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Obsessive-compulsive personality disorder may involve brain abnormalities
A clue to the neuroanatomy of obsessive-compulsive personality disorder may lay in abnormal hippocampal or amygdalar structures, according to a new observational imaging study.
MRI showed that the right and left volumes of the hippocampus and amygdala are smaller in patients with obsessive-compulsive personality disorder than in healthy controls, researchers found.
These findings lend support to the likelihood that obsessive-compulsive personality disorder “seems to be a neurocognitive function disorder rather than a personality disorder,” Mehmet Gurkan Gurok, of Firat University, Elazig, Turkey, and his associates reported in the Journal of Clinical Neuroscience.
The authors previously had investigated volumes of hippocampus and amygdala in patients with obsessive-compulsive disorder and found these patients had “increased white matter volumes, greater left and right thalamus volumes and significantly reduced left and right orbitofrontal cortex volumes, compared with healthy controls.”
For this study, they similarly used MRI to assess hippocampal and amygdalar volumes in 16 patients with obsessive-compulsive personality disorder (inpatients and outpatients at Firat University) and in 18 healthy controls – matched for age, sex, education, and handedness – who were studying at the hospital.
The researchers used the DSM-IV and the Structured Clinical Interview for the Diagnostic Schedule for Mental Disorders-Fourth Edition for diagnoses but noted later in their limitations that “the validity of diagnosis should be questioned” for personality disorders.
Participants were excluded if they had a comorbid Axis I psychiatric diagnosis besides depression, any contraindications for MRI, history of alcohol or substance dependence within the previous 6 months, use of psychoactive medications within 4 weeks of the study, or any current severe medical conditions. In addition, neither controls nor their first-degree relatives had a history of psychiatric disorders.
The findings showed that those with obsessive-compulsive personality disorder had smaller volumes on both sides of the hippocampus, compared with healthy controls. Amygdalar volume on both the left and right sides were similarly smaller in patients with obsessive-compulsive personality disorder, compared with healthy controls (left, P = .001; right, P = .002). The authors also reported they “did not find any correlation between hippocampus and amygdala volumes and any clinical and demographic variables.”
The research was funded by Firat University. The authors reported having no conflicts of interest.
SOURCE: Gurok MG et al. J Clin Neurosci. 2019 Apr 5. doi: 10.1016/j.jocn.2019.03.060.
A clue to the neuroanatomy of obsessive-compulsive personality disorder may lay in abnormal hippocampal or amygdalar structures, according to a new observational imaging study.
MRI showed that the right and left volumes of the hippocampus and amygdala are smaller in patients with obsessive-compulsive personality disorder than in healthy controls, researchers found.
These findings lend support to the likelihood that obsessive-compulsive personality disorder “seems to be a neurocognitive function disorder rather than a personality disorder,” Mehmet Gurkan Gurok, of Firat University, Elazig, Turkey, and his associates reported in the Journal of Clinical Neuroscience.
The authors previously had investigated volumes of hippocampus and amygdala in patients with obsessive-compulsive disorder and found these patients had “increased white matter volumes, greater left and right thalamus volumes and significantly reduced left and right orbitofrontal cortex volumes, compared with healthy controls.”
For this study, they similarly used MRI to assess hippocampal and amygdalar volumes in 16 patients with obsessive-compulsive personality disorder (inpatients and outpatients at Firat University) and in 18 healthy controls – matched for age, sex, education, and handedness – who were studying at the hospital.
The researchers used the DSM-IV and the Structured Clinical Interview for the Diagnostic Schedule for Mental Disorders-Fourth Edition for diagnoses but noted later in their limitations that “the validity of diagnosis should be questioned” for personality disorders.
Participants were excluded if they had a comorbid Axis I psychiatric diagnosis besides depression, any contraindications for MRI, history of alcohol or substance dependence within the previous 6 months, use of psychoactive medications within 4 weeks of the study, or any current severe medical conditions. In addition, neither controls nor their first-degree relatives had a history of psychiatric disorders.
The findings showed that those with obsessive-compulsive personality disorder had smaller volumes on both sides of the hippocampus, compared with healthy controls. Amygdalar volume on both the left and right sides were similarly smaller in patients with obsessive-compulsive personality disorder, compared with healthy controls (left, P = .001; right, P = .002). The authors also reported they “did not find any correlation between hippocampus and amygdala volumes and any clinical and demographic variables.”
The research was funded by Firat University. The authors reported having no conflicts of interest.
SOURCE: Gurok MG et al. J Clin Neurosci. 2019 Apr 5. doi: 10.1016/j.jocn.2019.03.060.
A clue to the neuroanatomy of obsessive-compulsive personality disorder may lay in abnormal hippocampal or amygdalar structures, according to a new observational imaging study.
MRI showed that the right and left volumes of the hippocampus and amygdala are smaller in patients with obsessive-compulsive personality disorder than in healthy controls, researchers found.
These findings lend support to the likelihood that obsessive-compulsive personality disorder “seems to be a neurocognitive function disorder rather than a personality disorder,” Mehmet Gurkan Gurok, of Firat University, Elazig, Turkey, and his associates reported in the Journal of Clinical Neuroscience.
The authors previously had investigated volumes of hippocampus and amygdala in patients with obsessive-compulsive disorder and found these patients had “increased white matter volumes, greater left and right thalamus volumes and significantly reduced left and right orbitofrontal cortex volumes, compared with healthy controls.”
For this study, they similarly used MRI to assess hippocampal and amygdalar volumes in 16 patients with obsessive-compulsive personality disorder (inpatients and outpatients at Firat University) and in 18 healthy controls – matched for age, sex, education, and handedness – who were studying at the hospital.
The researchers used the DSM-IV and the Structured Clinical Interview for the Diagnostic Schedule for Mental Disorders-Fourth Edition for diagnoses but noted later in their limitations that “the validity of diagnosis should be questioned” for personality disorders.
Participants were excluded if they had a comorbid Axis I psychiatric diagnosis besides depression, any contraindications for MRI, history of alcohol or substance dependence within the previous 6 months, use of psychoactive medications within 4 weeks of the study, or any current severe medical conditions. In addition, neither controls nor their first-degree relatives had a history of psychiatric disorders.
The findings showed that those with obsessive-compulsive personality disorder had smaller volumes on both sides of the hippocampus, compared with healthy controls. Amygdalar volume on both the left and right sides were similarly smaller in patients with obsessive-compulsive personality disorder, compared with healthy controls (left, P = .001; right, P = .002). The authors also reported they “did not find any correlation between hippocampus and amygdala volumes and any clinical and demographic variables.”
The research was funded by Firat University. The authors reported having no conflicts of interest.
SOURCE: Gurok MG et al. J Clin Neurosci. 2019 Apr 5. doi: 10.1016/j.jocn.2019.03.060.
FROM THE JOURNAL OF CLINICAL NEUROSCIENCE
Bariatric surgery viable for teens with cognitive disabilities
Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.
“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.
“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”
Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.
They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m2 or one of at least 35 kg/m2 with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.
Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.
The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.
In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.
But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.
SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.
Despite increasing evidence to support the safety and effectiveness of bariatric surgery in confronting the challenge of increasing obesity rates among adolescents, access to care remains limited for many such teens.
Prominent examples include a significant disparity in insurance authorization for bariatric surgical care when comparing pediatric patients to their adult counterparts, low rates of referral from primary caregivers, and general uncertainty regarding potential exclusionary criteria.
The researchers should be commended for exploring bariatric surgery outcomes in an understudied population. However, both the likely importance of social supports to the participants’ success and, especially, the need to approach the issue of informed thoughtfully, perhaps with additional institutional guidance are crucial to success.
Although literature addressing ethical concerns specifically associated with bariatric surgery for children with intellectual or developmental disability is limited, previous attempts to offer a logical clinical framework highlight the importance of using a case-by-case approach predicated on the need to establish a well-defined risk/benefit ratio.
As an important part of efforts to tackle such challenges, bariatric surgical care providers should strongly consider the routine use of available resources (i.e., institutional ethics committees) to assist in complex medical decision making.”
These comments are adapted from an accompanying editorial by Marc P. Michalsky, MD, of the Ohio State University and Nationwide Children’s Hospital, both in Columbus (Pediatrics. 15 April 2019; doi: 10.1542/peds.2018-4112). He reported having no disclosures.
Despite increasing evidence to support the safety and effectiveness of bariatric surgery in confronting the challenge of increasing obesity rates among adolescents, access to care remains limited for many such teens.
Prominent examples include a significant disparity in insurance authorization for bariatric surgical care when comparing pediatric patients to their adult counterparts, low rates of referral from primary caregivers, and general uncertainty regarding potential exclusionary criteria.
The researchers should be commended for exploring bariatric surgery outcomes in an understudied population. However, both the likely importance of social supports to the participants’ success and, especially, the need to approach the issue of informed thoughtfully, perhaps with additional institutional guidance are crucial to success.
Although literature addressing ethical concerns specifically associated with bariatric surgery for children with intellectual or developmental disability is limited, previous attempts to offer a logical clinical framework highlight the importance of using a case-by-case approach predicated on the need to establish a well-defined risk/benefit ratio.
As an important part of efforts to tackle such challenges, bariatric surgical care providers should strongly consider the routine use of available resources (i.e., institutional ethics committees) to assist in complex medical decision making.”
These comments are adapted from an accompanying editorial by Marc P. Michalsky, MD, of the Ohio State University and Nationwide Children’s Hospital, both in Columbus (Pediatrics. 15 April 2019; doi: 10.1542/peds.2018-4112). He reported having no disclosures.
Despite increasing evidence to support the safety and effectiveness of bariatric surgery in confronting the challenge of increasing obesity rates among adolescents, access to care remains limited for many such teens.
Prominent examples include a significant disparity in insurance authorization for bariatric surgical care when comparing pediatric patients to their adult counterparts, low rates of referral from primary caregivers, and general uncertainty regarding potential exclusionary criteria.
The researchers should be commended for exploring bariatric surgery outcomes in an understudied population. However, both the likely importance of social supports to the participants’ success and, especially, the need to approach the issue of informed thoughtfully, perhaps with additional institutional guidance are crucial to success.
Although literature addressing ethical concerns specifically associated with bariatric surgery for children with intellectual or developmental disability is limited, previous attempts to offer a logical clinical framework highlight the importance of using a case-by-case approach predicated on the need to establish a well-defined risk/benefit ratio.
As an important part of efforts to tackle such challenges, bariatric surgical care providers should strongly consider the routine use of available resources (i.e., institutional ethics committees) to assist in complex medical decision making.”
These comments are adapted from an accompanying editorial by Marc P. Michalsky, MD, of the Ohio State University and Nationwide Children’s Hospital, both in Columbus (Pediatrics. 15 April 2019; doi: 10.1542/peds.2018-4112). He reported having no disclosures.
Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.
“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.
“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”
Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.
They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m2 or one of at least 35 kg/m2 with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.
Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.
The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.
In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.
But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.
SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.
Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.
“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.
“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”
Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.
They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m2 or one of at least 35 kg/m2 with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.
Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.
The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.
In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.
But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.
SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.
FROM PEDIATRICS
AAP, AHA push for policies limiting children’s sugary beverage consumption
Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.
As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.
Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.
Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.
Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.
The statement makes six major recommendations:
• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.
Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.
• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.
• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.
• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.
• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.
• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.
Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”
The statement used no external funding, and the authors had no disclosures or conflicts of interest.
SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282
Make counseling on healthy eating and exercise a priority
Pediatricians daily bear witness to the impact of poor nutrition on the health and quality of life of children. Healthy eating and drinking has long been an expected domain of conversation with children, adolescents and their families. In recent years, counseling regarding the consumption of added sugars, especially those in sugar-sweetened beverages (SSB), has gained traction. Pediatricians are aware of the health risks associated with over-consumption of SSB and that these risks, and consumption of sugary drinks, are more prevalent among the most vulnerable of children, including minorities and those living in low-income communities.
Primary care pediatricians face many demands that compete for time and attention, and time spent counseling on healthy eating and exercise needs to continue to be a priority. AAP-supported initiatives, such as the 5-3-2-1-0 rule – five vegetables and fruits per day, three structured meals, 2 hours or less of screen time, 1 hour or more of physical activity and zero sugary drinks most days – provide simple, clear messaging about limiting of sugary drinks. We should promote drinking of water as first choice, including during sports activities.
Messaging with community partners and on social media maximizes the impact of these important messages. The new AAP guideline “Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents” also advocates for decreasing sugary drink marketing to children and adolescents. Pediatricians are trusted, credible voices who are well-positioned to advocate for an ad-free childhood, including SSB ads.
Melinda Clark, MD, is an associate professor of pediatrics at the Albany (N.Y.) Medical Center, and a MDedge Pediatrics editorial advisory board member. Dr. Clark had no disclosures.
Make counseling on healthy eating and exercise a priority
Pediatricians daily bear witness to the impact of poor nutrition on the health and quality of life of children. Healthy eating and drinking has long been an expected domain of conversation with children, adolescents and their families. In recent years, counseling regarding the consumption of added sugars, especially those in sugar-sweetened beverages (SSB), has gained traction. Pediatricians are aware of the health risks associated with over-consumption of SSB and that these risks, and consumption of sugary drinks, are more prevalent among the most vulnerable of children, including minorities and those living in low-income communities.
Primary care pediatricians face many demands that compete for time and attention, and time spent counseling on healthy eating and exercise needs to continue to be a priority. AAP-supported initiatives, such as the 5-3-2-1-0 rule – five vegetables and fruits per day, three structured meals, 2 hours or less of screen time, 1 hour or more of physical activity and zero sugary drinks most days – provide simple, clear messaging about limiting of sugary drinks. We should promote drinking of water as first choice, including during sports activities.
Messaging with community partners and on social media maximizes the impact of these important messages. The new AAP guideline “Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents” also advocates for decreasing sugary drink marketing to children and adolescents. Pediatricians are trusted, credible voices who are well-positioned to advocate for an ad-free childhood, including SSB ads.
Melinda Clark, MD, is an associate professor of pediatrics at the Albany (N.Y.) Medical Center, and a MDedge Pediatrics editorial advisory board member. Dr. Clark had no disclosures.
Make counseling on healthy eating and exercise a priority
Pediatricians daily bear witness to the impact of poor nutrition on the health and quality of life of children. Healthy eating and drinking has long been an expected domain of conversation with children, adolescents and their families. In recent years, counseling regarding the consumption of added sugars, especially those in sugar-sweetened beverages (SSB), has gained traction. Pediatricians are aware of the health risks associated with over-consumption of SSB and that these risks, and consumption of sugary drinks, are more prevalent among the most vulnerable of children, including minorities and those living in low-income communities.
Primary care pediatricians face many demands that compete for time and attention, and time spent counseling on healthy eating and exercise needs to continue to be a priority. AAP-supported initiatives, such as the 5-3-2-1-0 rule – five vegetables and fruits per day, three structured meals, 2 hours or less of screen time, 1 hour or more of physical activity and zero sugary drinks most days – provide simple, clear messaging about limiting of sugary drinks. We should promote drinking of water as first choice, including during sports activities.
Messaging with community partners and on social media maximizes the impact of these important messages. The new AAP guideline “Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents” also advocates for decreasing sugary drink marketing to children and adolescents. Pediatricians are trusted, credible voices who are well-positioned to advocate for an ad-free childhood, including SSB ads.
Melinda Clark, MD, is an associate professor of pediatrics at the Albany (N.Y.) Medical Center, and a MDedge Pediatrics editorial advisory board member. Dr. Clark had no disclosures.
Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.
As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.
Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.
Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.
Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.
The statement makes six major recommendations:
• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.
Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.
• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.
• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.
• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.
• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.
• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.
Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”
The statement used no external funding, and the authors had no disclosures or conflicts of interest.
SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282
Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.
As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.
Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.
Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.
Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.
The statement makes six major recommendations:
• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.
Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.
• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.
• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.
• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.
• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.
• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.
Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”
The statement used no external funding, and the authors had no disclosures or conflicts of interest.
SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282
FROM PEDIATRICS
Adolescent psychiatric ED visits more than doubled in 4 years
a study found.
Visits by African American youth and Latino youth both increased by a significant amount, yet only a minority of all youth (16%) were seen by mental health professionals during their psychiatric ED visits.
“This study unmistakably reveals that adolescents are a population with urgent mental health needs,” Luther G. Kalb, PhD, of the Johns Hopkins Bloomberg School of Public Health and the Kennedy Krieger Institute in Baltimore, and his colleagues reported in Pediatrics. “Not only were their visits the most acute, but their probability of suicidal attempt and/or self-harm increased as well,” a finding that matches recent national increases in suicidal ideation.
The researchers used the 2011-2015 National Hospital Ambulatory Medical Care Survey to analyze data on psychiatric ED visits among U.S. youth aged 6-24 years. A psychiatric visit was identified based on the patient’s reason for visit and the International Classification of Diseases, ninth revision, codes for mood, behavioral, or substance use disorders; psychosis; or other psychiatric reasons. Suicide attempt or intentional self-harm were identified with reason for visit codes.
Psychiatric ED visits among all youth increased 28%, from 31 to 40 visits per 1,000 U.S. youth, in the period from 2011 to 2015, a finding “heavily driven by 2015, in which the largest increase in visits was observed,” the authors noted.
The biggest jump occurred among adolescents, whose visits increased 54%, and among black and Latino patients, whose visits rose 53% and 91%, respectively. Adolescent suicide-related and self-injury ED visits more than doubled from 2011 to 2015, from 5 to 12 visits per 1,000 U.S. youth. They were the only age group to see an increase in odds of a suicide-related visit over time (odds ratio, 1.27, P less than .01)
“Ultimately, it is unclear if the findings represent a change in identification (by providers) or reporting (by patients or family members) of mental health in the ED, a shift in the epidemiology of psychiatric disorders in the United States, or fluctuations in referral patterns or service-seeking behavior,” Dr. Kalb and his associates reported.
Study limitations included “an inability to confirm diagnostic validity” and some missing data for visit acuity and race/ethnicity, they said.
The research was funded by the National Institute of Health, and in part by the National Institute of Mental Health Intramural Research program. The authors reported no relevant financial disclosures.
SOURCE: Kalb LG et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2018-2192.
Even though the “fast-paced, stimulating environment” of an emergency department is not the ideal setting for children and families to receive care for mental health concerns, it remains a crucial safety net – particularly for lower-income individuals – because so many children lack access to mental health services, Dr. Chun and his associates wrote in an accompanying editorial.
“Some of the factors contributing to deficiencies in ED preparedness include a lack of staff trained in the identification and management of acute mental health problems; safe and quiet spaces within the ED; appropriate milieu for respectful, safe care; policies and procedures for ensuring best practices and consistent care; professional expertise to evaluate children’s mental health problems; and access to appropriate and timely follow-up care.”
Yet rates of youth’s psychiatric visits to the ED continue to climb because of a combination of increasing awareness, decreasing stigma for care seeking, limited mental health services, a shortage of pediatric mental health providers, insufficient specialty services, and true increases in mental health needs.
Solving this problem will require multiple coordinated approaches, but innovative options already are being explored, such as integrating child psychiatry services into EDs and “instituting next-day or other timely mental health evaluations,” they wrote. Other approaches include telepsychiatry; bringing mental health resources into schools and clinics; mental health resource sharing among communities; and mobile crisis units that visit schools, homes, primary care clinics, and low-resourced EDs.
Finally, medical training programs must change to adapt to the increasing need for pediatric mental health needs. “Embracing mental health problems as a routine component of pediatric medicine may be part of the solution to addressing the crisis,” they wrote.
Thomas H. Chun, MD, MPH, and Susan J. Duffy, MD, MPH, are at the Hasbro Children’s Hospital in Providence, R.I., and Jacqueline Grupp-Phelan, MD, MPH, is at the University of California, San Francisco, Benioff Children’s Hospital. These comments are a summary of a commentary accompanying Kalb et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2019-0251. The physicians used no external funding and had no financial disclosures relevant to their commentary.
Even though the “fast-paced, stimulating environment” of an emergency department is not the ideal setting for children and families to receive care for mental health concerns, it remains a crucial safety net – particularly for lower-income individuals – because so many children lack access to mental health services, Dr. Chun and his associates wrote in an accompanying editorial.
“Some of the factors contributing to deficiencies in ED preparedness include a lack of staff trained in the identification and management of acute mental health problems; safe and quiet spaces within the ED; appropriate milieu for respectful, safe care; policies and procedures for ensuring best practices and consistent care; professional expertise to evaluate children’s mental health problems; and access to appropriate and timely follow-up care.”
Yet rates of youth’s psychiatric visits to the ED continue to climb because of a combination of increasing awareness, decreasing stigma for care seeking, limited mental health services, a shortage of pediatric mental health providers, insufficient specialty services, and true increases in mental health needs.
Solving this problem will require multiple coordinated approaches, but innovative options already are being explored, such as integrating child psychiatry services into EDs and “instituting next-day or other timely mental health evaluations,” they wrote. Other approaches include telepsychiatry; bringing mental health resources into schools and clinics; mental health resource sharing among communities; and mobile crisis units that visit schools, homes, primary care clinics, and low-resourced EDs.
Finally, medical training programs must change to adapt to the increasing need for pediatric mental health needs. “Embracing mental health problems as a routine component of pediatric medicine may be part of the solution to addressing the crisis,” they wrote.
Thomas H. Chun, MD, MPH, and Susan J. Duffy, MD, MPH, are at the Hasbro Children’s Hospital in Providence, R.I., and Jacqueline Grupp-Phelan, MD, MPH, is at the University of California, San Francisco, Benioff Children’s Hospital. These comments are a summary of a commentary accompanying Kalb et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2019-0251. The physicians used no external funding and had no financial disclosures relevant to their commentary.
Even though the “fast-paced, stimulating environment” of an emergency department is not the ideal setting for children and families to receive care for mental health concerns, it remains a crucial safety net – particularly for lower-income individuals – because so many children lack access to mental health services, Dr. Chun and his associates wrote in an accompanying editorial.
“Some of the factors contributing to deficiencies in ED preparedness include a lack of staff trained in the identification and management of acute mental health problems; safe and quiet spaces within the ED; appropriate milieu for respectful, safe care; policies and procedures for ensuring best practices and consistent care; professional expertise to evaluate children’s mental health problems; and access to appropriate and timely follow-up care.”
Yet rates of youth’s psychiatric visits to the ED continue to climb because of a combination of increasing awareness, decreasing stigma for care seeking, limited mental health services, a shortage of pediatric mental health providers, insufficient specialty services, and true increases in mental health needs.
Solving this problem will require multiple coordinated approaches, but innovative options already are being explored, such as integrating child psychiatry services into EDs and “instituting next-day or other timely mental health evaluations,” they wrote. Other approaches include telepsychiatry; bringing mental health resources into schools and clinics; mental health resource sharing among communities; and mobile crisis units that visit schools, homes, primary care clinics, and low-resourced EDs.
Finally, medical training programs must change to adapt to the increasing need for pediatric mental health needs. “Embracing mental health problems as a routine component of pediatric medicine may be part of the solution to addressing the crisis,” they wrote.
Thomas H. Chun, MD, MPH, and Susan J. Duffy, MD, MPH, are at the Hasbro Children’s Hospital in Providence, R.I., and Jacqueline Grupp-Phelan, MD, MPH, is at the University of California, San Francisco, Benioff Children’s Hospital. These comments are a summary of a commentary accompanying Kalb et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2019-0251. The physicians used no external funding and had no financial disclosures relevant to their commentary.
a study found.
Visits by African American youth and Latino youth both increased by a significant amount, yet only a minority of all youth (16%) were seen by mental health professionals during their psychiatric ED visits.
“This study unmistakably reveals that adolescents are a population with urgent mental health needs,” Luther G. Kalb, PhD, of the Johns Hopkins Bloomberg School of Public Health and the Kennedy Krieger Institute in Baltimore, and his colleagues reported in Pediatrics. “Not only were their visits the most acute, but their probability of suicidal attempt and/or self-harm increased as well,” a finding that matches recent national increases in suicidal ideation.
The researchers used the 2011-2015 National Hospital Ambulatory Medical Care Survey to analyze data on psychiatric ED visits among U.S. youth aged 6-24 years. A psychiatric visit was identified based on the patient’s reason for visit and the International Classification of Diseases, ninth revision, codes for mood, behavioral, or substance use disorders; psychosis; or other psychiatric reasons. Suicide attempt or intentional self-harm were identified with reason for visit codes.
Psychiatric ED visits among all youth increased 28%, from 31 to 40 visits per 1,000 U.S. youth, in the period from 2011 to 2015, a finding “heavily driven by 2015, in which the largest increase in visits was observed,” the authors noted.
The biggest jump occurred among adolescents, whose visits increased 54%, and among black and Latino patients, whose visits rose 53% and 91%, respectively. Adolescent suicide-related and self-injury ED visits more than doubled from 2011 to 2015, from 5 to 12 visits per 1,000 U.S. youth. They were the only age group to see an increase in odds of a suicide-related visit over time (odds ratio, 1.27, P less than .01)
“Ultimately, it is unclear if the findings represent a change in identification (by providers) or reporting (by patients or family members) of mental health in the ED, a shift in the epidemiology of psychiatric disorders in the United States, or fluctuations in referral patterns or service-seeking behavior,” Dr. Kalb and his associates reported.
Study limitations included “an inability to confirm diagnostic validity” and some missing data for visit acuity and race/ethnicity, they said.
The research was funded by the National Institute of Health, and in part by the National Institute of Mental Health Intramural Research program. The authors reported no relevant financial disclosures.
SOURCE: Kalb LG et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2018-2192.
a study found.
Visits by African American youth and Latino youth both increased by a significant amount, yet only a minority of all youth (16%) were seen by mental health professionals during their psychiatric ED visits.
“This study unmistakably reveals that adolescents are a population with urgent mental health needs,” Luther G. Kalb, PhD, of the Johns Hopkins Bloomberg School of Public Health and the Kennedy Krieger Institute in Baltimore, and his colleagues reported in Pediatrics. “Not only were their visits the most acute, but their probability of suicidal attempt and/or self-harm increased as well,” a finding that matches recent national increases in suicidal ideation.
The researchers used the 2011-2015 National Hospital Ambulatory Medical Care Survey to analyze data on psychiatric ED visits among U.S. youth aged 6-24 years. A psychiatric visit was identified based on the patient’s reason for visit and the International Classification of Diseases, ninth revision, codes for mood, behavioral, or substance use disorders; psychosis; or other psychiatric reasons. Suicide attempt or intentional self-harm were identified with reason for visit codes.
Psychiatric ED visits among all youth increased 28%, from 31 to 40 visits per 1,000 U.S. youth, in the period from 2011 to 2015, a finding “heavily driven by 2015, in which the largest increase in visits was observed,” the authors noted.
The biggest jump occurred among adolescents, whose visits increased 54%, and among black and Latino patients, whose visits rose 53% and 91%, respectively. Adolescent suicide-related and self-injury ED visits more than doubled from 2011 to 2015, from 5 to 12 visits per 1,000 U.S. youth. They were the only age group to see an increase in odds of a suicide-related visit over time (odds ratio, 1.27, P less than .01)
“Ultimately, it is unclear if the findings represent a change in identification (by providers) or reporting (by patients or family members) of mental health in the ED, a shift in the epidemiology of psychiatric disorders in the United States, or fluctuations in referral patterns or service-seeking behavior,” Dr. Kalb and his associates reported.
Study limitations included “an inability to confirm diagnostic validity” and some missing data for visit acuity and race/ethnicity, they said.
The research was funded by the National Institute of Health, and in part by the National Institute of Mental Health Intramural Research program. The authors reported no relevant financial disclosures.
SOURCE: Kalb LG et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2018-2192.
FROM PEDIATRICS
Policy statement on drowning highlights high-risk groups
Wider availability of low-cost swim lessons could reduce drowning risk in children over 1 year old, but such lessons are only one component of reducing drowning risk and cannot “drown-proof” children, who should still be fully supervised around water, according to a new policy statement from the American Academy of Pediatrics.
These strategies include barriers, supervision, swim lessons, use of life jackets, and training in cardiopulmonary resuscitation (CPR). Parents should be advised to restrict unsupervised access to pools and other bodies of water, as well as understand the risks of substance use around water, Sarah A. Denny, MD, and the members of the AAP’s Council on Injury, Violence, and Poison Prevention, wrote.
The committee made five major recommendations for pediatricians:
• Recognize high-risk groups and leading causes of drowning in their area and customize advice to parents about drowning risk accordingly.
• Pay special attention to needs of children with medical conditions that increase drowning risk, such as seizure disorders, autism spectrum disorder and cardiac arrhythmias, and advise uninterrupted supervision for these children even in baths.
• Inform parents and children of the increased risk of drowning with substance use, especially for teen boys.
• Discuss water skill levels with parents and children to avoid either overestimating a youth’s competency.
• Encourage CPR training in high schools.
Accidental drowning rates have declined from 2.7 per 100,000 children in 1985 to 1.1 per 100,000 children in 2017, yet drowning remains the top cause of injury death among children ages 1-4 years, reported Dr. Denny, of Nationwide Hospital in Columbus, Ohio, and her colleagues (Pediatrics. March 15, 2019). For those ages 5-19 years old, drowning is the third leading cause of accidental death.
Nearly 1,000 children and adolescents under 20 years old die from drowning each year. An estimated 8,700 others went to the emergency department for drowning-related incidents in 2017. Of these children, 25% required admission or additional care.
“Most victims of nonfatal drowning recover fully with no neurologic deficits, but severe long-term neurologic deficits are seen with extended submersion times (over 6 minutes), prolonged resuscitation efforts, and lack of early bystander-initiated cardiopulmonary resuscitation (CPR),” the committee wrote.
Children at highest drowning risk include toddlers and teen boys of all races/ethnicities as well as black and Native American/Alaska Native children. Black male teens had the highest overall rates, 4 drowning deaths per 100,000 children, for 2013-2017.
Among those aged 4 years and under, drowning risk was primarily related to the lack of barriers to prevent unanticipated, unsupervised access to water, including swimming pools, hot tubs and spas, bathtubs, natural bodies of water, and standing water in homes (buckets, tubs, and toilets), the committee wrote.
Teens are most likely to die in natural water settings, such as ponds, rivers, lakes and sea water. “The increased risk for fatal drowning in adolescents can be attributed to multiple factors, including overestimation of skills, underestimation of dangerous situations, engaging in high-risk and impulsive behaviors, and substance use,” particularly alcohol consumption, according to the statement.
Children with seizure disorders have up to a 10-times greater risk of drowning, and therefore require constant supervision around water. Whenever possible, children with seizure disorders should shower instead of bathe and swim only at locations where there is a lifeguard.
Similarly, supervision is essential for children with autism spectrum disorder, especially those under age 15 and with greater intellectual disability. Wandering is the most commonly reported behavior leading to drowning, accounting for nearly 74% of fatal drowning incidents among children with autism.
The committee also recommended four community advocacy activities:
• Actively work with legislators to develop policy aimed at reducing the risk of drowning, such as pool/water fencing requirements and laws related to boating, life jacket use, EMS systems and overall water safety.
• Use “non-fatal drowning” — not “near drowning” — to describe drowning incidents that do not result in death and inform parents that “dry drowning” and “secondary drowning” are not medically accurate terms.
• Work with community groups to ensure life jackets are accessible for all people at pools and boating sites.
• Encourage, identify and support “high-quality, culturally sensitive, and affordable” swim lesson programs, particularly for children in low-income, disability or other high-risk groups.“Socioeconomic and cultural disparities in water safety knowledge, swimming skills and drowning risk can be addressed through “community-based programs targeting high-risk groups by providing free or low-cost swim lessons, developing special programs that address cultural concerns as well as swim lessons for youth with developmental disabilities, and changing pool policies to meet the needs of specific communities,” the committee wrote.
The statement did not use external funding, and the authors reported no financial conflicts.
SOURCE: Denny SA et al. Pediatrics.
Wider availability of low-cost swim lessons could reduce drowning risk in children over 1 year old, but such lessons are only one component of reducing drowning risk and cannot “drown-proof” children, who should still be fully supervised around water, according to a new policy statement from the American Academy of Pediatrics.
These strategies include barriers, supervision, swim lessons, use of life jackets, and training in cardiopulmonary resuscitation (CPR). Parents should be advised to restrict unsupervised access to pools and other bodies of water, as well as understand the risks of substance use around water, Sarah A. Denny, MD, and the members of the AAP’s Council on Injury, Violence, and Poison Prevention, wrote.
The committee made five major recommendations for pediatricians:
• Recognize high-risk groups and leading causes of drowning in their area and customize advice to parents about drowning risk accordingly.
• Pay special attention to needs of children with medical conditions that increase drowning risk, such as seizure disorders, autism spectrum disorder and cardiac arrhythmias, and advise uninterrupted supervision for these children even in baths.
• Inform parents and children of the increased risk of drowning with substance use, especially for teen boys.
• Discuss water skill levels with parents and children to avoid either overestimating a youth’s competency.
• Encourage CPR training in high schools.
Accidental drowning rates have declined from 2.7 per 100,000 children in 1985 to 1.1 per 100,000 children in 2017, yet drowning remains the top cause of injury death among children ages 1-4 years, reported Dr. Denny, of Nationwide Hospital in Columbus, Ohio, and her colleagues (Pediatrics. March 15, 2019). For those ages 5-19 years old, drowning is the third leading cause of accidental death.
Nearly 1,000 children and adolescents under 20 years old die from drowning each year. An estimated 8,700 others went to the emergency department for drowning-related incidents in 2017. Of these children, 25% required admission or additional care.
“Most victims of nonfatal drowning recover fully with no neurologic deficits, but severe long-term neurologic deficits are seen with extended submersion times (over 6 minutes), prolonged resuscitation efforts, and lack of early bystander-initiated cardiopulmonary resuscitation (CPR),” the committee wrote.
Children at highest drowning risk include toddlers and teen boys of all races/ethnicities as well as black and Native American/Alaska Native children. Black male teens had the highest overall rates, 4 drowning deaths per 100,000 children, for 2013-2017.
Among those aged 4 years and under, drowning risk was primarily related to the lack of barriers to prevent unanticipated, unsupervised access to water, including swimming pools, hot tubs and spas, bathtubs, natural bodies of water, and standing water in homes (buckets, tubs, and toilets), the committee wrote.
Teens are most likely to die in natural water settings, such as ponds, rivers, lakes and sea water. “The increased risk for fatal drowning in adolescents can be attributed to multiple factors, including overestimation of skills, underestimation of dangerous situations, engaging in high-risk and impulsive behaviors, and substance use,” particularly alcohol consumption, according to the statement.
Children with seizure disorders have up to a 10-times greater risk of drowning, and therefore require constant supervision around water. Whenever possible, children with seizure disorders should shower instead of bathe and swim only at locations where there is a lifeguard.
Similarly, supervision is essential for children with autism spectrum disorder, especially those under age 15 and with greater intellectual disability. Wandering is the most commonly reported behavior leading to drowning, accounting for nearly 74% of fatal drowning incidents among children with autism.
The committee also recommended four community advocacy activities:
• Actively work with legislators to develop policy aimed at reducing the risk of drowning, such as pool/water fencing requirements and laws related to boating, life jacket use, EMS systems and overall water safety.
• Use “non-fatal drowning” — not “near drowning” — to describe drowning incidents that do not result in death and inform parents that “dry drowning” and “secondary drowning” are not medically accurate terms.
• Work with community groups to ensure life jackets are accessible for all people at pools and boating sites.
• Encourage, identify and support “high-quality, culturally sensitive, and affordable” swim lesson programs, particularly for children in low-income, disability or other high-risk groups.“Socioeconomic and cultural disparities in water safety knowledge, swimming skills and drowning risk can be addressed through “community-based programs targeting high-risk groups by providing free or low-cost swim lessons, developing special programs that address cultural concerns as well as swim lessons for youth with developmental disabilities, and changing pool policies to meet the needs of specific communities,” the committee wrote.
The statement did not use external funding, and the authors reported no financial conflicts.
SOURCE: Denny SA et al. Pediatrics.
Wider availability of low-cost swim lessons could reduce drowning risk in children over 1 year old, but such lessons are only one component of reducing drowning risk and cannot “drown-proof” children, who should still be fully supervised around water, according to a new policy statement from the American Academy of Pediatrics.
These strategies include barriers, supervision, swim lessons, use of life jackets, and training in cardiopulmonary resuscitation (CPR). Parents should be advised to restrict unsupervised access to pools and other bodies of water, as well as understand the risks of substance use around water, Sarah A. Denny, MD, and the members of the AAP’s Council on Injury, Violence, and Poison Prevention, wrote.
The committee made five major recommendations for pediatricians:
• Recognize high-risk groups and leading causes of drowning in their area and customize advice to parents about drowning risk accordingly.
• Pay special attention to needs of children with medical conditions that increase drowning risk, such as seizure disorders, autism spectrum disorder and cardiac arrhythmias, and advise uninterrupted supervision for these children even in baths.
• Inform parents and children of the increased risk of drowning with substance use, especially for teen boys.
• Discuss water skill levels with parents and children to avoid either overestimating a youth’s competency.
• Encourage CPR training in high schools.
Accidental drowning rates have declined from 2.7 per 100,000 children in 1985 to 1.1 per 100,000 children in 2017, yet drowning remains the top cause of injury death among children ages 1-4 years, reported Dr. Denny, of Nationwide Hospital in Columbus, Ohio, and her colleagues (Pediatrics. March 15, 2019). For those ages 5-19 years old, drowning is the third leading cause of accidental death.
Nearly 1,000 children and adolescents under 20 years old die from drowning each year. An estimated 8,700 others went to the emergency department for drowning-related incidents in 2017. Of these children, 25% required admission or additional care.
“Most victims of nonfatal drowning recover fully with no neurologic deficits, but severe long-term neurologic deficits are seen with extended submersion times (over 6 minutes), prolonged resuscitation efforts, and lack of early bystander-initiated cardiopulmonary resuscitation (CPR),” the committee wrote.
Children at highest drowning risk include toddlers and teen boys of all races/ethnicities as well as black and Native American/Alaska Native children. Black male teens had the highest overall rates, 4 drowning deaths per 100,000 children, for 2013-2017.
Among those aged 4 years and under, drowning risk was primarily related to the lack of barriers to prevent unanticipated, unsupervised access to water, including swimming pools, hot tubs and spas, bathtubs, natural bodies of water, and standing water in homes (buckets, tubs, and toilets), the committee wrote.
Teens are most likely to die in natural water settings, such as ponds, rivers, lakes and sea water. “The increased risk for fatal drowning in adolescents can be attributed to multiple factors, including overestimation of skills, underestimation of dangerous situations, engaging in high-risk and impulsive behaviors, and substance use,” particularly alcohol consumption, according to the statement.
Children with seizure disorders have up to a 10-times greater risk of drowning, and therefore require constant supervision around water. Whenever possible, children with seizure disorders should shower instead of bathe and swim only at locations where there is a lifeguard.
Similarly, supervision is essential for children with autism spectrum disorder, especially those under age 15 and with greater intellectual disability. Wandering is the most commonly reported behavior leading to drowning, accounting for nearly 74% of fatal drowning incidents among children with autism.
The committee also recommended four community advocacy activities:
• Actively work with legislators to develop policy aimed at reducing the risk of drowning, such as pool/water fencing requirements and laws related to boating, life jacket use, EMS systems and overall water safety.
• Use “non-fatal drowning” — not “near drowning” — to describe drowning incidents that do not result in death and inform parents that “dry drowning” and “secondary drowning” are not medically accurate terms.
• Work with community groups to ensure life jackets are accessible for all people at pools and boating sites.
• Encourage, identify and support “high-quality, culturally sensitive, and affordable” swim lesson programs, particularly for children in low-income, disability or other high-risk groups.“Socioeconomic and cultural disparities in water safety knowledge, swimming skills and drowning risk can be addressed through “community-based programs targeting high-risk groups by providing free or low-cost swim lessons, developing special programs that address cultural concerns as well as swim lessons for youth with developmental disabilities, and changing pool policies to meet the needs of specific communities,” the committee wrote.
The statement did not use external funding, and the authors reported no financial conflicts.
SOURCE: Denny SA et al. Pediatrics.
FROM PEDIATRICS
Antenatal steroids for preterm birth is cost effective
Administering antenatal corticosteroids to pregnant women at high risk for preterm birth was a cost-effective intervention that improved infant respiratory outcomes, according to a new study.
“This intervention has a potential cost saving in the United States of approximately $100 million dollars annually from the benefit in the immediate neonatal outcome alone,” Cynthia Gyamfi-Bannerman, MD, of Columbia University, New York, and her associates reported in JAMA Pediatrics. “Because late preterm birth comprises a large proportion of all preterm births, our findings have the potential for a large influence on public health.”
The researchers conducted a retrospective secondary analysis of the randomized Antenatal Late Preterm Steroids (ALPS) clinical trial October 2010 to February 2015. The trial enrolled randomly assigned antenatal administration of betamethasone or placebo to women pregnant with a singleton and at high risk for preterm birth while between 34 weeks, 6 days, and 36 weeks, 0 days, of gestation.
Antenatal corticosteroid administration was regarded as effective if a newborn did not require treatment in the first 72 hours for respiratory distress or illness. Treatment could include “continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation,” Dr. Gyamfi-Bannerman and her associates wrote.
To tally the costs, the researchers used Medicaid rates to estimate the total in 2015 U.S. dollars for betamethasone, outpatient visits or inpatient stays to administer it, and all direct newborn care costs, including neonatal ICU daily costs stratified by respiratory illness severity. Betamethasone administration included an initial 12-mg intramuscular dose followed by another after 24 hours if the infant had not been delivered.
“Because therapy often persists for longer than this 72-hour duration, we measured costs through hospital discharge,” the authors wrote. “The analysis took the perspective of a third-party payer in which we included direct medical costs and associated overhead accruing to hospitals and medical payers for the care of enrolled patients and their infants.”
Among 2,821 mothers not lost to follow-up during the secondary analysis, 1,426 received betamethasone and 1,395 received placebo. For mothers who received betamethasone antenatally, the total mean cost was $4,681 per mother-infant pair. Total mean cost for those in the placebo group was $5,379 per pair, resulting in a significant mean $698 savings (P = .02). Respiratory morbidity was 2.9% lower in infants whose mothers received antenatal corticosteroid treatment.
“Thus, because the treated group had lower costs and this strategy was more effective, administration of betamethasone to women at risk for late preterm birth was judged to be a dominant strategy, which is defined as one in which costs are lower and effectiveness is higher than a comparator (incremental cost-effectiveness ratio [ICER], −23 986),” Dr. Gyamfi-Bannerman and her associates reported. ICER is defined as the difference in mean total cost per patient in the betamethasone and placebo arms divided by the difference in the effectiveness.
Study limitations were an inability to estimate costs according to quality-adjusted life years or to include families’/caregivers’ costs.
SOURCE: Gyamfi-Bannerman C. JAMA Pediatr. 2019 Mar 11. doi: 10.1001/jamapediatrics.2019.0032.
Administering antenatal corticosteroids to pregnant women at high risk for preterm birth was a cost-effective intervention that improved infant respiratory outcomes, according to a new study.
“This intervention has a potential cost saving in the United States of approximately $100 million dollars annually from the benefit in the immediate neonatal outcome alone,” Cynthia Gyamfi-Bannerman, MD, of Columbia University, New York, and her associates reported in JAMA Pediatrics. “Because late preterm birth comprises a large proportion of all preterm births, our findings have the potential for a large influence on public health.”
The researchers conducted a retrospective secondary analysis of the randomized Antenatal Late Preterm Steroids (ALPS) clinical trial October 2010 to February 2015. The trial enrolled randomly assigned antenatal administration of betamethasone or placebo to women pregnant with a singleton and at high risk for preterm birth while between 34 weeks, 6 days, and 36 weeks, 0 days, of gestation.
Antenatal corticosteroid administration was regarded as effective if a newborn did not require treatment in the first 72 hours for respiratory distress or illness. Treatment could include “continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation,” Dr. Gyamfi-Bannerman and her associates wrote.
To tally the costs, the researchers used Medicaid rates to estimate the total in 2015 U.S. dollars for betamethasone, outpatient visits or inpatient stays to administer it, and all direct newborn care costs, including neonatal ICU daily costs stratified by respiratory illness severity. Betamethasone administration included an initial 12-mg intramuscular dose followed by another after 24 hours if the infant had not been delivered.
“Because therapy often persists for longer than this 72-hour duration, we measured costs through hospital discharge,” the authors wrote. “The analysis took the perspective of a third-party payer in which we included direct medical costs and associated overhead accruing to hospitals and medical payers for the care of enrolled patients and their infants.”
Among 2,821 mothers not lost to follow-up during the secondary analysis, 1,426 received betamethasone and 1,395 received placebo. For mothers who received betamethasone antenatally, the total mean cost was $4,681 per mother-infant pair. Total mean cost for those in the placebo group was $5,379 per pair, resulting in a significant mean $698 savings (P = .02). Respiratory morbidity was 2.9% lower in infants whose mothers received antenatal corticosteroid treatment.
“Thus, because the treated group had lower costs and this strategy was more effective, administration of betamethasone to women at risk for late preterm birth was judged to be a dominant strategy, which is defined as one in which costs are lower and effectiveness is higher than a comparator (incremental cost-effectiveness ratio [ICER], −23 986),” Dr. Gyamfi-Bannerman and her associates reported. ICER is defined as the difference in mean total cost per patient in the betamethasone and placebo arms divided by the difference in the effectiveness.
Study limitations were an inability to estimate costs according to quality-adjusted life years or to include families’/caregivers’ costs.
SOURCE: Gyamfi-Bannerman C. JAMA Pediatr. 2019 Mar 11. doi: 10.1001/jamapediatrics.2019.0032.
Administering antenatal corticosteroids to pregnant women at high risk for preterm birth was a cost-effective intervention that improved infant respiratory outcomes, according to a new study.
“This intervention has a potential cost saving in the United States of approximately $100 million dollars annually from the benefit in the immediate neonatal outcome alone,” Cynthia Gyamfi-Bannerman, MD, of Columbia University, New York, and her associates reported in JAMA Pediatrics. “Because late preterm birth comprises a large proportion of all preterm births, our findings have the potential for a large influence on public health.”
The researchers conducted a retrospective secondary analysis of the randomized Antenatal Late Preterm Steroids (ALPS) clinical trial October 2010 to February 2015. The trial enrolled randomly assigned antenatal administration of betamethasone or placebo to women pregnant with a singleton and at high risk for preterm birth while between 34 weeks, 6 days, and 36 weeks, 0 days, of gestation.
Antenatal corticosteroid administration was regarded as effective if a newborn did not require treatment in the first 72 hours for respiratory distress or illness. Treatment could include “continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation,” Dr. Gyamfi-Bannerman and her associates wrote.
To tally the costs, the researchers used Medicaid rates to estimate the total in 2015 U.S. dollars for betamethasone, outpatient visits or inpatient stays to administer it, and all direct newborn care costs, including neonatal ICU daily costs stratified by respiratory illness severity. Betamethasone administration included an initial 12-mg intramuscular dose followed by another after 24 hours if the infant had not been delivered.
“Because therapy often persists for longer than this 72-hour duration, we measured costs through hospital discharge,” the authors wrote. “The analysis took the perspective of a third-party payer in which we included direct medical costs and associated overhead accruing to hospitals and medical payers for the care of enrolled patients and their infants.”
Among 2,821 mothers not lost to follow-up during the secondary analysis, 1,426 received betamethasone and 1,395 received placebo. For mothers who received betamethasone antenatally, the total mean cost was $4,681 per mother-infant pair. Total mean cost for those in the placebo group was $5,379 per pair, resulting in a significant mean $698 savings (P = .02). Respiratory morbidity was 2.9% lower in infants whose mothers received antenatal corticosteroid treatment.
“Thus, because the treated group had lower costs and this strategy was more effective, administration of betamethasone to women at risk for late preterm birth was judged to be a dominant strategy, which is defined as one in which costs are lower and effectiveness is higher than a comparator (incremental cost-effectiveness ratio [ICER], −23 986),” Dr. Gyamfi-Bannerman and her associates reported. ICER is defined as the difference in mean total cost per patient in the betamethasone and placebo arms divided by the difference in the effectiveness.
Study limitations were an inability to estimate costs according to quality-adjusted life years or to include families’/caregivers’ costs.
SOURCE: Gyamfi-Bannerman C. JAMA Pediatr. 2019 Mar 11. doi: 10.1001/jamapediatrics.2019.0032.
FROM JAMA PEDIATRICS
Daily aspirin associated with lower risk of COPD flareup
Daily aspirin use could reduce the risk of acute exacerbations of chronic obstructive pulmonary disease, new data suggest.
Researchers reported the outcomes of an observational cohort study of 1,698 individuals with COPD, 45% of whom said they were taking daily aspirin at baseline. Their findings were published in Chest.
After a median follow up of 2.7 years, aspirin users had an overall 22% lower incidence of acute COPD exacerbations compared with nonusers. This was largely accounted for by a 25% reduction in moderate exacerbations, but there was no significant difference between aspirin users and nonusers in severe exacerbations.
A similar pattern was seen after just 1 year of follow-up, with an overall 30% reduction in the incidence of exacerbations, a 37% reduction in moderate exacerbations, but no significant reduction in severe exacerbations.
“Though aspirin use has previously been linked with reduced mortality risk in patients with COPD, to our knowledge, this is the first study to investigate the association of daily aspirin use with respiratory morbidity in COPD,” wrote Ashraf Fawzy, MD, of the division of pulmonary and critical care medicine at Johns Hopkins University, Baltimore, and his coauthors.
The association between aspirin use and reduced incidence of exacerbations was stronger among individuals with chronic bronchitis, which prompted the authors to suggest that future studies of aspirin in COPD should focus on participants with chronic bronchitis.
However, the association was not affected by COPD severity, emphysema presence or severity, or cardiometabolic phenotype.
Aspirin users reported better respiratory-specific quality of life than that of nonusers, including 34% lower odds of reporting moderate to severe dyspnea, and better baseline COPD health status.
“Findings of this study add to the existing literature by highlighting that aspirin use is also associated with reduced respiratory morbidity across several domains – including exacerbation risk, quality of life, and dyspnea – factors related to patient well-being and healthcare utilization,” the authors wrote.
Aspirin users were more likely to be white, male, and obese, and less likely to be smokers. They had better lung function but more cardiovascular comorbidities at baseline, although the aspirin users and nonusers were matched on baseline characteristics.
Speculating on the mechanisms by which aspirin might impact COPD exacerbations, the authors noted that the drug has both systemic and local pulmonary mechanisms of action.
For example, a pathway that results in elevated levels of a urinary metabolite in patients with COPD is irreversibly blocked by aspirin. Aspirin also attenuates the elevation of inflammatory markers interleukin-6 and C-reactive protein, which are part of the inflammatory phenotype of COPD. Aspirin has been shown to reduce proinflammatory cytokines in the lung.
The authors did note that aspirin use was self-reported, so they did not have data on dosage or duration of use.
The National Institutes of Health funded the study. Six authors declared advisory board positions, research support, and other funding from the pharmaceutical sector. One author was also a founder of a company commercializing lung image analysis software. No other conflicts of interest were declared.
SOURCE: Fawzy A et al. Chest. 2019 Mar;155(3): 519-27. doi: 10.1016/j.chest.2018.11.028.
Daily aspirin use could reduce the risk of acute exacerbations of chronic obstructive pulmonary disease, new data suggest.
Researchers reported the outcomes of an observational cohort study of 1,698 individuals with COPD, 45% of whom said they were taking daily aspirin at baseline. Their findings were published in Chest.
After a median follow up of 2.7 years, aspirin users had an overall 22% lower incidence of acute COPD exacerbations compared with nonusers. This was largely accounted for by a 25% reduction in moderate exacerbations, but there was no significant difference between aspirin users and nonusers in severe exacerbations.
A similar pattern was seen after just 1 year of follow-up, with an overall 30% reduction in the incidence of exacerbations, a 37% reduction in moderate exacerbations, but no significant reduction in severe exacerbations.
“Though aspirin use has previously been linked with reduced mortality risk in patients with COPD, to our knowledge, this is the first study to investigate the association of daily aspirin use with respiratory morbidity in COPD,” wrote Ashraf Fawzy, MD, of the division of pulmonary and critical care medicine at Johns Hopkins University, Baltimore, and his coauthors.
The association between aspirin use and reduced incidence of exacerbations was stronger among individuals with chronic bronchitis, which prompted the authors to suggest that future studies of aspirin in COPD should focus on participants with chronic bronchitis.
However, the association was not affected by COPD severity, emphysema presence or severity, or cardiometabolic phenotype.
Aspirin users reported better respiratory-specific quality of life than that of nonusers, including 34% lower odds of reporting moderate to severe dyspnea, and better baseline COPD health status.
“Findings of this study add to the existing literature by highlighting that aspirin use is also associated with reduced respiratory morbidity across several domains – including exacerbation risk, quality of life, and dyspnea – factors related to patient well-being and healthcare utilization,” the authors wrote.
Aspirin users were more likely to be white, male, and obese, and less likely to be smokers. They had better lung function but more cardiovascular comorbidities at baseline, although the aspirin users and nonusers were matched on baseline characteristics.
Speculating on the mechanisms by which aspirin might impact COPD exacerbations, the authors noted that the drug has both systemic and local pulmonary mechanisms of action.
For example, a pathway that results in elevated levels of a urinary metabolite in patients with COPD is irreversibly blocked by aspirin. Aspirin also attenuates the elevation of inflammatory markers interleukin-6 and C-reactive protein, which are part of the inflammatory phenotype of COPD. Aspirin has been shown to reduce proinflammatory cytokines in the lung.
The authors did note that aspirin use was self-reported, so they did not have data on dosage or duration of use.
The National Institutes of Health funded the study. Six authors declared advisory board positions, research support, and other funding from the pharmaceutical sector. One author was also a founder of a company commercializing lung image analysis software. No other conflicts of interest were declared.
SOURCE: Fawzy A et al. Chest. 2019 Mar;155(3): 519-27. doi: 10.1016/j.chest.2018.11.028.
Daily aspirin use could reduce the risk of acute exacerbations of chronic obstructive pulmonary disease, new data suggest.
Researchers reported the outcomes of an observational cohort study of 1,698 individuals with COPD, 45% of whom said they were taking daily aspirin at baseline. Their findings were published in Chest.
After a median follow up of 2.7 years, aspirin users had an overall 22% lower incidence of acute COPD exacerbations compared with nonusers. This was largely accounted for by a 25% reduction in moderate exacerbations, but there was no significant difference between aspirin users and nonusers in severe exacerbations.
A similar pattern was seen after just 1 year of follow-up, with an overall 30% reduction in the incidence of exacerbations, a 37% reduction in moderate exacerbations, but no significant reduction in severe exacerbations.
“Though aspirin use has previously been linked with reduced mortality risk in patients with COPD, to our knowledge, this is the first study to investigate the association of daily aspirin use with respiratory morbidity in COPD,” wrote Ashraf Fawzy, MD, of the division of pulmonary and critical care medicine at Johns Hopkins University, Baltimore, and his coauthors.
The association between aspirin use and reduced incidence of exacerbations was stronger among individuals with chronic bronchitis, which prompted the authors to suggest that future studies of aspirin in COPD should focus on participants with chronic bronchitis.
However, the association was not affected by COPD severity, emphysema presence or severity, or cardiometabolic phenotype.
Aspirin users reported better respiratory-specific quality of life than that of nonusers, including 34% lower odds of reporting moderate to severe dyspnea, and better baseline COPD health status.
“Findings of this study add to the existing literature by highlighting that aspirin use is also associated with reduced respiratory morbidity across several domains – including exacerbation risk, quality of life, and dyspnea – factors related to patient well-being and healthcare utilization,” the authors wrote.
Aspirin users were more likely to be white, male, and obese, and less likely to be smokers. They had better lung function but more cardiovascular comorbidities at baseline, although the aspirin users and nonusers were matched on baseline characteristics.
Speculating on the mechanisms by which aspirin might impact COPD exacerbations, the authors noted that the drug has both systemic and local pulmonary mechanisms of action.
For example, a pathway that results in elevated levels of a urinary metabolite in patients with COPD is irreversibly blocked by aspirin. Aspirin also attenuates the elevation of inflammatory markers interleukin-6 and C-reactive protein, which are part of the inflammatory phenotype of COPD. Aspirin has been shown to reduce proinflammatory cytokines in the lung.
The authors did note that aspirin use was self-reported, so they did not have data on dosage or duration of use.
The National Institutes of Health funded the study. Six authors declared advisory board positions, research support, and other funding from the pharmaceutical sector. One author was also a founder of a company commercializing lung image analysis software. No other conflicts of interest were declared.
SOURCE: Fawzy A et al. Chest. 2019 Mar;155(3): 519-27. doi: 10.1016/j.chest.2018.11.028.
FROM CHEST
Quitting smoking during pregnancy cuts SUID risk
Odds of sudden unexpected infant death (SUID) more than doubled with maternal prenatal smoking and increased linearly with each additional cigarette mothers smoked during pregnancy, but quitting smoking during pregnancy cut SUID risk, according to a new study in Pediatrics.
“As prevalence of prone sleeping has declined, the relative contribution of prenatal maternal smoking to the risk of sudden infant death has increased,” Tatiana M. Anderson, PhD, of the Seattle Children’s Research Institute and her associates reported. When the researchers considered causality, they estimated that approximately 800 infants (22% of all SUID cases) per year in the United States could be attributed to maternal smoking during pregnancy.
The researchers analyzed 19,127 SUID cases among 20,685,463 births included in the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set for 2007-2011. A SUID diagnosis included sudden infant death syndrome, infant death from ill-defined or unknown cause, and accidental suffocation or strangulation in bed for any infants under 1 year old.
When the authors calculated odds related to prenatal maternal smoking and SUID, they adjusted for infant sex and birth weight, gestational length of pregnancy, delivery method (vaginal or cesarean), total prenatal visits, live birth order, maternal marital status and education, and maternal and paternal age and race/ethnicity.
Any maternal smoking at all during pregnancy was associated with more than twice the odds of SUID (adjusted odds ratio, 2.44). Odds of SUID also doubled for smoking one cigarette daily during pregnancy versus smoking none. For each additional cigarette smoked daily during pregnancy, odds of SUID increased by 0.07 up until 20 cigarettes, when the risk evened out, which suggests “that smoking cessation efforts may have greater impact on decreasing SUID rates when directed toward those who smoke fewer than 1 pack per day versus the more traditionally targeted heavy ([more than] 20 cigarettes per day) smokers,” the authors wrote.
Odds of SUID dropped 12% when mothers cut down on smoking during pregnancy and dropped 23% when they quit altogether (aORs, 0.88 and 0.77, respectively). “However, there may be some selection bias because the group who reduced smoking started at a higher average number of cigarettes in the first trimester, whereas those who successfully quit smoked fewer cigarettes in the first trimester,” the authors noted.
Among the 11.6% of mothers who said in 2011 that they smoked in the 3 months leading up to pregnancy, only a quarter quit while pregnant, the authors wrote. Quitting after having smoked before pregnancy was linked to a 47% increased risk of SUID, although the researchers noted that second- and third-hand smoke may have played a role since mothers who smoke may begin smoking again post partum and/or often have a partner who smokes.
“This group may have also included women who stopped smoking as soon as they knew they were pregnant and thus reported that they were nonsmokers in the first trimester, but the fetus had been exposed to maternal smoking during the period before pregnancy was diagnosed,” the authors wrote. They also acknowledged the possibility of residual confounding, particularly from socioeconomic factors or alcohol consumption during pregnancy.
The research was funded by the National Institutes of Health, Microsoft, and the Aaron Matthew Sudden Infant Death Syndrome Research Guild. One author has testified as a paid expert in a SUID case. No other authors reported conflicts of interest.
SOURCE: Anderson TM et al. Pediatrics. 2019 March 11. doi: 10.1542/peds.2018-3325.
Odds of sudden unexpected infant death (SUID) more than doubled with maternal prenatal smoking and increased linearly with each additional cigarette mothers smoked during pregnancy, but quitting smoking during pregnancy cut SUID risk, according to a new study in Pediatrics.
“As prevalence of prone sleeping has declined, the relative contribution of prenatal maternal smoking to the risk of sudden infant death has increased,” Tatiana M. Anderson, PhD, of the Seattle Children’s Research Institute and her associates reported. When the researchers considered causality, they estimated that approximately 800 infants (22% of all SUID cases) per year in the United States could be attributed to maternal smoking during pregnancy.
The researchers analyzed 19,127 SUID cases among 20,685,463 births included in the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set for 2007-2011. A SUID diagnosis included sudden infant death syndrome, infant death from ill-defined or unknown cause, and accidental suffocation or strangulation in bed for any infants under 1 year old.
When the authors calculated odds related to prenatal maternal smoking and SUID, they adjusted for infant sex and birth weight, gestational length of pregnancy, delivery method (vaginal or cesarean), total prenatal visits, live birth order, maternal marital status and education, and maternal and paternal age and race/ethnicity.
Any maternal smoking at all during pregnancy was associated with more than twice the odds of SUID (adjusted odds ratio, 2.44). Odds of SUID also doubled for smoking one cigarette daily during pregnancy versus smoking none. For each additional cigarette smoked daily during pregnancy, odds of SUID increased by 0.07 up until 20 cigarettes, when the risk evened out, which suggests “that smoking cessation efforts may have greater impact on decreasing SUID rates when directed toward those who smoke fewer than 1 pack per day versus the more traditionally targeted heavy ([more than] 20 cigarettes per day) smokers,” the authors wrote.
Odds of SUID dropped 12% when mothers cut down on smoking during pregnancy and dropped 23% when they quit altogether (aORs, 0.88 and 0.77, respectively). “However, there may be some selection bias because the group who reduced smoking started at a higher average number of cigarettes in the first trimester, whereas those who successfully quit smoked fewer cigarettes in the first trimester,” the authors noted.
Among the 11.6% of mothers who said in 2011 that they smoked in the 3 months leading up to pregnancy, only a quarter quit while pregnant, the authors wrote. Quitting after having smoked before pregnancy was linked to a 47% increased risk of SUID, although the researchers noted that second- and third-hand smoke may have played a role since mothers who smoke may begin smoking again post partum and/or often have a partner who smokes.
“This group may have also included women who stopped smoking as soon as they knew they were pregnant and thus reported that they were nonsmokers in the first trimester, but the fetus had been exposed to maternal smoking during the period before pregnancy was diagnosed,” the authors wrote. They also acknowledged the possibility of residual confounding, particularly from socioeconomic factors or alcohol consumption during pregnancy.
The research was funded by the National Institutes of Health, Microsoft, and the Aaron Matthew Sudden Infant Death Syndrome Research Guild. One author has testified as a paid expert in a SUID case. No other authors reported conflicts of interest.
SOURCE: Anderson TM et al. Pediatrics. 2019 March 11. doi: 10.1542/peds.2018-3325.
Odds of sudden unexpected infant death (SUID) more than doubled with maternal prenatal smoking and increased linearly with each additional cigarette mothers smoked during pregnancy, but quitting smoking during pregnancy cut SUID risk, according to a new study in Pediatrics.
“As prevalence of prone sleeping has declined, the relative contribution of prenatal maternal smoking to the risk of sudden infant death has increased,” Tatiana M. Anderson, PhD, of the Seattle Children’s Research Institute and her associates reported. When the researchers considered causality, they estimated that approximately 800 infants (22% of all SUID cases) per year in the United States could be attributed to maternal smoking during pregnancy.
The researchers analyzed 19,127 SUID cases among 20,685,463 births included in the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set for 2007-2011. A SUID diagnosis included sudden infant death syndrome, infant death from ill-defined or unknown cause, and accidental suffocation or strangulation in bed for any infants under 1 year old.
When the authors calculated odds related to prenatal maternal smoking and SUID, they adjusted for infant sex and birth weight, gestational length of pregnancy, delivery method (vaginal or cesarean), total prenatal visits, live birth order, maternal marital status and education, and maternal and paternal age and race/ethnicity.
Any maternal smoking at all during pregnancy was associated with more than twice the odds of SUID (adjusted odds ratio, 2.44). Odds of SUID also doubled for smoking one cigarette daily during pregnancy versus smoking none. For each additional cigarette smoked daily during pregnancy, odds of SUID increased by 0.07 up until 20 cigarettes, when the risk evened out, which suggests “that smoking cessation efforts may have greater impact on decreasing SUID rates when directed toward those who smoke fewer than 1 pack per day versus the more traditionally targeted heavy ([more than] 20 cigarettes per day) smokers,” the authors wrote.
Odds of SUID dropped 12% when mothers cut down on smoking during pregnancy and dropped 23% when they quit altogether (aORs, 0.88 and 0.77, respectively). “However, there may be some selection bias because the group who reduced smoking started at a higher average number of cigarettes in the first trimester, whereas those who successfully quit smoked fewer cigarettes in the first trimester,” the authors noted.
Among the 11.6% of mothers who said in 2011 that they smoked in the 3 months leading up to pregnancy, only a quarter quit while pregnant, the authors wrote. Quitting after having smoked before pregnancy was linked to a 47% increased risk of SUID, although the researchers noted that second- and third-hand smoke may have played a role since mothers who smoke may begin smoking again post partum and/or often have a partner who smokes.
“This group may have also included women who stopped smoking as soon as they knew they were pregnant and thus reported that they were nonsmokers in the first trimester, but the fetus had been exposed to maternal smoking during the period before pregnancy was diagnosed,” the authors wrote. They also acknowledged the possibility of residual confounding, particularly from socioeconomic factors or alcohol consumption during pregnancy.
The research was funded by the National Institutes of Health, Microsoft, and the Aaron Matthew Sudden Infant Death Syndrome Research Guild. One author has testified as a paid expert in a SUID case. No other authors reported conflicts of interest.
SOURCE: Anderson TM et al. Pediatrics. 2019 March 11. doi: 10.1542/peds.2018-3325.
FROM PEDIATRICS
Prenatal betamethasone not linked to later adverse neurocognitive problems
Administering prenatal corticosteroids to women at risk for preterm birth does not appear to contribute to adverse neurocognitive function in children 6-8 years later, regardless of whether they had fetal growth restriction, a new study found.
Women at less than 32 weeks’ gestation are recommended to receive multiple betamethasone doses if they have a high ongoing risk of preterm birth. However, concern existed regarding possible effects of these steroid doses on the infant in later childhood, particularly in cases of fetal growth restriction (FGR) because of “animal studies suggesting long-term adverse effects of treatment on neurosensory function,” Robert D. Cartwright of the University of Auckland (New Zealand), and his associates reported in JAMA Network Open.
Yet no such effects were identified in this preplanned follow-up analysis of the placebo-controlled, randomized Australasian Collaborative Trial of Repeat Doses of Corticosteroids (ACTORDS). “Physicians should use repeated doses of antenatal corticosteroids when indicated before preterm birth, regardless of fetal growth restriction, in view of the associated neonatal benefits and absence of later adverse effects,” the authors concluded.
The original ACTORDS study involved 982 women pregnant with 1,146 fetuses at 23 hospitals throughout Australia and New Zealand, enrolled from April 1998 to July 2004. All enrolled women were less than 32 weeks’ gestation, had received an initial course of corticosteroids, and had an ongoing risk of preterm birth at least 7 days later.
Women were randomly assigned to receive an intramuscular dose of betamethasone or saline placebo weekly until birth or preterm birth risk abated. The current follow-up, when children were 6-8 years old, was planned during the 2-year follow-up. Children underwent a pediatrician’s physical and neurologic exam, vision and hearing screening, and fine and gross motor testing. A psychologist tested children’s IQ, attention, executive function, and academic skills using standardized, validated assessment tools. Caregivers also rated children’s behavioral and emotional problems, executive function abilities, and attention in questionnaires.
Among 988 of 1,059 surviving children assessed, FGR occurred in 28% of children exposed to betamethasone and 25% in the placebo group.
For the primary outcomes, rates of disability-free survival were similar in both the placebo and betamethasone groups for children with (odds ratio, 1.1) and without FGR (OR, 1.0). Rates also were similar for death or survival with moderate to severe disability (FGR: OR, 0.9; and non-FGR: OR, 0.8).
“Some evidence suggested a differential effect for several secondary outcomes, with better scores for selective and divided attention after exposure to repeated antenatal betamethasone in children with FGR, but poorer scores for impulse control in children without FGR,” Dr. Cartwright and his associates reported. “These effects were small and of uncertain clinical significance and may reflect type I error.
“For all other measures of neurocognitive function and learning, exposure to repeated antenatal betamethasone treatment did not alter performance in midchildhood, even in the presence of FGR,” they added.
Children with FGR had an increased risk of death or moderate to severe disability, compared with children without FGR, regardless of treatment group. Those with FGR also had greater risk of motor impairment.
One possible reason for not finding adverse neurocognitive effects in the betamethasone group is “that infants with fetal growth restriction appeared to have greater benefit from repeated antenatal corticosteroid therapy, with a nearly twofold reduction in serious neonatal morbidity,” the authors surmised. “Thus, the decrease in serious postnatal complications may have counteracted any potential adverse effects of corticosteroid exposure.” But they noted a continuing concern about whether “repeated antenatal corticosteroids in FGR could increase the risk of ADHD.”
The research was funded by the National Health Medical Research Council of Australia, the Health Research Council of New Zealand and the Auckland Medical Research Foundation. One coauthor reported receiving grants from National Health and Medical Research Council of Australia, and a second coauthor received grants from the Auckland Medical Research Foundation.
SOURCE: Cartwright RD et al. JAMA Netw Open. 2019 Feb 1. doi:10.1001/jamanetworkopen.2018.7636.
Administering prenatal corticosteroids to women at risk for preterm birth does not appear to contribute to adverse neurocognitive function in children 6-8 years later, regardless of whether they had fetal growth restriction, a new study found.
Women at less than 32 weeks’ gestation are recommended to receive multiple betamethasone doses if they have a high ongoing risk of preterm birth. However, concern existed regarding possible effects of these steroid doses on the infant in later childhood, particularly in cases of fetal growth restriction (FGR) because of “animal studies suggesting long-term adverse effects of treatment on neurosensory function,” Robert D. Cartwright of the University of Auckland (New Zealand), and his associates reported in JAMA Network Open.
Yet no such effects were identified in this preplanned follow-up analysis of the placebo-controlled, randomized Australasian Collaborative Trial of Repeat Doses of Corticosteroids (ACTORDS). “Physicians should use repeated doses of antenatal corticosteroids when indicated before preterm birth, regardless of fetal growth restriction, in view of the associated neonatal benefits and absence of later adverse effects,” the authors concluded.
The original ACTORDS study involved 982 women pregnant with 1,146 fetuses at 23 hospitals throughout Australia and New Zealand, enrolled from April 1998 to July 2004. All enrolled women were less than 32 weeks’ gestation, had received an initial course of corticosteroids, and had an ongoing risk of preterm birth at least 7 days later.
Women were randomly assigned to receive an intramuscular dose of betamethasone or saline placebo weekly until birth or preterm birth risk abated. The current follow-up, when children were 6-8 years old, was planned during the 2-year follow-up. Children underwent a pediatrician’s physical and neurologic exam, vision and hearing screening, and fine and gross motor testing. A psychologist tested children’s IQ, attention, executive function, and academic skills using standardized, validated assessment tools. Caregivers also rated children’s behavioral and emotional problems, executive function abilities, and attention in questionnaires.
Among 988 of 1,059 surviving children assessed, FGR occurred in 28% of children exposed to betamethasone and 25% in the placebo group.
For the primary outcomes, rates of disability-free survival were similar in both the placebo and betamethasone groups for children with (odds ratio, 1.1) and without FGR (OR, 1.0). Rates also were similar for death or survival with moderate to severe disability (FGR: OR, 0.9; and non-FGR: OR, 0.8).
“Some evidence suggested a differential effect for several secondary outcomes, with better scores for selective and divided attention after exposure to repeated antenatal betamethasone in children with FGR, but poorer scores for impulse control in children without FGR,” Dr. Cartwright and his associates reported. “These effects were small and of uncertain clinical significance and may reflect type I error.
“For all other measures of neurocognitive function and learning, exposure to repeated antenatal betamethasone treatment did not alter performance in midchildhood, even in the presence of FGR,” they added.
Children with FGR had an increased risk of death or moderate to severe disability, compared with children without FGR, regardless of treatment group. Those with FGR also had greater risk of motor impairment.
One possible reason for not finding adverse neurocognitive effects in the betamethasone group is “that infants with fetal growth restriction appeared to have greater benefit from repeated antenatal corticosteroid therapy, with a nearly twofold reduction in serious neonatal morbidity,” the authors surmised. “Thus, the decrease in serious postnatal complications may have counteracted any potential adverse effects of corticosteroid exposure.” But they noted a continuing concern about whether “repeated antenatal corticosteroids in FGR could increase the risk of ADHD.”
The research was funded by the National Health Medical Research Council of Australia, the Health Research Council of New Zealand and the Auckland Medical Research Foundation. One coauthor reported receiving grants from National Health and Medical Research Council of Australia, and a second coauthor received grants from the Auckland Medical Research Foundation.
SOURCE: Cartwright RD et al. JAMA Netw Open. 2019 Feb 1. doi:10.1001/jamanetworkopen.2018.7636.
Administering prenatal corticosteroids to women at risk for preterm birth does not appear to contribute to adverse neurocognitive function in children 6-8 years later, regardless of whether they had fetal growth restriction, a new study found.
Women at less than 32 weeks’ gestation are recommended to receive multiple betamethasone doses if they have a high ongoing risk of preterm birth. However, concern existed regarding possible effects of these steroid doses on the infant in later childhood, particularly in cases of fetal growth restriction (FGR) because of “animal studies suggesting long-term adverse effects of treatment on neurosensory function,” Robert D. Cartwright of the University of Auckland (New Zealand), and his associates reported in JAMA Network Open.
Yet no such effects were identified in this preplanned follow-up analysis of the placebo-controlled, randomized Australasian Collaborative Trial of Repeat Doses of Corticosteroids (ACTORDS). “Physicians should use repeated doses of antenatal corticosteroids when indicated before preterm birth, regardless of fetal growth restriction, in view of the associated neonatal benefits and absence of later adverse effects,” the authors concluded.
The original ACTORDS study involved 982 women pregnant with 1,146 fetuses at 23 hospitals throughout Australia and New Zealand, enrolled from April 1998 to July 2004. All enrolled women were less than 32 weeks’ gestation, had received an initial course of corticosteroids, and had an ongoing risk of preterm birth at least 7 days later.
Women were randomly assigned to receive an intramuscular dose of betamethasone or saline placebo weekly until birth or preterm birth risk abated. The current follow-up, when children were 6-8 years old, was planned during the 2-year follow-up. Children underwent a pediatrician’s physical and neurologic exam, vision and hearing screening, and fine and gross motor testing. A psychologist tested children’s IQ, attention, executive function, and academic skills using standardized, validated assessment tools. Caregivers also rated children’s behavioral and emotional problems, executive function abilities, and attention in questionnaires.
Among 988 of 1,059 surviving children assessed, FGR occurred in 28% of children exposed to betamethasone and 25% in the placebo group.
For the primary outcomes, rates of disability-free survival were similar in both the placebo and betamethasone groups for children with (odds ratio, 1.1) and without FGR (OR, 1.0). Rates also were similar for death or survival with moderate to severe disability (FGR: OR, 0.9; and non-FGR: OR, 0.8).
“Some evidence suggested a differential effect for several secondary outcomes, with better scores for selective and divided attention after exposure to repeated antenatal betamethasone in children with FGR, but poorer scores for impulse control in children without FGR,” Dr. Cartwright and his associates reported. “These effects were small and of uncertain clinical significance and may reflect type I error.
“For all other measures of neurocognitive function and learning, exposure to repeated antenatal betamethasone treatment did not alter performance in midchildhood, even in the presence of FGR,” they added.
Children with FGR had an increased risk of death or moderate to severe disability, compared with children without FGR, regardless of treatment group. Those with FGR also had greater risk of motor impairment.
One possible reason for not finding adverse neurocognitive effects in the betamethasone group is “that infants with fetal growth restriction appeared to have greater benefit from repeated antenatal corticosteroid therapy, with a nearly twofold reduction in serious neonatal morbidity,” the authors surmised. “Thus, the decrease in serious postnatal complications may have counteracted any potential adverse effects of corticosteroid exposure.” But they noted a continuing concern about whether “repeated antenatal corticosteroids in FGR could increase the risk of ADHD.”
The research was funded by the National Health Medical Research Council of Australia, the Health Research Council of New Zealand and the Auckland Medical Research Foundation. One coauthor reported receiving grants from National Health and Medical Research Council of Australia, and a second coauthor received grants from the Auckland Medical Research Foundation.
SOURCE: Cartwright RD et al. JAMA Netw Open. 2019 Feb 1. doi:10.1001/jamanetworkopen.2018.7636.
FROM JAMA NETWORK OPEN
‘Telereferrals’ improved mental health referral follow-through
Children referred for mental health services in Los Angeles County using a telehealth referral were three times more likely to complete a community mental health clinic (CMHC) screening than children receiving conventional mental health referrals, a study found.
“Our findings highlight the importance of this initial access point for a successful referral to the CHMC,” Tumaini R. Coker, MD, MBA, of the University of Washington, Seattle, and Seattle Children’s Research Institute, and her colleagues wrote in Pediatrics. “We can hypothesize that the assistance from the telehealth care coordinator may have played an important role in access for families.”
Although this study was not powered to compare psychological health or quality-of-life differences, a larger study with a longer follow-up period may allow study of “variation in health outcomes … among a sample of all who were initially referred, particularly if the higher rates of access for children in the intervention translate into a greater proportion of children receiving services,” the authors wrote.
The research group partnered with two community mental health clinics (CMHCs) and six federally qualified health center clinics, the latter randomly assigned as control or intervention. The telehealth-enhanced referral process developed by the researchers involved patients at the intervention clinics viewing a video orientation to the CMHC and then participating in a live video conference for screening. Completion of the referral screening visit was the measure for CMHC access as a primary endpoint.
Among the 342 children, aged 5-12 years (average, 9 years), enrolled in the study, 87% were Latino, and 62% were boys.
Of children using the telehealth referral process, 80% completed an initial CMHC screening, compared to 64% of children receiving referrals via usual care procedures, resulting in three-times greater odds of a screening in the intervention group (adjusted odds ratio, 3.02).
It took approximately 6 more days for the telehealth-referred children to complete the screening.
“The increased time to the initial access point was anticipated for the intervention clinics because the telehealth care coordinator and CMHC staff held all the videoconference screening visits on a single preselected day each week,” which thereby limited availability of slots for screenings, Dr. Coker and her associates wrote.
Children who received telehealth-enabled referrals reported higher satisfaction levels with the referral system and with care, compared with those using usual care methods. Of the 342 children in the study, 213 were considered eligible to receive CMHC services. Reasons for ineligibility for services included presence of a developmental disability, lack of an mental health need, private health insurance coverage, a zip code outside of the CMHC’s catchment area, and not meeting income requirements.
Of those 213, 80% of the intervention group and 84% of controls subsequently had a mental health visit.
A study limitation is its personalization to the community partners involved, which may require different procedures in other settings, the authors noted. The study also did not look at the quality of mental health services received after initial screenings, precluding the ability to assess clinical outcomes. In addition, “the CMHCs did not involve the payers of mental health care for this population, limiting our capacity to identify barriers and system solutions that may improve the intervention’s sustainability,” the authors wrote.
The research was funded by grants from the Patient-Centered Outcomes Research Institute and the California Community Foundation. The authors reported having no relevant financial disclosures.
SOURCE: Coker TR et al. Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-2738.
Despite the challenges of meeting patients’ and their families’ mental and behavioral needs, Coker et al. “had the courage to think outside the box to solve a practice and community need,” Susan J. Kressly, MD, is in private practice in Warrington, Pa., wrote in an accompanying editorial.
Some practices have been able to fully integrate a mental health service within their practice, usually on-site, but that model does not work for everyone. Space and privacy can be problematic, depending on the practice, and payment models can become complex, especially when mental health benefits are not managed by the same payer or through the same plan as other health insurance benefits, Dr. Kressly noted.
“The innovative model in this study combines a ‘soft hand-off’ referral model and takes advantage of telehealth technology for implementation,” she wrote. Families frequently do not follow through on recommendations and referrals, but practices can improve follow-through when they make personal introductions and appointments from their own practice. And using technology to do so can particularly resonate with the generations of children and parents now coming to pediatric practices.
“As pediatricians, we have a unique opportunity to provide care to families who are digital natives,” Dr. Kressly wrote. “As part of the family’s health care team, if we truly decide to put the patient and family at the center, pediatricians should examine their own hesitancy and trepidation regarding telehealth and technology-enabled communications and work to overcome them.”
Other ways to use telehealth beyond the referral system described by Coker et al. might include providing actual telepsychiatry visits at the child’s medical home or connecting families to local resources.
“Those practices that innovate to solve their problems by extending their medical home to include care teams outside their practice walls will likely see improved family satisfaction and, hopefully, improved outcomes,” Dr. Kressly suggested.
Dr. Kressly is in private practice in Warrington, Pa. She used no external funding and has no financial conflicts to report. These comments are condensed and summarized from her editorial accompanying the article by Coker et al (Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-3765).
Despite the challenges of meeting patients’ and their families’ mental and behavioral needs, Coker et al. “had the courage to think outside the box to solve a practice and community need,” Susan J. Kressly, MD, is in private practice in Warrington, Pa., wrote in an accompanying editorial.
Some practices have been able to fully integrate a mental health service within their practice, usually on-site, but that model does not work for everyone. Space and privacy can be problematic, depending on the practice, and payment models can become complex, especially when mental health benefits are not managed by the same payer or through the same plan as other health insurance benefits, Dr. Kressly noted.
“The innovative model in this study combines a ‘soft hand-off’ referral model and takes advantage of telehealth technology for implementation,” she wrote. Families frequently do not follow through on recommendations and referrals, but practices can improve follow-through when they make personal introductions and appointments from their own practice. And using technology to do so can particularly resonate with the generations of children and parents now coming to pediatric practices.
“As pediatricians, we have a unique opportunity to provide care to families who are digital natives,” Dr. Kressly wrote. “As part of the family’s health care team, if we truly decide to put the patient and family at the center, pediatricians should examine their own hesitancy and trepidation regarding telehealth and technology-enabled communications and work to overcome them.”
Other ways to use telehealth beyond the referral system described by Coker et al. might include providing actual telepsychiatry visits at the child’s medical home or connecting families to local resources.
“Those practices that innovate to solve their problems by extending their medical home to include care teams outside their practice walls will likely see improved family satisfaction and, hopefully, improved outcomes,” Dr. Kressly suggested.
Dr. Kressly is in private practice in Warrington, Pa. She used no external funding and has no financial conflicts to report. These comments are condensed and summarized from her editorial accompanying the article by Coker et al (Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-3765).
Despite the challenges of meeting patients’ and their families’ mental and behavioral needs, Coker et al. “had the courage to think outside the box to solve a practice and community need,” Susan J. Kressly, MD, is in private practice in Warrington, Pa., wrote in an accompanying editorial.
Some practices have been able to fully integrate a mental health service within their practice, usually on-site, but that model does not work for everyone. Space and privacy can be problematic, depending on the practice, and payment models can become complex, especially when mental health benefits are not managed by the same payer or through the same plan as other health insurance benefits, Dr. Kressly noted.
“The innovative model in this study combines a ‘soft hand-off’ referral model and takes advantage of telehealth technology for implementation,” she wrote. Families frequently do not follow through on recommendations and referrals, but practices can improve follow-through when they make personal introductions and appointments from their own practice. And using technology to do so can particularly resonate with the generations of children and parents now coming to pediatric practices.
“As pediatricians, we have a unique opportunity to provide care to families who are digital natives,” Dr. Kressly wrote. “As part of the family’s health care team, if we truly decide to put the patient and family at the center, pediatricians should examine their own hesitancy and trepidation regarding telehealth and technology-enabled communications and work to overcome them.”
Other ways to use telehealth beyond the referral system described by Coker et al. might include providing actual telepsychiatry visits at the child’s medical home or connecting families to local resources.
“Those practices that innovate to solve their problems by extending their medical home to include care teams outside their practice walls will likely see improved family satisfaction and, hopefully, improved outcomes,” Dr. Kressly suggested.
Dr. Kressly is in private practice in Warrington, Pa. She used no external funding and has no financial conflicts to report. These comments are condensed and summarized from her editorial accompanying the article by Coker et al (Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-3765).
Children referred for mental health services in Los Angeles County using a telehealth referral were three times more likely to complete a community mental health clinic (CMHC) screening than children receiving conventional mental health referrals, a study found.
“Our findings highlight the importance of this initial access point for a successful referral to the CHMC,” Tumaini R. Coker, MD, MBA, of the University of Washington, Seattle, and Seattle Children’s Research Institute, and her colleagues wrote in Pediatrics. “We can hypothesize that the assistance from the telehealth care coordinator may have played an important role in access for families.”
Although this study was not powered to compare psychological health or quality-of-life differences, a larger study with a longer follow-up period may allow study of “variation in health outcomes … among a sample of all who were initially referred, particularly if the higher rates of access for children in the intervention translate into a greater proportion of children receiving services,” the authors wrote.
The research group partnered with two community mental health clinics (CMHCs) and six federally qualified health center clinics, the latter randomly assigned as control or intervention. The telehealth-enhanced referral process developed by the researchers involved patients at the intervention clinics viewing a video orientation to the CMHC and then participating in a live video conference for screening. Completion of the referral screening visit was the measure for CMHC access as a primary endpoint.
Among the 342 children, aged 5-12 years (average, 9 years), enrolled in the study, 87% were Latino, and 62% were boys.
Of children using the telehealth referral process, 80% completed an initial CMHC screening, compared to 64% of children receiving referrals via usual care procedures, resulting in three-times greater odds of a screening in the intervention group (adjusted odds ratio, 3.02).
It took approximately 6 more days for the telehealth-referred children to complete the screening.
“The increased time to the initial access point was anticipated for the intervention clinics because the telehealth care coordinator and CMHC staff held all the videoconference screening visits on a single preselected day each week,” which thereby limited availability of slots for screenings, Dr. Coker and her associates wrote.
Children who received telehealth-enabled referrals reported higher satisfaction levels with the referral system and with care, compared with those using usual care methods. Of the 342 children in the study, 213 were considered eligible to receive CMHC services. Reasons for ineligibility for services included presence of a developmental disability, lack of an mental health need, private health insurance coverage, a zip code outside of the CMHC’s catchment area, and not meeting income requirements.
Of those 213, 80% of the intervention group and 84% of controls subsequently had a mental health visit.
A study limitation is its personalization to the community partners involved, which may require different procedures in other settings, the authors noted. The study also did not look at the quality of mental health services received after initial screenings, precluding the ability to assess clinical outcomes. In addition, “the CMHCs did not involve the payers of mental health care for this population, limiting our capacity to identify barriers and system solutions that may improve the intervention’s sustainability,” the authors wrote.
The research was funded by grants from the Patient-Centered Outcomes Research Institute and the California Community Foundation. The authors reported having no relevant financial disclosures.
SOURCE: Coker TR et al. Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-2738.
Children referred for mental health services in Los Angeles County using a telehealth referral were three times more likely to complete a community mental health clinic (CMHC) screening than children receiving conventional mental health referrals, a study found.
“Our findings highlight the importance of this initial access point for a successful referral to the CHMC,” Tumaini R. Coker, MD, MBA, of the University of Washington, Seattle, and Seattle Children’s Research Institute, and her colleagues wrote in Pediatrics. “We can hypothesize that the assistance from the telehealth care coordinator may have played an important role in access for families.”
Although this study was not powered to compare psychological health or quality-of-life differences, a larger study with a longer follow-up period may allow study of “variation in health outcomes … among a sample of all who were initially referred, particularly if the higher rates of access for children in the intervention translate into a greater proportion of children receiving services,” the authors wrote.
The research group partnered with two community mental health clinics (CMHCs) and six federally qualified health center clinics, the latter randomly assigned as control or intervention. The telehealth-enhanced referral process developed by the researchers involved patients at the intervention clinics viewing a video orientation to the CMHC and then participating in a live video conference for screening. Completion of the referral screening visit was the measure for CMHC access as a primary endpoint.
Among the 342 children, aged 5-12 years (average, 9 years), enrolled in the study, 87% were Latino, and 62% were boys.
Of children using the telehealth referral process, 80% completed an initial CMHC screening, compared to 64% of children receiving referrals via usual care procedures, resulting in three-times greater odds of a screening in the intervention group (adjusted odds ratio, 3.02).
It took approximately 6 more days for the telehealth-referred children to complete the screening.
“The increased time to the initial access point was anticipated for the intervention clinics because the telehealth care coordinator and CMHC staff held all the videoconference screening visits on a single preselected day each week,” which thereby limited availability of slots for screenings, Dr. Coker and her associates wrote.
Children who received telehealth-enabled referrals reported higher satisfaction levels with the referral system and with care, compared with those using usual care methods. Of the 342 children in the study, 213 were considered eligible to receive CMHC services. Reasons for ineligibility for services included presence of a developmental disability, lack of an mental health need, private health insurance coverage, a zip code outside of the CMHC’s catchment area, and not meeting income requirements.
Of those 213, 80% of the intervention group and 84% of controls subsequently had a mental health visit.
A study limitation is its personalization to the community partners involved, which may require different procedures in other settings, the authors noted. The study also did not look at the quality of mental health services received after initial screenings, precluding the ability to assess clinical outcomes. In addition, “the CMHCs did not involve the payers of mental health care for this population, limiting our capacity to identify barriers and system solutions that may improve the intervention’s sustainability,” the authors wrote.
The research was funded by grants from the Patient-Centered Outcomes Research Institute and the California Community Foundation. The authors reported having no relevant financial disclosures.
SOURCE: Coker TR et al. Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-2738.
FROM PEDIATRICS
Key clinical point: Use of telehealth referrals increased children’s access to mental health services in an urban county.
Major finding:
Study details: The findings are based on a multisite, randomized, controlled trial that included 342 children, aged 5-12 years, at two community mental health clinics and six federally qualified health center clinics in Los Angeles County.
Disclosures: The research was funded by the Patient-Centered Outcomes Research Institute and the California Community Foundation. The authors reported having no relevant financial disclosures.
Source: Coker TR et al. Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-2738.
