User login
Asthma step-up therapy in children improves outcomes
SAN FRANCISCO – Stepping up pharmacotherapy in children with poorly controlled asthma resulted in fewer asthma-related emergency department (ED) visits and inpatient stays than maintaining current medication therapy, a study found.
Perhaps surprisingly, however, the patients with the worst outcomes were those who were told only to improve their medication adherence, said Dane Snyder, MD, a physician at Nationwide Children’s Hospital who is also in the department of pediatrics at Ohio State University, Columbus.
Asthma affects nearly 1 in 10 children, and national guidelines recommend step-up asthma pharmacotherapy in patients with poorly controlled asthma. The researchers assessed the impact of step-up therapy on inpatient care, and emergency and urgent care visits for children with poor asthma control in the Nationwide Children’s Hospital Primary Care Network in Columbus, Ohio. More than 10,000 asthma patients are treated at the 12 clinics in the network, and the study was part of a quality improvement initiative starting in July 2015.
Between August and October 2015, researchers used documentation in a standard asthma note to identify 908 patients aged 2-18 years who had poor asthma control based on their Asthma Control Test (ACT) score and history. Of these patients, 463 with a mean ACT score of 15.8 were assigned to step-up pharmacotherapy, while 445 with a mean ACT of 16.2 were not. The two groups also were similar in their use of unscheduled health care utilization in the 12 months before the study period.
Over the next 12 months, 1.3% of patients receiving step-up therapy had inpatient stays, compared with 4% in the other group, translating to a 68% lower risk of admission with step-up therapy (relative risk, 0.316; P = .01). Those receiving step-up therapy also were 37% less likely to visit the ED for asthma, with 7.1% of ED visits for those with step-up therapy and 11.2% of visits for those without it (RR, 0.634; P = .032). Visits to urgent care, however, showed no significant difference between those receiving step-up therapy (10.8%) and those who had not (10.3%).
After comparing these findings, the researchers went back and manually reviewed all 463 charts of the group who received step-up therapy to determine whether the children actually did receive a step up in therapy. Nearly a quarter (23%) of the children in the intervention group simply resumed taking their previously prescribed mediation, and 8% took allergy medication. The remaining 69% had step-up therapy.
The researchers then reanalyzed the data among those who truly had step-up pharmacotherapy, those who did not, and those who resumed taking their prior medication. The difference in inpatient admissions remained the same because none of the children who had resumed medication were admitted.
ED visits showed a more gradual distribution: 7.3% of those receiving step-up therapy, 8.4% of those who resumed taking their medication, and 11% of those with no intervention went to the ED. But these differences did not reach statistical significance.
Similarly, the differences among the three groups in urgent care visits was not statistically significant, but 15% of those who resumed taking prior medication had urgent care visits, compared with 10.3% of those with step-up therapy and 9.2% of those in the control group.
Those findings suggest that “stepping up pharmacotherapy, even in the face of controller nonadherence, can improve outcomes,” Dr. Snyder told his colleagues.
“While challenging, management changes in a large primary care network are possible,” Dr. Snyder said. He also emphasized that manually auditing bulk data, as they did with the 463 records, can be important in assessing outcomes of quality improvement measures.
The research did not use external funding, and Dr. Snyder had no disclosures.
SAN FRANCISCO – Stepping up pharmacotherapy in children with poorly controlled asthma resulted in fewer asthma-related emergency department (ED) visits and inpatient stays than maintaining current medication therapy, a study found.
Perhaps surprisingly, however, the patients with the worst outcomes were those who were told only to improve their medication adherence, said Dane Snyder, MD, a physician at Nationwide Children’s Hospital who is also in the department of pediatrics at Ohio State University, Columbus.
Asthma affects nearly 1 in 10 children, and national guidelines recommend step-up asthma pharmacotherapy in patients with poorly controlled asthma. The researchers assessed the impact of step-up therapy on inpatient care, and emergency and urgent care visits for children with poor asthma control in the Nationwide Children’s Hospital Primary Care Network in Columbus, Ohio. More than 10,000 asthma patients are treated at the 12 clinics in the network, and the study was part of a quality improvement initiative starting in July 2015.
Between August and October 2015, researchers used documentation in a standard asthma note to identify 908 patients aged 2-18 years who had poor asthma control based on their Asthma Control Test (ACT) score and history. Of these patients, 463 with a mean ACT score of 15.8 were assigned to step-up pharmacotherapy, while 445 with a mean ACT of 16.2 were not. The two groups also were similar in their use of unscheduled health care utilization in the 12 months before the study period.
Over the next 12 months, 1.3% of patients receiving step-up therapy had inpatient stays, compared with 4% in the other group, translating to a 68% lower risk of admission with step-up therapy (relative risk, 0.316; P = .01). Those receiving step-up therapy also were 37% less likely to visit the ED for asthma, with 7.1% of ED visits for those with step-up therapy and 11.2% of visits for those without it (RR, 0.634; P = .032). Visits to urgent care, however, showed no significant difference between those receiving step-up therapy (10.8%) and those who had not (10.3%).
After comparing these findings, the researchers went back and manually reviewed all 463 charts of the group who received step-up therapy to determine whether the children actually did receive a step up in therapy. Nearly a quarter (23%) of the children in the intervention group simply resumed taking their previously prescribed mediation, and 8% took allergy medication. The remaining 69% had step-up therapy.
The researchers then reanalyzed the data among those who truly had step-up pharmacotherapy, those who did not, and those who resumed taking their prior medication. The difference in inpatient admissions remained the same because none of the children who had resumed medication were admitted.
ED visits showed a more gradual distribution: 7.3% of those receiving step-up therapy, 8.4% of those who resumed taking their medication, and 11% of those with no intervention went to the ED. But these differences did not reach statistical significance.
Similarly, the differences among the three groups in urgent care visits was not statistically significant, but 15% of those who resumed taking prior medication had urgent care visits, compared with 10.3% of those with step-up therapy and 9.2% of those in the control group.
Those findings suggest that “stepping up pharmacotherapy, even in the face of controller nonadherence, can improve outcomes,” Dr. Snyder told his colleagues.
“While challenging, management changes in a large primary care network are possible,” Dr. Snyder said. He also emphasized that manually auditing bulk data, as they did with the 463 records, can be important in assessing outcomes of quality improvement measures.
The research did not use external funding, and Dr. Snyder had no disclosures.
SAN FRANCISCO – Stepping up pharmacotherapy in children with poorly controlled asthma resulted in fewer asthma-related emergency department (ED) visits and inpatient stays than maintaining current medication therapy, a study found.
Perhaps surprisingly, however, the patients with the worst outcomes were those who were told only to improve their medication adherence, said Dane Snyder, MD, a physician at Nationwide Children’s Hospital who is also in the department of pediatrics at Ohio State University, Columbus.
Asthma affects nearly 1 in 10 children, and national guidelines recommend step-up asthma pharmacotherapy in patients with poorly controlled asthma. The researchers assessed the impact of step-up therapy on inpatient care, and emergency and urgent care visits for children with poor asthma control in the Nationwide Children’s Hospital Primary Care Network in Columbus, Ohio. More than 10,000 asthma patients are treated at the 12 clinics in the network, and the study was part of a quality improvement initiative starting in July 2015.
Between August and October 2015, researchers used documentation in a standard asthma note to identify 908 patients aged 2-18 years who had poor asthma control based on their Asthma Control Test (ACT) score and history. Of these patients, 463 with a mean ACT score of 15.8 were assigned to step-up pharmacotherapy, while 445 with a mean ACT of 16.2 were not. The two groups also were similar in their use of unscheduled health care utilization in the 12 months before the study period.
Over the next 12 months, 1.3% of patients receiving step-up therapy had inpatient stays, compared with 4% in the other group, translating to a 68% lower risk of admission with step-up therapy (relative risk, 0.316; P = .01). Those receiving step-up therapy also were 37% less likely to visit the ED for asthma, with 7.1% of ED visits for those with step-up therapy and 11.2% of visits for those without it (RR, 0.634; P = .032). Visits to urgent care, however, showed no significant difference between those receiving step-up therapy (10.8%) and those who had not (10.3%).
After comparing these findings, the researchers went back and manually reviewed all 463 charts of the group who received step-up therapy to determine whether the children actually did receive a step up in therapy. Nearly a quarter (23%) of the children in the intervention group simply resumed taking their previously prescribed mediation, and 8% took allergy medication. The remaining 69% had step-up therapy.
The researchers then reanalyzed the data among those who truly had step-up pharmacotherapy, those who did not, and those who resumed taking their prior medication. The difference in inpatient admissions remained the same because none of the children who had resumed medication were admitted.
ED visits showed a more gradual distribution: 7.3% of those receiving step-up therapy, 8.4% of those who resumed taking their medication, and 11% of those with no intervention went to the ED. But these differences did not reach statistical significance.
Similarly, the differences among the three groups in urgent care visits was not statistically significant, but 15% of those who resumed taking prior medication had urgent care visits, compared with 10.3% of those with step-up therapy and 9.2% of those in the control group.
Those findings suggest that “stepping up pharmacotherapy, even in the face of controller nonadherence, can improve outcomes,” Dr. Snyder told his colleagues.
“While challenging, management changes in a large primary care network are possible,” Dr. Snyder said. He also emphasized that manually auditing bulk data, as they did with the 463 records, can be important in assessing outcomes of quality improvement measures.
The research did not use external funding, and Dr. Snyder had no disclosures.
AT PAS 2017
Key clinical point:
Major finding: Children with poorly controlled asthma receiving step-up pharmacotherapy had a 68% lower risk of inpatient admission and 37% lower risk of emergency department visits for asthma (P less than .05).
Data source: The findings are based on a nonrandomized trial of 903 children, aged 2-18 years, tracked for 12 months in the Nationwide Children’s Hospital Primary Care Network in Columbus, Ohio.
Disclosures: The research did not use external funding, and Dr. Snyder had no disclosures.
Infants’ responses to multiple vaccines affected by maternal antibodies
Maternal antibody concentrations continue to affect children’s immune response to their first and later vaccine doses as late as age 2 years, according to study findings.
Greater spacing between doses did not eliminate the maternal antibody effects, the research published in JAMA Pediatrics showed.
“Our analysis comprehensively models the effects of maternal antibody inhibition and infant age at vaccination on the majority of vaccine antigens contained in current global infant immunization programs and reveals that, for almost all antigens, transplacental antibody inhibits the antibody response to priming vaccinations,” wrote Merryn Voysey of the University of Oxford (England), and her associates.
Booster doses do not diminish the effect, the authors add. “These analyses further reveal the benefit of infants being older when first immunized, an association that remains after adjusting for waning maternal antibody levels” (JAMA Pediatrics. 2017 May 15. doi: 10.1001/jamapediatrics.2017.0638).
Although the blunting from maternal antibodies has been long understood for the measles vaccine, this new study showed that even conjugate vaccines have this blunting in infancy, both due to “preexisting antibodies to the polysaccharide antigen [and] from antibodies associated with carrier proteins,” the authors wrote, referring to findings related to pneumococcal conjugate vaccines.
“Therefore, prenatal immunization programs containing multicomponent vaccines have the potential to interfere with the immunogenicity of current immunization programs,” Ms. Voysey and her colleagues wrote.
The authors requested and then analyzed deidentified participant data from GlaxoSmithKline vaccine immunogenicity clinical trials in which antibody concentration data were available before and after infants’ first vaccine dose. The analysis included 7,630 infants enrolled in 32 studies in 17 countries from Europe, Africa, Latin America, East Asia, Russia, and Australia. About half were boys, and infants’ mean age at baseline was 9 weeks.
The researchers found that infants’ antibody responses were blunted for 20 of 21 antigens due to maternal antibodies they still had. The inactivated polio vaccine was affected the most: a maternal antibody twice as high as other infants’ resulted in a 20% lower antibody geometric mean ratio for type 1 and a 28% lower antibody geometric mean ratio for type 2 after vaccination.
All three vaccines in the DTaP showed inhibited responses as well. Having twice as high a maternal antibody for acellular pertussis antigens resulted in an 11% reduction in infants’ antibody for both pertussis toxoid and filamentous hemagglutinin. Antibody for pertactin was 22% lower. Double the maternal antibody for tetanus translated to 13% lower response, and diphtheria antibody was similarly 24% lower.
Even at 12-24 months, children showed a blunted response due to maternal antibodies for the acellular pertussis, inactivated polio, and diphtheria vaccines. For each additional month of age children were when first immunized, their antibody response ranged from 10%-71% greater for 18 of 21 antigens, after accounting for the influence of maternal antibodies.
“In contrast to previous reports, the effects of maternal antibodies and the infant’s age when first immunized are not only seen in response to a priming series of vaccines, but continue to affect antibody responses to booster vaccinations at ages 12 to 24 months for many antigens,” the authors reported. “This finding suggests the importance of the quality of the immune response to the first dose of antigen, regardless of subsequent doses.”
For example, delaying administration of a first vaccine dose by 2-5 weeks resulted in offsetting a two- to fivefold greater concentration of maternal pertussis antibodies. To offset similarly higher maternal antibody concentrations for the other components of the DTaP would require a delay of 3-6 weeks for diphtheria and 2-4 weeks for tetanus.
The research funding came from the National Institute for Health Research via a fellowship of one author and salary support of another. Ms. Voysey had no relevant financial disclosures. Most of her colleagues received research grants or other assistance from pharmaceutical companies.
Maternal antibody concentrations continue to affect children’s immune response to their first and later vaccine doses as late as age 2 years, according to study findings.
Greater spacing between doses did not eliminate the maternal antibody effects, the research published in JAMA Pediatrics showed.
“Our analysis comprehensively models the effects of maternal antibody inhibition and infant age at vaccination on the majority of vaccine antigens contained in current global infant immunization programs and reveals that, for almost all antigens, transplacental antibody inhibits the antibody response to priming vaccinations,” wrote Merryn Voysey of the University of Oxford (England), and her associates.
Booster doses do not diminish the effect, the authors add. “These analyses further reveal the benefit of infants being older when first immunized, an association that remains after adjusting for waning maternal antibody levels” (JAMA Pediatrics. 2017 May 15. doi: 10.1001/jamapediatrics.2017.0638).
Although the blunting from maternal antibodies has been long understood for the measles vaccine, this new study showed that even conjugate vaccines have this blunting in infancy, both due to “preexisting antibodies to the polysaccharide antigen [and] from antibodies associated with carrier proteins,” the authors wrote, referring to findings related to pneumococcal conjugate vaccines.
“Therefore, prenatal immunization programs containing multicomponent vaccines have the potential to interfere with the immunogenicity of current immunization programs,” Ms. Voysey and her colleagues wrote.
The authors requested and then analyzed deidentified participant data from GlaxoSmithKline vaccine immunogenicity clinical trials in which antibody concentration data were available before and after infants’ first vaccine dose. The analysis included 7,630 infants enrolled in 32 studies in 17 countries from Europe, Africa, Latin America, East Asia, Russia, and Australia. About half were boys, and infants’ mean age at baseline was 9 weeks.
The researchers found that infants’ antibody responses were blunted for 20 of 21 antigens due to maternal antibodies they still had. The inactivated polio vaccine was affected the most: a maternal antibody twice as high as other infants’ resulted in a 20% lower antibody geometric mean ratio for type 1 and a 28% lower antibody geometric mean ratio for type 2 after vaccination.
All three vaccines in the DTaP showed inhibited responses as well. Having twice as high a maternal antibody for acellular pertussis antigens resulted in an 11% reduction in infants’ antibody for both pertussis toxoid and filamentous hemagglutinin. Antibody for pertactin was 22% lower. Double the maternal antibody for tetanus translated to 13% lower response, and diphtheria antibody was similarly 24% lower.
Even at 12-24 months, children showed a blunted response due to maternal antibodies for the acellular pertussis, inactivated polio, and diphtheria vaccines. For each additional month of age children were when first immunized, their antibody response ranged from 10%-71% greater for 18 of 21 antigens, after accounting for the influence of maternal antibodies.
“In contrast to previous reports, the effects of maternal antibodies and the infant’s age when first immunized are not only seen in response to a priming series of vaccines, but continue to affect antibody responses to booster vaccinations at ages 12 to 24 months for many antigens,” the authors reported. “This finding suggests the importance of the quality of the immune response to the first dose of antigen, regardless of subsequent doses.”
For example, delaying administration of a first vaccine dose by 2-5 weeks resulted in offsetting a two- to fivefold greater concentration of maternal pertussis antibodies. To offset similarly higher maternal antibody concentrations for the other components of the DTaP would require a delay of 3-6 weeks for diphtheria and 2-4 weeks for tetanus.
The research funding came from the National Institute for Health Research via a fellowship of one author and salary support of another. Ms. Voysey had no relevant financial disclosures. Most of her colleagues received research grants or other assistance from pharmaceutical companies.
Maternal antibody concentrations continue to affect children’s immune response to their first and later vaccine doses as late as age 2 years, according to study findings.
Greater spacing between doses did not eliminate the maternal antibody effects, the research published in JAMA Pediatrics showed.
“Our analysis comprehensively models the effects of maternal antibody inhibition and infant age at vaccination on the majority of vaccine antigens contained in current global infant immunization programs and reveals that, for almost all antigens, transplacental antibody inhibits the antibody response to priming vaccinations,” wrote Merryn Voysey of the University of Oxford (England), and her associates.
Booster doses do not diminish the effect, the authors add. “These analyses further reveal the benefit of infants being older when first immunized, an association that remains after adjusting for waning maternal antibody levels” (JAMA Pediatrics. 2017 May 15. doi: 10.1001/jamapediatrics.2017.0638).
Although the blunting from maternal antibodies has been long understood for the measles vaccine, this new study showed that even conjugate vaccines have this blunting in infancy, both due to “preexisting antibodies to the polysaccharide antigen [and] from antibodies associated with carrier proteins,” the authors wrote, referring to findings related to pneumococcal conjugate vaccines.
“Therefore, prenatal immunization programs containing multicomponent vaccines have the potential to interfere with the immunogenicity of current immunization programs,” Ms. Voysey and her colleagues wrote.
The authors requested and then analyzed deidentified participant data from GlaxoSmithKline vaccine immunogenicity clinical trials in which antibody concentration data were available before and after infants’ first vaccine dose. The analysis included 7,630 infants enrolled in 32 studies in 17 countries from Europe, Africa, Latin America, East Asia, Russia, and Australia. About half were boys, and infants’ mean age at baseline was 9 weeks.
The researchers found that infants’ antibody responses were blunted for 20 of 21 antigens due to maternal antibodies they still had. The inactivated polio vaccine was affected the most: a maternal antibody twice as high as other infants’ resulted in a 20% lower antibody geometric mean ratio for type 1 and a 28% lower antibody geometric mean ratio for type 2 after vaccination.
All three vaccines in the DTaP showed inhibited responses as well. Having twice as high a maternal antibody for acellular pertussis antigens resulted in an 11% reduction in infants’ antibody for both pertussis toxoid and filamentous hemagglutinin. Antibody for pertactin was 22% lower. Double the maternal antibody for tetanus translated to 13% lower response, and diphtheria antibody was similarly 24% lower.
Even at 12-24 months, children showed a blunted response due to maternal antibodies for the acellular pertussis, inactivated polio, and diphtheria vaccines. For each additional month of age children were when first immunized, their antibody response ranged from 10%-71% greater for 18 of 21 antigens, after accounting for the influence of maternal antibodies.
“In contrast to previous reports, the effects of maternal antibodies and the infant’s age when first immunized are not only seen in response to a priming series of vaccines, but continue to affect antibody responses to booster vaccinations at ages 12 to 24 months for many antigens,” the authors reported. “This finding suggests the importance of the quality of the immune response to the first dose of antigen, regardless of subsequent doses.”
For example, delaying administration of a first vaccine dose by 2-5 weeks resulted in offsetting a two- to fivefold greater concentration of maternal pertussis antibodies. To offset similarly higher maternal antibody concentrations for the other components of the DTaP would require a delay of 3-6 weeks for diphtheria and 2-4 weeks for tetanus.
The research funding came from the National Institute for Health Research via a fellowship of one author and salary support of another. Ms. Voysey had no relevant financial disclosures. Most of her colleagues received research grants or other assistance from pharmaceutical companies.
FROM JAMA PEDIATRICS
Key clinical point:
Major finding: Infants’ antibody concentrations after vaccination were inhibited for 20 of 21 antigens after a first dose and for 18 of 21 antigens up to 24 months later.
Data source: The findings are based on an analysis of pre- and postimmunization antibody concentrations to 21 vaccine antigens in 7,630 infants enrolled in 32 immunogenicity clinical studies in 17 countries.
Disclosures: The research funding came from the National Institute for Health Research via a fellowship of one author and salary support of another. Ms. Voysey had no relevant financial disclosures. Most of her colleagues received research grants or other assistance from pharmaceutical companies.
BMI z scores less accurate for teen obesity than new measure
A different measurement tool than body mass index (BMI) z scores was more accurate in assessing adolescents’ body fat percentage than BMI z scores, a study found.
More than twice as many adolescents aged 8-17 years were misclassified as overweight using BMI z scores than using triponderal mass index (TMI), which uses a formula for calculating a weight-to-height ratio, researchers reported. Obesity was similarly overreported with BMI z scores, compared with TMI scores.
They suggest that TMI therefore may be superior to BMI or BMI z scores in assessing adolescents’ weight at least among non-Hispanic whites, although further studies would need to assess TMI as an assessment tool in other racial/ethnic groups.
The standard formula for adult BMI – weight in kilograms divided by height in meters squared – has been known to be inappropriate for children and teens for more than a century because their proportions change with age. The currently established alternative of using youth’s BMI percentiles for their age in the BMI z system, however, “fails to take into account that both body proportions and body fat levels change during adolescent growth in a way that is inconsistent with BMI,” the authors wrote (JAMA Pediatrics. 2017 May 15. doi: 10.1001/jamapediatrics.2017.0460).
They therefore explored other methods of assessing appropriate weight ranges for adolescents and compared them with BMI, using dual-energy x-ray absorptiometry findings and anthropometric data collected from 4,398 non-Hispanic white participants, aged 8-29 years, in U.S. National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2006.
Dr. Peterson’s team first evaluated the value of using BMI by looking at the following:
• How percent body fat influences the timing of the adolescent growth spurt in height.
• How percent body fat varies by age.
• How body proportions scale during adolescence.
Then they explored changing the exponent in the weight-to-height formula to see which alternatives might result in a measurement that’s more stable with an individuals’ age, more accurate in estimating body fat percentage, and more accurate in identifying which youths are overweight.
“In girls and women, percent body fat increased with age and reached a plateau by age 18 years, rising from a mean of 31.2% at age 8-9 years to 36.4% at ages 25-29 years (P less than .001),” the authors wrote. “By contrast, in boys and men, percent body fat decreased from a mean of 27.8%-23.0% between ages 12-13 years and 14-15 years (P less than .001) before stabilizing at approximately 25%-26% for ages 20 years and older.”
Because variations in body fat percentage occurred with both age and height in adolescence, Dr. Peterson and her associates concluded that the usual BMI weight-to-height formula is not ideal for assessing body fat in youth. The better alternative, they found, uses the formula of weight divided by height cubed (instead of squared), called triponderal mass index (TMI).
The threshold for overweight status with TMI was 16.0 kg/m3 for boys and 16.8 kg/m3 for girls. For obesity, the threshold was 18.8 kg/m3 for boys and 19.7 kg/m3 for girls. Using TMI instead of BMI resulted in improved stability with age and estimated percent body fat for those aged 8-17 years.
In addition, using BMI z scores misclassified 19.4% of adolescents as overweight instead of a healthy weight whereas TMI only misclassified 8.4% of youth as such in the same data set. BMI z scores also classified more youth as obese (11.3%), compared with TMI (8%).
The research was funded by the National Center for Advancing Translational Sciences and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. One investigator serves on the medical advisory boards for Medifast and Rice Lake Weighing System, unrelated to this study. Another investigator helped develop a trademarked smartphone weight loss intervention app called SmartLoss, whose licensing could benefit that investigator and Montclair State University.
A different measurement tool than body mass index (BMI) z scores was more accurate in assessing adolescents’ body fat percentage than BMI z scores, a study found.
More than twice as many adolescents aged 8-17 years were misclassified as overweight using BMI z scores than using triponderal mass index (TMI), which uses a formula for calculating a weight-to-height ratio, researchers reported. Obesity was similarly overreported with BMI z scores, compared with TMI scores.
They suggest that TMI therefore may be superior to BMI or BMI z scores in assessing adolescents’ weight at least among non-Hispanic whites, although further studies would need to assess TMI as an assessment tool in other racial/ethnic groups.
The standard formula for adult BMI – weight in kilograms divided by height in meters squared – has been known to be inappropriate for children and teens for more than a century because their proportions change with age. The currently established alternative of using youth’s BMI percentiles for their age in the BMI z system, however, “fails to take into account that both body proportions and body fat levels change during adolescent growth in a way that is inconsistent with BMI,” the authors wrote (JAMA Pediatrics. 2017 May 15. doi: 10.1001/jamapediatrics.2017.0460).
They therefore explored other methods of assessing appropriate weight ranges for adolescents and compared them with BMI, using dual-energy x-ray absorptiometry findings and anthropometric data collected from 4,398 non-Hispanic white participants, aged 8-29 years, in U.S. National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2006.
Dr. Peterson’s team first evaluated the value of using BMI by looking at the following:
• How percent body fat influences the timing of the adolescent growth spurt in height.
• How percent body fat varies by age.
• How body proportions scale during adolescence.
Then they explored changing the exponent in the weight-to-height formula to see which alternatives might result in a measurement that’s more stable with an individuals’ age, more accurate in estimating body fat percentage, and more accurate in identifying which youths are overweight.
“In girls and women, percent body fat increased with age and reached a plateau by age 18 years, rising from a mean of 31.2% at age 8-9 years to 36.4% at ages 25-29 years (P less than .001),” the authors wrote. “By contrast, in boys and men, percent body fat decreased from a mean of 27.8%-23.0% between ages 12-13 years and 14-15 years (P less than .001) before stabilizing at approximately 25%-26% for ages 20 years and older.”
Because variations in body fat percentage occurred with both age and height in adolescence, Dr. Peterson and her associates concluded that the usual BMI weight-to-height formula is not ideal for assessing body fat in youth. The better alternative, they found, uses the formula of weight divided by height cubed (instead of squared), called triponderal mass index (TMI).
The threshold for overweight status with TMI was 16.0 kg/m3 for boys and 16.8 kg/m3 for girls. For obesity, the threshold was 18.8 kg/m3 for boys and 19.7 kg/m3 for girls. Using TMI instead of BMI resulted in improved stability with age and estimated percent body fat for those aged 8-17 years.
In addition, using BMI z scores misclassified 19.4% of adolescents as overweight instead of a healthy weight whereas TMI only misclassified 8.4% of youth as such in the same data set. BMI z scores also classified more youth as obese (11.3%), compared with TMI (8%).
The research was funded by the National Center for Advancing Translational Sciences and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. One investigator serves on the medical advisory boards for Medifast and Rice Lake Weighing System, unrelated to this study. Another investigator helped develop a trademarked smartphone weight loss intervention app called SmartLoss, whose licensing could benefit that investigator and Montclair State University.
A different measurement tool than body mass index (BMI) z scores was more accurate in assessing adolescents’ body fat percentage than BMI z scores, a study found.
More than twice as many adolescents aged 8-17 years were misclassified as overweight using BMI z scores than using triponderal mass index (TMI), which uses a formula for calculating a weight-to-height ratio, researchers reported. Obesity was similarly overreported with BMI z scores, compared with TMI scores.
They suggest that TMI therefore may be superior to BMI or BMI z scores in assessing adolescents’ weight at least among non-Hispanic whites, although further studies would need to assess TMI as an assessment tool in other racial/ethnic groups.
The standard formula for adult BMI – weight in kilograms divided by height in meters squared – has been known to be inappropriate for children and teens for more than a century because their proportions change with age. The currently established alternative of using youth’s BMI percentiles for their age in the BMI z system, however, “fails to take into account that both body proportions and body fat levels change during adolescent growth in a way that is inconsistent with BMI,” the authors wrote (JAMA Pediatrics. 2017 May 15. doi: 10.1001/jamapediatrics.2017.0460).
They therefore explored other methods of assessing appropriate weight ranges for adolescents and compared them with BMI, using dual-energy x-ray absorptiometry findings and anthropometric data collected from 4,398 non-Hispanic white participants, aged 8-29 years, in U.S. National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2006.
Dr. Peterson’s team first evaluated the value of using BMI by looking at the following:
• How percent body fat influences the timing of the adolescent growth spurt in height.
• How percent body fat varies by age.
• How body proportions scale during adolescence.
Then they explored changing the exponent in the weight-to-height formula to see which alternatives might result in a measurement that’s more stable with an individuals’ age, more accurate in estimating body fat percentage, and more accurate in identifying which youths are overweight.
“In girls and women, percent body fat increased with age and reached a plateau by age 18 years, rising from a mean of 31.2% at age 8-9 years to 36.4% at ages 25-29 years (P less than .001),” the authors wrote. “By contrast, in boys and men, percent body fat decreased from a mean of 27.8%-23.0% between ages 12-13 years and 14-15 years (P less than .001) before stabilizing at approximately 25%-26% for ages 20 years and older.”
Because variations in body fat percentage occurred with both age and height in adolescence, Dr. Peterson and her associates concluded that the usual BMI weight-to-height formula is not ideal for assessing body fat in youth. The better alternative, they found, uses the formula of weight divided by height cubed (instead of squared), called triponderal mass index (TMI).
The threshold for overweight status with TMI was 16.0 kg/m3 for boys and 16.8 kg/m3 for girls. For obesity, the threshold was 18.8 kg/m3 for boys and 19.7 kg/m3 for girls. Using TMI instead of BMI resulted in improved stability with age and estimated percent body fat for those aged 8-17 years.
In addition, using BMI z scores misclassified 19.4% of adolescents as overweight instead of a healthy weight whereas TMI only misclassified 8.4% of youth as such in the same data set. BMI z scores also classified more youth as obese (11.3%), compared with TMI (8%).
The research was funded by the National Center for Advancing Translational Sciences and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. One investigator serves on the medical advisory boards for Medifast and Rice Lake Weighing System, unrelated to this study. Another investigator helped develop a trademarked smartphone weight loss intervention app called SmartLoss, whose licensing could benefit that investigator and Montclair State University.
FROM JAMA PEDIATRICS
Key clinical point: TMI is more accurate at assessing adolescents’ body fat percentage than body mass index z scores in non-Hispanic whites.
Major finding: 19.4% of youth aged 8-17 were misclassified as overweight using BMI, compared with 8.4% using TMI.
Data source: The findings are based on an analysis of data on 4,398 non-Hispanic white participants, aged 8-29 years, surveyed in the U.S. National Health and Nutrition Examination Surveys from 1999 to 2006.
Disclosures: The research was funded by the National Center for Advancing Translational Sciences and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. One investigator serves on the medical advisory boards for Medifast and Rice Lake Weighing System, unrelated to this study. Another investigator helped develop a trademarked smartphone weight loss intervention app called SmartLoss, whose licensing could benefit that investigator and Montclair State University.
Children’s asthma risk reduced with prenatal vitamin D supplementation
SAN FRANCISCO – Vitamin D supplementation during pregnancy may reduce the incidence of asthma or allergies in children at high risk for atopic disease, a study showed.
At age 3 years, asthma or recurrent wheeze occurred in 24% of children born to mothers with substantial vitamin D3 supplementation in pregnancy, compared with 30% of children whose mothers took a placebo during pregnancy.
However, observational study findings on vitamin D deficiency in pregnancy and asthma risk have been mixed, with no effect seen in research using measurements of 25OHD levels, despite protective effects seen in studies estimating vitamin D intake based on diet. Dr. Litonjua, therefore, led a randomized, controlled trial at three clinical centers to test whether vitamin D supplementation in pregnancy could prevent children at high risk of asthma from developing the condition. High-risk status was based on the presence of maternal and/or paternal asthma, allergic rhinitis, or eczema.
The 881 initial participants, enrolled between October 2009 and January 2015, were randomized to receive either 4,000 IU daily of vitamin D3 (440 women) or a placebo daily (436 women). Both groups took a multivitamin that contained 400 IU of vitamin D3. The participants included 43% black women, 26% white women, 14% Hispanic women, and 17% of other races/ethnicities.
The researchers collected maternal blood at the start of the study, between 32 and 38 weeks’ post partum, and at 1-year post partum. They collected cord blood at birth and then children’s blood at 1, 3, and 6 years old. At the third trimester, 87% of the women in the intervention group and 72% of the control group women had at least 50 nmol/L of 25OHD. Levels of at least 75 nmol/L were present in 75% of the intervention group and 35% of the control group in the third trimester.
Primary follow-up occurred at 3 years old with continuing follow-up through 6 years old, but data also were collected every 3 months regarding asthma and allergy symptoms and environmental exposures and diet. Stool was collected for microbiome analysis at 6 months, 1 year, and 3 years, and then annually after age 3 years. Children’s lung function was assessed with impulse oscillometry annually starting at age 4 years, with spirometry annually starting at age 5 years, and with bronchodilator response at age 6 years, Dr. Litonjua reported at the Pediatric Academic Societies meeting.
Just over one-quarter (27%) of the 806 children included in the final analysis had parental report of either an asthma diagnosis or recurrent wheeze, defined using any of five criteria involving multiple wheeze reports and/or use of an asthma controller. Rates of asthma or wheeze were significantly lower in children of women supplemented with 4,400 IU of vitamin D than in those born to women in the control group.
At age 1 year, the rate of asthma or wheeze among children from the intervention group was 9 percentage points lower than that of children from the control group, a 36% reduction. By age 2 years, the rate difference was 7%, a 25% reduced risk for intervention children, compared with control children. Children from the intervention group had a 20% lower risk of asthma or wheeze at age 3 years than those from the control group, with a rate difference of 6% (P = .051).
“Both maternal baseline 25OHD levels and third-trimester 25OHD levels were inversely associated with asthma/recurrent wheeze by age 3 years,” Dr. Litonjua reported, and relative risk at age 3 years was identical in black and white children. Maternal levels of 25OHD in the first trimester, however, “modified the effects of supplementation such that children born to women with higher levels and [who] were in the treatment arm had lowest risks for asthma/recurrent wheeze,” he said.
The greater reduction among women with higher baseline levels and supplementation suggests that higher levels than 30 ng/mL may be necessary for the prevention of asthma or allergies, Dr. Litonjua said. Personalized dosing or earlier supplementation may, therefore, be needed, he said.
“One of the main findings from our trial was that there were no serious adverse effects,” he said. Other trials, however, have found concerns with vitamin D toxicity. One challenge in the study was very low adherence: Only about half the women regularly took their vitamin D supplements at first, Dr. Litonjua said, although they were eventually able to raise adherence to around 80%.
The research was funded by the National Heart, Lung, and Blood Institute. Dr. Litonjua reported royalties from UpToDate and Springer Humana Press and consultation fees from AstraZeneca.
SAN FRANCISCO – Vitamin D supplementation during pregnancy may reduce the incidence of asthma or allergies in children at high risk for atopic disease, a study showed.
At age 3 years, asthma or recurrent wheeze occurred in 24% of children born to mothers with substantial vitamin D3 supplementation in pregnancy, compared with 30% of children whose mothers took a placebo during pregnancy.
However, observational study findings on vitamin D deficiency in pregnancy and asthma risk have been mixed, with no effect seen in research using measurements of 25OHD levels, despite protective effects seen in studies estimating vitamin D intake based on diet. Dr. Litonjua, therefore, led a randomized, controlled trial at three clinical centers to test whether vitamin D supplementation in pregnancy could prevent children at high risk of asthma from developing the condition. High-risk status was based on the presence of maternal and/or paternal asthma, allergic rhinitis, or eczema.
The 881 initial participants, enrolled between October 2009 and January 2015, were randomized to receive either 4,000 IU daily of vitamin D3 (440 women) or a placebo daily (436 women). Both groups took a multivitamin that contained 400 IU of vitamin D3. The participants included 43% black women, 26% white women, 14% Hispanic women, and 17% of other races/ethnicities.
The researchers collected maternal blood at the start of the study, between 32 and 38 weeks’ post partum, and at 1-year post partum. They collected cord blood at birth and then children’s blood at 1, 3, and 6 years old. At the third trimester, 87% of the women in the intervention group and 72% of the control group women had at least 50 nmol/L of 25OHD. Levels of at least 75 nmol/L were present in 75% of the intervention group and 35% of the control group in the third trimester.
Primary follow-up occurred at 3 years old with continuing follow-up through 6 years old, but data also were collected every 3 months regarding asthma and allergy symptoms and environmental exposures and diet. Stool was collected for microbiome analysis at 6 months, 1 year, and 3 years, and then annually after age 3 years. Children’s lung function was assessed with impulse oscillometry annually starting at age 4 years, with spirometry annually starting at age 5 years, and with bronchodilator response at age 6 years, Dr. Litonjua reported at the Pediatric Academic Societies meeting.
Just over one-quarter (27%) of the 806 children included in the final analysis had parental report of either an asthma diagnosis or recurrent wheeze, defined using any of five criteria involving multiple wheeze reports and/or use of an asthma controller. Rates of asthma or wheeze were significantly lower in children of women supplemented with 4,400 IU of vitamin D than in those born to women in the control group.
At age 1 year, the rate of asthma or wheeze among children from the intervention group was 9 percentage points lower than that of children from the control group, a 36% reduction. By age 2 years, the rate difference was 7%, a 25% reduced risk for intervention children, compared with control children. Children from the intervention group had a 20% lower risk of asthma or wheeze at age 3 years than those from the control group, with a rate difference of 6% (P = .051).
“Both maternal baseline 25OHD levels and third-trimester 25OHD levels were inversely associated with asthma/recurrent wheeze by age 3 years,” Dr. Litonjua reported, and relative risk at age 3 years was identical in black and white children. Maternal levels of 25OHD in the first trimester, however, “modified the effects of supplementation such that children born to women with higher levels and [who] were in the treatment arm had lowest risks for asthma/recurrent wheeze,” he said.
The greater reduction among women with higher baseline levels and supplementation suggests that higher levels than 30 ng/mL may be necessary for the prevention of asthma or allergies, Dr. Litonjua said. Personalized dosing or earlier supplementation may, therefore, be needed, he said.
“One of the main findings from our trial was that there were no serious adverse effects,” he said. Other trials, however, have found concerns with vitamin D toxicity. One challenge in the study was very low adherence: Only about half the women regularly took their vitamin D supplements at first, Dr. Litonjua said, although they were eventually able to raise adherence to around 80%.
The research was funded by the National Heart, Lung, and Blood Institute. Dr. Litonjua reported royalties from UpToDate and Springer Humana Press and consultation fees from AstraZeneca.
SAN FRANCISCO – Vitamin D supplementation during pregnancy may reduce the incidence of asthma or allergies in children at high risk for atopic disease, a study showed.
At age 3 years, asthma or recurrent wheeze occurred in 24% of children born to mothers with substantial vitamin D3 supplementation in pregnancy, compared with 30% of children whose mothers took a placebo during pregnancy.
However, observational study findings on vitamin D deficiency in pregnancy and asthma risk have been mixed, with no effect seen in research using measurements of 25OHD levels, despite protective effects seen in studies estimating vitamin D intake based on diet. Dr. Litonjua, therefore, led a randomized, controlled trial at three clinical centers to test whether vitamin D supplementation in pregnancy could prevent children at high risk of asthma from developing the condition. High-risk status was based on the presence of maternal and/or paternal asthma, allergic rhinitis, or eczema.
The 881 initial participants, enrolled between October 2009 and January 2015, were randomized to receive either 4,000 IU daily of vitamin D3 (440 women) or a placebo daily (436 women). Both groups took a multivitamin that contained 400 IU of vitamin D3. The participants included 43% black women, 26% white women, 14% Hispanic women, and 17% of other races/ethnicities.
The researchers collected maternal blood at the start of the study, between 32 and 38 weeks’ post partum, and at 1-year post partum. They collected cord blood at birth and then children’s blood at 1, 3, and 6 years old. At the third trimester, 87% of the women in the intervention group and 72% of the control group women had at least 50 nmol/L of 25OHD. Levels of at least 75 nmol/L were present in 75% of the intervention group and 35% of the control group in the third trimester.
Primary follow-up occurred at 3 years old with continuing follow-up through 6 years old, but data also were collected every 3 months regarding asthma and allergy symptoms and environmental exposures and diet. Stool was collected for microbiome analysis at 6 months, 1 year, and 3 years, and then annually after age 3 years. Children’s lung function was assessed with impulse oscillometry annually starting at age 4 years, with spirometry annually starting at age 5 years, and with bronchodilator response at age 6 years, Dr. Litonjua reported at the Pediatric Academic Societies meeting.
Just over one-quarter (27%) of the 806 children included in the final analysis had parental report of either an asthma diagnosis or recurrent wheeze, defined using any of five criteria involving multiple wheeze reports and/or use of an asthma controller. Rates of asthma or wheeze were significantly lower in children of women supplemented with 4,400 IU of vitamin D than in those born to women in the control group.
At age 1 year, the rate of asthma or wheeze among children from the intervention group was 9 percentage points lower than that of children from the control group, a 36% reduction. By age 2 years, the rate difference was 7%, a 25% reduced risk for intervention children, compared with control children. Children from the intervention group had a 20% lower risk of asthma or wheeze at age 3 years than those from the control group, with a rate difference of 6% (P = .051).
“Both maternal baseline 25OHD levels and third-trimester 25OHD levels were inversely associated with asthma/recurrent wheeze by age 3 years,” Dr. Litonjua reported, and relative risk at age 3 years was identical in black and white children. Maternal levels of 25OHD in the first trimester, however, “modified the effects of supplementation such that children born to women with higher levels and [who] were in the treatment arm had lowest risks for asthma/recurrent wheeze,” he said.
The greater reduction among women with higher baseline levels and supplementation suggests that higher levels than 30 ng/mL may be necessary for the prevention of asthma or allergies, Dr. Litonjua said. Personalized dosing or earlier supplementation may, therefore, be needed, he said.
“One of the main findings from our trial was that there were no serious adverse effects,” he said. Other trials, however, have found concerns with vitamin D toxicity. One challenge in the study was very low adherence: Only about half the women regularly took their vitamin D supplements at first, Dr. Litonjua said, although they were eventually able to raise adherence to around 80%.
The research was funded by the National Heart, Lung, and Blood Institute. Dr. Litonjua reported royalties from UpToDate and Springer Humana Press and consultation fees from AstraZeneca.
AT PAS 2017
Key clinical point: Higher levels of vitamin D3 in pregnancy led to a reduced risk of asthma or allergies in subsequent children at high risk for the condition.
Major finding: (P = .051).
Data source: A randomized controlled trial at three clinical centers from October 2009 through January 2015, involving 881 pregnant women whose children had a high risk of asthma or allergies and 806 subsequent children.
Disclosures: The research was funded by the National Heart, Lung, and Blood Institute. Dr. Litonjua reported royalties from UpToDate and Springer Humana Press, and consultation fees from AstraZeneca.
Antacid use in infants linked to increased fracture risk
SAN FRANCISCO – Children were more likely to experience a fracture if they were prescribed antacids before age 1 year, according to a study of military families.
The large study revealed that use of proton pump inhibitors (PPIs) before age 1 year was linked to a 22% increased risk of fracture, compared with those not prescribed antacids. Similarly, children prescribed both PPIs and H2 blockers before age 1 year were 31% more likely to have a fracture compared to those not taking the drugs.
“A lot of data are coming out that proton pump inhibitors are not quite as benign as we used to think, and we are seeing that fracture risk is increased with use,” U.S. Air Force Capt. Laura Malchodi, MD, a pediatrics resident at Walter Reed National Military Medical Center in Bethesda, Md., told colleagues at the Pediatric Academic Societies meeting.
Antacid use has been increasing among both adults and children, but the biggest rise has been in children under age 1 year, she said. Previous research into adult use of antacids has revealed an increased incidence of fractures, so Dr. Malchodi investigated the incidence of fractures in children under age 1 year among those who had taken PPIs, H2 blockers, neither, or both.
“What this means for doctors is that when you do start to think of using proton pump inhibitors or any antacid therapy in children, we should really think of limiting it to one type if possible – H2 blockers are now preferable – and for the shortest amount of time as possible,” Dr. Malchodi said of her findings.
The retrospective study’s cohort comprised 874,447 children born between 2001 and 2013 who had been in the U.S. Military Health System for at least 2 years. Children who took antacids after age 1, spent more than a week in a neonatal intensive care unit, or had nonaccidental trauma (abuse) or osteogenesis imperfecta were excluded.
Ninety percent of the cohort had not received prescriptions for any antacids (789,631 children) in their first year of life, and 1.2% had received prescriptions for both PPIs and H2 blockers before age 1 year. Of the remaining children, 7.7% had received prescriptions for H2 blockers, and 0.8% for PPIs.
The children who had and had not been prescribed antacids were similar in median years enrolled in the system, but nearly twice as many who received antacid prescription had been preterm (6.4% vs. 3.5%, P less than .05). Similarly, 3.7% of those prescribed antacids had a low birth weight, compared with 2.2% of those not prescribed antacids (P less than .05). The median age of fracture also differed for the two groups: 3.9 years for those prescribed antacids and 4.5 years for those not (P less than .05).
In using medical records during their analysis, the researchers excluded follow-up visits for the same fracture within the previous 6 months. Before adjustment for covariates, boys had a slightly increased risk of fracture (hazard ratio [HR], 1.08), and those with a previous fracture had an 85% increased risk (HR, 1.85). Compared with children not prescribed antacids, those prescribed PPIs had a 23% increased risk of fracture (HR, 1.23), and those prescribed H2 blockers had a 13% increased risk (HR, 1.13). Those prescribed combination antacid therapy had a 32% increased risk of fractures (HR, 1.32).
Adjustment for preterm birth, low birth weight, sex, and a previous fracture barely reduced those risks: 22% increased risk for PPI use, 4% increased risk for H2 blocker use, and 31% increased risk for using both. The vast majority of children who took antacids had been prescribed them in their first 6 months, so the researchers calculated adjusted risk by age of exposure. For H2 blockers, no statistically significant increased risk of fracture existed in those taking them before or after 6 months old.
Those taking PPIs, however, had a 25% increased risk of fracture if they took them before 6 months old, compared with a 20% increased risk if prescribed PPIs between 6 and 12 months. Likewise, children taking both PPIs and H2 blockers before 6 months old had a 32% increased risk of fracture, compared with a 23% increased risk between 6 and 12 months old.
Analysis of the duration of children’s use of antacids revealed a dose-response relationship, with an increasing risk alongside increasing days taking the medication. For example, those on PPIs for a month or less had a 19% increased risk of fracture, compared with children not prescribed antacids, but that rose to a 23% increased risk for those taking PPIs from 60 to 150 days and to a 42% increased risk for taking them longer than 150 days.
Similarly, the risk of fracture after having taken H2 blockers for up to a month was 14%, which increased to 22% for medication durations over 120 days. Children on combination therapy took the medication for much longer than did children prescribed either antacid. The risk of fracture was 17% greater for those taking them for up to 4 months, but that increased to a 50% greater risk for children taking both antacids for longer than 338 days.
“A couple of decades ago, we thought these medications were super safe, that there could be no problem with them,” Dr. Malchodi said, suggesting that their availability over the counter for adults may contribute to that perception. “With this growing evidence, there’s at least a lot more caution about using them,” she said.
Because the study relied on prescriptions for antacids, the researchers could not take into account which children actually took the antacids. Another limitation was their inability to consider other potential confounders, such as socioeconomic status or comorbidities that may later increase the risk of fracture. Further, exclusion of 6 months of follow-up after one fracture may have missed new fractures in that time period. Using a military cohort, on the other hand, meant having a geographically and socioeconomically diverse population with less risk of care bias because all the children had universal health care coverage.
No external funding was used. Dr. Malchodi reported having no disclosures.
*The View on the News was added on 6/13/17.
Acid suppression is frequently prescribed in infants for the treatment of symptoms such as fussiness, arching, and poor feeding, despite randomized controlled trials showing no benefit for these symptoms over placebo. These medications are often prescribed because physicians think they are useful; families are frustrated, exhausted, and worried about the infant’s symptoms; and these medications are considered safe and well tolerated. Recent adult studies have raised the possibility that these medications may not be as safe as once thought, with case-controlled studies linking them to increased risk of infectious, renal, cardiac, neurologic, and orthopedic complications. While there are pediatric studies supporting an increased infectious risk from both PPI and H2 antagonist use, there are no pediatric studies that address other complications. In this study by Dr. Malchodi et al., acid suppression use in infants under the age of 1 year was associated with an increased risk of fractures over the duration of enrollment in the U.S. Military Health System. They also found a dose-dependent effect, which further strengthens the conclusions that acid suppression may predispose patients to fractures. This research is a critical first step in elucidating the relationship of acid suppression and fracture risk in infants.
As with all database studies, there are some limitations to this study. First, patients taking acid suppression often have more comorbidities than do patients who are not taking the medications; because these patients are sicker, they may have more risk factors including compromised nutritional status and malabsorption predisposing them to fractures. The authors controlled for some of these comorbidities, but future studies should address additional ones. Second, as with all case-control studies, proving causality, not just association, is difficult so any future prospective acid suppression trials should include an assessment of bone health. Third, because the dosing per kilogram is not included, it is difficult to determine if there is a safe level of acid suppression for those children who need it. Fourth, because this is a database review, it is not clear if patients actually took the prescribed medication.
Because of the safety concerns regarding acid suppression as well as the lack of benefit in reducing symptoms in infants, nonpharmacologic therapies should be considered as first-line therapy for the treatment of bothersome symptoms. In the fussy, arching, or irritable child, changing the frequency or volume of feeds, thickening feeds, or changing to partially hydrolyzed formulas or eliminating dairy from the maternal diet (for breastfed infants) should be considered before starting acid suppression therapy. Other diagnoses besides gastroesophageal reflux disease, such as colic and cow’s milk protein allergy, need to be considered as well to ensure that the therapy matches the diagnosis. For those patients in whom acid suppression is required, using the lowest dose possible for the shortest amount of time is critical. Finally, for patients on multiple medications that may impact fracture risk (such as acid suppression, steroids), extra vigilance is needed to stop unnecessary medications as soon as possible.
Acid suppression is frequently prescribed in infants for the treatment of symptoms such as fussiness, arching, and poor feeding, despite randomized controlled trials showing no benefit for these symptoms over placebo. These medications are often prescribed because physicians think they are useful; families are frustrated, exhausted, and worried about the infant’s symptoms; and these medications are considered safe and well tolerated. Recent adult studies have raised the possibility that these medications may not be as safe as once thought, with case-controlled studies linking them to increased risk of infectious, renal, cardiac, neurologic, and orthopedic complications. While there are pediatric studies supporting an increased infectious risk from both PPI and H2 antagonist use, there are no pediatric studies that address other complications. In this study by Dr. Malchodi et al., acid suppression use in infants under the age of 1 year was associated with an increased risk of fractures over the duration of enrollment in the U.S. Military Health System. They also found a dose-dependent effect, which further strengthens the conclusions that acid suppression may predispose patients to fractures. This research is a critical first step in elucidating the relationship of acid suppression and fracture risk in infants.
As with all database studies, there are some limitations to this study. First, patients taking acid suppression often have more comorbidities than do patients who are not taking the medications; because these patients are sicker, they may have more risk factors including compromised nutritional status and malabsorption predisposing them to fractures. The authors controlled for some of these comorbidities, but future studies should address additional ones. Second, as with all case-control studies, proving causality, not just association, is difficult so any future prospective acid suppression trials should include an assessment of bone health. Third, because the dosing per kilogram is not included, it is difficult to determine if there is a safe level of acid suppression for those children who need it. Fourth, because this is a database review, it is not clear if patients actually took the prescribed medication.
Because of the safety concerns regarding acid suppression as well as the lack of benefit in reducing symptoms in infants, nonpharmacologic therapies should be considered as first-line therapy for the treatment of bothersome symptoms. In the fussy, arching, or irritable child, changing the frequency or volume of feeds, thickening feeds, or changing to partially hydrolyzed formulas or eliminating dairy from the maternal diet (for breastfed infants) should be considered before starting acid suppression therapy. Other diagnoses besides gastroesophageal reflux disease, such as colic and cow’s milk protein allergy, need to be considered as well to ensure that the therapy matches the diagnosis. For those patients in whom acid suppression is required, using the lowest dose possible for the shortest amount of time is critical. Finally, for patients on multiple medications that may impact fracture risk (such as acid suppression, steroids), extra vigilance is needed to stop unnecessary medications as soon as possible.
Acid suppression is frequently prescribed in infants for the treatment of symptoms such as fussiness, arching, and poor feeding, despite randomized controlled trials showing no benefit for these symptoms over placebo. These medications are often prescribed because physicians think they are useful; families are frustrated, exhausted, and worried about the infant’s symptoms; and these medications are considered safe and well tolerated. Recent adult studies have raised the possibility that these medications may not be as safe as once thought, with case-controlled studies linking them to increased risk of infectious, renal, cardiac, neurologic, and orthopedic complications. While there are pediatric studies supporting an increased infectious risk from both PPI and H2 antagonist use, there are no pediatric studies that address other complications. In this study by Dr. Malchodi et al., acid suppression use in infants under the age of 1 year was associated with an increased risk of fractures over the duration of enrollment in the U.S. Military Health System. They also found a dose-dependent effect, which further strengthens the conclusions that acid suppression may predispose patients to fractures. This research is a critical first step in elucidating the relationship of acid suppression and fracture risk in infants.
As with all database studies, there are some limitations to this study. First, patients taking acid suppression often have more comorbidities than do patients who are not taking the medications; because these patients are sicker, they may have more risk factors including compromised nutritional status and malabsorption predisposing them to fractures. The authors controlled for some of these comorbidities, but future studies should address additional ones. Second, as with all case-control studies, proving causality, not just association, is difficult so any future prospective acid suppression trials should include an assessment of bone health. Third, because the dosing per kilogram is not included, it is difficult to determine if there is a safe level of acid suppression for those children who need it. Fourth, because this is a database review, it is not clear if patients actually took the prescribed medication.
Because of the safety concerns regarding acid suppression as well as the lack of benefit in reducing symptoms in infants, nonpharmacologic therapies should be considered as first-line therapy for the treatment of bothersome symptoms. In the fussy, arching, or irritable child, changing the frequency or volume of feeds, thickening feeds, or changing to partially hydrolyzed formulas or eliminating dairy from the maternal diet (for breastfed infants) should be considered before starting acid suppression therapy. Other diagnoses besides gastroesophageal reflux disease, such as colic and cow’s milk protein allergy, need to be considered as well to ensure that the therapy matches the diagnosis. For those patients in whom acid suppression is required, using the lowest dose possible for the shortest amount of time is critical. Finally, for patients on multiple medications that may impact fracture risk (such as acid suppression, steroids), extra vigilance is needed to stop unnecessary medications as soon as possible.
SAN FRANCISCO – Children were more likely to experience a fracture if they were prescribed antacids before age 1 year, according to a study of military families.
The large study revealed that use of proton pump inhibitors (PPIs) before age 1 year was linked to a 22% increased risk of fracture, compared with those not prescribed antacids. Similarly, children prescribed both PPIs and H2 blockers before age 1 year were 31% more likely to have a fracture compared to those not taking the drugs.
“A lot of data are coming out that proton pump inhibitors are not quite as benign as we used to think, and we are seeing that fracture risk is increased with use,” U.S. Air Force Capt. Laura Malchodi, MD, a pediatrics resident at Walter Reed National Military Medical Center in Bethesda, Md., told colleagues at the Pediatric Academic Societies meeting.
Antacid use has been increasing among both adults and children, but the biggest rise has been in children under age 1 year, she said. Previous research into adult use of antacids has revealed an increased incidence of fractures, so Dr. Malchodi investigated the incidence of fractures in children under age 1 year among those who had taken PPIs, H2 blockers, neither, or both.
“What this means for doctors is that when you do start to think of using proton pump inhibitors or any antacid therapy in children, we should really think of limiting it to one type if possible – H2 blockers are now preferable – and for the shortest amount of time as possible,” Dr. Malchodi said of her findings.
The retrospective study’s cohort comprised 874,447 children born between 2001 and 2013 who had been in the U.S. Military Health System for at least 2 years. Children who took antacids after age 1, spent more than a week in a neonatal intensive care unit, or had nonaccidental trauma (abuse) or osteogenesis imperfecta were excluded.
Ninety percent of the cohort had not received prescriptions for any antacids (789,631 children) in their first year of life, and 1.2% had received prescriptions for both PPIs and H2 blockers before age 1 year. Of the remaining children, 7.7% had received prescriptions for H2 blockers, and 0.8% for PPIs.
The children who had and had not been prescribed antacids were similar in median years enrolled in the system, but nearly twice as many who received antacid prescription had been preterm (6.4% vs. 3.5%, P less than .05). Similarly, 3.7% of those prescribed antacids had a low birth weight, compared with 2.2% of those not prescribed antacids (P less than .05). The median age of fracture also differed for the two groups: 3.9 years for those prescribed antacids and 4.5 years for those not (P less than .05).
In using medical records during their analysis, the researchers excluded follow-up visits for the same fracture within the previous 6 months. Before adjustment for covariates, boys had a slightly increased risk of fracture (hazard ratio [HR], 1.08), and those with a previous fracture had an 85% increased risk (HR, 1.85). Compared with children not prescribed antacids, those prescribed PPIs had a 23% increased risk of fracture (HR, 1.23), and those prescribed H2 blockers had a 13% increased risk (HR, 1.13). Those prescribed combination antacid therapy had a 32% increased risk of fractures (HR, 1.32).
Adjustment for preterm birth, low birth weight, sex, and a previous fracture barely reduced those risks: 22% increased risk for PPI use, 4% increased risk for H2 blocker use, and 31% increased risk for using both. The vast majority of children who took antacids had been prescribed them in their first 6 months, so the researchers calculated adjusted risk by age of exposure. For H2 blockers, no statistically significant increased risk of fracture existed in those taking them before or after 6 months old.
Those taking PPIs, however, had a 25% increased risk of fracture if they took them before 6 months old, compared with a 20% increased risk if prescribed PPIs between 6 and 12 months. Likewise, children taking both PPIs and H2 blockers before 6 months old had a 32% increased risk of fracture, compared with a 23% increased risk between 6 and 12 months old.
Analysis of the duration of children’s use of antacids revealed a dose-response relationship, with an increasing risk alongside increasing days taking the medication. For example, those on PPIs for a month or less had a 19% increased risk of fracture, compared with children not prescribed antacids, but that rose to a 23% increased risk for those taking PPIs from 60 to 150 days and to a 42% increased risk for taking them longer than 150 days.
Similarly, the risk of fracture after having taken H2 blockers for up to a month was 14%, which increased to 22% for medication durations over 120 days. Children on combination therapy took the medication for much longer than did children prescribed either antacid. The risk of fracture was 17% greater for those taking them for up to 4 months, but that increased to a 50% greater risk for children taking both antacids for longer than 338 days.
“A couple of decades ago, we thought these medications were super safe, that there could be no problem with them,” Dr. Malchodi said, suggesting that their availability over the counter for adults may contribute to that perception. “With this growing evidence, there’s at least a lot more caution about using them,” she said.
Because the study relied on prescriptions for antacids, the researchers could not take into account which children actually took the antacids. Another limitation was their inability to consider other potential confounders, such as socioeconomic status or comorbidities that may later increase the risk of fracture. Further, exclusion of 6 months of follow-up after one fracture may have missed new fractures in that time period. Using a military cohort, on the other hand, meant having a geographically and socioeconomically diverse population with less risk of care bias because all the children had universal health care coverage.
No external funding was used. Dr. Malchodi reported having no disclosures.
*The View on the News was added on 6/13/17.
SAN FRANCISCO – Children were more likely to experience a fracture if they were prescribed antacids before age 1 year, according to a study of military families.
The large study revealed that use of proton pump inhibitors (PPIs) before age 1 year was linked to a 22% increased risk of fracture, compared with those not prescribed antacids. Similarly, children prescribed both PPIs and H2 blockers before age 1 year were 31% more likely to have a fracture compared to those not taking the drugs.
“A lot of data are coming out that proton pump inhibitors are not quite as benign as we used to think, and we are seeing that fracture risk is increased with use,” U.S. Air Force Capt. Laura Malchodi, MD, a pediatrics resident at Walter Reed National Military Medical Center in Bethesda, Md., told colleagues at the Pediatric Academic Societies meeting.
Antacid use has been increasing among both adults and children, but the biggest rise has been in children under age 1 year, she said. Previous research into adult use of antacids has revealed an increased incidence of fractures, so Dr. Malchodi investigated the incidence of fractures in children under age 1 year among those who had taken PPIs, H2 blockers, neither, or both.
“What this means for doctors is that when you do start to think of using proton pump inhibitors or any antacid therapy in children, we should really think of limiting it to one type if possible – H2 blockers are now preferable – and for the shortest amount of time as possible,” Dr. Malchodi said of her findings.
The retrospective study’s cohort comprised 874,447 children born between 2001 and 2013 who had been in the U.S. Military Health System for at least 2 years. Children who took antacids after age 1, spent more than a week in a neonatal intensive care unit, or had nonaccidental trauma (abuse) or osteogenesis imperfecta were excluded.
Ninety percent of the cohort had not received prescriptions for any antacids (789,631 children) in their first year of life, and 1.2% had received prescriptions for both PPIs and H2 blockers before age 1 year. Of the remaining children, 7.7% had received prescriptions for H2 blockers, and 0.8% for PPIs.
The children who had and had not been prescribed antacids were similar in median years enrolled in the system, but nearly twice as many who received antacid prescription had been preterm (6.4% vs. 3.5%, P less than .05). Similarly, 3.7% of those prescribed antacids had a low birth weight, compared with 2.2% of those not prescribed antacids (P less than .05). The median age of fracture also differed for the two groups: 3.9 years for those prescribed antacids and 4.5 years for those not (P less than .05).
In using medical records during their analysis, the researchers excluded follow-up visits for the same fracture within the previous 6 months. Before adjustment for covariates, boys had a slightly increased risk of fracture (hazard ratio [HR], 1.08), and those with a previous fracture had an 85% increased risk (HR, 1.85). Compared with children not prescribed antacids, those prescribed PPIs had a 23% increased risk of fracture (HR, 1.23), and those prescribed H2 blockers had a 13% increased risk (HR, 1.13). Those prescribed combination antacid therapy had a 32% increased risk of fractures (HR, 1.32).
Adjustment for preterm birth, low birth weight, sex, and a previous fracture barely reduced those risks: 22% increased risk for PPI use, 4% increased risk for H2 blocker use, and 31% increased risk for using both. The vast majority of children who took antacids had been prescribed them in their first 6 months, so the researchers calculated adjusted risk by age of exposure. For H2 blockers, no statistically significant increased risk of fracture existed in those taking them before or after 6 months old.
Those taking PPIs, however, had a 25% increased risk of fracture if they took them before 6 months old, compared with a 20% increased risk if prescribed PPIs between 6 and 12 months. Likewise, children taking both PPIs and H2 blockers before 6 months old had a 32% increased risk of fracture, compared with a 23% increased risk between 6 and 12 months old.
Analysis of the duration of children’s use of antacids revealed a dose-response relationship, with an increasing risk alongside increasing days taking the medication. For example, those on PPIs for a month or less had a 19% increased risk of fracture, compared with children not prescribed antacids, but that rose to a 23% increased risk for those taking PPIs from 60 to 150 days and to a 42% increased risk for taking them longer than 150 days.
Similarly, the risk of fracture after having taken H2 blockers for up to a month was 14%, which increased to 22% for medication durations over 120 days. Children on combination therapy took the medication for much longer than did children prescribed either antacid. The risk of fracture was 17% greater for those taking them for up to 4 months, but that increased to a 50% greater risk for children taking both antacids for longer than 338 days.
“A couple of decades ago, we thought these medications were super safe, that there could be no problem with them,” Dr. Malchodi said, suggesting that their availability over the counter for adults may contribute to that perception. “With this growing evidence, there’s at least a lot more caution about using them,” she said.
Because the study relied on prescriptions for antacids, the researchers could not take into account which children actually took the antacids. Another limitation was their inability to consider other potential confounders, such as socioeconomic status or comorbidities that may later increase the risk of fracture. Further, exclusion of 6 months of follow-up after one fracture may have missed new fractures in that time period. Using a military cohort, on the other hand, meant having a geographically and socioeconomically diverse population with less risk of care bias because all the children had universal health care coverage.
No external funding was used. Dr. Malchodi reported having no disclosures.
*The View on the News was added on 6/13/17.
AT PAS 17
Key clinical point:
Major finding: Risk of fracture increased 22% among children who took proton pump inhibitors in their first year of life and increased 31% among children taking both PPIs and H2 blockers.
Data source: A retrospective cohort study of 874,447 children born between 2001 and 2013 and who were in the U.S. Military Health System for at least 2 years.
Disclosures: No external funding was used. Dr. Malchodi reported having no relevant financial disclosures.
Parenting style linked to toddler sensory adaptation, behavior
SAN FRANCISCO – Children of parents who have a permissive parenting style were more likely to have atypical sensory adaptation at age 1 year and increased behavior difficulties at 2 years, compared to children exposed to other parenting styles, in a new, unpublished study.
Toddlers with permissive parents had more than double the risk of internalizing behaviors and triple the risk of externalizing behaviors compared to peers whose parents used an authoritative or authoritarian parenting style, reported Mary Lauren Neel, MD, a fellow in pediatrics at Vanderbilt University, Nashville, Tenn. This association appeared stronger among preterm infants, but without a statistically significant increased effect.
Dr. Neel’s study tested whether children’s sensory adaptation differed according to parenting styles, as defined by the validated Baumrind’s framework of authoritative, authoritarian, and permissive parenting (Genet Psychol Monogr. 1967 Feb;75[1]:43-88). These styles are based on parents’ demandingness (whether they have developmentally appropriate expectations of their child) and responsivity (how sensitively parents perceive and respond to children’s needs), Dr. Neel explained. The majority of the children’s parents (61%) had an authoritative style, while 18% had an authoritarian style, and 11% had a permissive style.
Previous research has identified a link between abnormal sensory interactions with the environment and early behavioral problems, and preterm infants are already more likely to experience both behavioral difficulties and atypical sensory adaption than are children born at term. Dr. Neel’s research, therefore, compared 52 term infants and 51 preterm infants. The median gestational age at birth was 35 weeks, and 29% of the cohort were very preterm, born at 32 weeks or earlier. Almost all (97%) of the mothers had at least a high school education.
The researchers assessed the infants at 12 months with the Infant/Toddler Sensory Profile and at 24 months with the Child Behavior Checklist. At 12 months, after adjustment for gestational age at birth, infants of authoritative parents had greater oral sensation seeking (P = .01) and decreased sensory sensitivity (P = .02), those of authoritarian parents had increased sensation seeking (P = .04), and those of permissive parents had decreased attention to children’s visual surroundings (P = .03).
One in five (21%) of the children had an atypical neurologic threshold at 1 year, but no statistically significant association was seen between an atypical threshold and authoritarian and authoritative parenting. Neither parenting style was associated with externalizing or internalizing behaviors.
Permissive parents’ children, however, were 2.6 times more likely to have atypical sensory adaptation. Further, at 2 years, these children were 2.2 times more likely to have internalizing behaviors and 3 times more likely to have externalizing behaviors, Dr. Neel reported.
“The association between permissive parenting and abnormal sensory neurological threshold in the home environment may explain the increased risk for behavior problems in children of permissive parents at 2 years,” she said. The results were consistent among term and preterm infants with a trend toward increasing significance preterm infants.
“It’s possible that prematurity augments these dynamics, but we would need a larger sample size,” she said, adding that the potential underlying mechanisms for that association are something that future research would need to tease out.
After an audience member asked about the possibility that children’s sensory capabilities might be driving parenting style, Dr. Neel acknowledged the bidirectional relationship between parent and child but noted that most psychology research suggest parenting style has more to do with the parents than with their children.
Limitations of the study include its small size and lack of data on other potential confounding factors, such as parental mental health.
The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development as well as a private grant. Dr. Neel reported having no disclosures.
SAN FRANCISCO – Children of parents who have a permissive parenting style were more likely to have atypical sensory adaptation at age 1 year and increased behavior difficulties at 2 years, compared to children exposed to other parenting styles, in a new, unpublished study.
Toddlers with permissive parents had more than double the risk of internalizing behaviors and triple the risk of externalizing behaviors compared to peers whose parents used an authoritative or authoritarian parenting style, reported Mary Lauren Neel, MD, a fellow in pediatrics at Vanderbilt University, Nashville, Tenn. This association appeared stronger among preterm infants, but without a statistically significant increased effect.
Dr. Neel’s study tested whether children’s sensory adaptation differed according to parenting styles, as defined by the validated Baumrind’s framework of authoritative, authoritarian, and permissive parenting (Genet Psychol Monogr. 1967 Feb;75[1]:43-88). These styles are based on parents’ demandingness (whether they have developmentally appropriate expectations of their child) and responsivity (how sensitively parents perceive and respond to children’s needs), Dr. Neel explained. The majority of the children’s parents (61%) had an authoritative style, while 18% had an authoritarian style, and 11% had a permissive style.
Previous research has identified a link between abnormal sensory interactions with the environment and early behavioral problems, and preterm infants are already more likely to experience both behavioral difficulties and atypical sensory adaption than are children born at term. Dr. Neel’s research, therefore, compared 52 term infants and 51 preterm infants. The median gestational age at birth was 35 weeks, and 29% of the cohort were very preterm, born at 32 weeks or earlier. Almost all (97%) of the mothers had at least a high school education.
The researchers assessed the infants at 12 months with the Infant/Toddler Sensory Profile and at 24 months with the Child Behavior Checklist. At 12 months, after adjustment for gestational age at birth, infants of authoritative parents had greater oral sensation seeking (P = .01) and decreased sensory sensitivity (P = .02), those of authoritarian parents had increased sensation seeking (P = .04), and those of permissive parents had decreased attention to children’s visual surroundings (P = .03).
One in five (21%) of the children had an atypical neurologic threshold at 1 year, but no statistically significant association was seen between an atypical threshold and authoritarian and authoritative parenting. Neither parenting style was associated with externalizing or internalizing behaviors.
Permissive parents’ children, however, were 2.6 times more likely to have atypical sensory adaptation. Further, at 2 years, these children were 2.2 times more likely to have internalizing behaviors and 3 times more likely to have externalizing behaviors, Dr. Neel reported.
“The association between permissive parenting and abnormal sensory neurological threshold in the home environment may explain the increased risk for behavior problems in children of permissive parents at 2 years,” she said. The results were consistent among term and preterm infants with a trend toward increasing significance preterm infants.
“It’s possible that prematurity augments these dynamics, but we would need a larger sample size,” she said, adding that the potential underlying mechanisms for that association are something that future research would need to tease out.
After an audience member asked about the possibility that children’s sensory capabilities might be driving parenting style, Dr. Neel acknowledged the bidirectional relationship between parent and child but noted that most psychology research suggest parenting style has more to do with the parents than with their children.
Limitations of the study include its small size and lack of data on other potential confounding factors, such as parental mental health.
The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development as well as a private grant. Dr. Neel reported having no disclosures.
SAN FRANCISCO – Children of parents who have a permissive parenting style were more likely to have atypical sensory adaptation at age 1 year and increased behavior difficulties at 2 years, compared to children exposed to other parenting styles, in a new, unpublished study.
Toddlers with permissive parents had more than double the risk of internalizing behaviors and triple the risk of externalizing behaviors compared to peers whose parents used an authoritative or authoritarian parenting style, reported Mary Lauren Neel, MD, a fellow in pediatrics at Vanderbilt University, Nashville, Tenn. This association appeared stronger among preterm infants, but without a statistically significant increased effect.
Dr. Neel’s study tested whether children’s sensory adaptation differed according to parenting styles, as defined by the validated Baumrind’s framework of authoritative, authoritarian, and permissive parenting (Genet Psychol Monogr. 1967 Feb;75[1]:43-88). These styles are based on parents’ demandingness (whether they have developmentally appropriate expectations of their child) and responsivity (how sensitively parents perceive and respond to children’s needs), Dr. Neel explained. The majority of the children’s parents (61%) had an authoritative style, while 18% had an authoritarian style, and 11% had a permissive style.
Previous research has identified a link between abnormal sensory interactions with the environment and early behavioral problems, and preterm infants are already more likely to experience both behavioral difficulties and atypical sensory adaption than are children born at term. Dr. Neel’s research, therefore, compared 52 term infants and 51 preterm infants. The median gestational age at birth was 35 weeks, and 29% of the cohort were very preterm, born at 32 weeks or earlier. Almost all (97%) of the mothers had at least a high school education.
The researchers assessed the infants at 12 months with the Infant/Toddler Sensory Profile and at 24 months with the Child Behavior Checklist. At 12 months, after adjustment for gestational age at birth, infants of authoritative parents had greater oral sensation seeking (P = .01) and decreased sensory sensitivity (P = .02), those of authoritarian parents had increased sensation seeking (P = .04), and those of permissive parents had decreased attention to children’s visual surroundings (P = .03).
One in five (21%) of the children had an atypical neurologic threshold at 1 year, but no statistically significant association was seen between an atypical threshold and authoritarian and authoritative parenting. Neither parenting style was associated with externalizing or internalizing behaviors.
Permissive parents’ children, however, were 2.6 times more likely to have atypical sensory adaptation. Further, at 2 years, these children were 2.2 times more likely to have internalizing behaviors and 3 times more likely to have externalizing behaviors, Dr. Neel reported.
“The association between permissive parenting and abnormal sensory neurological threshold in the home environment may explain the increased risk for behavior problems in children of permissive parents at 2 years,” she said. The results were consistent among term and preterm infants with a trend toward increasing significance preterm infants.
“It’s possible that prematurity augments these dynamics, but we would need a larger sample size,” she said, adding that the potential underlying mechanisms for that association are something that future research would need to tease out.
After an audience member asked about the possibility that children’s sensory capabilities might be driving parenting style, Dr. Neel acknowledged the bidirectional relationship between parent and child but noted that most psychology research suggest parenting style has more to do with the parents than with their children.
Limitations of the study include its small size and lack of data on other potential confounding factors, such as parental mental health.
The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development as well as a private grant. Dr. Neel reported having no disclosures.
AT PAS 17
Key clinical point: A permissive parenting style is associated with greater behavioral problems in children at age 2 years.
Major finding: Children of permissive parents had 2.2 times greater likelihood of internalizing behaviors and 3 times greater risk of externalizing behaviors at age 2, compared to children of parents with other styles.
Data source: A prospective observational study of 103 infants assessed at 12 and 24 months.
Disclosures: The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development as well as a private grant. Dr. Neel reported having no disclosures.
Hormonal IUDs have higher expulsion rates immediately postpartum
Hormonal intrauterine devices inserted immediately postpartum had a nearly six times greater likelihood of expulsion compared with copper IUDs, but most women who requested any type of long-acting reversible contraception (LARC) postpartum were still using it half a year later, a recent study found.
“With more than eight out of ten women continuing use at 6 months, in-hospital placement of postpartum LARC devices is a worthwhile intervention,” reported Jennifer L. Eggebroten, MD, and her associates at the University of Utah. “More than half of women who experienced IUD expulsion without commencement of another highly effective contraceptive went on to become pregnant within 2 years, highlighting the need for appropriate counseling prior to device placement and backup contraception planning.”
Ninety percent of the patients were Hispanic, 87% had prior children, and 87% had an income below $24,000. Most (77%) had a vaginal delivery. Those who requested the copper IUD tended to be older and have more children compared with those who asked for the hormonal IUD or implant.
Among the 289 patients who completed the 6 months of follow-up, 17% of those with a hormonal IUD had an expulsion, compared with 4% of women with copper IUDs. That translated to a 5.8 times greater risk of expulsion for hormonal IUDs than for copper ones after the researchers accounted for age, mode of delivery, parity, and any breastfeeding. Expulsion rates were statistically similar between those who had vaginal deliveries and those who had cesarean deliveries.
Just 8% of the women requested removal of their device during the 6 months of follow-up. Most (67%) of the 21 women who had expulsions asked for a replacement. Cost of the device delayed or prevented replacement in some cases. Over the next 2 years, 6 of the 11 women who did not get replacement devices became pregnant.
Meanwhile, 81% of women with a hormonal IUD (88% including replacements), 83% with a copper IUD (86% including replacements), and 90% with an implant were still using that device 6 months later. A quarter of the women who completed the study follow-up reported that they did not return to their providers for their postpartum exams.
“For patients at high risk of rapid repeat pregnancy or who may not return for a postpartum visit, the benefit of placement of a highly effective method of contraception in the hospital prior to discharge may outweigh the increased risk of expulsion,” the researchers wrote. “In some states, by 8 weeks, public insurance coverage may expire and women face much more challenging obstacles to affordable, highly effective birth control options.”
The University of Utah and the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the research. The University of Utah receives research funding from LARC manufacturers and one of the coauthors reported financial relationships with LARC manufacturers.
Hormonal intrauterine devices inserted immediately postpartum had a nearly six times greater likelihood of expulsion compared with copper IUDs, but most women who requested any type of long-acting reversible contraception (LARC) postpartum were still using it half a year later, a recent study found.
“With more than eight out of ten women continuing use at 6 months, in-hospital placement of postpartum LARC devices is a worthwhile intervention,” reported Jennifer L. Eggebroten, MD, and her associates at the University of Utah. “More than half of women who experienced IUD expulsion without commencement of another highly effective contraceptive went on to become pregnant within 2 years, highlighting the need for appropriate counseling prior to device placement and backup contraception planning.”
Ninety percent of the patients were Hispanic, 87% had prior children, and 87% had an income below $24,000. Most (77%) had a vaginal delivery. Those who requested the copper IUD tended to be older and have more children compared with those who asked for the hormonal IUD or implant.
Among the 289 patients who completed the 6 months of follow-up, 17% of those with a hormonal IUD had an expulsion, compared with 4% of women with copper IUDs. That translated to a 5.8 times greater risk of expulsion for hormonal IUDs than for copper ones after the researchers accounted for age, mode of delivery, parity, and any breastfeeding. Expulsion rates were statistically similar between those who had vaginal deliveries and those who had cesarean deliveries.
Just 8% of the women requested removal of their device during the 6 months of follow-up. Most (67%) of the 21 women who had expulsions asked for a replacement. Cost of the device delayed or prevented replacement in some cases. Over the next 2 years, 6 of the 11 women who did not get replacement devices became pregnant.
Meanwhile, 81% of women with a hormonal IUD (88% including replacements), 83% with a copper IUD (86% including replacements), and 90% with an implant were still using that device 6 months later. A quarter of the women who completed the study follow-up reported that they did not return to their providers for their postpartum exams.
“For patients at high risk of rapid repeat pregnancy or who may not return for a postpartum visit, the benefit of placement of a highly effective method of contraception in the hospital prior to discharge may outweigh the increased risk of expulsion,” the researchers wrote. “In some states, by 8 weeks, public insurance coverage may expire and women face much more challenging obstacles to affordable, highly effective birth control options.”
The University of Utah and the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the research. The University of Utah receives research funding from LARC manufacturers and one of the coauthors reported financial relationships with LARC manufacturers.
Hormonal intrauterine devices inserted immediately postpartum had a nearly six times greater likelihood of expulsion compared with copper IUDs, but most women who requested any type of long-acting reversible contraception (LARC) postpartum were still using it half a year later, a recent study found.
“With more than eight out of ten women continuing use at 6 months, in-hospital placement of postpartum LARC devices is a worthwhile intervention,” reported Jennifer L. Eggebroten, MD, and her associates at the University of Utah. “More than half of women who experienced IUD expulsion without commencement of another highly effective contraceptive went on to become pregnant within 2 years, highlighting the need for appropriate counseling prior to device placement and backup contraception planning.”
Ninety percent of the patients were Hispanic, 87% had prior children, and 87% had an income below $24,000. Most (77%) had a vaginal delivery. Those who requested the copper IUD tended to be older and have more children compared with those who asked for the hormonal IUD or implant.
Among the 289 patients who completed the 6 months of follow-up, 17% of those with a hormonal IUD had an expulsion, compared with 4% of women with copper IUDs. That translated to a 5.8 times greater risk of expulsion for hormonal IUDs than for copper ones after the researchers accounted for age, mode of delivery, parity, and any breastfeeding. Expulsion rates were statistically similar between those who had vaginal deliveries and those who had cesarean deliveries.
Just 8% of the women requested removal of their device during the 6 months of follow-up. Most (67%) of the 21 women who had expulsions asked for a replacement. Cost of the device delayed or prevented replacement in some cases. Over the next 2 years, 6 of the 11 women who did not get replacement devices became pregnant.
Meanwhile, 81% of women with a hormonal IUD (88% including replacements), 83% with a copper IUD (86% including replacements), and 90% with an implant were still using that device 6 months later. A quarter of the women who completed the study follow-up reported that they did not return to their providers for their postpartum exams.
“For patients at high risk of rapid repeat pregnancy or who may not return for a postpartum visit, the benefit of placement of a highly effective method of contraception in the hospital prior to discharge may outweigh the increased risk of expulsion,” the researchers wrote. “In some states, by 8 weeks, public insurance coverage may expire and women face much more challenging obstacles to affordable, highly effective birth control options.”
The University of Utah and the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the research. The University of Utah receives research funding from LARC manufacturers and one of the coauthors reported financial relationships with LARC manufacturers.
FROM THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
Key clinical point:
Major finding: Hormonal IUDs were 5.8 times more likely to be expelled than were copper ones, but at least 80% of women who received a LARC still had it 6 months later.
Data source: A prospective cohort of 325 women who received a hormonal or copper IUD or a contraceptive implant immediately postpartum between October 2013 and February 2016.
Disclosures: The University of Utah and the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the research. The University of Utah receives research funding from LARC manufacturers and one of the coauthors reported financial relationships with LARC manufacturers.
Shingles vaccine deemed effective in people with autoimmune disease
The herpes zoster vaccine reduces the risk of shingles in older adults with autoimmune disease, even if they are taking immunosuppressants for their condition, but the protection begins to wane after about 5 years, a recent retrospective study found.
“There has been some concern that patients with autoimmune conditions might have a lower immunogenic response to herpes zoster vaccination, especially when treated with immunosuppressive medications such as glucocorticoids,” wrote Huifeng Yun, PhD, of the University of Alabama at Birmingham, and her colleagues.
The researchers used 2006-2013 Medicare data to calculate the risk of shingles among Medicare recipients who had an autoimmune disease and either did or did not receive the herpes zoster vaccine. All the patients had been enrolled in Medicare for at least 12 continuous months and had a diagnosis of ankylosing spondylitis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or rheumatoid arthritis.
The researchers matched 59,627 patients who received the herpes zoster vaccine with 119,254 unvaccinated patients, based on age, sex, race, calendar year, autoimmune disease type, and use of autoimmune drugs (biologics, disease-modifying antirheumatic drugs, and glucocorticoids). During a follow-up of up to 7 years, the researchers additionally accounted for comorbid medical conditions and concurrent medications each year.
The cohort, with an average age of 73.5 years in both groups, included 53.1% of adults with rheumatoid arthritis, 31.6% with psoriasis, 20.9% with inflammatory bowel disease, 4.7% with psoriatic arthritis, and 1.4% with ankylosing spondylitis.
Those who received the vaccine had a rate of 0.75 herpes zoster cases per 100 people during the first year, which rose to 1.25 cases per 100 people per year at the seventh year after vaccination. The rate among unvaccinated individuals stayed steady at approximately 1.3-1.7 cases per 100 people per year throughout the study period. These rates, as expected, were approximately 50% higher than in the general population over age 70 without autoimmune disease.
Compared with unvaccinated individuals, vaccinated individuals had a reduced relative risk for shingles of 0.74-0.77 after adjustment for confounders, but the risk reduction only remained statistically significant for the first 5 years after vaccination.
The waning seen with the vaccine’s effectiveness “raises the possibility that patients might benefit from a booster vaccine at some point after initial vaccination, although no recommendation currently exists that would support such a practice,” the authors wrote.
Dr. Yun has received research funding from Amgen. Other authors disclosed ties to Amgen, AstraZeneca, Bristol-Myers Squibb, Crescendo Bioscience, Janssen, and Pfizer. One author has received research support and consulting fees from Corrona. The study did not note an external source of funding.
The herpes zoster vaccine reduces the risk of shingles in older adults with autoimmune disease, even if they are taking immunosuppressants for their condition, but the protection begins to wane after about 5 years, a recent retrospective study found.
“There has been some concern that patients with autoimmune conditions might have a lower immunogenic response to herpes zoster vaccination, especially when treated with immunosuppressive medications such as glucocorticoids,” wrote Huifeng Yun, PhD, of the University of Alabama at Birmingham, and her colleagues.
The researchers used 2006-2013 Medicare data to calculate the risk of shingles among Medicare recipients who had an autoimmune disease and either did or did not receive the herpes zoster vaccine. All the patients had been enrolled in Medicare for at least 12 continuous months and had a diagnosis of ankylosing spondylitis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or rheumatoid arthritis.
The researchers matched 59,627 patients who received the herpes zoster vaccine with 119,254 unvaccinated patients, based on age, sex, race, calendar year, autoimmune disease type, and use of autoimmune drugs (biologics, disease-modifying antirheumatic drugs, and glucocorticoids). During a follow-up of up to 7 years, the researchers additionally accounted for comorbid medical conditions and concurrent medications each year.
The cohort, with an average age of 73.5 years in both groups, included 53.1% of adults with rheumatoid arthritis, 31.6% with psoriasis, 20.9% with inflammatory bowel disease, 4.7% with psoriatic arthritis, and 1.4% with ankylosing spondylitis.
Those who received the vaccine had a rate of 0.75 herpes zoster cases per 100 people during the first year, which rose to 1.25 cases per 100 people per year at the seventh year after vaccination. The rate among unvaccinated individuals stayed steady at approximately 1.3-1.7 cases per 100 people per year throughout the study period. These rates, as expected, were approximately 50% higher than in the general population over age 70 without autoimmune disease.
Compared with unvaccinated individuals, vaccinated individuals had a reduced relative risk for shingles of 0.74-0.77 after adjustment for confounders, but the risk reduction only remained statistically significant for the first 5 years after vaccination.
The waning seen with the vaccine’s effectiveness “raises the possibility that patients might benefit from a booster vaccine at some point after initial vaccination, although no recommendation currently exists that would support such a practice,” the authors wrote.
Dr. Yun has received research funding from Amgen. Other authors disclosed ties to Amgen, AstraZeneca, Bristol-Myers Squibb, Crescendo Bioscience, Janssen, and Pfizer. One author has received research support and consulting fees from Corrona. The study did not note an external source of funding.
The herpes zoster vaccine reduces the risk of shingles in older adults with autoimmune disease, even if they are taking immunosuppressants for their condition, but the protection begins to wane after about 5 years, a recent retrospective study found.
“There has been some concern that patients with autoimmune conditions might have a lower immunogenic response to herpes zoster vaccination, especially when treated with immunosuppressive medications such as glucocorticoids,” wrote Huifeng Yun, PhD, of the University of Alabama at Birmingham, and her colleagues.
The researchers used 2006-2013 Medicare data to calculate the risk of shingles among Medicare recipients who had an autoimmune disease and either did or did not receive the herpes zoster vaccine. All the patients had been enrolled in Medicare for at least 12 continuous months and had a diagnosis of ankylosing spondylitis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or rheumatoid arthritis.
The researchers matched 59,627 patients who received the herpes zoster vaccine with 119,254 unvaccinated patients, based on age, sex, race, calendar year, autoimmune disease type, and use of autoimmune drugs (biologics, disease-modifying antirheumatic drugs, and glucocorticoids). During a follow-up of up to 7 years, the researchers additionally accounted for comorbid medical conditions and concurrent medications each year.
The cohort, with an average age of 73.5 years in both groups, included 53.1% of adults with rheumatoid arthritis, 31.6% with psoriasis, 20.9% with inflammatory bowel disease, 4.7% with psoriatic arthritis, and 1.4% with ankylosing spondylitis.
Those who received the vaccine had a rate of 0.75 herpes zoster cases per 100 people during the first year, which rose to 1.25 cases per 100 people per year at the seventh year after vaccination. The rate among unvaccinated individuals stayed steady at approximately 1.3-1.7 cases per 100 people per year throughout the study period. These rates, as expected, were approximately 50% higher than in the general population over age 70 without autoimmune disease.
Compared with unvaccinated individuals, vaccinated individuals had a reduced relative risk for shingles of 0.74-0.77 after adjustment for confounders, but the risk reduction only remained statistically significant for the first 5 years after vaccination.
The waning seen with the vaccine’s effectiveness “raises the possibility that patients might benefit from a booster vaccine at some point after initial vaccination, although no recommendation currently exists that would support such a practice,” the authors wrote.
Dr. Yun has received research funding from Amgen. Other authors disclosed ties to Amgen, AstraZeneca, Bristol-Myers Squibb, Crescendo Bioscience, Janssen, and Pfizer. One author has received research support and consulting fees from Corrona. The study did not note an external source of funding.
Key clinical point:
Major finding: Medicare patients with autoimmune disease had a 23%-26% reduced risk of shingles for 5 years after receiving the herpes zoster vaccine.
Data source: The findings are based on analysis of 2006-2013 Medicare data on 59,627 patients who received the herpes zoster vaccine and 119,254 patients who didn’t.
Disclosures: Dr. Yun has received research funding from Amgen. Other authors disclosed ties to Amgen, AstraZeneca, Bristol-Myers Squibb, Crescendo Bioscience, Janssen, and Pfizer. One author has received research support and consulting fees from Corrona. The study did not note an external source of funding.
Adolescent opioid use common but decreasing
About a quarter of high school seniors have taken prescription opioids, medically or nonmedically, but exposures have declined over the past 2 years, according to a study.
“The recent declines in medical use of prescription opioids and nonmedical use of prescribed opioids from 2013 through 2015 found in the current study coincide with similar recent declines in U.S. opioid analgesic prescribing,” reported Sean Esteban McCabe, PhD, of the University of Michigan, Ann Arbor, and his associates (Pediatrics 2017 March 20. doi: 10.1542/peds.2016-2387). “Among adolescents who report both medical use of prescription opioids and nonmedical use of prescribed opioids, medical use before initiating nonmedical use of prescribed opioids tended to be most prevalent, and this pattern may be driven by the one-third of adolescents who report nonmedical use of prescribed opioids involving leftover opioid medications from their own previous prescriptions.”
The researchers analyzed data from the Monitoring the Future study from 1976 through 2015, an annual cross-sectional survey of high school seniors from 135 public and private high schools in the United States. Cohorts were nationally representative and varied in size from 2,181 to 3,791 students.
Students were asked whether they had ever been prescribed opioids by a doctor and how often they had ever taken opioids nonmedically. The list of opioids included all the ones available that year, including Vicodin, OxyContin, Percodan, Percocet, Demerol, Ultram, methadone, morphine, opium, and codeine.
Use of opioids for any reason ranged from 16.5% to 24% over the 4 decades, with medical use ranging from a low of 8.5% in 2000 to a peak of 14.4% in 1989. Though 16% of teens had used medical opioids in 1976, prevalence rose to 20% in 1989, then dropped to 13% in 1997 and remained stable. Rates sharply increased to 20% in 2002 – the year Vicodin, OxyContin, and Percocet were included in the questions – and then began declining again in 2013.
Nonmedical use correlated with medical use though remained less prevalent throughout the study period. This correlation was stronger for males, who are more likely to use opioids recreationally, than for females, who are more likely to use them to self-treat pain, the authors wrote.
Both medical and nonmedical use were more prevalent among white students than black students, in line with previous research showing “health disparities for receiving prescription opioids among racial minority patients,” the authors wrote.
Black teens are more often motivated to use opioids for pain relief, suggesting that their lower exposure rates “could result from a lack of adequate treatment, insufficient availability, overprescribing among white populations or underprescribing among nonwhite populations,” they wrote.
One limitation of the study was that absent students or those who had dropped out have a higher risk of opioid use, thereby possibly contributing to underreporting.
The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.
This research is important because nonmedical use of prescribed opiates is believed to be a major cause of morbidity and mortality associated with opiates. The consistency of the Monitoring the Future survey provides a high-level view of opiate use across the country from 1975 to 2015. Although helpful, this perspective can obscure critically important changes in local areas or within specific populations.
It is important to recognize the strong relationship between opioid prescription and nonmedical opioid use. These findings support the policy recommendations to prescribe opioids only when patients have strong indications for opioids and no better treatment options are available.
We view the recent decrease in the medical use of prescription opioids and nonmedical opioid use as an important finding, but there are significant small-area variations that would not appear in a national study. The epidemic of opioid use disproportionately affects some urban and more rural areas. Nonmedical use of prescribed opiates in general has become more common in rural areas. West Virginia, a predominantly rural state, has the highest rate of opioid overdose fatality in the country at 41.5 deaths per 100,000 in 2015. The state also has the second highest rate of opioid prescriptions per capita.
We are heartened to see a recent decrease, but we see it as a measured improvement. We understand that the appropriate use of opioids to manage pain can be helpful for our patients, but we must continue to search for solutions to the current crisis. Possible interventions include better education of our patients and families when we prescribe these drugs, better drug regulation, development of new affordable approaches to pain management that have lower potential for abuse, and accessible and affordable treatment programs for those already afflicted.
These comments were taken from an editorial published in Pediatrics by David A. Rosen, MD, FAAP, and Pamela J. Murray, MD, MHP, FAAP, both of West Virginia University in Morgantown. They reported having no disclosures or external funding.
This research is important because nonmedical use of prescribed opiates is believed to be a major cause of morbidity and mortality associated with opiates. The consistency of the Monitoring the Future survey provides a high-level view of opiate use across the country from 1975 to 2015. Although helpful, this perspective can obscure critically important changes in local areas or within specific populations.
It is important to recognize the strong relationship between opioid prescription and nonmedical opioid use. These findings support the policy recommendations to prescribe opioids only when patients have strong indications for opioids and no better treatment options are available.
We view the recent decrease in the medical use of prescription opioids and nonmedical opioid use as an important finding, but there are significant small-area variations that would not appear in a national study. The epidemic of opioid use disproportionately affects some urban and more rural areas. Nonmedical use of prescribed opiates in general has become more common in rural areas. West Virginia, a predominantly rural state, has the highest rate of opioid overdose fatality in the country at 41.5 deaths per 100,000 in 2015. The state also has the second highest rate of opioid prescriptions per capita.
We are heartened to see a recent decrease, but we see it as a measured improvement. We understand that the appropriate use of opioids to manage pain can be helpful for our patients, but we must continue to search for solutions to the current crisis. Possible interventions include better education of our patients and families when we prescribe these drugs, better drug regulation, development of new affordable approaches to pain management that have lower potential for abuse, and accessible and affordable treatment programs for those already afflicted.
These comments were taken from an editorial published in Pediatrics by David A. Rosen, MD, FAAP, and Pamela J. Murray, MD, MHP, FAAP, both of West Virginia University in Morgantown. They reported having no disclosures or external funding.
This research is important because nonmedical use of prescribed opiates is believed to be a major cause of morbidity and mortality associated with opiates. The consistency of the Monitoring the Future survey provides a high-level view of opiate use across the country from 1975 to 2015. Although helpful, this perspective can obscure critically important changes in local areas or within specific populations.
It is important to recognize the strong relationship between opioid prescription and nonmedical opioid use. These findings support the policy recommendations to prescribe opioids only when patients have strong indications for opioids and no better treatment options are available.
We view the recent decrease in the medical use of prescription opioids and nonmedical opioid use as an important finding, but there are significant small-area variations that would not appear in a national study. The epidemic of opioid use disproportionately affects some urban and more rural areas. Nonmedical use of prescribed opiates in general has become more common in rural areas. West Virginia, a predominantly rural state, has the highest rate of opioid overdose fatality in the country at 41.5 deaths per 100,000 in 2015. The state also has the second highest rate of opioid prescriptions per capita.
We are heartened to see a recent decrease, but we see it as a measured improvement. We understand that the appropriate use of opioids to manage pain can be helpful for our patients, but we must continue to search for solutions to the current crisis. Possible interventions include better education of our patients and families when we prescribe these drugs, better drug regulation, development of new affordable approaches to pain management that have lower potential for abuse, and accessible and affordable treatment programs for those already afflicted.
These comments were taken from an editorial published in Pediatrics by David A. Rosen, MD, FAAP, and Pamela J. Murray, MD, MHP, FAAP, both of West Virginia University in Morgantown. They reported having no disclosures or external funding.
About a quarter of high school seniors have taken prescription opioids, medically or nonmedically, but exposures have declined over the past 2 years, according to a study.
“The recent declines in medical use of prescription opioids and nonmedical use of prescribed opioids from 2013 through 2015 found in the current study coincide with similar recent declines in U.S. opioid analgesic prescribing,” reported Sean Esteban McCabe, PhD, of the University of Michigan, Ann Arbor, and his associates (Pediatrics 2017 March 20. doi: 10.1542/peds.2016-2387). “Among adolescents who report both medical use of prescription opioids and nonmedical use of prescribed opioids, medical use before initiating nonmedical use of prescribed opioids tended to be most prevalent, and this pattern may be driven by the one-third of adolescents who report nonmedical use of prescribed opioids involving leftover opioid medications from their own previous prescriptions.”
The researchers analyzed data from the Monitoring the Future study from 1976 through 2015, an annual cross-sectional survey of high school seniors from 135 public and private high schools in the United States. Cohorts were nationally representative and varied in size from 2,181 to 3,791 students.
Students were asked whether they had ever been prescribed opioids by a doctor and how often they had ever taken opioids nonmedically. The list of opioids included all the ones available that year, including Vicodin, OxyContin, Percodan, Percocet, Demerol, Ultram, methadone, morphine, opium, and codeine.
Use of opioids for any reason ranged from 16.5% to 24% over the 4 decades, with medical use ranging from a low of 8.5% in 2000 to a peak of 14.4% in 1989. Though 16% of teens had used medical opioids in 1976, prevalence rose to 20% in 1989, then dropped to 13% in 1997 and remained stable. Rates sharply increased to 20% in 2002 – the year Vicodin, OxyContin, and Percocet were included in the questions – and then began declining again in 2013.
Nonmedical use correlated with medical use though remained less prevalent throughout the study period. This correlation was stronger for males, who are more likely to use opioids recreationally, than for females, who are more likely to use them to self-treat pain, the authors wrote.
Both medical and nonmedical use were more prevalent among white students than black students, in line with previous research showing “health disparities for receiving prescription opioids among racial minority patients,” the authors wrote.
Black teens are more often motivated to use opioids for pain relief, suggesting that their lower exposure rates “could result from a lack of adequate treatment, insufficient availability, overprescribing among white populations or underprescribing among nonwhite populations,” they wrote.
One limitation of the study was that absent students or those who had dropped out have a higher risk of opioid use, thereby possibly contributing to underreporting.
The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.
About a quarter of high school seniors have taken prescription opioids, medically or nonmedically, but exposures have declined over the past 2 years, according to a study.
“The recent declines in medical use of prescription opioids and nonmedical use of prescribed opioids from 2013 through 2015 found in the current study coincide with similar recent declines in U.S. opioid analgesic prescribing,” reported Sean Esteban McCabe, PhD, of the University of Michigan, Ann Arbor, and his associates (Pediatrics 2017 March 20. doi: 10.1542/peds.2016-2387). “Among adolescents who report both medical use of prescription opioids and nonmedical use of prescribed opioids, medical use before initiating nonmedical use of prescribed opioids tended to be most prevalent, and this pattern may be driven by the one-third of adolescents who report nonmedical use of prescribed opioids involving leftover opioid medications from their own previous prescriptions.”
The researchers analyzed data from the Monitoring the Future study from 1976 through 2015, an annual cross-sectional survey of high school seniors from 135 public and private high schools in the United States. Cohorts were nationally representative and varied in size from 2,181 to 3,791 students.
Students were asked whether they had ever been prescribed opioids by a doctor and how often they had ever taken opioids nonmedically. The list of opioids included all the ones available that year, including Vicodin, OxyContin, Percodan, Percocet, Demerol, Ultram, methadone, morphine, opium, and codeine.
Use of opioids for any reason ranged from 16.5% to 24% over the 4 decades, with medical use ranging from a low of 8.5% in 2000 to a peak of 14.4% in 1989. Though 16% of teens had used medical opioids in 1976, prevalence rose to 20% in 1989, then dropped to 13% in 1997 and remained stable. Rates sharply increased to 20% in 2002 – the year Vicodin, OxyContin, and Percocet were included in the questions – and then began declining again in 2013.
Nonmedical use correlated with medical use though remained less prevalent throughout the study period. This correlation was stronger for males, who are more likely to use opioids recreationally, than for females, who are more likely to use them to self-treat pain, the authors wrote.
Both medical and nonmedical use were more prevalent among white students than black students, in line with previous research showing “health disparities for receiving prescription opioids among racial minority patients,” the authors wrote.
Black teens are more often motivated to use opioids for pain relief, suggesting that their lower exposure rates “could result from a lack of adequate treatment, insufficient availability, overprescribing among white populations or underprescribing among nonwhite populations,” they wrote.
One limitation of the study was that absent students or those who had dropped out have a higher risk of opioid use, thereby possibly contributing to underreporting.
The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.
FROM PEDIATRICS
Key clinical point: Teen opioid use began to decline from 2013 through 2015 but remains common.
Major finding: Prevalence of teens’ medical or nonmedical use of prescription opioids ranged from 16.5% to 24% between 1976 and 2015.
Data source: Analysis of 40 annual surveys of U.S. high school seniors from 1976 through 2015.
Disclosures: The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.
STD testing in youth hindered by confidentiality concerns
Adolescents and young adults on their parents’ health insurance plan are less likely to receive sexual preventive health care, such as sexual risk assessments and testing for sexually transmitted disease, a study found.
Further, teen girls (aged 15-17 years), were more than twice as likely to be tested for chlamydia if they met with their provider alone than if they did not, researchers found.
“Confidentiality issues, including concerns that parents might find out, might be barriers to the use of STD [sexually transmitted disease] services among some subpopulations,” Jami S. Leichliter, PhD, and colleagues at the Centers for Disease Control and Prevention wrote. “Public health efforts to reduce these confidentiality concerns might be useful,” such as providers meeting privately for at least part of an appointment with an adolescent (MMWR. 2017 Mar 10;66[9]:237-41).
The researchers examined data collected from the 2013-2015 National Survey of Family Growth regarding sexual and reproductive health care experiences and behaviors of youth with sexual experience, specifically teens aged 15-17 and young adults aged 18-25 who were on their parents’ health plan. Sexual experience refers to having ever had vaginal, anal, or oral sex with any partner.
Overall, 12.7% of these youth avoided seeking care for sexual and reproductive health because they worried their parents could find out. For those aged 15-17 years, the rate was even higher, at 22.6%.
These concerns were also reflected in the overall prevalence of chlamydia screenings: Just 17.1% of young women who worried about confidentiality had been screened for chlamydia, compared with 38.7% of young women who did not report that concern.
The researchers also compared teens aged 15-17 who had and had not received a sexual risk assessment, which includes being asked by a provider about their (or their partners’) sexual orientation, number of sexual partners, condom use, and types of sex. Among teens who met with a provider alone in the past year, 71.1% reported receiving a sexual risk assessment, compared with about 36.6% who did not meet privately with a provider.
Similarly, 34.0% of teen girls (aged 15-17 years) who saw their provider alone were tested for chlamydia, compared with 14.9% who never met with their provider alone. Slightly more teen boys (13.6%) received STD testing if they met with their provider alone than if they didn’t (9.5%), but this difference did not reach statistical significance.
The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
Adolescents and young adults on their parents’ health insurance plan are less likely to receive sexual preventive health care, such as sexual risk assessments and testing for sexually transmitted disease, a study found.
Further, teen girls (aged 15-17 years), were more than twice as likely to be tested for chlamydia if they met with their provider alone than if they did not, researchers found.
“Confidentiality issues, including concerns that parents might find out, might be barriers to the use of STD [sexually transmitted disease] services among some subpopulations,” Jami S. Leichliter, PhD, and colleagues at the Centers for Disease Control and Prevention wrote. “Public health efforts to reduce these confidentiality concerns might be useful,” such as providers meeting privately for at least part of an appointment with an adolescent (MMWR. 2017 Mar 10;66[9]:237-41).
The researchers examined data collected from the 2013-2015 National Survey of Family Growth regarding sexual and reproductive health care experiences and behaviors of youth with sexual experience, specifically teens aged 15-17 and young adults aged 18-25 who were on their parents’ health plan. Sexual experience refers to having ever had vaginal, anal, or oral sex with any partner.
Overall, 12.7% of these youth avoided seeking care for sexual and reproductive health because they worried their parents could find out. For those aged 15-17 years, the rate was even higher, at 22.6%.
These concerns were also reflected in the overall prevalence of chlamydia screenings: Just 17.1% of young women who worried about confidentiality had been screened for chlamydia, compared with 38.7% of young women who did not report that concern.
The researchers also compared teens aged 15-17 who had and had not received a sexual risk assessment, which includes being asked by a provider about their (or their partners’) sexual orientation, number of sexual partners, condom use, and types of sex. Among teens who met with a provider alone in the past year, 71.1% reported receiving a sexual risk assessment, compared with about 36.6% who did not meet privately with a provider.
Similarly, 34.0% of teen girls (aged 15-17 years) who saw their provider alone were tested for chlamydia, compared with 14.9% who never met with their provider alone. Slightly more teen boys (13.6%) received STD testing if they met with their provider alone than if they didn’t (9.5%), but this difference did not reach statistical significance.
The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
Adolescents and young adults on their parents’ health insurance plan are less likely to receive sexual preventive health care, such as sexual risk assessments and testing for sexually transmitted disease, a study found.
Further, teen girls (aged 15-17 years), were more than twice as likely to be tested for chlamydia if they met with their provider alone than if they did not, researchers found.
“Confidentiality issues, including concerns that parents might find out, might be barriers to the use of STD [sexually transmitted disease] services among some subpopulations,” Jami S. Leichliter, PhD, and colleagues at the Centers for Disease Control and Prevention wrote. “Public health efforts to reduce these confidentiality concerns might be useful,” such as providers meeting privately for at least part of an appointment with an adolescent (MMWR. 2017 Mar 10;66[9]:237-41).
The researchers examined data collected from the 2013-2015 National Survey of Family Growth regarding sexual and reproductive health care experiences and behaviors of youth with sexual experience, specifically teens aged 15-17 and young adults aged 18-25 who were on their parents’ health plan. Sexual experience refers to having ever had vaginal, anal, or oral sex with any partner.
Overall, 12.7% of these youth avoided seeking care for sexual and reproductive health because they worried their parents could find out. For those aged 15-17 years, the rate was even higher, at 22.6%.
These concerns were also reflected in the overall prevalence of chlamydia screenings: Just 17.1% of young women who worried about confidentiality had been screened for chlamydia, compared with 38.7% of young women who did not report that concern.
The researchers also compared teens aged 15-17 who had and had not received a sexual risk assessment, which includes being asked by a provider about their (or their partners’) sexual orientation, number of sexual partners, condom use, and types of sex. Among teens who met with a provider alone in the past year, 71.1% reported receiving a sexual risk assessment, compared with about 36.6% who did not meet privately with a provider.
Similarly, 34.0% of teen girls (aged 15-17 years) who saw their provider alone were tested for chlamydia, compared with 14.9% who never met with their provider alone. Slightly more teen boys (13.6%) received STD testing if they met with their provider alone than if they didn’t (9.5%), but this difference did not reach statistical significance.
The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
FROM MMWR
Key clinical point:
Major finding: Overall, 12.7% of sexually experienced youths (aged 15-25 years) who were on their parents’ health plan would not seek sexual and reproductive health care because of confidentiality concerns.
Data source: Responses from sexually experienced youth aged 15-25 years provided during the 2013-2015 U.S. National Survey of Family Growth.
Disclosures: The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.