Tara Haelle

An estimated 1 in 10 high school students uses synthetic cannabinoids, which are linked to multiple other risk behaviors, and use is more likely among students with depressive symptoms, marijuana use, and alcohol use, investigators in two studies reported.

Synthetic cannabinoids are structurally similar to delta-9-tetrahydrocannabinol, but they may be more potent, with adverse health effects not seen with natural tetrahydrocannabinol in marijuana. These synthetic products are accessible to teens online, in convenience stores, and in smoke shops. Past research has suggested that adolescents aren’t aware of the possible negative effects of these products, such as tachycardia, hypertension, lethargy, nausea, vomiting, irritability, chest pain, hallucinations, confusion, and vertigo.

Courtesy DEA

An estimated 1 in 10 high school students uses synthetic cannabinoids, which are linked to multiple other risk behaviors, and use is more likely among students with depressive symptoms, marijuana use, and alcohol use, investigators in two studies reported.

Synthetic cannabinoids are structurally similar to delta-9-tetrahydrocannabinol, but they may be more potent, with adverse health effects not seen with natural tetrahydrocannabinol in marijuana. These synthetic products are accessible to teens online, in convenience stores, and in smoke shops. Past research has suggested that adolescents aren’t aware of the possible negative effects of these products, such as tachycardia, hypertension, lethargy, nausea, vomiting, irritability, chest pain, hallucinations, confusion, and vertigo.

Courtesy DEA

An estimated 1 in 10 high school students uses synthetic cannabinoids, which are linked to multiple other risk behaviors, and use is more likely among students with depressive symptoms, marijuana use, and alcohol use, investigators in two studies reported.

Synthetic cannabinoids are structurally similar to delta-9-tetrahydrocannabinol, but they may be more potent, with adverse health effects not seen with natural tetrahydrocannabinol in marijuana. These synthetic products are accessible to teens online, in convenience stores, and in smoke shops. Past research has suggested that adolescents aren’t aware of the possible negative effects of these products, such as tachycardia, hypertension, lethargy, nausea, vomiting, irritability, chest pain, hallucinations, confusion, and vertigo.

Courtesy DEA

SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.

In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.

kokouu/iStockphoto.com

• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.

• Document your thinking in terms of differential diagnoses.

• Document a follow-up plan beyond just checking the box of a patient’s return date.

• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.

• Learn the entry fields for diagnosis codes and for medications and their route of administration.

• Double check that you’re clicking the correct patient, medication, and date of service.

• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.

• Narrative notes should be customized and included, even if the records ask many yes/no questions.

• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.

• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”

• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.

“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.

Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.

SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.

In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.

kokouu/iStockphoto.com

• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.

• Document your thinking in terms of differential diagnoses.

• Document a follow-up plan beyond just checking the box of a patient’s return date.

• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.

• Learn the entry fields for diagnosis codes and for medications and their route of administration.

• Double check that you’re clicking the correct patient, medication, and date of service.

• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.

• Narrative notes should be customized and included, even if the records ask many yes/no questions.

• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.

• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”

• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.

“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.

Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.

SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.

In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.

kokouu/iStockphoto.com

• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.

• Document your thinking in terms of differential diagnoses.

• Document a follow-up plan beyond just checking the box of a patient’s return date.

• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.

• Learn the entry fields for diagnosis codes and for medications and their route of administration.

• Double check that you’re clicking the correct patient, medication, and date of service.

• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.

• Narrative notes should be customized and included, even if the records ask many yes/no questions.

• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.

• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”

• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.

“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.

Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.

ATLANTA – Both the influenza and the tetanus-diphtheria-acellular pertussis (Tdap) vaccines have been recommended during pregnancy for years, but uptake remains low.

The most recent national data from the Centers for Disease Control and Prevention show that the Tdap vaccination rate is about 14% before pregnancy and 10% during pregnancy. For influenza, the vaccination rate among pregnant women is about 50%, with 14% of women being vaccinated in the 6 months before pregnancy and 36% during pregnancy.

Piotr Marcinski/Thinkstock

Barriers

Reimbursement-related issues topped the reasons that ob.gyns. found it burdensome to stock and administer vaccines. The most commonly reported barrier – cited by 54% of the respondents – was lack of adequate reimbursement for purchasing vaccines, and 30% of physicians cited this as a major barrier. Similarly, lack of adequate reimbursement for administration of the vaccine was listed as a major barrier for a quarter of the respondents and a moderate barrier by 21% of the respondents.

A quarter of physicians also cited difficulty determining if a patient’s insurance would reimburse for a vaccine as a major barrier.

Other barriers included having too little time for vaccination during visits when other preventive services took precedence, having patients who refused vaccines because of safety concerns, the burden of storing, ordering, and tracking vaccines, and difficulty determining whether a patient had already received a particular vaccine.

Fewer than 2% of ob.gyns., however, reported uncertainty about a particular vaccine’s effectiveness or safety in pregnant women as a barrier.

“Physician attitudinal barriers are nonexistent,” Dr. O’Leary said. “The perceived barriers were primarily financial, but logistical and patient attitudinal barriers were also important.”

Testing interventions

While the barriers to routine vaccine administration are clear, the solutions are less obvious. A recently reported intensive intervention to increase the uptake of maternal vaccines in ob.gyn. practices had only modest success in increasing Tdap vaccination and no significant impact on administration of the influenza vaccine.

“Immunization delivery in the ob.gyn. setting may present different challenges than more traditional settings for adult vaccination, such as family medicine or internal medicine offices,” Dr. O’Leary said.

The study involved eight ob.gyn. practices in Colorado and ran from August 2011 through March 2014, a period during which the Advisory Committee for Immunization Practices recommended that Tdap vaccination be given in every pregnancy.

Four ob.gyn. practices – one rural and three urban – were randomly assigned to usual care while the other four – two rural and two urban – were randomly assigned to the intervention. The practices were balanced in terms of their number of providers, the proportion of Medicaid patients they served, the number of deliveries per month, and an immunization delivery score at baseline.

The researchers assessed receipt of influenza vaccines among women pregnant during the previous influenza season and receipt of the Tdap vaccine among women at at least 34 weeks’ gestation. There were 13,324 patients in the control arm and 12,103 patients in the intervention arm.

The multimodal intervention involved seven components:

1. Designating immunization champions at each practice.

2. Assisting with vaccine purchasing and management.

3. Historical vaccination documentation training.

4. Implementing standing orders for both vaccines.

5. Chart review and feedback.

6. Patient/staff education materials and training.

7. Frequent contact with the project team, at least once a month during the study period.

At baseline, the rate of Tdap vaccination among pregnant women was 3% in the intervention clinics and 11% in the control clinics. During year 2, following the intervention, 38% of women at the intervention clinics and 34% of the women at the control clinics had received the Tdap vaccine. Those increases translated to a four times greater likelihood of getting the Tdap vaccine among women at clinics who underwent the intervention (risk ratio, 3.9; 95% confidence interval, 1.1-13.3).

Influenza vaccine uptake also increased collectively at the clinics, from 19% at intervention clinics and 18% at control clinics at baseline, to 21% at intervention clinics and 25% at control clinics a year later. But there was no significant difference in uptake between the intervention and control clinics.

An additional qualitative component of the study involved hour-long interviews with staff members from six of the clinics to assess specific components of the intervention, such as implementing standing orders for each vaccine.

“Prior to establishing standing orders at practices, the responsibility for assessing immunization history and eligibility had fallen to the medical providers,” Dr. O’Leary said. “By establishing standing orders for immunizations, providers and staff reported overall improved immunization delivery to their patient population.”

But barriers existed for standing orders as well, including patient reluctance to receive the vaccine without first discussing it with her physician.

The qualitative interviews also revealed that some nurses may have felt anxious about administering vaccines to pregnant women until they received vaccine education. Overall, staff education and implementation of standing orders were well received at the intervention practices.

“Adding immunization questions to standard intake forms was an efficient and effective method to collect immunization history that fit into already established patient check-in processes,” Dr. O’Leary said.

Standing order templates could also be customized to each practice’s processes, and the process of the staff reviewing these templates often led to consensus about how to integrate the orders into routine care, according to Dr. O’Leary.

“To increase the uptake of vaccinations in pregnancy, all ob.gyns. need to stock and administer influenza and Tdap vaccines,” Dr. O’Leary said. “And if ob.gyns. are to play a significant role as vaccinators of nonpregnant women, a paradigm shift is required.”

Both studies were funded by the CDC. Dr. O’Leary reported having no relevant financial disclosures, but one of the coinvestigators in the intervention study reported financial relationships with Merck and Pfizer.

ATLANTA – Both the influenza and the tetanus-diphtheria-acellular pertussis (Tdap) vaccines have been recommended during pregnancy for years, but uptake remains low.

The most recent national data from the Centers for Disease Control and Prevention show that the Tdap vaccination rate is about 14% before pregnancy and 10% during pregnancy. For influenza, the vaccination rate among pregnant women is about 50%, with 14% of women being vaccinated in the 6 months before pregnancy and 36% during pregnancy.

Piotr Marcinski/Thinkstock

Barriers

Reimbursement-related issues topped the reasons that ob.gyns. found it burdensome to stock and administer vaccines. The most commonly reported barrier – cited by 54% of the respondents – was lack of adequate reimbursement for purchasing vaccines, and 30% of physicians cited this as a major barrier. Similarly, lack of adequate reimbursement for administration of the vaccine was listed as a major barrier for a quarter of the respondents and a moderate barrier by 21% of the respondents.

A quarter of physicians also cited difficulty determining if a patient’s insurance would reimburse for a vaccine as a major barrier.

Other barriers included having too little time for vaccination during visits when other preventive services took precedence, having patients who refused vaccines because of safety concerns, the burden of storing, ordering, and tracking vaccines, and difficulty determining whether a patient had already received a particular vaccine.

Fewer than 2% of ob.gyns., however, reported uncertainty about a particular vaccine’s effectiveness or safety in pregnant women as a barrier.

“Physician attitudinal barriers are nonexistent,” Dr. O’Leary said. “The perceived barriers were primarily financial, but logistical and patient attitudinal barriers were also important.”

Testing interventions

While the barriers to routine vaccine administration are clear, the solutions are less obvious. A recently reported intensive intervention to increase the uptake of maternal vaccines in ob.gyn. practices had only modest success in increasing Tdap vaccination and no significant impact on administration of the influenza vaccine.

“Immunization delivery in the ob.gyn. setting may present different challenges than more traditional settings for adult vaccination, such as family medicine or internal medicine offices,” Dr. O’Leary said.

The study involved eight ob.gyn. practices in Colorado and ran from August 2011 through March 2014, a period during which the Advisory Committee for Immunization Practices recommended that Tdap vaccination be given in every pregnancy.

Four ob.gyn. practices – one rural and three urban – were randomly assigned to usual care while the other four – two rural and two urban – were randomly assigned to the intervention. The practices were balanced in terms of their number of providers, the proportion of Medicaid patients they served, the number of deliveries per month, and an immunization delivery score at baseline.

The researchers assessed receipt of influenza vaccines among women pregnant during the previous influenza season and receipt of the Tdap vaccine among women at at least 34 weeks’ gestation. There were 13,324 patients in the control arm and 12,103 patients in the intervention arm.

The multimodal intervention involved seven components:

1. Designating immunization champions at each practice.

2. Assisting with vaccine purchasing and management.

3. Historical vaccination documentation training.

4. Implementing standing orders for both vaccines.

5. Chart review and feedback.

6. Patient/staff education materials and training.

7. Frequent contact with the project team, at least once a month during the study period.

At baseline, the rate of Tdap vaccination among pregnant women was 3% in the intervention clinics and 11% in the control clinics. During year 2, following the intervention, 38% of women at the intervention clinics and 34% of the women at the control clinics had received the Tdap vaccine. Those increases translated to a four times greater likelihood of getting the Tdap vaccine among women at clinics who underwent the intervention (risk ratio, 3.9; 95% confidence interval, 1.1-13.3).

Influenza vaccine uptake also increased collectively at the clinics, from 19% at intervention clinics and 18% at control clinics at baseline, to 21% at intervention clinics and 25% at control clinics a year later. But there was no significant difference in uptake between the intervention and control clinics.

An additional qualitative component of the study involved hour-long interviews with staff members from six of the clinics to assess specific components of the intervention, such as implementing standing orders for each vaccine.

“Prior to establishing standing orders at practices, the responsibility for assessing immunization history and eligibility had fallen to the medical providers,” Dr. O’Leary said. “By establishing standing orders for immunizations, providers and staff reported overall improved immunization delivery to their patient population.”

But barriers existed for standing orders as well, including patient reluctance to receive the vaccine without first discussing it with her physician.

The qualitative interviews also revealed that some nurses may have felt anxious about administering vaccines to pregnant women until they received vaccine education. Overall, staff education and implementation of standing orders were well received at the intervention practices.

“Adding immunization questions to standard intake forms was an efficient and effective method to collect immunization history that fit into already established patient check-in processes,” Dr. O’Leary said.

Standing order templates could also be customized to each practice’s processes, and the process of the staff reviewing these templates often led to consensus about how to integrate the orders into routine care, according to Dr. O’Leary.

“To increase the uptake of vaccinations in pregnancy, all ob.gyns. need to stock and administer influenza and Tdap vaccines,” Dr. O’Leary said. “And if ob.gyns. are to play a significant role as vaccinators of nonpregnant women, a paradigm shift is required.”

Both studies were funded by the CDC. Dr. O’Leary reported having no relevant financial disclosures, but one of the coinvestigators in the intervention study reported financial relationships with Merck and Pfizer.

ATLANTA – Both the influenza and the tetanus-diphtheria-acellular pertussis (Tdap) vaccines have been recommended during pregnancy for years, but uptake remains low.

The most recent national data from the Centers for Disease Control and Prevention show that the Tdap vaccination rate is about 14% before pregnancy and 10% during pregnancy. For influenza, the vaccination rate among pregnant women is about 50%, with 14% of women being vaccinated in the 6 months before pregnancy and 36% during pregnancy.

Piotr Marcinski/Thinkstock

Barriers

Reimbursement-related issues topped the reasons that ob.gyns. found it burdensome to stock and administer vaccines. The most commonly reported barrier – cited by 54% of the respondents – was lack of adequate reimbursement for purchasing vaccines, and 30% of physicians cited this as a major barrier. Similarly, lack of adequate reimbursement for administration of the vaccine was listed as a major barrier for a quarter of the respondents and a moderate barrier by 21% of the respondents.

A quarter of physicians also cited difficulty determining if a patient’s insurance would reimburse for a vaccine as a major barrier.

Other barriers included having too little time for vaccination during visits when other preventive services took precedence, having patients who refused vaccines because of safety concerns, the burden of storing, ordering, and tracking vaccines, and difficulty determining whether a patient had already received a particular vaccine.

Fewer than 2% of ob.gyns., however, reported uncertainty about a particular vaccine’s effectiveness or safety in pregnant women as a barrier.

“Physician attitudinal barriers are nonexistent,” Dr. O’Leary said. “The perceived barriers were primarily financial, but logistical and patient attitudinal barriers were also important.”

Testing interventions

While the barriers to routine vaccine administration are clear, the solutions are less obvious. A recently reported intensive intervention to increase the uptake of maternal vaccines in ob.gyn. practices had only modest success in increasing Tdap vaccination and no significant impact on administration of the influenza vaccine.

“Immunization delivery in the ob.gyn. setting may present different challenges than more traditional settings for adult vaccination, such as family medicine or internal medicine offices,” Dr. O’Leary said.

The study involved eight ob.gyn. practices in Colorado and ran from August 2011 through March 2014, a period during which the Advisory Committee for Immunization Practices recommended that Tdap vaccination be given in every pregnancy.

Four ob.gyn. practices – one rural and three urban – were randomly assigned to usual care while the other four – two rural and two urban – were randomly assigned to the intervention. The practices were balanced in terms of their number of providers, the proportion of Medicaid patients they served, the number of deliveries per month, and an immunization delivery score at baseline.

The researchers assessed receipt of influenza vaccines among women pregnant during the previous influenza season and receipt of the Tdap vaccine among women at at least 34 weeks’ gestation. There were 13,324 patients in the control arm and 12,103 patients in the intervention arm.

The multimodal intervention involved seven components:

1. Designating immunization champions at each practice.

2. Assisting with vaccine purchasing and management.

3. Historical vaccination documentation training.

4. Implementing standing orders for both vaccines.

5. Chart review and feedback.

6. Patient/staff education materials and training.

7. Frequent contact with the project team, at least once a month during the study period.

At baseline, the rate of Tdap vaccination among pregnant women was 3% in the intervention clinics and 11% in the control clinics. During year 2, following the intervention, 38% of women at the intervention clinics and 34% of the women at the control clinics had received the Tdap vaccine. Those increases translated to a four times greater likelihood of getting the Tdap vaccine among women at clinics who underwent the intervention (risk ratio, 3.9; 95% confidence interval, 1.1-13.3).

Influenza vaccine uptake also increased collectively at the clinics, from 19% at intervention clinics and 18% at control clinics at baseline, to 21% at intervention clinics and 25% at control clinics a year later. But there was no significant difference in uptake between the intervention and control clinics.

An additional qualitative component of the study involved hour-long interviews with staff members from six of the clinics to assess specific components of the intervention, such as implementing standing orders for each vaccine.

“Prior to establishing standing orders at practices, the responsibility for assessing immunization history and eligibility had fallen to the medical providers,” Dr. O’Leary said. “By establishing standing orders for immunizations, providers and staff reported overall improved immunization delivery to their patient population.”

But barriers existed for standing orders as well, including patient reluctance to receive the vaccine without first discussing it with her physician.

The qualitative interviews also revealed that some nurses may have felt anxious about administering vaccines to pregnant women until they received vaccine education. Overall, staff education and implementation of standing orders were well received at the intervention practices.

“Adding immunization questions to standard intake forms was an efficient and effective method to collect immunization history that fit into already established patient check-in processes,” Dr. O’Leary said.

Standing order templates could also be customized to each practice’s processes, and the process of the staff reviewing these templates often led to consensus about how to integrate the orders into routine care, according to Dr. O’Leary.

“To increase the uptake of vaccinations in pregnancy, all ob.gyns. need to stock and administer influenza and Tdap vaccines,” Dr. O’Leary said. “And if ob.gyns. are to play a significant role as vaccinators of nonpregnant women, a paradigm shift is required.”

Both studies were funded by the CDC. Dr. O’Leary reported having no relevant financial disclosures, but one of the coinvestigators in the intervention study reported financial relationships with Merck and Pfizer.

SAN FRANCISCO – Vitamin D deficiency is common among children and adolescents, particularly those with chronic disease, Catherine Gordon, MD, said at the annual meeting of the American Academy of Pediatrics.

Yet the precise definition of vitamin D deficiency and the healthy threshold for vitamin D levels lack universally agreed-upon standards. Generally speaking, levels of at least 30 ng/mL (75 nmol/L) appear safe and reasonable for children with chronic disease, and additional research is confirming whether this range is appropriate for other pediatric groups as well. Although too much vitamin D can lead to hypercalcemia, vitamin D intoxication is very rare, said Dr. Gordon, director of the division of adolescents and transition medicine at the University of Cincinnati.

©Kaspri/Fotolia.com

Vitamin D deficiency rates vary by population

It’s difficult to pin down rates of vitamin D deficiency. One 2004 study of just over 300 children found nearly a quarter of them (24%) were deficient based on a threshold of levels below 15 ng/mL, and another 42% had insufficient levels, defined as 20 ng/mL or lower, but all were asymptomatic. Another 2008 study using different cut-offs found that 12% of healthy 8- to 24-month-olds were deficient, defined as levels below 20 ng/mL. Forty percent of the children had suboptimal levels below 30 ng/mL. Overall, a third of the children showed demineralization on their x-rays. While the season of the year and race/ethnicity did not emerge as predictors of vitamin D insufficiency, breastfeeding without supplementation and lack of milk consumption did.

Because the vitamin D content in human breast milk is low, breastfed infants typically develop low vitamin D levels unless they receive supplementation or plenty of exposure to sunlight. A maternal dose of 6,400 IU of vitamin D is needed for breastfed infants to reach normal vitamin D levels, Dr. Gordon said. Babies born to mothers with vitamin D deficiency have the highest risk of becoming deficient themselves, although formula-fed babies usually receive plenty through the vitamin D fortification in infant formula.

Among adolescents, obesity remains a common risk factor, and those with obesity require higher doses to correct deficiency or insufficiency. A study in the Journal of Pediatrics this year found that adult-sized teens need at least 5,000 IU of vitamin D3 a day for 8 weeks to correct deficiency. Similarly, a small 2012 study of 61 children and adolescents with inflammatory bowel disease found that supplementation of 2,000 IU of vitamin D3 daily or 50,000 IU of D2 weekly, for 6 weeks, more effectively corrected vitamin D deficiency than 2,000 IU daily of vitamin D2 without any changes to parathyroid hormone suppression.

How much to supplement

Much debate and uncertainty surround how much (if at all) healthy infants, children, and adolescents should be supplemented with vitamin D. The American Academy of Pediatrics recommends daily supplementation of 400 IU of vitamin D from birth through adolescence for all children and teens, although that’s far below the safe upper limit of vitamin D intake, Dr. Gordon said.

The health and sciences division (formerly the Institute of Medicine) of the National Academies of Sciences, Engineering, and Medicine, by contrast, recommends a daily intake of 400 IU of vitamin D for the first year of life and then 600 IU for age 1 through old age. The safe upper limits set by the health and sciences division include 1,000 IU for infants up to 6 months old, 1,500 IU for infants aged 6 months to 1 year, 2,500 IU for toddlers up to 3 years, 3,000 IU for children aged 4-8 years, and 4,000 IU for those 9 years and older.

Yet the Endocrine Society recommends a greater amount of supplementation for children at risk for vitamin D deficiency or low bone density mass: from 400 to 1,000 IU for children 1 year and younger, and 600-1,000 IU for all older children, adolescents, and adults. The Endocrine Society also cites a higher safe upper limit of 2,000 IU for infants up to 12 months and 4,000 IU for those aged 1 year and up.

Part of the discordance in these recommendations lies in what populations they are aimed at, Dr. Gordon explained. While the health and sciences division recommendations were written for healthy children and adolescents, the Endocrine Society is specifically addressing those in risk groups, such as transplant recipients, those with chronic conditions that can cause malabsorption, and those taking anticonvulsants or receiving other treatments that can threaten bone health. Among older children and adolescents, anorexia nervosa is also a risk factor for inadequate vitamin D levels.

Dr. Gordon recommended 600 IU of vitamin D daily for all healthy children and teens while noting that those in risk groups may require 1,000-2,000 IU to prevent vitamin D deficiency.

Additional concerns with inadequate vitamin D

Aside from bone mineral density and levels of 25(OH)D (25-hydroxy vitamin D) and parathyroid hormone, vitamin D insufficiency may be suspected based on several other biomarkers, including fractures or falls, intestinal calcium absorption, dental health, insulin sensitivity, beta-cell or immune functioning, respiratory disease such as wheezing or tuberculosis, and possibly hypertension.

Researchers have developed new interest in exploring whether factors during childhood and adolescence – critical years for bone acquisition – such as vitamin D levels might influence the risk for osteoporosis later in life, Dr. Gordon said.

Both males and females reach their peak bone mass and skeletal strength in their early to mid-20s and maintain these through about their mid-40s. While individuals have no control over intrinsic factors that help determine their bone mass, such as sex, family history, and ethnicity, other extrinsic factors are also bone mass determinants, including diet, body mass, a particular individual’s hormonal mix, illnesses and their treatments, physical activity level, and lifestyle choices.

Therefore, health providers should encourage patients to regularly exercise, maintain a healthy weight, eat healthfully, and take daily supplements, Dr. Gordon said. She only recommended testing 25(OH)D levels in those at risk for deficiency and/or low bone mass.

Dr. Gordon reported no relevant financial disclosures.

SAN FRANCISCO – Vitamin D deficiency is common among children and adolescents, particularly those with chronic disease, Catherine Gordon, MD, said at the annual meeting of the American Academy of Pediatrics.

Yet the precise definition of vitamin D deficiency and the healthy threshold for vitamin D levels lack universally agreed-upon standards. Generally speaking, levels of at least 30 ng/mL (75 nmol/L) appear safe and reasonable for children with chronic disease, and additional research is confirming whether this range is appropriate for other pediatric groups as well. Although too much vitamin D can lead to hypercalcemia, vitamin D intoxication is very rare, said Dr. Gordon, director of the division of adolescents and transition medicine at the University of Cincinnati.

©Kaspri/Fotolia.com

Vitamin D deficiency rates vary by population

It’s difficult to pin down rates of vitamin D deficiency. One 2004 study of just over 300 children found nearly a quarter of them (24%) were deficient based on a threshold of levels below 15 ng/mL, and another 42% had insufficient levels, defined as 20 ng/mL or lower, but all were asymptomatic. Another 2008 study using different cut-offs found that 12% of healthy 8- to 24-month-olds were deficient, defined as levels below 20 ng/mL. Forty percent of the children had suboptimal levels below 30 ng/mL. Overall, a third of the children showed demineralization on their x-rays. While the season of the year and race/ethnicity did not emerge as predictors of vitamin D insufficiency, breastfeeding without supplementation and lack of milk consumption did.

Because the vitamin D content in human breast milk is low, breastfed infants typically develop low vitamin D levels unless they receive supplementation or plenty of exposure to sunlight. A maternal dose of 6,400 IU of vitamin D is needed for breastfed infants to reach normal vitamin D levels, Dr. Gordon said. Babies born to mothers with vitamin D deficiency have the highest risk of becoming deficient themselves, although formula-fed babies usually receive plenty through the vitamin D fortification in infant formula.

Among adolescents, obesity remains a common risk factor, and those with obesity require higher doses to correct deficiency or insufficiency. A study in the Journal of Pediatrics this year found that adult-sized teens need at least 5,000 IU of vitamin D3 a day for 8 weeks to correct deficiency. Similarly, a small 2012 study of 61 children and adolescents with inflammatory bowel disease found that supplementation of 2,000 IU of vitamin D3 daily or 50,000 IU of D2 weekly, for 6 weeks, more effectively corrected vitamin D deficiency than 2,000 IU daily of vitamin D2 without any changes to parathyroid hormone suppression.

How much to supplement

Much debate and uncertainty surround how much (if at all) healthy infants, children, and adolescents should be supplemented with vitamin D. The American Academy of Pediatrics recommends daily supplementation of 400 IU of vitamin D from birth through adolescence for all children and teens, although that’s far below the safe upper limit of vitamin D intake, Dr. Gordon said.

The health and sciences division (formerly the Institute of Medicine) of the National Academies of Sciences, Engineering, and Medicine, by contrast, recommends a daily intake of 400 IU of vitamin D for the first year of life and then 600 IU for age 1 through old age. The safe upper limits set by the health and sciences division include 1,000 IU for infants up to 6 months old, 1,500 IU for infants aged 6 months to 1 year, 2,500 IU for toddlers up to 3 years, 3,000 IU for children aged 4-8 years, and 4,000 IU for those 9 years and older.

Yet the Endocrine Society recommends a greater amount of supplementation for children at risk for vitamin D deficiency or low bone density mass: from 400 to 1,000 IU for children 1 year and younger, and 600-1,000 IU for all older children, adolescents, and adults. The Endocrine Society also cites a higher safe upper limit of 2,000 IU for infants up to 12 months and 4,000 IU for those aged 1 year and up.

Part of the discordance in these recommendations lies in what populations they are aimed at, Dr. Gordon explained. While the health and sciences division recommendations were written for healthy children and adolescents, the Endocrine Society is specifically addressing those in risk groups, such as transplant recipients, those with chronic conditions that can cause malabsorption, and those taking anticonvulsants or receiving other treatments that can threaten bone health. Among older children and adolescents, anorexia nervosa is also a risk factor for inadequate vitamin D levels.

Dr. Gordon recommended 600 IU of vitamin D daily for all healthy children and teens while noting that those in risk groups may require 1,000-2,000 IU to prevent vitamin D deficiency.

Additional concerns with inadequate vitamin D

Aside from bone mineral density and levels of 25(OH)D (25-hydroxy vitamin D) and parathyroid hormone, vitamin D insufficiency may be suspected based on several other biomarkers, including fractures or falls, intestinal calcium absorption, dental health, insulin sensitivity, beta-cell or immune functioning, respiratory disease such as wheezing or tuberculosis, and possibly hypertension.

Researchers have developed new interest in exploring whether factors during childhood and adolescence – critical years for bone acquisition – such as vitamin D levels might influence the risk for osteoporosis later in life, Dr. Gordon said.

Both males and females reach their peak bone mass and skeletal strength in their early to mid-20s and maintain these through about their mid-40s. While individuals have no control over intrinsic factors that help determine their bone mass, such as sex, family history, and ethnicity, other extrinsic factors are also bone mass determinants, including diet, body mass, a particular individual’s hormonal mix, illnesses and their treatments, physical activity level, and lifestyle choices.

Therefore, health providers should encourage patients to regularly exercise, maintain a healthy weight, eat healthfully, and take daily supplements, Dr. Gordon said. She only recommended testing 25(OH)D levels in those at risk for deficiency and/or low bone mass.

Dr. Gordon reported no relevant financial disclosures.

SAN FRANCISCO – Vitamin D deficiency is common among children and adolescents, particularly those with chronic disease, Catherine Gordon, MD, said at the annual meeting of the American Academy of Pediatrics.

Yet the precise definition of vitamin D deficiency and the healthy threshold for vitamin D levels lack universally agreed-upon standards. Generally speaking, levels of at least 30 ng/mL (75 nmol/L) appear safe and reasonable for children with chronic disease, and additional research is confirming whether this range is appropriate for other pediatric groups as well. Although too much vitamin D can lead to hypercalcemia, vitamin D intoxication is very rare, said Dr. Gordon, director of the division of adolescents and transition medicine at the University of Cincinnati.

©Kaspri/Fotolia.com

Vitamin D deficiency rates vary by population

It’s difficult to pin down rates of vitamin D deficiency. One 2004 study of just over 300 children found nearly a quarter of them (24%) were deficient based on a threshold of levels below 15 ng/mL, and another 42% had insufficient levels, defined as 20 ng/mL or lower, but all were asymptomatic. Another 2008 study using different cut-offs found that 12% of healthy 8- to 24-month-olds were deficient, defined as levels below 20 ng/mL. Forty percent of the children had suboptimal levels below 30 ng/mL. Overall, a third of the children showed demineralization on their x-rays. While the season of the year and race/ethnicity did not emerge as predictors of vitamin D insufficiency, breastfeeding without supplementation and lack of milk consumption did.

Because the vitamin D content in human breast milk is low, breastfed infants typically develop low vitamin D levels unless they receive supplementation or plenty of exposure to sunlight. A maternal dose of 6,400 IU of vitamin D is needed for breastfed infants to reach normal vitamin D levels, Dr. Gordon said. Babies born to mothers with vitamin D deficiency have the highest risk of becoming deficient themselves, although formula-fed babies usually receive plenty through the vitamin D fortification in infant formula.

Among adolescents, obesity remains a common risk factor, and those with obesity require higher doses to correct deficiency or insufficiency. A study in the Journal of Pediatrics this year found that adult-sized teens need at least 5,000 IU of vitamin D3 a day for 8 weeks to correct deficiency. Similarly, a small 2012 study of 61 children and adolescents with inflammatory bowel disease found that supplementation of 2,000 IU of vitamin D3 daily or 50,000 IU of D2 weekly, for 6 weeks, more effectively corrected vitamin D deficiency than 2,000 IU daily of vitamin D2 without any changes to parathyroid hormone suppression.

How much to supplement

Much debate and uncertainty surround how much (if at all) healthy infants, children, and adolescents should be supplemented with vitamin D. The American Academy of Pediatrics recommends daily supplementation of 400 IU of vitamin D from birth through adolescence for all children and teens, although that’s far below the safe upper limit of vitamin D intake, Dr. Gordon said.

The health and sciences division (formerly the Institute of Medicine) of the National Academies of Sciences, Engineering, and Medicine, by contrast, recommends a daily intake of 400 IU of vitamin D for the first year of life and then 600 IU for age 1 through old age. The safe upper limits set by the health and sciences division include 1,000 IU for infants up to 6 months old, 1,500 IU for infants aged 6 months to 1 year, 2,500 IU for toddlers up to 3 years, 3,000 IU for children aged 4-8 years, and 4,000 IU for those 9 years and older.

Yet the Endocrine Society recommends a greater amount of supplementation for children at risk for vitamin D deficiency or low bone density mass: from 400 to 1,000 IU for children 1 year and younger, and 600-1,000 IU for all older children, adolescents, and adults. The Endocrine Society also cites a higher safe upper limit of 2,000 IU for infants up to 12 months and 4,000 IU for those aged 1 year and up.

Part of the discordance in these recommendations lies in what populations they are aimed at, Dr. Gordon explained. While the health and sciences division recommendations were written for healthy children and adolescents, the Endocrine Society is specifically addressing those in risk groups, such as transplant recipients, those with chronic conditions that can cause malabsorption, and those taking anticonvulsants or receiving other treatments that can threaten bone health. Among older children and adolescents, anorexia nervosa is also a risk factor for inadequate vitamin D levels.

Dr. Gordon recommended 600 IU of vitamin D daily for all healthy children and teens while noting that those in risk groups may require 1,000-2,000 IU to prevent vitamin D deficiency.

Additional concerns with inadequate vitamin D

Aside from bone mineral density and levels of 25(OH)D (25-hydroxy vitamin D) and parathyroid hormone, vitamin D insufficiency may be suspected based on several other biomarkers, including fractures or falls, intestinal calcium absorption, dental health, insulin sensitivity, beta-cell or immune functioning, respiratory disease such as wheezing or tuberculosis, and possibly hypertension.

Researchers have developed new interest in exploring whether factors during childhood and adolescence – critical years for bone acquisition – such as vitamin D levels might influence the risk for osteoporosis later in life, Dr. Gordon said.

Both males and females reach their peak bone mass and skeletal strength in their early to mid-20s and maintain these through about their mid-40s. While individuals have no control over intrinsic factors that help determine their bone mass, such as sex, family history, and ethnicity, other extrinsic factors are also bone mass determinants, including diet, body mass, a particular individual’s hormonal mix, illnesses and their treatments, physical activity level, and lifestyle choices.

Therefore, health providers should encourage patients to regularly exercise, maintain a healthy weight, eat healthfully, and take daily supplements, Dr. Gordon said. She only recommended testing 25(OH)D levels in those at risk for deficiency and/or low bone mass.

Dr. Gordon reported no relevant financial disclosures.

SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.

But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.

©Dima_sidelnikov/Thinkstock

Understanding celiac disease

This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).

But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.

Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.

Wheat allergy

A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.

Nonceliac gluten sensitivity or intolerance

Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.

Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.

Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.

Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.

Irritable bowel syndrome

The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.

Importance of differential diagnosis

It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.

Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.

Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.

SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.

But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.

©Dima_sidelnikov/Thinkstock

Understanding celiac disease

This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).

But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.

Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.

Wheat allergy

A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.

Nonceliac gluten sensitivity or intolerance

Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.

Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.

Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.

Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.

Irritable bowel syndrome

The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.

Importance of differential diagnosis

It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.

Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.

Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.

SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.

But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.

©Dima_sidelnikov/Thinkstock

Understanding celiac disease

This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).

But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.

Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.

Wheat allergy

A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.

Nonceliac gluten sensitivity or intolerance

Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.

Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.

Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.

Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.

Irritable bowel syndrome

The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.

Importance of differential diagnosis

It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.

Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.

Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.

ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.

Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.

In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..

She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.

Qualitative findings from focus groups

Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.

Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.

Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.

“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”

Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:

• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.

The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.

“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”

Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.

“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”

What messages work?

The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.

“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.

What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.

“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”

Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.

“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”

The researchers reported no disclosures and did not report external funding sources.

[email protected]

ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.

Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.

In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..

She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.

Qualitative findings from focus groups

Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.

Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.

Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.

“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”

Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:

• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.

The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.

“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”

Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.

“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”

What messages work?

The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.

“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.

What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.

“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”

Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.

“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”

The researchers reported no disclosures and did not report external funding sources.

[email protected]

ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.

Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.

In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..

She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.

Qualitative findings from focus groups

Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.

Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.

Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.

“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”

Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:

• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.

The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.

“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”

Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.

“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”

What messages work?

The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.

“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.

What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.

“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”

Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.

“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”

The researchers reported no disclosures and did not report external funding sources.

[email protected]

ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.

copyright jarun011/Thinkstock

In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.

One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”

For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.

Ms. Groom provided three other recommended statements as well:

• “I strongly believe in the importance of this cancer-preventing vaccine.”

• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”

• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”

Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.

The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.

Ms. Groom reported no disclosures. No external funding was reported.

Communication strategies to improve HPV immunization

Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.

Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.

“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.

Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.

“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.

She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.

Ms. Garcia reported no disclosures. No external funding was reported.

This article was updated Dec. 2, 2016.

ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.

copyright jarun011/Thinkstock

In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.

One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”

For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.

Ms. Groom provided three other recommended statements as well:

• “I strongly believe in the importance of this cancer-preventing vaccine.”

• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”

• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”

Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.

The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.

Ms. Groom reported no disclosures. No external funding was reported.

Communication strategies to improve HPV immunization

Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.

Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.

“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.

Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.

“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.

She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.

Ms. Garcia reported no disclosures. No external funding was reported.

This article was updated Dec. 2, 2016.

ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.

copyright jarun011/Thinkstock

In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.

One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”

For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.

Ms. Groom provided three other recommended statements as well:

• “I strongly believe in the importance of this cancer-preventing vaccine.”

• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”

• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”

Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.

The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.

Ms. Groom reported no disclosures. No external funding was reported.

Communication strategies to improve HPV immunization

Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.

Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.

“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.

Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.

“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.

She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.

Ms. Garcia reported no disclosures. No external funding was reported.

This article was updated Dec. 2, 2016.

ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.

Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.

Fibonacci Blue [CC BY 2.0

ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.

Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.

Fibonacci Blue [CC BY 2.0

ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.

Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.

Fibonacci Blue [CC BY 2.0

ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.

Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.

National Cancer Institute

ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.

Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.

National Cancer Institute

ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.

Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.

National Cancer Institute

SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.

Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.

“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.

She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.

“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”

The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.

The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.

The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.

More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.

Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.

“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”

A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.

But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.

Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.

“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”

Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.

“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.

For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.

Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.

“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.

Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.

“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”

Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.

SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.

Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.

“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.

She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.

“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”

The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.

The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.

The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.

More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.

Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.

“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”

A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.

But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.

Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.

“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”

Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.

“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.

For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.

Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.

“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.

Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.

“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”

Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.

SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.

Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.

“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.

She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.

“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”

The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.

The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.

The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.

More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.

Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.

“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”

A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.

But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.

Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.

“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”

Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.

“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.

For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.

Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.

“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.

Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.

“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”

Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.