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Drug-related deaths continue to rise in United States
TORONTO – Drug-related deaths in America are rising faster than ever.
Rear Adm. Wanda D. Barfield, MD shared recent data from the U.S. National Center for Health Statistics on people aged 15 years and older at the Pediatric Academic Societies annual meeting. Between 1999 and 2016, for example, the number of drug overdose deaths rose more than threefold, from 6.1/100,000 standard population in 1999 to 19.8/100,000 in 2016. For males, the rate increased from 8.2/100,000 in 1999 to 26.2/100,000 in 2016. For females, the rate increased from 3.9/100,000 in 1999 to 13.4/100,000 in 2016.
Dr. Barfield, director of the division of reproductive health at the Centers for Disease Control and Prevention, said that in 2016, the NCHS also found that 22 states and the District of Columbia had drug overdoses that were significantly higher than the national average. The states with the highest number of drug overdose deaths were the District of Columbia, New Hampshire, Pennsylvania, and West Virginia while the states with the lowest observed rates were Nebraska, North Dakota, South Dakota, and Texas.
“Many of these drug overdose deaths are linked to opioids, but not exclusively,” Dr. Barfield said. “In the past, the overall opioid-related overdose deaths were mainly attributed to commonly prescribed opioid medications. However, in recent years, we’re seeing more deaths due to illicit drugs such as heroin and fentanyl.”
The NCHS found that the age-adjusted rate for drug overdose deaths involving synthetic opioids other than methadone doubled from 2015 to 2016, and that drug overdose deaths involving synthetic opioids other than methadone increased from 0.3/100,000 in 1999 to 6.2/100,000 in 2016. The rate increased an average of 18% per year from 1999 to 2006, remained steady from 2006 to 2013, but increased by 88% per year from 2013 to 2016. At the same time, drug overdose deaths involving heroin increased from 0.7/100,000 in 1999 to 1/100,000 in 2010, to 4.9/100,000 in 2016.
According to Dr. Barfield, the spike in opioid use since 1999 stems directly from increased prescribing rates. “In 2015, the number of opioids prescribed was enough so that every American could be medicated around the clock for 3 weeks,” she said. “In addition to the number of prescriptions, the average day’s supply of prescription opioids increased from 2006 to 2015, from 13.3 days in 2006 to 17.7 days in 2015.” What’s more, a recent CDC Vital Signs found that the amount of opioids prescribed per person varied widely among U.S. counties in 2015. “The wide variation among counties suggests a lack of consistency among providers when prescribing opioids,” Dr. Barfield said. “It’s concerning, as higher opioid prescribing puts patients at risk for addiction.”
At the same time, opioid overdose ED visits continue to rise. Data from the CDC’s National Syndromic Surveillance Program found that from July 2016 to September 2017, opioid overdose ED visits increased by 30% for men, by 24% for women, and for all adult age groups (31% among those aged 25-34 years, 36% among those aged 35-54 years, and 32% among those aged 55 years and older).
There’s a problem of prescription opioid use among pregnant women. Published estimates indicate that 14%-22% of women filled an opioid prescription during pregnancy, Dr. Barfield said. Among pregnant women, the prevalence of maternal opioid use or dependence during hospitalization for delivery has increased 127%, from 1.7 /1,000 delivery admissions in 1998 to 3.9/1,000 delivery admissions in 2011 (Anesthesiology 2014;121[6]:1158-65). There also has been a significant increase in neonatal abstinence syndrome (NAS), which is most commonly attributed to opioid exposure during pregnancy, from 1.2/1,000 U.S. hospital births in 2000 to 8/1,000 U.S. hospital births in 2014. “NAS is still on the rise,” Dr. Barfield said. “In 2012, we saw one baby with NAS born every 25 minutes. In 2014, that number jumped to one baby born with NAS every 15 minutes. That means about 96 infants with NAS are born daily,” she said. “Where do you think we’re going to be when we look at 2018 data?”
Role for pediatricians
Dr. Barfield closed her presentation by underscoring the role pediatricians play in counseling patients about opioid abuse or dependence during pregnancy. “We know that providers have a tremendous impact on patients and their families,” she said. “We also know that issues leading to a newborn having NAS are complex, so adopting a public health approach focused on prevention, expansion of treatment, and improvements in child welfare systems is vital.” Specifically, she said, health care providers can “bridge the gap” between clinical care and public health; lead in their communities, not just within their hospital or practice; work as a team member with colleagues in other fields of medicine such as obstetrics, family medicine, and addiction care when caring for infants with NAS, and by considering the social determinants of health.
“One way to adopt a public health perspective is to remember that the health of the fetus and baby rely on more than just prenatal care,” Dr. Barfield said. “We’re all part of a larger whole, surrounded by our families, communities, regions, state, and even our countries of origin. What’s going on with the mom, her family, and the larger community impacts the baby’s health. In other words, the social determinants of health matter, and are an important part of the conversation on NAS.”
She reported having no financial disclosures.
TORONTO – Drug-related deaths in America are rising faster than ever.
Rear Adm. Wanda D. Barfield, MD shared recent data from the U.S. National Center for Health Statistics on people aged 15 years and older at the Pediatric Academic Societies annual meeting. Between 1999 and 2016, for example, the number of drug overdose deaths rose more than threefold, from 6.1/100,000 standard population in 1999 to 19.8/100,000 in 2016. For males, the rate increased from 8.2/100,000 in 1999 to 26.2/100,000 in 2016. For females, the rate increased from 3.9/100,000 in 1999 to 13.4/100,000 in 2016.
Dr. Barfield, director of the division of reproductive health at the Centers for Disease Control and Prevention, said that in 2016, the NCHS also found that 22 states and the District of Columbia had drug overdoses that were significantly higher than the national average. The states with the highest number of drug overdose deaths were the District of Columbia, New Hampshire, Pennsylvania, and West Virginia while the states with the lowest observed rates were Nebraska, North Dakota, South Dakota, and Texas.
“Many of these drug overdose deaths are linked to opioids, but not exclusively,” Dr. Barfield said. “In the past, the overall opioid-related overdose deaths were mainly attributed to commonly prescribed opioid medications. However, in recent years, we’re seeing more deaths due to illicit drugs such as heroin and fentanyl.”
The NCHS found that the age-adjusted rate for drug overdose deaths involving synthetic opioids other than methadone doubled from 2015 to 2016, and that drug overdose deaths involving synthetic opioids other than methadone increased from 0.3/100,000 in 1999 to 6.2/100,000 in 2016. The rate increased an average of 18% per year from 1999 to 2006, remained steady from 2006 to 2013, but increased by 88% per year from 2013 to 2016. At the same time, drug overdose deaths involving heroin increased from 0.7/100,000 in 1999 to 1/100,000 in 2010, to 4.9/100,000 in 2016.
According to Dr. Barfield, the spike in opioid use since 1999 stems directly from increased prescribing rates. “In 2015, the number of opioids prescribed was enough so that every American could be medicated around the clock for 3 weeks,” she said. “In addition to the number of prescriptions, the average day’s supply of prescription opioids increased from 2006 to 2015, from 13.3 days in 2006 to 17.7 days in 2015.” What’s more, a recent CDC Vital Signs found that the amount of opioids prescribed per person varied widely among U.S. counties in 2015. “The wide variation among counties suggests a lack of consistency among providers when prescribing opioids,” Dr. Barfield said. “It’s concerning, as higher opioid prescribing puts patients at risk for addiction.”
At the same time, opioid overdose ED visits continue to rise. Data from the CDC’s National Syndromic Surveillance Program found that from July 2016 to September 2017, opioid overdose ED visits increased by 30% for men, by 24% for women, and for all adult age groups (31% among those aged 25-34 years, 36% among those aged 35-54 years, and 32% among those aged 55 years and older).
There’s a problem of prescription opioid use among pregnant women. Published estimates indicate that 14%-22% of women filled an opioid prescription during pregnancy, Dr. Barfield said. Among pregnant women, the prevalence of maternal opioid use or dependence during hospitalization for delivery has increased 127%, from 1.7 /1,000 delivery admissions in 1998 to 3.9/1,000 delivery admissions in 2011 (Anesthesiology 2014;121[6]:1158-65). There also has been a significant increase in neonatal abstinence syndrome (NAS), which is most commonly attributed to opioid exposure during pregnancy, from 1.2/1,000 U.S. hospital births in 2000 to 8/1,000 U.S. hospital births in 2014. “NAS is still on the rise,” Dr. Barfield said. “In 2012, we saw one baby with NAS born every 25 minutes. In 2014, that number jumped to one baby born with NAS every 15 minutes. That means about 96 infants with NAS are born daily,” she said. “Where do you think we’re going to be when we look at 2018 data?”
Role for pediatricians
Dr. Barfield closed her presentation by underscoring the role pediatricians play in counseling patients about opioid abuse or dependence during pregnancy. “We know that providers have a tremendous impact on patients and their families,” she said. “We also know that issues leading to a newborn having NAS are complex, so adopting a public health approach focused on prevention, expansion of treatment, and improvements in child welfare systems is vital.” Specifically, she said, health care providers can “bridge the gap” between clinical care and public health; lead in their communities, not just within their hospital or practice; work as a team member with colleagues in other fields of medicine such as obstetrics, family medicine, and addiction care when caring for infants with NAS, and by considering the social determinants of health.
“One way to adopt a public health perspective is to remember that the health of the fetus and baby rely on more than just prenatal care,” Dr. Barfield said. “We’re all part of a larger whole, surrounded by our families, communities, regions, state, and even our countries of origin. What’s going on with the mom, her family, and the larger community impacts the baby’s health. In other words, the social determinants of health matter, and are an important part of the conversation on NAS.”
She reported having no financial disclosures.
TORONTO – Drug-related deaths in America are rising faster than ever.
Rear Adm. Wanda D. Barfield, MD shared recent data from the U.S. National Center for Health Statistics on people aged 15 years and older at the Pediatric Academic Societies annual meeting. Between 1999 and 2016, for example, the number of drug overdose deaths rose more than threefold, from 6.1/100,000 standard population in 1999 to 19.8/100,000 in 2016. For males, the rate increased from 8.2/100,000 in 1999 to 26.2/100,000 in 2016. For females, the rate increased from 3.9/100,000 in 1999 to 13.4/100,000 in 2016.
Dr. Barfield, director of the division of reproductive health at the Centers for Disease Control and Prevention, said that in 2016, the NCHS also found that 22 states and the District of Columbia had drug overdoses that were significantly higher than the national average. The states with the highest number of drug overdose deaths were the District of Columbia, New Hampshire, Pennsylvania, and West Virginia while the states with the lowest observed rates were Nebraska, North Dakota, South Dakota, and Texas.
“Many of these drug overdose deaths are linked to opioids, but not exclusively,” Dr. Barfield said. “In the past, the overall opioid-related overdose deaths were mainly attributed to commonly prescribed opioid medications. However, in recent years, we’re seeing more deaths due to illicit drugs such as heroin and fentanyl.”
The NCHS found that the age-adjusted rate for drug overdose deaths involving synthetic opioids other than methadone doubled from 2015 to 2016, and that drug overdose deaths involving synthetic opioids other than methadone increased from 0.3/100,000 in 1999 to 6.2/100,000 in 2016. The rate increased an average of 18% per year from 1999 to 2006, remained steady from 2006 to 2013, but increased by 88% per year from 2013 to 2016. At the same time, drug overdose deaths involving heroin increased from 0.7/100,000 in 1999 to 1/100,000 in 2010, to 4.9/100,000 in 2016.
According to Dr. Barfield, the spike in opioid use since 1999 stems directly from increased prescribing rates. “In 2015, the number of opioids prescribed was enough so that every American could be medicated around the clock for 3 weeks,” she said. “In addition to the number of prescriptions, the average day’s supply of prescription opioids increased from 2006 to 2015, from 13.3 days in 2006 to 17.7 days in 2015.” What’s more, a recent CDC Vital Signs found that the amount of opioids prescribed per person varied widely among U.S. counties in 2015. “The wide variation among counties suggests a lack of consistency among providers when prescribing opioids,” Dr. Barfield said. “It’s concerning, as higher opioid prescribing puts patients at risk for addiction.”
At the same time, opioid overdose ED visits continue to rise. Data from the CDC’s National Syndromic Surveillance Program found that from July 2016 to September 2017, opioid overdose ED visits increased by 30% for men, by 24% for women, and for all adult age groups (31% among those aged 25-34 years, 36% among those aged 35-54 years, and 32% among those aged 55 years and older).
There’s a problem of prescription opioid use among pregnant women. Published estimates indicate that 14%-22% of women filled an opioid prescription during pregnancy, Dr. Barfield said. Among pregnant women, the prevalence of maternal opioid use or dependence during hospitalization for delivery has increased 127%, from 1.7 /1,000 delivery admissions in 1998 to 3.9/1,000 delivery admissions in 2011 (Anesthesiology 2014;121[6]:1158-65). There also has been a significant increase in neonatal abstinence syndrome (NAS), which is most commonly attributed to opioid exposure during pregnancy, from 1.2/1,000 U.S. hospital births in 2000 to 8/1,000 U.S. hospital births in 2014. “NAS is still on the rise,” Dr. Barfield said. “In 2012, we saw one baby with NAS born every 25 minutes. In 2014, that number jumped to one baby born with NAS every 15 minutes. That means about 96 infants with NAS are born daily,” she said. “Where do you think we’re going to be when we look at 2018 data?”
Role for pediatricians
Dr. Barfield closed her presentation by underscoring the role pediatricians play in counseling patients about opioid abuse or dependence during pregnancy. “We know that providers have a tremendous impact on patients and their families,” she said. “We also know that issues leading to a newborn having NAS are complex, so adopting a public health approach focused on prevention, expansion of treatment, and improvements in child welfare systems is vital.” Specifically, she said, health care providers can “bridge the gap” between clinical care and public health; lead in their communities, not just within their hospital or practice; work as a team member with colleagues in other fields of medicine such as obstetrics, family medicine, and addiction care when caring for infants with NAS, and by considering the social determinants of health.
“One way to adopt a public health perspective is to remember that the health of the fetus and baby rely on more than just prenatal care,” Dr. Barfield said. “We’re all part of a larger whole, surrounded by our families, communities, regions, state, and even our countries of origin. What’s going on with the mom, her family, and the larger community impacts the baby’s health. In other words, the social determinants of health matter, and are an important part of the conversation on NAS.”
She reported having no financial disclosures.
EXPERT ANALYSIS FROM PAS 2018
Simple QI intervention helped improve HPV vaccination rates
TORONTO – Teaching simple quality improvement principles to individual pediatric practices can improve adolescent human papillomavirus (HPV) vaccination rates, results from a multicenter study showed.
“We know that HPV vaccination rates are low, and there have been many efforts to improve the vaccination rates nationwide,” one of the study authors, Manika Suryadevara, MD, said in an interview at the Pediatric Academic Societies meeting. “One reason that vaccine rates are low in adolescents is missed opportunities. Adolescents don’t always show up for routine well-child visits where immunization records are reviewed, but they may show up with a cold, a sprained ankle, or a hospital follow-up. Providers do not routinely check immunizations at these visits, then don’t recommend vaccine to those who need it. These are the missed opportunities we need to act upon.”
Data were entered into the AAP Quality Improvement Data Aggregator and run charts were printed. Next, each practice held monthly team meetings for 5 months to discuss chart review data, run chart results, and to determine intervention change for the next cycle. “Most of the interventions included standing orders, optimizing nurse’s visits, using electronic medical reminders to review immunization records, and having immunization records pulled for all adolescents who show up in their practice,” Dr. Suryadevara said. “The goal of these systematic changes is to make the work flow seamless.”
Analysis of run chart data revealed that over the five monthly cycles, the HPV vaccine completion rate improved from 45% to 65%, while the overall HPV vaccine missed opportunities was reduced from 45% to 19%. Specifically, reductions in missed opportunities fell from 9% to 0% during well-child visits, from 80% to 61% during acute visits, from 25% to 0% during follow-up visits, and from 11% to 0% during nurse-only visits. “We did see missed opportunities for acute visits – those who come in sick, but even these missed opportunities decreased over the 6-month study period,” Dr. Suryadevara said.
During follow-up teleconference calls, practice representatives reported positive experiences about the QI process and outcome improvements. “Once the practices were able to pull everyone on board and develop practice changes, I wasn’t surprised that the interventions worked,” she said. “They were able to develop systematic interventions, change the work flow in their practice, and get the results we anticipated.”
The study was funded by the AAP Hub and Spoke Initiative. Dr. Suryadevara reported having no financial disclosures.
[email protected]
TORONTO – Teaching simple quality improvement principles to individual pediatric practices can improve adolescent human papillomavirus (HPV) vaccination rates, results from a multicenter study showed.
“We know that HPV vaccination rates are low, and there have been many efforts to improve the vaccination rates nationwide,” one of the study authors, Manika Suryadevara, MD, said in an interview at the Pediatric Academic Societies meeting. “One reason that vaccine rates are low in adolescents is missed opportunities. Adolescents don’t always show up for routine well-child visits where immunization records are reviewed, but they may show up with a cold, a sprained ankle, or a hospital follow-up. Providers do not routinely check immunizations at these visits, then don’t recommend vaccine to those who need it. These are the missed opportunities we need to act upon.”
Data were entered into the AAP Quality Improvement Data Aggregator and run charts were printed. Next, each practice held monthly team meetings for 5 months to discuss chart review data, run chart results, and to determine intervention change for the next cycle. “Most of the interventions included standing orders, optimizing nurse’s visits, using electronic medical reminders to review immunization records, and having immunization records pulled for all adolescents who show up in their practice,” Dr. Suryadevara said. “The goal of these systematic changes is to make the work flow seamless.”
Analysis of run chart data revealed that over the five monthly cycles, the HPV vaccine completion rate improved from 45% to 65%, while the overall HPV vaccine missed opportunities was reduced from 45% to 19%. Specifically, reductions in missed opportunities fell from 9% to 0% during well-child visits, from 80% to 61% during acute visits, from 25% to 0% during follow-up visits, and from 11% to 0% during nurse-only visits. “We did see missed opportunities for acute visits – those who come in sick, but even these missed opportunities decreased over the 6-month study period,” Dr. Suryadevara said.
During follow-up teleconference calls, practice representatives reported positive experiences about the QI process and outcome improvements. “Once the practices were able to pull everyone on board and develop practice changes, I wasn’t surprised that the interventions worked,” she said. “They were able to develop systematic interventions, change the work flow in their practice, and get the results we anticipated.”
The study was funded by the AAP Hub and Spoke Initiative. Dr. Suryadevara reported having no financial disclosures.
[email protected]
TORONTO – Teaching simple quality improvement principles to individual pediatric practices can improve adolescent human papillomavirus (HPV) vaccination rates, results from a multicenter study showed.
“We know that HPV vaccination rates are low, and there have been many efforts to improve the vaccination rates nationwide,” one of the study authors, Manika Suryadevara, MD, said in an interview at the Pediatric Academic Societies meeting. “One reason that vaccine rates are low in adolescents is missed opportunities. Adolescents don’t always show up for routine well-child visits where immunization records are reviewed, but they may show up with a cold, a sprained ankle, or a hospital follow-up. Providers do not routinely check immunizations at these visits, then don’t recommend vaccine to those who need it. These are the missed opportunities we need to act upon.”
Data were entered into the AAP Quality Improvement Data Aggregator and run charts were printed. Next, each practice held monthly team meetings for 5 months to discuss chart review data, run chart results, and to determine intervention change for the next cycle. “Most of the interventions included standing orders, optimizing nurse’s visits, using electronic medical reminders to review immunization records, and having immunization records pulled for all adolescents who show up in their practice,” Dr. Suryadevara said. “The goal of these systematic changes is to make the work flow seamless.”
Analysis of run chart data revealed that over the five monthly cycles, the HPV vaccine completion rate improved from 45% to 65%, while the overall HPV vaccine missed opportunities was reduced from 45% to 19%. Specifically, reductions in missed opportunities fell from 9% to 0% during well-child visits, from 80% to 61% during acute visits, from 25% to 0% during follow-up visits, and from 11% to 0% during nurse-only visits. “We did see missed opportunities for acute visits – those who come in sick, but even these missed opportunities decreased over the 6-month study period,” Dr. Suryadevara said.
During follow-up teleconference calls, practice representatives reported positive experiences about the QI process and outcome improvements. “Once the practices were able to pull everyone on board and develop practice changes, I wasn’t surprised that the interventions worked,” she said. “They were able to develop systematic interventions, change the work flow in their practice, and get the results we anticipated.”
The study was funded by the AAP Hub and Spoke Initiative. Dr. Suryadevara reported having no financial disclosures.
[email protected]
REPORTING FROM PAS 2018
Key clinical point: Teaching quality improvement to pediatric practices can improve adolescent human papillomavirus (HPV) vaccine completion rates.
Major finding:
Study details: A quality improvement project conducted at five large pediatric practices in New York state aimed at reducing missed vaccination opportunities in an effort to improve HPV vaccination completion rates.
Disclosures: The study was funded by the American Academy of Pediatrics Hub and Spoke Initiative. Dr. Suryadevara reported having no financial disclosures.
Which infants with invasive bacterial infections are at risk for adverse outcomes?
TORONTO – Among infants up to 60 days old with an invasive bacterial infection, adverse outcomes are associated with prematurity, ill appearance, and bacterial meningitis, a multicenter retrospective analysis found.
“Young infants are susceptible to serious bacterial infections, particularly when they’re less than 60 days of age,” Christopher Pruitt, MD, said at the annual Pediatric Academic Societies meeting. “Among these infants, bacteremia and bacterial meningitis, also referred to as invasive bacterial infections, are associated with higher rates of morbidity and mortality.”
The primary outcome measure was occurrence of an adverse clinical outcome within 30 days following the index ED visit. Adverse outcomes were defined as use of mechanical ventilation, vasoactive medications, any neurologic sequelae, and death. The researchers used a mixed-effects logistic regression model and retained covariates with a P value of less than .10. Covariates analyzed included age less than 28 days, prematurity, presence or absence of a complex chronic condition, presence of fever, ill appearance, bacterial meningitis, and concordant empiric antimicrobial therapy.
Of the 442 infants included in the final analysis, the majority (80%) had bacteremia, 14% had bacterial meningitis plus bacteremia, and 6% had bacterial meningitis only. “For purposes of this study, patients with bacterial meningitis with or without bacteremia were categorized as having bacterial meningitis,” Dr. Pruitt said. He and his associates found that 14.5% of infants had one or more adverse outcomes. Adverse outcomes occurred in 39% of infants with bacterial meningitis, compared with 8.2% of infants with isolated bacteremia. Need for mechanical ventilation, vasoactive medications, and neurologic disability also was more common among infants with bacterial meningitis than it was among children with isolated bacteremia. There were 10 deaths overall, which amounted to about 2% in both groups.
On multivariate analysis, the rate of adverse outcomes was significantly higher for patients with bacterial meningitis than it was for those with isolated bacteremia (adjusted odds ratio, 8.8), for premature versus term infants (AOR, 5.9), for infants who were ill appearing versus non-ill appearing (AOR, 3.9), and for infants with no fever versus those with fever (AOR, 2.4). No significant associations with 30-day adverse outcomes were seen in patients with a complex chronic condition, compared with those without a complex chronic condition (AOR, 2.0), nor in the those aged 29-60 days versus those younger than 29 days (15% vs. 14%, respectively; AOR 0.7).
“When looking at the most common scenario – a full-term infant without an ill appearance, and bacteremia as opposed to bacterial meningitis – 3 of these 219 infants, or 1.4%, had an adverse outcome,” said Dr. Pruitt, who cares for patients in the ED at Children’s of Alabama in Birmingham. “And there were no deaths.” He also reported that 12 infants with invasive bacterial infections were discharged from the index ED visit without antimicrobial treatment. All had bacteremia and none had an adverse outcome.
Dr. Pruitt acknowledged certain limitations of the study, including its retrospective design, that the outcomes were limited to 30 days, and the fact that the findings may not be generalizable to nontertiary settings. “Our findings have important implications for the care of infants with invasive bacterial infections,” he concluded. “In particular, the high rate of adverse outcomes for infants with bacterial meningitis can provide some context for clinicians in assessing the need for diagnostic evaluation for invasive bacterial infection and discussing testing and treatment with parents. Our findings may also help to inform inpatient management for hospitalized infants with invasive bacterial infections, as well as anticipatory guidance for parents, particularly around follow-up. Further prospective studies evaluating the long-term outcomes of infants with invasive bacterial infections are needed.”
The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.
TORONTO – Among infants up to 60 days old with an invasive bacterial infection, adverse outcomes are associated with prematurity, ill appearance, and bacterial meningitis, a multicenter retrospective analysis found.
“Young infants are susceptible to serious bacterial infections, particularly when they’re less than 60 days of age,” Christopher Pruitt, MD, said at the annual Pediatric Academic Societies meeting. “Among these infants, bacteremia and bacterial meningitis, also referred to as invasive bacterial infections, are associated with higher rates of morbidity and mortality.”
The primary outcome measure was occurrence of an adverse clinical outcome within 30 days following the index ED visit. Adverse outcomes were defined as use of mechanical ventilation, vasoactive medications, any neurologic sequelae, and death. The researchers used a mixed-effects logistic regression model and retained covariates with a P value of less than .10. Covariates analyzed included age less than 28 days, prematurity, presence or absence of a complex chronic condition, presence of fever, ill appearance, bacterial meningitis, and concordant empiric antimicrobial therapy.
Of the 442 infants included in the final analysis, the majority (80%) had bacteremia, 14% had bacterial meningitis plus bacteremia, and 6% had bacterial meningitis only. “For purposes of this study, patients with bacterial meningitis with or without bacteremia were categorized as having bacterial meningitis,” Dr. Pruitt said. He and his associates found that 14.5% of infants had one or more adverse outcomes. Adverse outcomes occurred in 39% of infants with bacterial meningitis, compared with 8.2% of infants with isolated bacteremia. Need for mechanical ventilation, vasoactive medications, and neurologic disability also was more common among infants with bacterial meningitis than it was among children with isolated bacteremia. There were 10 deaths overall, which amounted to about 2% in both groups.
On multivariate analysis, the rate of adverse outcomes was significantly higher for patients with bacterial meningitis than it was for those with isolated bacteremia (adjusted odds ratio, 8.8), for premature versus term infants (AOR, 5.9), for infants who were ill appearing versus non-ill appearing (AOR, 3.9), and for infants with no fever versus those with fever (AOR, 2.4). No significant associations with 30-day adverse outcomes were seen in patients with a complex chronic condition, compared with those without a complex chronic condition (AOR, 2.0), nor in the those aged 29-60 days versus those younger than 29 days (15% vs. 14%, respectively; AOR 0.7).
“When looking at the most common scenario – a full-term infant without an ill appearance, and bacteremia as opposed to bacterial meningitis – 3 of these 219 infants, or 1.4%, had an adverse outcome,” said Dr. Pruitt, who cares for patients in the ED at Children’s of Alabama in Birmingham. “And there were no deaths.” He also reported that 12 infants with invasive bacterial infections were discharged from the index ED visit without antimicrobial treatment. All had bacteremia and none had an adverse outcome.
Dr. Pruitt acknowledged certain limitations of the study, including its retrospective design, that the outcomes were limited to 30 days, and the fact that the findings may not be generalizable to nontertiary settings. “Our findings have important implications for the care of infants with invasive bacterial infections,” he concluded. “In particular, the high rate of adverse outcomes for infants with bacterial meningitis can provide some context for clinicians in assessing the need for diagnostic evaluation for invasive bacterial infection and discussing testing and treatment with parents. Our findings may also help to inform inpatient management for hospitalized infants with invasive bacterial infections, as well as anticipatory guidance for parents, particularly around follow-up. Further prospective studies evaluating the long-term outcomes of infants with invasive bacterial infections are needed.”
The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.
TORONTO – Among infants up to 60 days old with an invasive bacterial infection, adverse outcomes are associated with prematurity, ill appearance, and bacterial meningitis, a multicenter retrospective analysis found.
“Young infants are susceptible to serious bacterial infections, particularly when they’re less than 60 days of age,” Christopher Pruitt, MD, said at the annual Pediatric Academic Societies meeting. “Among these infants, bacteremia and bacterial meningitis, also referred to as invasive bacterial infections, are associated with higher rates of morbidity and mortality.”
The primary outcome measure was occurrence of an adverse clinical outcome within 30 days following the index ED visit. Adverse outcomes were defined as use of mechanical ventilation, vasoactive medications, any neurologic sequelae, and death. The researchers used a mixed-effects logistic regression model and retained covariates with a P value of less than .10. Covariates analyzed included age less than 28 days, prematurity, presence or absence of a complex chronic condition, presence of fever, ill appearance, bacterial meningitis, and concordant empiric antimicrobial therapy.
Of the 442 infants included in the final analysis, the majority (80%) had bacteremia, 14% had bacterial meningitis plus bacteremia, and 6% had bacterial meningitis only. “For purposes of this study, patients with bacterial meningitis with or without bacteremia were categorized as having bacterial meningitis,” Dr. Pruitt said. He and his associates found that 14.5% of infants had one or more adverse outcomes. Adverse outcomes occurred in 39% of infants with bacterial meningitis, compared with 8.2% of infants with isolated bacteremia. Need for mechanical ventilation, vasoactive medications, and neurologic disability also was more common among infants with bacterial meningitis than it was among children with isolated bacteremia. There were 10 deaths overall, which amounted to about 2% in both groups.
On multivariate analysis, the rate of adverse outcomes was significantly higher for patients with bacterial meningitis than it was for those with isolated bacteremia (adjusted odds ratio, 8.8), for premature versus term infants (AOR, 5.9), for infants who were ill appearing versus non-ill appearing (AOR, 3.9), and for infants with no fever versus those with fever (AOR, 2.4). No significant associations with 30-day adverse outcomes were seen in patients with a complex chronic condition, compared with those without a complex chronic condition (AOR, 2.0), nor in the those aged 29-60 days versus those younger than 29 days (15% vs. 14%, respectively; AOR 0.7).
“When looking at the most common scenario – a full-term infant without an ill appearance, and bacteremia as opposed to bacterial meningitis – 3 of these 219 infants, or 1.4%, had an adverse outcome,” said Dr. Pruitt, who cares for patients in the ED at Children’s of Alabama in Birmingham. “And there were no deaths.” He also reported that 12 infants with invasive bacterial infections were discharged from the index ED visit without antimicrobial treatment. All had bacteremia and none had an adverse outcome.
Dr. Pruitt acknowledged certain limitations of the study, including its retrospective design, that the outcomes were limited to 30 days, and the fact that the findings may not be generalizable to nontertiary settings. “Our findings have important implications for the care of infants with invasive bacterial infections,” he concluded. “In particular, the high rate of adverse outcomes for infants with bacterial meningitis can provide some context for clinicians in assessing the need for diagnostic evaluation for invasive bacterial infection and discussing testing and treatment with parents. Our findings may also help to inform inpatient management for hospitalized infants with invasive bacterial infections, as well as anticipatory guidance for parents, particularly around follow-up. Further prospective studies evaluating the long-term outcomes of infants with invasive bacterial infections are needed.”
The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.
REPORTING FROM PAS 2018
Key clinical point:
Major finding: The rate of adverse outcomes was significantly higher for patients with bacterial meningitis versus those with isolated bacteremia (adjusted odds ratio, 8.8) and for premature versus term infants (AOR, 5.9).
Study details: A multicenter, retrospective review of 442 infants with invasive bacterial infections who were initially evaluated in the ED.
Disclosures: The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.
Babies exposed to SSRIs in utero have decreased LV size
TORONTO – according to a small study presented at the Pediatric Academic Societies annual meeting.
“Given the frequency of SSRI use during pregnancy and continued conflicting results regarding cardiac effects, it is an important area of study,” senior author Sarah Haskell, DO, said in an interview. Her group at the University of Iowa in Coralville, which includes first author Deidra Ansah, MD, previously demonstrated reduced ventricular size and cardiac function in sertraline-exposed animal models.
Compared with unexposed newborns, SSRI-exposed infants had a 16% reduction in right ventricular (RV) diameter in diastole (P = .02) and a 22% reduction in left ventricular (LV) volume in systole (P = .02). They also had decreased LV lengths in diastole and systole (P = .045 and .004, respectively), but no impact was noted on cardiac function, as measured by shortening fraction.
“While cardiac function was appropriate on the initial echocardiogram, there were significant differences in cardiac dimensions,” said Dr. Haskell. “Whether these differences influence health and disease susceptibility requires further, longer-term studies.”
Her group plans to continue investigating the effects of SSRIs on cardiac development and also plans to study the offspring of women who are depressed but not on pharmacologic treatment to determine the effects of depression alone on cardiac size and function.
Dr. Haskell and her colleagues studied 21 term infants without and 20 term infants with exposure to in utero SSRIs who underwent standard echocardiograms including four-chamber and M-mode views within 48 hours of life. Exclusion criteria included prematurity, large or small for gestational age, any respiratory or cardiac support, and any major congenital malformations.
The mothers of exposed infants had higher depression scores compared with controls (P = .004), and had minimal to mild depression. Otherwise, they were similar in terms of age, weight, and likelihood of having chronic or gestational hypertension or diabetes. There also were no differences in maternal conditions or infant birth weight, body surface area or gestational age.
In the infants, no differences were seen in the occurrence of patent foramen ovale, patent ductus arteriosus, ventricular septal defect, or peripheral pulmonary artery stenosis.
This research was supported by the Department of Pediatric K12 Child Health Research Career Development Award, the Stead Family Department of Pediatrics at the University of Iowa, an NIH T32 grant, and the Children’s Miracle Network. The authors reported no financial disclosures.
TORONTO – according to a small study presented at the Pediatric Academic Societies annual meeting.
“Given the frequency of SSRI use during pregnancy and continued conflicting results regarding cardiac effects, it is an important area of study,” senior author Sarah Haskell, DO, said in an interview. Her group at the University of Iowa in Coralville, which includes first author Deidra Ansah, MD, previously demonstrated reduced ventricular size and cardiac function in sertraline-exposed animal models.
Compared with unexposed newborns, SSRI-exposed infants had a 16% reduction in right ventricular (RV) diameter in diastole (P = .02) and a 22% reduction in left ventricular (LV) volume in systole (P = .02). They also had decreased LV lengths in diastole and systole (P = .045 and .004, respectively), but no impact was noted on cardiac function, as measured by shortening fraction.
“While cardiac function was appropriate on the initial echocardiogram, there were significant differences in cardiac dimensions,” said Dr. Haskell. “Whether these differences influence health and disease susceptibility requires further, longer-term studies.”
Her group plans to continue investigating the effects of SSRIs on cardiac development and also plans to study the offspring of women who are depressed but not on pharmacologic treatment to determine the effects of depression alone on cardiac size and function.
Dr. Haskell and her colleagues studied 21 term infants without and 20 term infants with exposure to in utero SSRIs who underwent standard echocardiograms including four-chamber and M-mode views within 48 hours of life. Exclusion criteria included prematurity, large or small for gestational age, any respiratory or cardiac support, and any major congenital malformations.
The mothers of exposed infants had higher depression scores compared with controls (P = .004), and had minimal to mild depression. Otherwise, they were similar in terms of age, weight, and likelihood of having chronic or gestational hypertension or diabetes. There also were no differences in maternal conditions or infant birth weight, body surface area or gestational age.
In the infants, no differences were seen in the occurrence of patent foramen ovale, patent ductus arteriosus, ventricular septal defect, or peripheral pulmonary artery stenosis.
This research was supported by the Department of Pediatric K12 Child Health Research Career Development Award, the Stead Family Department of Pediatrics at the University of Iowa, an NIH T32 grant, and the Children’s Miracle Network. The authors reported no financial disclosures.
TORONTO – according to a small study presented at the Pediatric Academic Societies annual meeting.
“Given the frequency of SSRI use during pregnancy and continued conflicting results regarding cardiac effects, it is an important area of study,” senior author Sarah Haskell, DO, said in an interview. Her group at the University of Iowa in Coralville, which includes first author Deidra Ansah, MD, previously demonstrated reduced ventricular size and cardiac function in sertraline-exposed animal models.
Compared with unexposed newborns, SSRI-exposed infants had a 16% reduction in right ventricular (RV) diameter in diastole (P = .02) and a 22% reduction in left ventricular (LV) volume in systole (P = .02). They also had decreased LV lengths in diastole and systole (P = .045 and .004, respectively), but no impact was noted on cardiac function, as measured by shortening fraction.
“While cardiac function was appropriate on the initial echocardiogram, there were significant differences in cardiac dimensions,” said Dr. Haskell. “Whether these differences influence health and disease susceptibility requires further, longer-term studies.”
Her group plans to continue investigating the effects of SSRIs on cardiac development and also plans to study the offspring of women who are depressed but not on pharmacologic treatment to determine the effects of depression alone on cardiac size and function.
Dr. Haskell and her colleagues studied 21 term infants without and 20 term infants with exposure to in utero SSRIs who underwent standard echocardiograms including four-chamber and M-mode views within 48 hours of life. Exclusion criteria included prematurity, large or small for gestational age, any respiratory or cardiac support, and any major congenital malformations.
The mothers of exposed infants had higher depression scores compared with controls (P = .004), and had minimal to mild depression. Otherwise, they were similar in terms of age, weight, and likelihood of having chronic or gestational hypertension or diabetes. There also were no differences in maternal conditions or infant birth weight, body surface area or gestational age.
In the infants, no differences were seen in the occurrence of patent foramen ovale, patent ductus arteriosus, ventricular septal defect, or peripheral pulmonary artery stenosis.
This research was supported by the Department of Pediatric K12 Child Health Research Career Development Award, the Stead Family Department of Pediatrics at the University of Iowa, an NIH T32 grant, and the Children’s Miracle Network. The authors reported no financial disclosures.
AT PAS 2018
Key clinical point: Babies exposed to SSRIs in utero have smaller hearts compared with babies not exposed to SSRIs.
Major finding: Compared with unexposed newborns, SSRI-exposed infants had a 16% reduction in right ventricular diameter in diastole (P = .02) and a 22% reduction in left ventricular volume in systole (P = .02).
Study details: A study of 20 babies exposed to SSRIs in utero and 21 not exposed.
Disclosures: This research was supported by the Department of Pediatric K12 Child Health Research Career Development Award, the Stead Family Department of Pediatrics at the University of Iowa, an NIH T32 grant, and the Children’s Miracle Network. The authors reported no financial disclosures.
Novel initiative aims to combat resident burnout
TORONTO – Studies have demonstrated that up to 50% of medical residents meet criteria for burnout, but a new initiative aims to change that worrisome trend.
At the Pediatric Academic Societies meeting, Michael Dolinger, MD, shared initial results from ResiLIEnCE (Resident-led Initiative to Empower a Change in Culture and Promote Resilience), a curriculum that is being carried out at Cohen Children’s Medical Center, New York. “We know that medical residents are a prime target for work burnout,” said Dr. Dolinger, one of the center’s pediatric chief residents, in an interview. “We wanted to study what we can do to combat that burnout on a daily basis, a monthly basis, and a longitudinal basis. How specific can we get so it’s portable, and that other programs can adapt what we are doing to help reduce this burnout?”
Interventions were enacted during traditional pediatric resident work hours to improve attendance. These included a resident-led wellness committee with faculty leadership and wellness champions, a longitudinal noon conference lecture series on nutrition (with topics such as how to eat on a budget and quick meal options), financial health (with topics such as student loan repayment, budgeting on a resident’s salary, and retirement planning), mindfulness, and resiliency. Optional activities after work included personal fitness boot camps, a book club, a minority support group, and other peer interest groups. Maslach Burnout Inventories were distributed to residents before implementation of the curriculum and at 3-month intervals. Surveys at the completion of activities assessed the effectiveness of sessions.
A total of 100 pediatric residents were surveyed. Dr. Dolinger reported that before implementation of the curriculum, 41.0% of third-year residents admitted to “feeling burned out from my work” and to “feeling more callous since I took this job,” while 8.8% of rising first-year residents admitted to feeling burned out prior to starting residency. In addition, 3 months after the curriculum began, 48.0% of first-year, 23.5% of second-year, and 83.3% of third-year residents reported believing that residency interfered with their personal wellness.
Analysis of the curriculum’s impact is ongoing, but Dr. Dolinger reported that among those who attended a nutrition series, 80% of residents planned to eat healthier, while only 15% reported eating healthy prior to the session. Among those who attended a financial series, 50% of those who did not previously contribute to their retirement planned to do so. In addition, 80% of residents who attended a resident fitness workshop joined a local fitness center, compared with only 20% of residents prior. Among those who attended a lecture series on resiliency, 90% of residents indicated that they were able to reflect on a negative patient experience and learn something valuable.
“Hopefully this curriculum helps reduce the overall burnout in our residents over time, by increasing their aspects of well-being and promoting resilience for them individually,” Dr. Dolinger said.
The initiative was funded by the Association of Pediatric Program Directors via the Harvey Aiges Memorial Trainee Investigator Award. Dr. Dolinger reported having no financial disclosures.
TORONTO – Studies have demonstrated that up to 50% of medical residents meet criteria for burnout, but a new initiative aims to change that worrisome trend.
At the Pediatric Academic Societies meeting, Michael Dolinger, MD, shared initial results from ResiLIEnCE (Resident-led Initiative to Empower a Change in Culture and Promote Resilience), a curriculum that is being carried out at Cohen Children’s Medical Center, New York. “We know that medical residents are a prime target for work burnout,” said Dr. Dolinger, one of the center’s pediatric chief residents, in an interview. “We wanted to study what we can do to combat that burnout on a daily basis, a monthly basis, and a longitudinal basis. How specific can we get so it’s portable, and that other programs can adapt what we are doing to help reduce this burnout?”
Interventions were enacted during traditional pediatric resident work hours to improve attendance. These included a resident-led wellness committee with faculty leadership and wellness champions, a longitudinal noon conference lecture series on nutrition (with topics such as how to eat on a budget and quick meal options), financial health (with topics such as student loan repayment, budgeting on a resident’s salary, and retirement planning), mindfulness, and resiliency. Optional activities after work included personal fitness boot camps, a book club, a minority support group, and other peer interest groups. Maslach Burnout Inventories were distributed to residents before implementation of the curriculum and at 3-month intervals. Surveys at the completion of activities assessed the effectiveness of sessions.
A total of 100 pediatric residents were surveyed. Dr. Dolinger reported that before implementation of the curriculum, 41.0% of third-year residents admitted to “feeling burned out from my work” and to “feeling more callous since I took this job,” while 8.8% of rising first-year residents admitted to feeling burned out prior to starting residency. In addition, 3 months after the curriculum began, 48.0% of first-year, 23.5% of second-year, and 83.3% of third-year residents reported believing that residency interfered with their personal wellness.
Analysis of the curriculum’s impact is ongoing, but Dr. Dolinger reported that among those who attended a nutrition series, 80% of residents planned to eat healthier, while only 15% reported eating healthy prior to the session. Among those who attended a financial series, 50% of those who did not previously contribute to their retirement planned to do so. In addition, 80% of residents who attended a resident fitness workshop joined a local fitness center, compared with only 20% of residents prior. Among those who attended a lecture series on resiliency, 90% of residents indicated that they were able to reflect on a negative patient experience and learn something valuable.
“Hopefully this curriculum helps reduce the overall burnout in our residents over time, by increasing their aspects of well-being and promoting resilience for them individually,” Dr. Dolinger said.
The initiative was funded by the Association of Pediatric Program Directors via the Harvey Aiges Memorial Trainee Investigator Award. Dr. Dolinger reported having no financial disclosures.
TORONTO – Studies have demonstrated that up to 50% of medical residents meet criteria for burnout, but a new initiative aims to change that worrisome trend.
At the Pediatric Academic Societies meeting, Michael Dolinger, MD, shared initial results from ResiLIEnCE (Resident-led Initiative to Empower a Change in Culture and Promote Resilience), a curriculum that is being carried out at Cohen Children’s Medical Center, New York. “We know that medical residents are a prime target for work burnout,” said Dr. Dolinger, one of the center’s pediatric chief residents, in an interview. “We wanted to study what we can do to combat that burnout on a daily basis, a monthly basis, and a longitudinal basis. How specific can we get so it’s portable, and that other programs can adapt what we are doing to help reduce this burnout?”
Interventions were enacted during traditional pediatric resident work hours to improve attendance. These included a resident-led wellness committee with faculty leadership and wellness champions, a longitudinal noon conference lecture series on nutrition (with topics such as how to eat on a budget and quick meal options), financial health (with topics such as student loan repayment, budgeting on a resident’s salary, and retirement planning), mindfulness, and resiliency. Optional activities after work included personal fitness boot camps, a book club, a minority support group, and other peer interest groups. Maslach Burnout Inventories were distributed to residents before implementation of the curriculum and at 3-month intervals. Surveys at the completion of activities assessed the effectiveness of sessions.
A total of 100 pediatric residents were surveyed. Dr. Dolinger reported that before implementation of the curriculum, 41.0% of third-year residents admitted to “feeling burned out from my work” and to “feeling more callous since I took this job,” while 8.8% of rising first-year residents admitted to feeling burned out prior to starting residency. In addition, 3 months after the curriculum began, 48.0% of first-year, 23.5% of second-year, and 83.3% of third-year residents reported believing that residency interfered with their personal wellness.
Analysis of the curriculum’s impact is ongoing, but Dr. Dolinger reported that among those who attended a nutrition series, 80% of residents planned to eat healthier, while only 15% reported eating healthy prior to the session. Among those who attended a financial series, 50% of those who did not previously contribute to their retirement planned to do so. In addition, 80% of residents who attended a resident fitness workshop joined a local fitness center, compared with only 20% of residents prior. Among those who attended a lecture series on resiliency, 90% of residents indicated that they were able to reflect on a negative patient experience and learn something valuable.
“Hopefully this curriculum helps reduce the overall burnout in our residents over time, by increasing their aspects of well-being and promoting resilience for them individually,” Dr. Dolinger said.
The initiative was funded by the Association of Pediatric Program Directors via the Harvey Aiges Memorial Trainee Investigator Award. Dr. Dolinger reported having no financial disclosures.
REPORTING FROM PAS 2018
Key clinical point: Interventions targeted at specific aspects of resident well-being yielded tangible improvement in resident wellness behaviors.
Major finding: Among those who attended a nutrition series as part of the curriculum, 80% of residents planned to eat healthier, while only 15% reported eating healthy prior to the session.
Study details: A survey of 100 pediatric residents who took part in a Resident-led Initiative to Empower a Change in Culture and Promote Resilience.
Disclosures: The initiative was funded by the Association of Pediatric Program Directors via the Harvey Aiges Memorial Trainee Investigator Award. Dr. Dolinger reported having no financial disclosures.
Multiple analgesia options for kids with acute pain
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
EXPERT ANALYSIS FROM PAS 2018
Texas pharmacies restrict access to morning-after pill
TORONTO – Despite federal legislation making emergency contraception available without age limits or a prescription, Texas adolescents may be denied or hindered in their attempts to obtain it, according to a study presented at the Pediatric Academic Societies.
When researchers queried 768 Texas pharmacy employees (97% of whom were pharmacists or pharmacy techs) about the availability of levonorgestrel at their stores, the drug was available in only 76% of pharmacies. However, contrary to federal law, 6% of stores required a prescription to obtain it.
Almost half (47%) of the pharmacies who stocked the drug reported an age requirement for purchase; this rose to 81% in the panhandle of the state, which is considered a more socially conservative region. The researchers divided the pharmacies into six geographic regions and 25% of pharmacies in each region were randomly selected for inclusion.
“Typically, the age limit these pharmacies picked was 17, which is what the most recent federal law said too, but in 2013, that was changed such that there is not supposed to be an age limit,” said Mr. Goff. “But it really varied – some told us 18, some said 21, and some said, ‘I don’t know the age limit, but I would give it out without checking their ID.’ ”
As well, 52% required some degree of interaction or consultation with pharmacy staff to obtain the drug – either it was behind the counter or on the shelf, but maybe in a locked cabinet.
Turns out, pharmacy staff also aren’t well versed in the use of levonorgestrel. Only 10% of those surveyed recognized that there may be a weight limitation with use of levonorgestrel and only 2% knew that the medication could be used up to 120 hours after unprotected intercourse.
“Texas has the fifth highest rate of teen pregnancy and the highest rate of repeat teen pregnancy in the United States, and we think these barriers are a big contributor to this,” Mr. Goff said in an interview.
Senior author, Maria C. Monge, MD, of the university, added in a press release that comprehensive sex education and contraception services also are not readily available to all adolescents across the state, which likely increases the use of emergency contraception.
In the United States, levonorgestrel 1.5 mg oral tablet has been available over the counter for more than 10 years and without an age limit since 2013.
TORONTO – Despite federal legislation making emergency contraception available without age limits or a prescription, Texas adolescents may be denied or hindered in their attempts to obtain it, according to a study presented at the Pediatric Academic Societies.
When researchers queried 768 Texas pharmacy employees (97% of whom were pharmacists or pharmacy techs) about the availability of levonorgestrel at their stores, the drug was available in only 76% of pharmacies. However, contrary to federal law, 6% of stores required a prescription to obtain it.
Almost half (47%) of the pharmacies who stocked the drug reported an age requirement for purchase; this rose to 81% in the panhandle of the state, which is considered a more socially conservative region. The researchers divided the pharmacies into six geographic regions and 25% of pharmacies in each region were randomly selected for inclusion.
“Typically, the age limit these pharmacies picked was 17, which is what the most recent federal law said too, but in 2013, that was changed such that there is not supposed to be an age limit,” said Mr. Goff. “But it really varied – some told us 18, some said 21, and some said, ‘I don’t know the age limit, but I would give it out without checking their ID.’ ”
As well, 52% required some degree of interaction or consultation with pharmacy staff to obtain the drug – either it was behind the counter or on the shelf, but maybe in a locked cabinet.
Turns out, pharmacy staff also aren’t well versed in the use of levonorgestrel. Only 10% of those surveyed recognized that there may be a weight limitation with use of levonorgestrel and only 2% knew that the medication could be used up to 120 hours after unprotected intercourse.
“Texas has the fifth highest rate of teen pregnancy and the highest rate of repeat teen pregnancy in the United States, and we think these barriers are a big contributor to this,” Mr. Goff said in an interview.
Senior author, Maria C. Monge, MD, of the university, added in a press release that comprehensive sex education and contraception services also are not readily available to all adolescents across the state, which likely increases the use of emergency contraception.
In the United States, levonorgestrel 1.5 mg oral tablet has been available over the counter for more than 10 years and without an age limit since 2013.
TORONTO – Despite federal legislation making emergency contraception available without age limits or a prescription, Texas adolescents may be denied or hindered in their attempts to obtain it, according to a study presented at the Pediatric Academic Societies.
When researchers queried 768 Texas pharmacy employees (97% of whom were pharmacists or pharmacy techs) about the availability of levonorgestrel at their stores, the drug was available in only 76% of pharmacies. However, contrary to federal law, 6% of stores required a prescription to obtain it.
Almost half (47%) of the pharmacies who stocked the drug reported an age requirement for purchase; this rose to 81% in the panhandle of the state, which is considered a more socially conservative region. The researchers divided the pharmacies into six geographic regions and 25% of pharmacies in each region were randomly selected for inclusion.
“Typically, the age limit these pharmacies picked was 17, which is what the most recent federal law said too, but in 2013, that was changed such that there is not supposed to be an age limit,” said Mr. Goff. “But it really varied – some told us 18, some said 21, and some said, ‘I don’t know the age limit, but I would give it out without checking their ID.’ ”
As well, 52% required some degree of interaction or consultation with pharmacy staff to obtain the drug – either it was behind the counter or on the shelf, but maybe in a locked cabinet.
Turns out, pharmacy staff also aren’t well versed in the use of levonorgestrel. Only 10% of those surveyed recognized that there may be a weight limitation with use of levonorgestrel and only 2% knew that the medication could be used up to 120 hours after unprotected intercourse.
“Texas has the fifth highest rate of teen pregnancy and the highest rate of repeat teen pregnancy in the United States, and we think these barriers are a big contributor to this,” Mr. Goff said in an interview.
Senior author, Maria C. Monge, MD, of the university, added in a press release that comprehensive sex education and contraception services also are not readily available to all adolescents across the state, which likely increases the use of emergency contraception.
In the United States, levonorgestrel 1.5 mg oral tablet has been available over the counter for more than 10 years and without an age limit since 2013.
AT PAS 2018
Key clinical point:
Major finding: 76% of pharmacies carried levonorgestrel, but 6% required a prescription, and 47% set an age requirement on its purchase.
Study details: A survey of 768 Texas pharmacy employees from randomly sampled pharmacies, 97% pharmacists or pharmacy technicians.
Disclosures: The author reported no financial conflict of interest.
Analysis finds inconsistent uptake of meningococcal B vaccines
TORONTO – results from a large analysis showed.
“In 2015, two meningococcal B (MenB) vaccines were given a Category B recommendation by the Advisory Committee on Immunization Practices with a preferred vaccination window of 16-18 years,” researchers led by Kristen A. Feemster, MD, MPH, wrote in an abstract presented at the Pediatric Academic Societies meeting. “Factors that may influence provider recommendation and subsequent uptake of a Category B vaccine are unknown.”
In an effort to identify sociodemographic and provider factors associated with MenB vaccine receipt, Dr. Feemster and her associates conducted a cross-sectional study of 85,789 Philadelphia youth aged 16-18 years who had a record in the KIDS Plus II Philadelphia database between Oct. 31, 2015 and July 31, 2017. They acquired neighborhood-level data from the 2016 U.S. Census American Community Survey. Next, the researchers used multivariate logistic regression to assess the association between MenB series initiation and individual- and neighborhood-level sociodemographic, clinical, and provider characteristics.
Of the 85,789 youth, only 16% received at least one MenB dose, while just 5% completed the series, reported Dr. Feemster, who is medical director of the Immunization Program and Acute Communicable Diseases at the Philadelphia department of public health in the division of disease control. Nearly half of youth (49%) were black or African-American, 25% were white, 5.5% were Asian, while the remainder were from “other” or “unknown” races. A private pediatrician was listed as the provider for 70% of the youth, followed by a community health center (11%), the Philadelphia District Center (7%), and hospitals (2%), while the remaining providers were “other” or “unknown.” The proportion of MenB recipients varied significantly by provider type, from 0.67% to 20%.
On multivariate logistic regression, MenB recipients were more likely to be female (adjusted odds ratio, 1.07; P = .0006); they were also more likely to be up-to-date on human papillomavirus vaccines (AOR, 1.65; P less than .0001) and measles-containing vaccines (AOR, 9.90; P less than .0001).
MenB recipients were more likely to be of “unknown” or “other” reported race, compared with those who were Black/African-American (AOR, 1.36 and 1.24, respectively; P less than .0001) or non-Hispanic/Latino (AOR, 1.21; P less than .0001); they were also more likely to reside in a neighborhood with median household income of greater than $100,000, compared with those who lived in a neighborhood where the median household income is less than $20,000 (AOR, 1.63; P less than .0001). Asian teens (AOR, 0.87; P = .0062) and teens who received care in community (AOR, 0.52; P less than .0001) or district health centers (AOR, 0.03; P less than .0001) also were less likely to receive the MenB vaccine, reported Dr. Feemster, who is also director of research for Children’s Hospital of Philadelphia’s Vaccine Education Center, and her colleagues.
“Variation in uptake by race, ethnicity, and neighborhood socioeconomic status suggest potential sociodemographic disparities in MenB receipt, [while] variation by neighborhood socioeconomic status may also suggest financial barriers related to access to care,” the researchers wrote in their abstract. They also speculated that variation in MenB receipt across different providers “may reflect different recommendation practices, perceived need for MenB vaccines in a provider’s patient population, or clinic-level purchasing decisions.”
The next steps in their research, they wrote, are to “investigate factors associated with provider recommendation of MenB vaccine to identify targets for initiatives to ensure equitable vaccine access.”
The researchers reported having no financial disclosures.
TORONTO – results from a large analysis showed.
“In 2015, two meningococcal B (MenB) vaccines were given a Category B recommendation by the Advisory Committee on Immunization Practices with a preferred vaccination window of 16-18 years,” researchers led by Kristen A. Feemster, MD, MPH, wrote in an abstract presented at the Pediatric Academic Societies meeting. “Factors that may influence provider recommendation and subsequent uptake of a Category B vaccine are unknown.”
In an effort to identify sociodemographic and provider factors associated with MenB vaccine receipt, Dr. Feemster and her associates conducted a cross-sectional study of 85,789 Philadelphia youth aged 16-18 years who had a record in the KIDS Plus II Philadelphia database between Oct. 31, 2015 and July 31, 2017. They acquired neighborhood-level data from the 2016 U.S. Census American Community Survey. Next, the researchers used multivariate logistic regression to assess the association between MenB series initiation and individual- and neighborhood-level sociodemographic, clinical, and provider characteristics.
Of the 85,789 youth, only 16% received at least one MenB dose, while just 5% completed the series, reported Dr. Feemster, who is medical director of the Immunization Program and Acute Communicable Diseases at the Philadelphia department of public health in the division of disease control. Nearly half of youth (49%) were black or African-American, 25% were white, 5.5% were Asian, while the remainder were from “other” or “unknown” races. A private pediatrician was listed as the provider for 70% of the youth, followed by a community health center (11%), the Philadelphia District Center (7%), and hospitals (2%), while the remaining providers were “other” or “unknown.” The proportion of MenB recipients varied significantly by provider type, from 0.67% to 20%.
On multivariate logistic regression, MenB recipients were more likely to be female (adjusted odds ratio, 1.07; P = .0006); they were also more likely to be up-to-date on human papillomavirus vaccines (AOR, 1.65; P less than .0001) and measles-containing vaccines (AOR, 9.90; P less than .0001).
MenB recipients were more likely to be of “unknown” or “other” reported race, compared with those who were Black/African-American (AOR, 1.36 and 1.24, respectively; P less than .0001) or non-Hispanic/Latino (AOR, 1.21; P less than .0001); they were also more likely to reside in a neighborhood with median household income of greater than $100,000, compared with those who lived in a neighborhood where the median household income is less than $20,000 (AOR, 1.63; P less than .0001). Asian teens (AOR, 0.87; P = .0062) and teens who received care in community (AOR, 0.52; P less than .0001) or district health centers (AOR, 0.03; P less than .0001) also were less likely to receive the MenB vaccine, reported Dr. Feemster, who is also director of research for Children’s Hospital of Philadelphia’s Vaccine Education Center, and her colleagues.
“Variation in uptake by race, ethnicity, and neighborhood socioeconomic status suggest potential sociodemographic disparities in MenB receipt, [while] variation by neighborhood socioeconomic status may also suggest financial barriers related to access to care,” the researchers wrote in their abstract. They also speculated that variation in MenB receipt across different providers “may reflect different recommendation practices, perceived need for MenB vaccines in a provider’s patient population, or clinic-level purchasing decisions.”
The next steps in their research, they wrote, are to “investigate factors associated with provider recommendation of MenB vaccine to identify targets for initiatives to ensure equitable vaccine access.”
The researchers reported having no financial disclosures.
TORONTO – results from a large analysis showed.
“In 2015, two meningococcal B (MenB) vaccines were given a Category B recommendation by the Advisory Committee on Immunization Practices with a preferred vaccination window of 16-18 years,” researchers led by Kristen A. Feemster, MD, MPH, wrote in an abstract presented at the Pediatric Academic Societies meeting. “Factors that may influence provider recommendation and subsequent uptake of a Category B vaccine are unknown.”
In an effort to identify sociodemographic and provider factors associated with MenB vaccine receipt, Dr. Feemster and her associates conducted a cross-sectional study of 85,789 Philadelphia youth aged 16-18 years who had a record in the KIDS Plus II Philadelphia database between Oct. 31, 2015 and July 31, 2017. They acquired neighborhood-level data from the 2016 U.S. Census American Community Survey. Next, the researchers used multivariate logistic regression to assess the association between MenB series initiation and individual- and neighborhood-level sociodemographic, clinical, and provider characteristics.
Of the 85,789 youth, only 16% received at least one MenB dose, while just 5% completed the series, reported Dr. Feemster, who is medical director of the Immunization Program and Acute Communicable Diseases at the Philadelphia department of public health in the division of disease control. Nearly half of youth (49%) were black or African-American, 25% were white, 5.5% were Asian, while the remainder were from “other” or “unknown” races. A private pediatrician was listed as the provider for 70% of the youth, followed by a community health center (11%), the Philadelphia District Center (7%), and hospitals (2%), while the remaining providers were “other” or “unknown.” The proportion of MenB recipients varied significantly by provider type, from 0.67% to 20%.
On multivariate logistic regression, MenB recipients were more likely to be female (adjusted odds ratio, 1.07; P = .0006); they were also more likely to be up-to-date on human papillomavirus vaccines (AOR, 1.65; P less than .0001) and measles-containing vaccines (AOR, 9.90; P less than .0001).
MenB recipients were more likely to be of “unknown” or “other” reported race, compared with those who were Black/African-American (AOR, 1.36 and 1.24, respectively; P less than .0001) or non-Hispanic/Latino (AOR, 1.21; P less than .0001); they were also more likely to reside in a neighborhood with median household income of greater than $100,000, compared with those who lived in a neighborhood where the median household income is less than $20,000 (AOR, 1.63; P less than .0001). Asian teens (AOR, 0.87; P = .0062) and teens who received care in community (AOR, 0.52; P less than .0001) or district health centers (AOR, 0.03; P less than .0001) also were less likely to receive the MenB vaccine, reported Dr. Feemster, who is also director of research for Children’s Hospital of Philadelphia’s Vaccine Education Center, and her colleagues.
“Variation in uptake by race, ethnicity, and neighborhood socioeconomic status suggest potential sociodemographic disparities in MenB receipt, [while] variation by neighborhood socioeconomic status may also suggest financial barriers related to access to care,” the researchers wrote in their abstract. They also speculated that variation in MenB receipt across different providers “may reflect different recommendation practices, perceived need for MenB vaccines in a provider’s patient population, or clinic-level purchasing decisions.”
The next steps in their research, they wrote, are to “investigate factors associated with provider recommendation of MenB vaccine to identify targets for initiatives to ensure equitable vaccine access.”
The researchers reported having no financial disclosures.
AT PAS 2018
Key clinical point: Significant variation in the likelihood of MenB vaccine receipt correlated with sociodemographic, clinical, and provider factors.
Major finding: Only 16% received at least one MenB dose while just 5% completed the series.
Study details: A cross-sectional study of 85,789 Philadelphia youth aged 16-18 years.
Disclosures: The researchers reported having no financial disclosures.
Most moms with PPD identified by pediatricians don’t receive mental health care
TORONTO – according to results of a retrospective study that used linked data from children’s EHRs and maternal Medicaid claims.
“My big takeaway from all of this is, if as pediatricians we’re committed to screening for postpartum depression, which we are – it’s in our Bright Futures guidelines – then we also need to focus on that next step and make sure that the mothers we find actually get services,” Stacey Kallem, MD, a pediatrician at Children’s Hospital of Philadelphia, reported at the Pediatric Academic Societies meeting.
“Most moms are still bringing their children to see us, the pediatricians, so we’re really a touch-point to the health care system for a lot of mothers, which is why over the last decade or so there has been a big shift within pediatrics to screen mothers for postpartum depression,” said Dr. Kallem.
Because of the growing prevalence of PPD – one in seven women will suffer from it – and mindful of its negative effects on infant health, safety, and development, the American Academy of Pediatrics recommends that pediatricians screen mothers when they bring children for visits. However, what is unknown is the effectiveness of this screening and if the affected mothers ultimately are getting mental health services.
Dr. Kallem and her colleagues designed a retrospective cohort study that would include mothers attending their infants’ 2-month well child visits at one of five academic urban primary care practices between 2011 and 2014. The obtained data came from linking the child’s EHRs and birth certificate records to maternal Medicaid claims.
The primary outcome was mental health care utilization within 6 months of screening positive for PPD on the Edinburgh Postnatal Depression Scale. A total of 3,052 mothers met study criteria, of whom 1,986 (65.1%) completed the PPD screen, and 263 (13.2%) screened positive for PPD. Only 9.9% of women had one Medicaid claim for depression in the 6 months after screening positive and 4.2% had two or more visits.
“Moms with postpartum depression are less likely to breastfeed and less likely to adhere to infant safety practices like using car seats, but the good news is that if you screen and treat mothers with postpartum depression, many of these negative effects on the child can be mitigated,” said Dr. Kallem, a National Clinical Scholar at the University of Pennsylvania, Philadelphia.
She noted a few limitations of the study, including that she was unable to collect any qualitative data regarding the interaction between the provider and the mother at the time of screening. Also, mothers may have received care that was not reimbursed by Medicaid.
Dr. Kallem reported having no financial conflicts of interest. The Eisenberg Fund and the National Clinician Scholars Program at the University of Pennsylvania, Philadelphia, supported the study.
TORONTO – according to results of a retrospective study that used linked data from children’s EHRs and maternal Medicaid claims.
“My big takeaway from all of this is, if as pediatricians we’re committed to screening for postpartum depression, which we are – it’s in our Bright Futures guidelines – then we also need to focus on that next step and make sure that the mothers we find actually get services,” Stacey Kallem, MD, a pediatrician at Children’s Hospital of Philadelphia, reported at the Pediatric Academic Societies meeting.
“Most moms are still bringing their children to see us, the pediatricians, so we’re really a touch-point to the health care system for a lot of mothers, which is why over the last decade or so there has been a big shift within pediatrics to screen mothers for postpartum depression,” said Dr. Kallem.
Because of the growing prevalence of PPD – one in seven women will suffer from it – and mindful of its negative effects on infant health, safety, and development, the American Academy of Pediatrics recommends that pediatricians screen mothers when they bring children for visits. However, what is unknown is the effectiveness of this screening and if the affected mothers ultimately are getting mental health services.
Dr. Kallem and her colleagues designed a retrospective cohort study that would include mothers attending their infants’ 2-month well child visits at one of five academic urban primary care practices between 2011 and 2014. The obtained data came from linking the child’s EHRs and birth certificate records to maternal Medicaid claims.
The primary outcome was mental health care utilization within 6 months of screening positive for PPD on the Edinburgh Postnatal Depression Scale. A total of 3,052 mothers met study criteria, of whom 1,986 (65.1%) completed the PPD screen, and 263 (13.2%) screened positive for PPD. Only 9.9% of women had one Medicaid claim for depression in the 6 months after screening positive and 4.2% had two or more visits.
“Moms with postpartum depression are less likely to breastfeed and less likely to adhere to infant safety practices like using car seats, but the good news is that if you screen and treat mothers with postpartum depression, many of these negative effects on the child can be mitigated,” said Dr. Kallem, a National Clinical Scholar at the University of Pennsylvania, Philadelphia.
She noted a few limitations of the study, including that she was unable to collect any qualitative data regarding the interaction between the provider and the mother at the time of screening. Also, mothers may have received care that was not reimbursed by Medicaid.
Dr. Kallem reported having no financial conflicts of interest. The Eisenberg Fund and the National Clinician Scholars Program at the University of Pennsylvania, Philadelphia, supported the study.
TORONTO – according to results of a retrospective study that used linked data from children’s EHRs and maternal Medicaid claims.
“My big takeaway from all of this is, if as pediatricians we’re committed to screening for postpartum depression, which we are – it’s in our Bright Futures guidelines – then we also need to focus on that next step and make sure that the mothers we find actually get services,” Stacey Kallem, MD, a pediatrician at Children’s Hospital of Philadelphia, reported at the Pediatric Academic Societies meeting.
“Most moms are still bringing their children to see us, the pediatricians, so we’re really a touch-point to the health care system for a lot of mothers, which is why over the last decade or so there has been a big shift within pediatrics to screen mothers for postpartum depression,” said Dr. Kallem.
Because of the growing prevalence of PPD – one in seven women will suffer from it – and mindful of its negative effects on infant health, safety, and development, the American Academy of Pediatrics recommends that pediatricians screen mothers when they bring children for visits. However, what is unknown is the effectiveness of this screening and if the affected mothers ultimately are getting mental health services.
Dr. Kallem and her colleagues designed a retrospective cohort study that would include mothers attending their infants’ 2-month well child visits at one of five academic urban primary care practices between 2011 and 2014. The obtained data came from linking the child’s EHRs and birth certificate records to maternal Medicaid claims.
The primary outcome was mental health care utilization within 6 months of screening positive for PPD on the Edinburgh Postnatal Depression Scale. A total of 3,052 mothers met study criteria, of whom 1,986 (65.1%) completed the PPD screen, and 263 (13.2%) screened positive for PPD. Only 9.9% of women had one Medicaid claim for depression in the 6 months after screening positive and 4.2% had two or more visits.
“Moms with postpartum depression are less likely to breastfeed and less likely to adhere to infant safety practices like using car seats, but the good news is that if you screen and treat mothers with postpartum depression, many of these negative effects on the child can be mitigated,” said Dr. Kallem, a National Clinical Scholar at the University of Pennsylvania, Philadelphia.
She noted a few limitations of the study, including that she was unable to collect any qualitative data regarding the interaction between the provider and the mother at the time of screening. Also, mothers may have received care that was not reimbursed by Medicaid.
Dr. Kallem reported having no financial conflicts of interest. The Eisenberg Fund and the National Clinician Scholars Program at the University of Pennsylvania, Philadelphia, supported the study.
AT PAS 18
Key clinical point: Mothers who screen positive for PPD in a pediatric setting may need more help accessing mental health services.
Major finding: Among women who screened positive for PPD, 9.9% had one Medicaid claim for depression in the 6 months post partum and 4.2% had two or more visits.
Study details: A retrospective study that used linked data from children’s EHRs and maternal Medicaid claims.
Disclosures: Dr. Kallem reported having no financial conflicts of interest. The Eisenberg Fund and the National Clinician Scholars Program at the University of Pennsylvania, Philadelphia, supported the study.
Responsive parenting intervention slows weight gain in infancy
TORONTO – Teaching parents of newborns to respond to eating and satiety cues in ways that promote self-regulation was associated with improvements in some weight outcomes at 3 years in a randomized clinical trial.
For the primary outcome of body mass index (BMI) z score at 3 years, a significant difference favoring the responsive parenting (RP) intervention was seen (–0.13 vs. 0.15 for controls; absolute difference, –0.28; P = .04). A longitudinal analysis examining the entire intervention period confirmed that the mean BMI group differences across seven study visits confirmed the effect of the RP intervention on BMI (P less than .001).
“We felt that the BMI z score and longitudinal growth analysis are probably the most sustained effects for an early-life intervention that have been recorded to date,” reported Ian M. Paul, MD, MSc, of Penn State University, Hershey. “While the differences between study groups were modest and not all achieved statistical significance, all favored the responsive-parenting intervention.”
Mean BMI percentile, a secondary outcome, was 47th for the RP group and 54th for controls, narrowly missing statistical significance (P = .07). Similarly, the percent of children deemed overweight at 3 years was 11.2% for the RP group and 19.8% for controls (P = .07), while 2.6% and 7.8%, respectively, were obese (P = .08).
No significant differences were seen in growth-related adverse events, such a weight-for-age less than the 5th percentile. The issue of “inducing” failure-to-thrive with a feeding intervention is a concern, said Dr. Paul, but there was no evidence for it in their study.
“One could question whether [the small differences seen between groups] are clinically significant, but if we look at how small differences have changed in the population over time and how those equate as far as longitudinal risk for cardiovascular outcomes and metabolic syndrome, etc., the small differences [we saw] might be important on a population level,” said Dr. Paul at the Pediatric Academic Societies meeting.
Study details
With upwards of one-quarter of U.S. children aged 2-5 years being overweight or obese, interventions to prevent rapid weight gain and reduce risk for overweight status in infancy are needed, noted Dr. Paul. Another reason to consider very early intervention, he added, is that infancy is a time of both “metabolic and behavioral plasticity.” However, most efforts to intervene early have, thus far, had limited success.
“Our responses to a baby crying are to feed that baby,” said Dr. Paul. This urge, along with others (such as “clear your plate”), evolved during times of food scarcity but persist now that we have inexpensive and palatable food, and promote rapid infant weight gain and increased obesity risk.
An alternative to those traditional parenting practices are responsive feeding and responsive parenting, he explained. “Responsive feeding and parenting requires prompt, developmentally appropriate responses to a child’s behaviors including hunger and satiety cues.”
In other studies, RP has been shown to foster cognitive, social, and emotional development. “The question we had was: Can responsive parenting reduce obesity risk?” he said.
The INSIGHT (Intervention Nurses Start Infants Growing on Healthy Trajectories) study is an ongoing, randomized clinical trial started in January 2012 comparing an RP intervention designed to prevent childhood obesity with a safety control, with the interventions matched on intensity and length.
Parent-child dyads were randomized 2 weeks after birth and were told that the purpose of the study was “to see if nurse visits to your home during your baby’s infancy can improve your ability to either respond to your child’s cues related to feeding and fussiness or improve your ability to provide a safe environment for your child and prevent injuries.”
A total of 279 primiparous mother-newborn dyads were studied. Most were white (89%) and non-Hispanic (94%), and the majority were married (75%). Mean prepregnancy BMI was 25.5 kg/m2.
“We chose first-time mothers because we thought they were more likely to listen to the parenting advice that we had to offer,” said Dr. Paul.
INSIGHT’s curriculum focused on RP in domains of infant feeding, sleep, interactive play, and emotion regulation. “We tried to promote self-regulation by setting limits but still being responsive in a variety of behavior domains,” Dr. Paul said. “So, for example…, for feeding we talked about exposure to healthy foods, shared feeding responsibility, for those that were bottle feeding we gave tips on size of bottle appropriate for the child and also not using bottle finishing practices. In the emotional and social regulation domain, we talked about alternatives to food to soothe, and emphasized embracing each child’s temperament and how to respond to different temperaments.”
Dr. Paul reported no conflicts of interest. INSIGHT is supported by National Institute of Diabetes and Digestive and Kidney Diseases research grants, with additional support from the Children’s Miracle Network at Penn State Children’s Hospital.
TORONTO – Teaching parents of newborns to respond to eating and satiety cues in ways that promote self-regulation was associated with improvements in some weight outcomes at 3 years in a randomized clinical trial.
For the primary outcome of body mass index (BMI) z score at 3 years, a significant difference favoring the responsive parenting (RP) intervention was seen (–0.13 vs. 0.15 for controls; absolute difference, –0.28; P = .04). A longitudinal analysis examining the entire intervention period confirmed that the mean BMI group differences across seven study visits confirmed the effect of the RP intervention on BMI (P less than .001).
“We felt that the BMI z score and longitudinal growth analysis are probably the most sustained effects for an early-life intervention that have been recorded to date,” reported Ian M. Paul, MD, MSc, of Penn State University, Hershey. “While the differences between study groups were modest and not all achieved statistical significance, all favored the responsive-parenting intervention.”
Mean BMI percentile, a secondary outcome, was 47th for the RP group and 54th for controls, narrowly missing statistical significance (P = .07). Similarly, the percent of children deemed overweight at 3 years was 11.2% for the RP group and 19.8% for controls (P = .07), while 2.6% and 7.8%, respectively, were obese (P = .08).
No significant differences were seen in growth-related adverse events, such a weight-for-age less than the 5th percentile. The issue of “inducing” failure-to-thrive with a feeding intervention is a concern, said Dr. Paul, but there was no evidence for it in their study.
“One could question whether [the small differences seen between groups] are clinically significant, but if we look at how small differences have changed in the population over time and how those equate as far as longitudinal risk for cardiovascular outcomes and metabolic syndrome, etc., the small differences [we saw] might be important on a population level,” said Dr. Paul at the Pediatric Academic Societies meeting.
Study details
With upwards of one-quarter of U.S. children aged 2-5 years being overweight or obese, interventions to prevent rapid weight gain and reduce risk for overweight status in infancy are needed, noted Dr. Paul. Another reason to consider very early intervention, he added, is that infancy is a time of both “metabolic and behavioral plasticity.” However, most efforts to intervene early have, thus far, had limited success.
“Our responses to a baby crying are to feed that baby,” said Dr. Paul. This urge, along with others (such as “clear your plate”), evolved during times of food scarcity but persist now that we have inexpensive and palatable food, and promote rapid infant weight gain and increased obesity risk.
An alternative to those traditional parenting practices are responsive feeding and responsive parenting, he explained. “Responsive feeding and parenting requires prompt, developmentally appropriate responses to a child’s behaviors including hunger and satiety cues.”
In other studies, RP has been shown to foster cognitive, social, and emotional development. “The question we had was: Can responsive parenting reduce obesity risk?” he said.
The INSIGHT (Intervention Nurses Start Infants Growing on Healthy Trajectories) study is an ongoing, randomized clinical trial started in January 2012 comparing an RP intervention designed to prevent childhood obesity with a safety control, with the interventions matched on intensity and length.
Parent-child dyads were randomized 2 weeks after birth and were told that the purpose of the study was “to see if nurse visits to your home during your baby’s infancy can improve your ability to either respond to your child’s cues related to feeding and fussiness or improve your ability to provide a safe environment for your child and prevent injuries.”
A total of 279 primiparous mother-newborn dyads were studied. Most were white (89%) and non-Hispanic (94%), and the majority were married (75%). Mean prepregnancy BMI was 25.5 kg/m2.
“We chose first-time mothers because we thought they were more likely to listen to the parenting advice that we had to offer,” said Dr. Paul.
INSIGHT’s curriculum focused on RP in domains of infant feeding, sleep, interactive play, and emotion regulation. “We tried to promote self-regulation by setting limits but still being responsive in a variety of behavior domains,” Dr. Paul said. “So, for example…, for feeding we talked about exposure to healthy foods, shared feeding responsibility, for those that were bottle feeding we gave tips on size of bottle appropriate for the child and also not using bottle finishing practices. In the emotional and social regulation domain, we talked about alternatives to food to soothe, and emphasized embracing each child’s temperament and how to respond to different temperaments.”
Dr. Paul reported no conflicts of interest. INSIGHT is supported by National Institute of Diabetes and Digestive and Kidney Diseases research grants, with additional support from the Children’s Miracle Network at Penn State Children’s Hospital.
TORONTO – Teaching parents of newborns to respond to eating and satiety cues in ways that promote self-regulation was associated with improvements in some weight outcomes at 3 years in a randomized clinical trial.
For the primary outcome of body mass index (BMI) z score at 3 years, a significant difference favoring the responsive parenting (RP) intervention was seen (–0.13 vs. 0.15 for controls; absolute difference, –0.28; P = .04). A longitudinal analysis examining the entire intervention period confirmed that the mean BMI group differences across seven study visits confirmed the effect of the RP intervention on BMI (P less than .001).
“We felt that the BMI z score and longitudinal growth analysis are probably the most sustained effects for an early-life intervention that have been recorded to date,” reported Ian M. Paul, MD, MSc, of Penn State University, Hershey. “While the differences between study groups were modest and not all achieved statistical significance, all favored the responsive-parenting intervention.”
Mean BMI percentile, a secondary outcome, was 47th for the RP group and 54th for controls, narrowly missing statistical significance (P = .07). Similarly, the percent of children deemed overweight at 3 years was 11.2% for the RP group and 19.8% for controls (P = .07), while 2.6% and 7.8%, respectively, were obese (P = .08).
No significant differences were seen in growth-related adverse events, such a weight-for-age less than the 5th percentile. The issue of “inducing” failure-to-thrive with a feeding intervention is a concern, said Dr. Paul, but there was no evidence for it in their study.
“One could question whether [the small differences seen between groups] are clinically significant, but if we look at how small differences have changed in the population over time and how those equate as far as longitudinal risk for cardiovascular outcomes and metabolic syndrome, etc., the small differences [we saw] might be important on a population level,” said Dr. Paul at the Pediatric Academic Societies meeting.
Study details
With upwards of one-quarter of U.S. children aged 2-5 years being overweight or obese, interventions to prevent rapid weight gain and reduce risk for overweight status in infancy are needed, noted Dr. Paul. Another reason to consider very early intervention, he added, is that infancy is a time of both “metabolic and behavioral plasticity.” However, most efforts to intervene early have, thus far, had limited success.
“Our responses to a baby crying are to feed that baby,” said Dr. Paul. This urge, along with others (such as “clear your plate”), evolved during times of food scarcity but persist now that we have inexpensive and palatable food, and promote rapid infant weight gain and increased obesity risk.
An alternative to those traditional parenting practices are responsive feeding and responsive parenting, he explained. “Responsive feeding and parenting requires prompt, developmentally appropriate responses to a child’s behaviors including hunger and satiety cues.”
In other studies, RP has been shown to foster cognitive, social, and emotional development. “The question we had was: Can responsive parenting reduce obesity risk?” he said.
The INSIGHT (Intervention Nurses Start Infants Growing on Healthy Trajectories) study is an ongoing, randomized clinical trial started in January 2012 comparing an RP intervention designed to prevent childhood obesity with a safety control, with the interventions matched on intensity and length.
Parent-child dyads were randomized 2 weeks after birth and were told that the purpose of the study was “to see if nurse visits to your home during your baby’s infancy can improve your ability to either respond to your child’s cues related to feeding and fussiness or improve your ability to provide a safe environment for your child and prevent injuries.”
A total of 279 primiparous mother-newborn dyads were studied. Most were white (89%) and non-Hispanic (94%), and the majority were married (75%). Mean prepregnancy BMI was 25.5 kg/m2.
“We chose first-time mothers because we thought they were more likely to listen to the parenting advice that we had to offer,” said Dr. Paul.
INSIGHT’s curriculum focused on RP in domains of infant feeding, sleep, interactive play, and emotion regulation. “We tried to promote self-regulation by setting limits but still being responsive in a variety of behavior domains,” Dr. Paul said. “So, for example…, for feeding we talked about exposure to healthy foods, shared feeding responsibility, for those that were bottle feeding we gave tips on size of bottle appropriate for the child and also not using bottle finishing practices. In the emotional and social regulation domain, we talked about alternatives to food to soothe, and emphasized embracing each child’s temperament and how to respond to different temperaments.”
Dr. Paul reported no conflicts of interest. INSIGHT is supported by National Institute of Diabetes and Digestive and Kidney Diseases research grants, with additional support from the Children’s Miracle Network at Penn State Children’s Hospital.
REPORTING FROM PAS 2018
Key clinical point:
Major finding: For the primary outcome of body mass index z score at 3 years, a significant difference favoring the responsive parenting intervention was seen (–0.13 vs. 0.15 for controls; absolute difference, –0.28; P = .04).
Study details: A randomized clinical trial including 279 mother-newborn dyads.
Disclosures: Dr. Paul reported no conflicts of interest. INSIGHT is supported by National Institute of Diabetes and Digestive and Kidney Diseases research grants, with additional support from the Children’s Miracle Network at Penn State Children’s Hospital.