016 doi: 10.1542/peds.2015-4225).
Of the 403 patients assessed, 240 met the inclusion criteria. Of these, 170 were identified as having BPD and were compared with the 70 patients without BPD. The study results revealed no statistically significant difference in respiratory decompensation between patients with and without BPD. In addition, both groups showed an increased incidence of cardiorespiratory events, but there was no statistically significant difference between those with and without BPD.
In addition to BPD, the authors assessed risk factors that may predispose preterm infants to respiratory decompensation after immunization, such as a history of necrotizing enterocolitis or spontaneous intestinal perforation, grade III or IV intraventricular hemorrhage, or periventricular leukomalacia. Results from these analyses indicated that severe intraventricular hemorrhage was a predictor of respiratory decompensation after immunization, and that a positive blood culture within 72 hours of immunization was predictive as well. The authors said that decompensation was likely secondary to the underlying infection in those with positive blood cultures, but that additional research would be required to better understand this finding.
The authors reported no external funding sources and no financial relationships relevant to this article.
Despite concerns that preterm infants with bronchopulmonary dysplasia (BPD) are more likely to experience respiratory decompensation after immunization than those without BPD, no difference in the incidence of respiratory decompensation within 72 hours after immunization was found between these groups in a cohort study at a tertiary care facility, according to a report published April 11 in Pediatrics.
These results demonstrate the safety of immunizing preterm infants with BPD, and that the findings should negate delays in immunizations in these patients based on safety concerns described in previous studies, Dr. Edwin Clark Montague of Emory University, Atlanta, and his colleagues assert.
In a retrospective observational study, Dr. Clark and his associates assessed a cohort of infants admitted to the NICU at a level 4, nonbirthing referral hospital, Children’s Healthcare of Atlanta at Egleston, who received any immunizations while hospitalized between Jan. 1, 2008, and Aug. 1, 2014. Inclusion criteria were birth at less than 32 weeks’ estimated gestational age and the availability of data for 72 hours before and 72 hours after immunization. The incidence of respiratory decompensation and cardiorespiratory events (apnea, bradycardia, desaturations) after immunization was compared between infants with and without BPD after immunization (Pediatrics. 2016 doi: 10.1542/peds.2015-4225).
Of the 403 patients assessed, 240 met the inclusion criteria. Of these, 170 were identified as having BPD and were compared with the 70 patients without BPD. The study results revealed no statistically significant difference in respiratory decompensation between patients with and without BPD. In addition, both groups showed an increased incidence of cardiorespiratory events, but there was no statistically significant difference between those with and without BPD.
In addition to BPD, the authors assessed risk factors that may predispose preterm infants to respiratory decompensation after immunization, such as a history of necrotizing enterocolitis or spontaneous intestinal perforation, grade III or IV intraventricular hemorrhage, or periventricular leukomalacia. Results from these analyses indicated that severe intraventricular hemorrhage was a predictor of respiratory decompensation after immunization, and that a positive blood culture within 72 hours of immunization was predictive as well. The authors said that decompensation was likely secondary to the underlying infection in those with positive blood cultures, but that additional research would be required to better understand this finding.
The authors reported no external funding sources and no financial relationships relevant to this article.
FROM PEDIATRICS
Key clinical point: Respiratory decompensation after immunization of preterm infants with bronchopulmonary dysplasia is rare and should not be a cause for delayed immunization.
Major finding: No statistically significant differences regarding respiratory decompensation within 72 hours of immunization or its individual components were found between preterm infants with or without bronchopulmonary dysplasia.
Data source: A retrospective observational study of a cohort of premature infants less than 32 weeks’ gestational age admitted to a tertiary level 4 NICU, Children’s Healthcare of Atlanta at Egleston, immunized as inpatients between January 1, 2008, and August 1, 2014.
Disclosures: The authors reported no external funding sources and no financial relationships relevant to this article.
Stick with wheat flour for baked egg and milk challenges
LOS ANGELES – Children who pass oral food challenges to baked egg and milk with wheat flour are at risk for reacting to baked goods made with nonwheat flours, according to a review of more than 200 pediatric food challenges at National Jewish Health in Denver.
The children were already known to be sensitive to egg and milk, and some were being challenged to see if exposure therapy was helping. Unbeknown to the pediatric food allergy team, a kitchen worker at National Jewish had started making muffins with rice flour, thinking it would be safer.
During the month of muffins with rice flour, the failure rate for baked egg challenge muffins rose from 28% (33/120) to 58% (11/19) with rice flour. Failure to baked milk muffins rose from 14% (9/66) to 36% (5/14) (J Allergy Clin Immunol. 2016 Feb. doi: 10.1016/j.jaci.2015.12.579).
Adjusting for age, gender, and atopic dermatitis, children were more than five times more likely to fail baked eggs without wheat (odds ratio, 5.4; P = .002), and more than four times more likely to fail baked milk (OR, 4.06; P = .05).
Given that the phenomenon hasn’t been reported before, “This was very surprising to us,” said study investigator Dr. Bruce Lanser, director of the pediatric food allergy program at National Jewish. “You have to warn parents that if children pass a baked challenge with wheat, they have to continue to eat their baked milk and egg with wheat. Gluten-free products are not going to have the same effect.
“If somebody is avoiding wheat because it causes a bit of redness and itchiness, you have to clear that wheat allergy” before moving to baked egg and milk, Dr. Lanser added.
There’s also concern that “kids will go home after passing a wheat muffin challenge, eat something that’s gluten-free, and have a reaction,” he noted. Wheat-free baked goods might also not build tolerance as well, although that’s not clear from the study, Dr. Lanser said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Wheat seems to have something unique that alters the allergic properties of egg and milk proteins to help children outgrow their sensitivities. “Rice doesn’t have the same effect,” he observed, and it’s not known if any other grains do. Dr. Lanser said he is interested in looking into rye, barley, oats, and other alternatives.
The mean age of the children in the study was 6 years, and most children had multiple food allergies. Sensitization was confirmed by skin tests and specific IgE.
Meanwhile, there’s a new rule in the National Jewish kitchen: Unless a child has true celiac disease, “always make [challenge] muffins with wheat,” Dr. Lanser said.
There was no industry funding for the work, and the investigators had no disclosures.
LOS ANGELES – Children who pass oral food challenges to baked egg and milk with wheat flour are at risk for reacting to baked goods made with nonwheat flours, according to a review of more than 200 pediatric food challenges at National Jewish Health in Denver.
The children were already known to be sensitive to egg and milk, and some were being challenged to see if exposure therapy was helping. Unbeknown to the pediatric food allergy team, a kitchen worker at National Jewish had started making muffins with rice flour, thinking it would be safer.
During the month of muffins with rice flour, the failure rate for baked egg challenge muffins rose from 28% (33/120) to 58% (11/19) with rice flour. Failure to baked milk muffins rose from 14% (9/66) to 36% (5/14) (J Allergy Clin Immunol. 2016 Feb. doi: 10.1016/j.jaci.2015.12.579).
Adjusting for age, gender, and atopic dermatitis, children were more than five times more likely to fail baked eggs without wheat (odds ratio, 5.4; P = .002), and more than four times more likely to fail baked milk (OR, 4.06; P = .05).
Given that the phenomenon hasn’t been reported before, “This was very surprising to us,” said study investigator Dr. Bruce Lanser, director of the pediatric food allergy program at National Jewish. “You have to warn parents that if children pass a baked challenge with wheat, they have to continue to eat their baked milk and egg with wheat. Gluten-free products are not going to have the same effect.
“If somebody is avoiding wheat because it causes a bit of redness and itchiness, you have to clear that wheat allergy” before moving to baked egg and milk, Dr. Lanser added.
There’s also concern that “kids will go home after passing a wheat muffin challenge, eat something that’s gluten-free, and have a reaction,” he noted. Wheat-free baked goods might also not build tolerance as well, although that’s not clear from the study, Dr. Lanser said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Wheat seems to have something unique that alters the allergic properties of egg and milk proteins to help children outgrow their sensitivities. “Rice doesn’t have the same effect,” he observed, and it’s not known if any other grains do. Dr. Lanser said he is interested in looking into rye, barley, oats, and other alternatives.
The mean age of the children in the study was 6 years, and most children had multiple food allergies. Sensitization was confirmed by skin tests and specific IgE.
Meanwhile, there’s a new rule in the National Jewish kitchen: Unless a child has true celiac disease, “always make [challenge] muffins with wheat,” Dr. Lanser said.
There was no industry funding for the work, and the investigators had no disclosures.
LOS ANGELES – Children who pass oral food challenges to baked egg and milk with wheat flour are at risk for reacting to baked goods made with nonwheat flours, according to a review of more than 200 pediatric food challenges at National Jewish Health in Denver.
The children were already known to be sensitive to egg and milk, and some were being challenged to see if exposure therapy was helping. Unbeknown to the pediatric food allergy team, a kitchen worker at National Jewish had started making muffins with rice flour, thinking it would be safer.
During the month of muffins with rice flour, the failure rate for baked egg challenge muffins rose from 28% (33/120) to 58% (11/19) with rice flour. Failure to baked milk muffins rose from 14% (9/66) to 36% (5/14) (J Allergy Clin Immunol. 2016 Feb. doi: 10.1016/j.jaci.2015.12.579).
Adjusting for age, gender, and atopic dermatitis, children were more than five times more likely to fail baked eggs without wheat (odds ratio, 5.4; P = .002), and more than four times more likely to fail baked milk (OR, 4.06; P = .05).
Given that the phenomenon hasn’t been reported before, “This was very surprising to us,” said study investigator Dr. Bruce Lanser, director of the pediatric food allergy program at National Jewish. “You have to warn parents that if children pass a baked challenge with wheat, they have to continue to eat their baked milk and egg with wheat. Gluten-free products are not going to have the same effect.
“If somebody is avoiding wheat because it causes a bit of redness and itchiness, you have to clear that wheat allergy” before moving to baked egg and milk, Dr. Lanser added.
There’s also concern that “kids will go home after passing a wheat muffin challenge, eat something that’s gluten-free, and have a reaction,” he noted. Wheat-free baked goods might also not build tolerance as well, although that’s not clear from the study, Dr. Lanser said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Wheat seems to have something unique that alters the allergic properties of egg and milk proteins to help children outgrow their sensitivities. “Rice doesn’t have the same effect,” he observed, and it’s not known if any other grains do. Dr. Lanser said he is interested in looking into rye, barley, oats, and other alternatives.
The mean age of the children in the study was 6 years, and most children had multiple food allergies. Sensitization was confirmed by skin tests and specific IgE.
Meanwhile, there’s a new rule in the National Jewish kitchen: Unless a child has true celiac disease, “always make [challenge] muffins with wheat,” Dr. Lanser said.
There was no industry funding for the work, and the investigators had no disclosures.
AT 2016 AAAAI ANNUAL MEETING
Key clinical point: Children are more likely to react to nonwheat challenge muffins, and wheat substitutes might not work as well for oral immunotherapy.
Major finding: The failure rate for baked egg challenge muffins rose from 28% (33/120) to 58% (11/19) with rice flour. Failure to baked milk muffins rose from 14% (9/66) to 36% (5/14).
Data source: Single-center review of more than 200 pediatric food challenges.
Disclosures: There was no industry funding for the work, and the investigators had no disclosures.
Some Infants Predisposed to Epidermal Barrier Breakdown, Atopic Dermatitis
Neonates with the highest transepidermal water loss at birth, likely mediated through an impaired epidermal barrier, show significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived natural moisturizing factors, which may predispose them to the development of atopic dermatitis, according to a report published online in the British Journal of Dermatology.
John Chittock of the University of Sheffield, England, and his colleagues assessed the biophysical, biologic, and functional properties of the developing neonatal stratum corneum (SC) from birth to 4 weeks of age in 115 healthy, full-term (at least 37 weeks’ gestation) neonates from the OBSERVE (Oil in Baby Skincare) randomized study birth cohort recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014.
For comparative purposes, an unrelated cohort of 20 adults with healthy skin was recruited from the local community between January and April 2015 (Br J Dermatol. 2016 Mar 19. doi: 10.1111/bjd.14568).
The researchers found that the biophysical properties of the neonatal SC are transitional from birth. For example, overall transepidermal water loss (TEWL) increased significantly during the first 4 weeks of infant life. Compared with adult skin, the newborn infant SC was found to be drier and more alkaline. In addition, levels of superficial chymotrypsinlike protease activity at birth did not differ between newborns and adults, while levels of filaggrin-derived natural moisturizing factors (NMF) were significantly lower at birth than in adulthood.
The increased chymotrypsinlike protease activity and NMF at 4 weeks of age exceeded levels found in healthy adults, rather than reaching their mature state. Compared with adult skin, the skin of infants is functionally immature, with undeveloped mechanisms of desquamation and differentiation, the investigators noted.
Further analysis revealed a correlation between TEWL and both superficial chymotrypsinlike protease activity and filaggrin-derived NMF at birth.
To explore that link, the researchers stratified the neonatal cohort according to TEWL percentile. The neonates in the 76th-100th percentile, the highest TEWL at birth, showed significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived NMF, compared with neonates in lower percentiles. Therefore, those neonates are at highest risk for developing atopic dermatitis, the study authors said.
The findings indicate a need for infant skin care regimens that protect and support normal barrier development from birth, the researchers noted. They also suggested that clinical strategies targeting the early mechanisms of barrier breakdown could act as preventive measures in neonates at increased risk of developing atopic dermatitis.
The research was funded jointly by the University of Sheffield and a doctoral research fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.
Neonates with the highest transepidermal water loss at birth, likely mediated through an impaired epidermal barrier, show significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived natural moisturizing factors, which may predispose them to the development of atopic dermatitis, according to a report published online in the British Journal of Dermatology.
John Chittock of the University of Sheffield, England, and his colleagues assessed the biophysical, biologic, and functional properties of the developing neonatal stratum corneum (SC) from birth to 4 weeks of age in 115 healthy, full-term (at least 37 weeks’ gestation) neonates from the OBSERVE (Oil in Baby Skincare) randomized study birth cohort recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014.
For comparative purposes, an unrelated cohort of 20 adults with healthy skin was recruited from the local community between January and April 2015 (Br J Dermatol. 2016 Mar 19. doi: 10.1111/bjd.14568).
The researchers found that the biophysical properties of the neonatal SC are transitional from birth. For example, overall transepidermal water loss (TEWL) increased significantly during the first 4 weeks of infant life. Compared with adult skin, the newborn infant SC was found to be drier and more alkaline. In addition, levels of superficial chymotrypsinlike protease activity at birth did not differ between newborns and adults, while levels of filaggrin-derived natural moisturizing factors (NMF) were significantly lower at birth than in adulthood.
The increased chymotrypsinlike protease activity and NMF at 4 weeks of age exceeded levels found in healthy adults, rather than reaching their mature state. Compared with adult skin, the skin of infants is functionally immature, with undeveloped mechanisms of desquamation and differentiation, the investigators noted.
Further analysis revealed a correlation between TEWL and both superficial chymotrypsinlike protease activity and filaggrin-derived NMF at birth.
To explore that link, the researchers stratified the neonatal cohort according to TEWL percentile. The neonates in the 76th-100th percentile, the highest TEWL at birth, showed significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived NMF, compared with neonates in lower percentiles. Therefore, those neonates are at highest risk for developing atopic dermatitis, the study authors said.
The findings indicate a need for infant skin care regimens that protect and support normal barrier development from birth, the researchers noted. They also suggested that clinical strategies targeting the early mechanisms of barrier breakdown could act as preventive measures in neonates at increased risk of developing atopic dermatitis.
The research was funded jointly by the University of Sheffield and a doctoral research fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.
Neonates with the highest transepidermal water loss at birth, likely mediated through an impaired epidermal barrier, show significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived natural moisturizing factors, which may predispose them to the development of atopic dermatitis, according to a report published online in the British Journal of Dermatology.
John Chittock of the University of Sheffield, England, and his colleagues assessed the biophysical, biologic, and functional properties of the developing neonatal stratum corneum (SC) from birth to 4 weeks of age in 115 healthy, full-term (at least 37 weeks’ gestation) neonates from the OBSERVE (Oil in Baby Skincare) randomized study birth cohort recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014.
For comparative purposes, an unrelated cohort of 20 adults with healthy skin was recruited from the local community between January and April 2015 (Br J Dermatol. 2016 Mar 19. doi: 10.1111/bjd.14568).
The researchers found that the biophysical properties of the neonatal SC are transitional from birth. For example, overall transepidermal water loss (TEWL) increased significantly during the first 4 weeks of infant life. Compared with adult skin, the newborn infant SC was found to be drier and more alkaline. In addition, levels of superficial chymotrypsinlike protease activity at birth did not differ between newborns and adults, while levels of filaggrin-derived natural moisturizing factors (NMF) were significantly lower at birth than in adulthood.
The increased chymotrypsinlike protease activity and NMF at 4 weeks of age exceeded levels found in healthy adults, rather than reaching their mature state. Compared with adult skin, the skin of infants is functionally immature, with undeveloped mechanisms of desquamation and differentiation, the investigators noted.
Further analysis revealed a correlation between TEWL and both superficial chymotrypsinlike protease activity and filaggrin-derived NMF at birth.
To explore that link, the researchers stratified the neonatal cohort according to TEWL percentile. The neonates in the 76th-100th percentile, the highest TEWL at birth, showed significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived NMF, compared with neonates in lower percentiles. Therefore, those neonates are at highest risk for developing atopic dermatitis, the study authors said.
The findings indicate a need for infant skin care regimens that protect and support normal barrier development from birth, the researchers noted. They also suggested that clinical strategies targeting the early mechanisms of barrier breakdown could act as preventive measures in neonates at increased risk of developing atopic dermatitis.
The research was funded jointly by the University of Sheffield and a doctoral research fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.
FROM THE BRITISH JOURNAL OF DERMATOLOGY
Some infants predisposed to epidermal barrier breakdown, atopic dermatitis
Neonates with the highest transepidermal water loss at birth, likely mediated through an impaired epidermal barrier, show significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived natural moisturizing factors, which may predispose them to the development of atopic dermatitis, according to a report published online in the British Journal of Dermatology.
John Chittock of the University of Sheffield, England, and his colleagues assessed the biophysical, biologic, and functional properties of the developing neonatal stratum corneum (SC) from birth to 4 weeks of age in 115 healthy, full-term (at least 37 weeks’ gestation) neonates from the OBSERVE (Oil in Baby Skincare) randomized study birth cohort recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014.
For comparative purposes, an unrelated cohort of 20 adults with healthy skin was recruited from the local community between January and April 2015 (Br J Dermatol. 2016 Mar 19. doi: 10.1111/bjd.14568).
The researchers found that the biophysical properties of the neonatal SC are transitional from birth. For example, overall transepidermal water loss (TEWL) increased significantly during the first 4 weeks of infant life. Compared with adult skin, the newborn infant SC was found to be drier and more alkaline. In addition, levels of superficial chymotrypsinlike protease activity at birth did not differ between newborns and adults, while levels of filaggrin-derived natural moisturizing factors (NMF) were significantly lower at birth than in adulthood.
The increased chymotrypsinlike protease activity and NMF at 4 weeks of age exceeded levels found in healthy adults, rather than reaching their mature state. Compared with adult skin, the skin of infants is functionally immature, with undeveloped mechanisms of desquamation and differentiation, the investigators noted.
Further analysis revealed a correlation between TEWL and both superficial chymotrypsinlike protease activity and filaggrin-derived NMF at birth.
To explore that link, the researchers stratified the neonatal cohort according to TEWL percentile. The neonates in the 76th-100th percentile, the highest TEWL at birth, showed significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived NMF, compared with neonates in lower percentiles. Therefore, those neonates are at highest risk for developing atopic dermatitis, the study authors said.
The findings indicate a need for infant skin care regimens that protect and support normal barrier development from birth, the researchers noted. They also suggested that clinical strategies targeting the early mechanisms of barrier breakdown could act as preventive measures in neonates at increased risk of developing atopic dermatitis.
The research was funded jointly by the University of Sheffield and a doctoral research fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.
Neonates with the highest transepidermal water loss at birth, likely mediated through an impaired epidermal barrier, show significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived natural moisturizing factors, which may predispose them to the development of atopic dermatitis, according to a report published online in the British Journal of Dermatology.
John Chittock of the University of Sheffield, England, and his colleagues assessed the biophysical, biologic, and functional properties of the developing neonatal stratum corneum (SC) from birth to 4 weeks of age in 115 healthy, full-term (at least 37 weeks’ gestation) neonates from the OBSERVE (Oil in Baby Skincare) randomized study birth cohort recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014.
For comparative purposes, an unrelated cohort of 20 adults with healthy skin was recruited from the local community between January and April 2015 (Br J Dermatol. 2016 Mar 19. doi: 10.1111/bjd.14568).
The researchers found that the biophysical properties of the neonatal SC are transitional from birth. For example, overall transepidermal water loss (TEWL) increased significantly during the first 4 weeks of infant life. Compared with adult skin, the newborn infant SC was found to be drier and more alkaline. In addition, levels of superficial chymotrypsinlike protease activity at birth did not differ between newborns and adults, while levels of filaggrin-derived natural moisturizing factors (NMF) were significantly lower at birth than in adulthood.
The increased chymotrypsinlike protease activity and NMF at 4 weeks of age exceeded levels found in healthy adults, rather than reaching their mature state. Compared with adult skin, the skin of infants is functionally immature, with undeveloped mechanisms of desquamation and differentiation, the investigators noted.
Further analysis revealed a correlation between TEWL and both superficial chymotrypsinlike protease activity and filaggrin-derived NMF at birth.
To explore that link, the researchers stratified the neonatal cohort according to TEWL percentile. The neonates in the 76th-100th percentile, the highest TEWL at birth, showed significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived NMF, compared with neonates in lower percentiles. Therefore, those neonates are at highest risk for developing atopic dermatitis, the study authors said.
The findings indicate a need for infant skin care regimens that protect and support normal barrier development from birth, the researchers noted. They also suggested that clinical strategies targeting the early mechanisms of barrier breakdown could act as preventive measures in neonates at increased risk of developing atopic dermatitis.
The research was funded jointly by the University of Sheffield and a doctoral research fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.
Neonates with the highest transepidermal water loss at birth, likely mediated through an impaired epidermal barrier, show significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived natural moisturizing factors, which may predispose them to the development of atopic dermatitis, according to a report published online in the British Journal of Dermatology.
John Chittock of the University of Sheffield, England, and his colleagues assessed the biophysical, biologic, and functional properties of the developing neonatal stratum corneum (SC) from birth to 4 weeks of age in 115 healthy, full-term (at least 37 weeks’ gestation) neonates from the OBSERVE (Oil in Baby Skincare) randomized study birth cohort recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014.
For comparative purposes, an unrelated cohort of 20 adults with healthy skin was recruited from the local community between January and April 2015 (Br J Dermatol. 2016 Mar 19. doi: 10.1111/bjd.14568).
The researchers found that the biophysical properties of the neonatal SC are transitional from birth. For example, overall transepidermal water loss (TEWL) increased significantly during the first 4 weeks of infant life. Compared with adult skin, the newborn infant SC was found to be drier and more alkaline. In addition, levels of superficial chymotrypsinlike protease activity at birth did not differ between newborns and adults, while levels of filaggrin-derived natural moisturizing factors (NMF) were significantly lower at birth than in adulthood.
The increased chymotrypsinlike protease activity and NMF at 4 weeks of age exceeded levels found in healthy adults, rather than reaching their mature state. Compared with adult skin, the skin of infants is functionally immature, with undeveloped mechanisms of desquamation and differentiation, the investigators noted.
Further analysis revealed a correlation between TEWL and both superficial chymotrypsinlike protease activity and filaggrin-derived NMF at birth.
To explore that link, the researchers stratified the neonatal cohort according to TEWL percentile. The neonates in the 76th-100th percentile, the highest TEWL at birth, showed significantly elevated chymotrypsinlike protease activity and reduced levels of filaggrin-derived NMF, compared with neonates in lower percentiles. Therefore, those neonates are at highest risk for developing atopic dermatitis, the study authors said.
The findings indicate a need for infant skin care regimens that protect and support normal barrier development from birth, the researchers noted. They also suggested that clinical strategies targeting the early mechanisms of barrier breakdown could act as preventive measures in neonates at increased risk of developing atopic dermatitis.
The research was funded jointly by the University of Sheffield and a doctoral research fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.
FROM THE BRITISH JOURNAL OF DERMATOLOGY
Key clinical point: Some infants are predisposed to epidermal barrier breakdown and the development of atopic dermatitis through elevated protease activity and reduced levels of natural moisturizing factors at birth.
Major finding: Significantly elevated chymotrypsinlike protease activity and reduced levels of natural moisturizing factors were associated with impaired epidermal barrier function at birth.
Data sources: The OBSERVE study birth cohort included a total of 115 healthy, full-term (at least 37 weeks’ gestation) neonates recruited at Saint Mary’s Hospital, Central Manchester NHS Foundation Trust, between September 2013 and June 2014, as well as an unrelated cohort of 20 adults with healthy skin recruited from the local community between January and April 2015.
Disclosures: This independent research was funded jointly by the University of Sheffield and a Doctoral Research Fellowship supported by the National Institute for Health Research. The authors declared no conflicts of interest.