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Medications provide best risk-to-benefit ratio for weight loss, says expert
Lifestyle changes result in the least weight loss and may be safest, while surgery provides the most weight loss and has the greatest risk. Antiobesity medications, especially the newer ones used in combination with lifestyle changes, can provide significant and sustained weight loss with manageable side effects, said Daniel Bessesen, MD, a professor in the endocrinology, diabetes, and metabolism at University of Colorado at Denver, Aurora.
New and more effective antiobesity medications have given internists more potential options to discuss with their patients, Dr. Bessesen said. He reviewed the pros and cons of the different options.
Medications are indicated for patients with a body mass index greater than 30, including those with a weight-related comorbidity, Dr. Bessesen said. The average weight loss is 5%-15% over 3-6 months but may vary greatly. Insurance often does not cover the medication costs.
Older FDA-approved antiobesity medications
Phentermine is the most widely prescribed antiobesity medication, partly because it is the only option most people can afford out of pocket. Dr. Bessesen presented recent data showing that long-term use of phentermine was associated with greater weight loss and that patients continuously taking phentermine for 24 months lost 7.5% of their weight.
Phentermine suppresses appetite by increasing norepinephrine production. Dr. Bessesen warned that internists should be careful when prescribing it to patients with mental conditions, because it acts as a stimulant. Early studies raised concerns about the risk of cardiovascular disease (CVD) in patients taking phentermine. However, analysis of data from over 13,000 individuals showed no evidence of a relationship between phentermine exposure and CVD events.
“These data provide some reassurance that it could be used in patients with CVD risk,” he noted. Phentermine can also be combined with topiramate extended release, a combination that provides greater efficacy (up to 10% weight loss) with fewer side effects. However, this combination is less effective in patients with diabetes than in those without.
Additional treatment options included orlistat and naltrexone sustained release/bupropion SR. Orlistat is a good treatment alternative for patients with constipation and is the safest option among older anti-obesity medications, whereas naltrexone SR/bupropion SR may be useful in patients with food cravings. However, there is more variability in the individual-level benefit from these agents compared to phentermine and phentermine/topiramate ER, Dr. Bessesen said.
Newer anti‐obesity medications
Liraglutide, an agent used for the management of type 2 diabetes, has recently been approved for weight loss. Liraglutide causes moderate weight loss, and it may reduce the risk of CVD. However, there are tolerability issues, such as nausea and other risks, and Dr. Bessesen advises internists to “start at low doses and increase slowly.”
Semaglutide is the newest and most effective antiobesity drug approved by the Food and Drug Administration, providing sustained weight loss of 8% for up to 48 weeks after starting treatment. Although its efficacy is lower in patients with diabetes, Dr. Bessesen noted that “this is common for antiobesity agents, and clinicians should not refrain from prescribing it in this population.”
Setmelanotide is another new medication approved for chronic weight management in patients with monogenic obesity. This medication can be considered for patients with early-onset severe obesity with abnormal feeding behavior.
Commenting on barriers to access to new antiobesity medications, Dr. Bessesen said that “the high cost of these medications is a substantial problem, but as more companies become involved and products are on the market for a longer period of time, I am hopeful that prices will come down.”
Emerging antiobesity medications
Dr. Bessesen presented recent phase 3 data showing that treatment with tirzepatide provided sustained chronic loss and improved cardiometabolic measures with no diet. Tirzepatide, which targets receptors for glucagonlike peptide–1 and glucose-dependent insulinotropic polypeptide, is used for the management of type 2 diabetes and is expected to be reviewed soon by the FDA for its use in weight management.
A semaglutide/cagrilintide combination may also provide a new treatment option for patients with obesity. In a phase 1b trial, semaglutide/cagrilintide treatment resulted in up to 17% weight loss in patients with obesity who were otherwise healthy; however, phase 2 and 3 data are needed to confirm its efficacy.
A ‘holistic approach’
When deciding whether to prescribe antiobesity medications, Dr. Bessesen noted that medications are better than exercise alone. Factors to consider when deciding whether to prescribe drugs, as well as which ones, include costs, local regulatory guidelines, requirement for long-term use, and patient comorbidities.
He also stated that lifestyle changes, such as adopting healthy nutrition and exercising regularly, are also important and can enhance weight loss when combined with medications.
Richele Corrado, DO, MPH, agreed that lifestyle management in combination with medications may provide greater weight loss than each of these interventions alone.
“If you look at the data, exercise doesn’t help you lose much weight,” said Dr. Corrado, a staff internist and obesity medicine specialist at Walter Reed National Military Medical Center in Bethesda, Md., who spoke at the same session. She added that she has many patients who struggle to lose weight despite having a healthy lifestyle. “It’s important to discuss with these patients about medications and surgery.”
Dr. Bessesen noted that management of mental health and emotional well-being should also be an integral part of obesity management. “Treatment for obesity may be more successful when underlying psychological conditions such as depression, childhood sexual trauma, or anxiety are addressed and treated,” he said.
Dr. Bessesen was involved in the study of the efficacy of semaglutide/cagrilintide. He does not have any financial conflicts with the companies that make other mentioned medications. He has received research grants or contracts from Novo Nordisk, honoraria from Novo Nordisk, and consultantship from Eli Lilly. Dr. Corrado reported no relevant financial conflicts.
Lifestyle changes result in the least weight loss and may be safest, while surgery provides the most weight loss and has the greatest risk. Antiobesity medications, especially the newer ones used in combination with lifestyle changes, can provide significant and sustained weight loss with manageable side effects, said Daniel Bessesen, MD, a professor in the endocrinology, diabetes, and metabolism at University of Colorado at Denver, Aurora.
New and more effective antiobesity medications have given internists more potential options to discuss with their patients, Dr. Bessesen said. He reviewed the pros and cons of the different options.
Medications are indicated for patients with a body mass index greater than 30, including those with a weight-related comorbidity, Dr. Bessesen said. The average weight loss is 5%-15% over 3-6 months but may vary greatly. Insurance often does not cover the medication costs.
Older FDA-approved antiobesity medications
Phentermine is the most widely prescribed antiobesity medication, partly because it is the only option most people can afford out of pocket. Dr. Bessesen presented recent data showing that long-term use of phentermine was associated with greater weight loss and that patients continuously taking phentermine for 24 months lost 7.5% of their weight.
Phentermine suppresses appetite by increasing norepinephrine production. Dr. Bessesen warned that internists should be careful when prescribing it to patients with mental conditions, because it acts as a stimulant. Early studies raised concerns about the risk of cardiovascular disease (CVD) in patients taking phentermine. However, analysis of data from over 13,000 individuals showed no evidence of a relationship between phentermine exposure and CVD events.
“These data provide some reassurance that it could be used in patients with CVD risk,” he noted. Phentermine can also be combined with topiramate extended release, a combination that provides greater efficacy (up to 10% weight loss) with fewer side effects. However, this combination is less effective in patients with diabetes than in those without.
Additional treatment options included orlistat and naltrexone sustained release/bupropion SR. Orlistat is a good treatment alternative for patients with constipation and is the safest option among older anti-obesity medications, whereas naltrexone SR/bupropion SR may be useful in patients with food cravings. However, there is more variability in the individual-level benefit from these agents compared to phentermine and phentermine/topiramate ER, Dr. Bessesen said.
Newer anti‐obesity medications
Liraglutide, an agent used for the management of type 2 diabetes, has recently been approved for weight loss. Liraglutide causes moderate weight loss, and it may reduce the risk of CVD. However, there are tolerability issues, such as nausea and other risks, and Dr. Bessesen advises internists to “start at low doses and increase slowly.”
Semaglutide is the newest and most effective antiobesity drug approved by the Food and Drug Administration, providing sustained weight loss of 8% for up to 48 weeks after starting treatment. Although its efficacy is lower in patients with diabetes, Dr. Bessesen noted that “this is common for antiobesity agents, and clinicians should not refrain from prescribing it in this population.”
Setmelanotide is another new medication approved for chronic weight management in patients with monogenic obesity. This medication can be considered for patients with early-onset severe obesity with abnormal feeding behavior.
Commenting on barriers to access to new antiobesity medications, Dr. Bessesen said that “the high cost of these medications is a substantial problem, but as more companies become involved and products are on the market for a longer period of time, I am hopeful that prices will come down.”
Emerging antiobesity medications
Dr. Bessesen presented recent phase 3 data showing that treatment with tirzepatide provided sustained chronic loss and improved cardiometabolic measures with no diet. Tirzepatide, which targets receptors for glucagonlike peptide–1 and glucose-dependent insulinotropic polypeptide, is used for the management of type 2 diabetes and is expected to be reviewed soon by the FDA for its use in weight management.
A semaglutide/cagrilintide combination may also provide a new treatment option for patients with obesity. In a phase 1b trial, semaglutide/cagrilintide treatment resulted in up to 17% weight loss in patients with obesity who were otherwise healthy; however, phase 2 and 3 data are needed to confirm its efficacy.
A ‘holistic approach’
When deciding whether to prescribe antiobesity medications, Dr. Bessesen noted that medications are better than exercise alone. Factors to consider when deciding whether to prescribe drugs, as well as which ones, include costs, local regulatory guidelines, requirement for long-term use, and patient comorbidities.
He also stated that lifestyle changes, such as adopting healthy nutrition and exercising regularly, are also important and can enhance weight loss when combined with medications.
Richele Corrado, DO, MPH, agreed that lifestyle management in combination with medications may provide greater weight loss than each of these interventions alone.
“If you look at the data, exercise doesn’t help you lose much weight,” said Dr. Corrado, a staff internist and obesity medicine specialist at Walter Reed National Military Medical Center in Bethesda, Md., who spoke at the same session. She added that she has many patients who struggle to lose weight despite having a healthy lifestyle. “It’s important to discuss with these patients about medications and surgery.”
Dr. Bessesen noted that management of mental health and emotional well-being should also be an integral part of obesity management. “Treatment for obesity may be more successful when underlying psychological conditions such as depression, childhood sexual trauma, or anxiety are addressed and treated,” he said.
Dr. Bessesen was involved in the study of the efficacy of semaglutide/cagrilintide. He does not have any financial conflicts with the companies that make other mentioned medications. He has received research grants or contracts from Novo Nordisk, honoraria from Novo Nordisk, and consultantship from Eli Lilly. Dr. Corrado reported no relevant financial conflicts.
Lifestyle changes result in the least weight loss and may be safest, while surgery provides the most weight loss and has the greatest risk. Antiobesity medications, especially the newer ones used in combination with lifestyle changes, can provide significant and sustained weight loss with manageable side effects, said Daniel Bessesen, MD, a professor in the endocrinology, diabetes, and metabolism at University of Colorado at Denver, Aurora.
New and more effective antiobesity medications have given internists more potential options to discuss with their patients, Dr. Bessesen said. He reviewed the pros and cons of the different options.
Medications are indicated for patients with a body mass index greater than 30, including those with a weight-related comorbidity, Dr. Bessesen said. The average weight loss is 5%-15% over 3-6 months but may vary greatly. Insurance often does not cover the medication costs.
Older FDA-approved antiobesity medications
Phentermine is the most widely prescribed antiobesity medication, partly because it is the only option most people can afford out of pocket. Dr. Bessesen presented recent data showing that long-term use of phentermine was associated with greater weight loss and that patients continuously taking phentermine for 24 months lost 7.5% of their weight.
Phentermine suppresses appetite by increasing norepinephrine production. Dr. Bessesen warned that internists should be careful when prescribing it to patients with mental conditions, because it acts as a stimulant. Early studies raised concerns about the risk of cardiovascular disease (CVD) in patients taking phentermine. However, analysis of data from over 13,000 individuals showed no evidence of a relationship between phentermine exposure and CVD events.
“These data provide some reassurance that it could be used in patients with CVD risk,” he noted. Phentermine can also be combined with topiramate extended release, a combination that provides greater efficacy (up to 10% weight loss) with fewer side effects. However, this combination is less effective in patients with diabetes than in those without.
Additional treatment options included orlistat and naltrexone sustained release/bupropion SR. Orlistat is a good treatment alternative for patients with constipation and is the safest option among older anti-obesity medications, whereas naltrexone SR/bupropion SR may be useful in patients with food cravings. However, there is more variability in the individual-level benefit from these agents compared to phentermine and phentermine/topiramate ER, Dr. Bessesen said.
Newer anti‐obesity medications
Liraglutide, an agent used for the management of type 2 diabetes, has recently been approved for weight loss. Liraglutide causes moderate weight loss, and it may reduce the risk of CVD. However, there are tolerability issues, such as nausea and other risks, and Dr. Bessesen advises internists to “start at low doses and increase slowly.”
Semaglutide is the newest and most effective antiobesity drug approved by the Food and Drug Administration, providing sustained weight loss of 8% for up to 48 weeks after starting treatment. Although its efficacy is lower in patients with diabetes, Dr. Bessesen noted that “this is common for antiobesity agents, and clinicians should not refrain from prescribing it in this population.”
Setmelanotide is another new medication approved for chronic weight management in patients with monogenic obesity. This medication can be considered for patients with early-onset severe obesity with abnormal feeding behavior.
Commenting on barriers to access to new antiobesity medications, Dr. Bessesen said that “the high cost of these medications is a substantial problem, but as more companies become involved and products are on the market for a longer period of time, I am hopeful that prices will come down.”
Emerging antiobesity medications
Dr. Bessesen presented recent phase 3 data showing that treatment with tirzepatide provided sustained chronic loss and improved cardiometabolic measures with no diet. Tirzepatide, which targets receptors for glucagonlike peptide–1 and glucose-dependent insulinotropic polypeptide, is used for the management of type 2 diabetes and is expected to be reviewed soon by the FDA for its use in weight management.
A semaglutide/cagrilintide combination may also provide a new treatment option for patients with obesity. In a phase 1b trial, semaglutide/cagrilintide treatment resulted in up to 17% weight loss in patients with obesity who were otherwise healthy; however, phase 2 and 3 data are needed to confirm its efficacy.
A ‘holistic approach’
When deciding whether to prescribe antiobesity medications, Dr. Bessesen noted that medications are better than exercise alone. Factors to consider when deciding whether to prescribe drugs, as well as which ones, include costs, local regulatory guidelines, requirement for long-term use, and patient comorbidities.
He also stated that lifestyle changes, such as adopting healthy nutrition and exercising regularly, are also important and can enhance weight loss when combined with medications.
Richele Corrado, DO, MPH, agreed that lifestyle management in combination with medications may provide greater weight loss than each of these interventions alone.
“If you look at the data, exercise doesn’t help you lose much weight,” said Dr. Corrado, a staff internist and obesity medicine specialist at Walter Reed National Military Medical Center in Bethesda, Md., who spoke at the same session. She added that she has many patients who struggle to lose weight despite having a healthy lifestyle. “It’s important to discuss with these patients about medications and surgery.”
Dr. Bessesen noted that management of mental health and emotional well-being should also be an integral part of obesity management. “Treatment for obesity may be more successful when underlying psychological conditions such as depression, childhood sexual trauma, or anxiety are addressed and treated,” he said.
Dr. Bessesen was involved in the study of the efficacy of semaglutide/cagrilintide. He does not have any financial conflicts with the companies that make other mentioned medications. He has received research grants or contracts from Novo Nordisk, honoraria from Novo Nordisk, and consultantship from Eli Lilly. Dr. Corrado reported no relevant financial conflicts.
AT INTERNAL MEDICINE 2023
Step count–heart rate link confirmed in children
, according to a study presented at the Pediatric Academic Societies annual meeting.
The new findings provide a new means for pediatricians to measure physical fitness, the researchers said.
“It really changes the way we evaluate kids’ fitness and gives us a new method of judging physical fitness other than body mass index,” said Susan Gasparino, MD, an instructor in pediatrics at the University of Rochester (N.Y.) Medical Center, who led the study.
Using data from the 2005 to 2006 National Health and Nutrition Examination Survey, Dr. Gasparino and her colleagues examined the association between resting heart rate (RHR) and step count among 899 children and 1,640 adolescents aged 6-19 years.
In the adolescent group, the mean RHR was 74.9 among those who walked more than 10,000 steps per day (n = 414) and 79.3 for those whose step counts fell below that cutoff (n = 1,226) (P < .001). For each additional 1,000 steps per day, RHR decreased by an average of 0.7 beats per minute in this group (P < .001).
In the younger age group, mean RHR was 85.3 among children who took more than 10,000 steps per day (n = 447) and 86.3 among those who did not reach that threshold (n = 452) (P = .29). For each additional 1,000 steps per day, RHR decreased by an average of 0.3 bpm in this group (P = .02)
Dr. Gasparino said next steps in research could include controlling for confounders, such as baseline anxiety and medications that could blunt the heart rate.
Broader implications
If similar results bear out in future studies, monitoring RHR could be incorporated into fitness programs for children and adolescents. Doing so could obviate “the need for intensive treadmill assessments using VO2max, time-consuming and emotionally fraught school-based physical fitness tests, and the fear and potential shame of the scale,” the researchers said.
Dr. Gasparino said measuring RHR during a 3-minute step test could help organizations and governments determine whether fitness programs are improving cardiovascular and overall health and could help them direct “funding and resources to the programs that are effective.” Such a test could also be incorporated into pediatrician wellness checks, she noted.
“It’s an exciting development, and [RHR measurement] holds a lot of promise as a clinical tool that can be applicable in a lot of settings,” said Nicholas M. Edwards, MD, MPH, a sports medicine pediatrician and an associate professor of orthopedics at the University of Minnesota in Minneapolis.
Dr. Edwards said that, because measurement of fitness in clinical settings is difficult, finding ways to “assess fitness in the office with the equipment already at hand would be a superb development.”
If use of RHR to measure fitness “is validated in a clinical setting,” Dr. Edwards said, “I think adoption would be a natural next step.”
Dr. Edwards has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
, according to a study presented at the Pediatric Academic Societies annual meeting.
The new findings provide a new means for pediatricians to measure physical fitness, the researchers said.
“It really changes the way we evaluate kids’ fitness and gives us a new method of judging physical fitness other than body mass index,” said Susan Gasparino, MD, an instructor in pediatrics at the University of Rochester (N.Y.) Medical Center, who led the study.
Using data from the 2005 to 2006 National Health and Nutrition Examination Survey, Dr. Gasparino and her colleagues examined the association between resting heart rate (RHR) and step count among 899 children and 1,640 adolescents aged 6-19 years.
In the adolescent group, the mean RHR was 74.9 among those who walked more than 10,000 steps per day (n = 414) and 79.3 for those whose step counts fell below that cutoff (n = 1,226) (P < .001). For each additional 1,000 steps per day, RHR decreased by an average of 0.7 beats per minute in this group (P < .001).
In the younger age group, mean RHR was 85.3 among children who took more than 10,000 steps per day (n = 447) and 86.3 among those who did not reach that threshold (n = 452) (P = .29). For each additional 1,000 steps per day, RHR decreased by an average of 0.3 bpm in this group (P = .02)
Dr. Gasparino said next steps in research could include controlling for confounders, such as baseline anxiety and medications that could blunt the heart rate.
Broader implications
If similar results bear out in future studies, monitoring RHR could be incorporated into fitness programs for children and adolescents. Doing so could obviate “the need for intensive treadmill assessments using VO2max, time-consuming and emotionally fraught school-based physical fitness tests, and the fear and potential shame of the scale,” the researchers said.
Dr. Gasparino said measuring RHR during a 3-minute step test could help organizations and governments determine whether fitness programs are improving cardiovascular and overall health and could help them direct “funding and resources to the programs that are effective.” Such a test could also be incorporated into pediatrician wellness checks, she noted.
“It’s an exciting development, and [RHR measurement] holds a lot of promise as a clinical tool that can be applicable in a lot of settings,” said Nicholas M. Edwards, MD, MPH, a sports medicine pediatrician and an associate professor of orthopedics at the University of Minnesota in Minneapolis.
Dr. Edwards said that, because measurement of fitness in clinical settings is difficult, finding ways to “assess fitness in the office with the equipment already at hand would be a superb development.”
If use of RHR to measure fitness “is validated in a clinical setting,” Dr. Edwards said, “I think adoption would be a natural next step.”
Dr. Edwards has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
, according to a study presented at the Pediatric Academic Societies annual meeting.
The new findings provide a new means for pediatricians to measure physical fitness, the researchers said.
“It really changes the way we evaluate kids’ fitness and gives us a new method of judging physical fitness other than body mass index,” said Susan Gasparino, MD, an instructor in pediatrics at the University of Rochester (N.Y.) Medical Center, who led the study.
Using data from the 2005 to 2006 National Health and Nutrition Examination Survey, Dr. Gasparino and her colleagues examined the association between resting heart rate (RHR) and step count among 899 children and 1,640 adolescents aged 6-19 years.
In the adolescent group, the mean RHR was 74.9 among those who walked more than 10,000 steps per day (n = 414) and 79.3 for those whose step counts fell below that cutoff (n = 1,226) (P < .001). For each additional 1,000 steps per day, RHR decreased by an average of 0.7 beats per minute in this group (P < .001).
In the younger age group, mean RHR was 85.3 among children who took more than 10,000 steps per day (n = 447) and 86.3 among those who did not reach that threshold (n = 452) (P = .29). For each additional 1,000 steps per day, RHR decreased by an average of 0.3 bpm in this group (P = .02)
Dr. Gasparino said next steps in research could include controlling for confounders, such as baseline anxiety and medications that could blunt the heart rate.
Broader implications
If similar results bear out in future studies, monitoring RHR could be incorporated into fitness programs for children and adolescents. Doing so could obviate “the need for intensive treadmill assessments using VO2max, time-consuming and emotionally fraught school-based physical fitness tests, and the fear and potential shame of the scale,” the researchers said.
Dr. Gasparino said measuring RHR during a 3-minute step test could help organizations and governments determine whether fitness programs are improving cardiovascular and overall health and could help them direct “funding and resources to the programs that are effective.” Such a test could also be incorporated into pediatrician wellness checks, she noted.
“It’s an exciting development, and [RHR measurement] holds a lot of promise as a clinical tool that can be applicable in a lot of settings,” said Nicholas M. Edwards, MD, MPH, a sports medicine pediatrician and an associate professor of orthopedics at the University of Minnesota in Minneapolis.
Dr. Edwards said that, because measurement of fitness in clinical settings is difficult, finding ways to “assess fitness in the office with the equipment already at hand would be a superb development.”
If use of RHR to measure fitness “is validated in a clinical setting,” Dr. Edwards said, “I think adoption would be a natural next step.”
Dr. Edwards has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FROM PAS 2023
The nation’s health secretary has this obstetrician on call
She’s seen progress, albeit slow, over three decades, yet the number of maternal deaths each year continues to rise.
Luckily, she’s got the ear of President Joe Biden’s health secretary.
Dr. Reyes, 64, is married to Health and Human Services Secretary Xavier Becerra, who is championing the administration’s initiative to require all states to provide Medicaid coverage to mothers for a year after giving birth. In March, the Centers for Disease Control and Prevention released data showing a 40% increase in U.S. maternal deaths from 2020 to 2021. The mortality rate among Black women was 2.6 times that of white women, no matter their economic status.
Over the years, Mr. Becerra has spoken highly of his wife’s expertise, but she downplays her influence, saying her husband of nearly 35 years “had it in him to begin with” to improve health care for women and to demand fewer pregnancy-related deaths. She, too, describes the nation’s high maternal mortality rate as unacceptable and preventable.
Dr. Reyes, a Latina who grew up as one of eight children in California’s agricultural heartland, now practices perinatology at the University of California, Davis. She is a member of a California Department of Public Health panel that reviews cases of maternal deaths and recommends improvements. And she chairs the board of the California Health Care Foundation, a nonprofit that works to increase health care access. (California Healthline is an editorially independent service of the California Health Care Foundation.)
Her work has been a blend of medicine and advocacy, and she worries recent federal court rulings will erode hard-fought victories regarding the safety of pregnant women and their babies. She discussed the nation’s maternal health crisis and health care disparities in an interview, which has been edited for length and clarity.
Question: When did you first realize there are disparities in the health care system?
Answer: When I was in high school in the Fresno Unified School District, we were under a consent decree to desegregate. And I was, at the time, student body president at Roosevelt High School. I was asked to be on this unified school district desegregation task force, where the district had to come up with a plan.
It was a time when I really had incredible exposure to how policies are made at a larger level, societal level, that really determine where people live, where they can seek health care, where they go to school. That experience had a tremendous impact on my life in terms of what I wanted to do in a career and how to give back.
Q: The U.S. has one of the best health care systems in the world, yet the maternal mortality rate is high compared with other developed countries. Why do think that is?
A. What we know by the CDC and maternal mortality review committees is that about 60% of maternal deaths are considered preventable. And that’s really been a lot of what I’ve tried to focus on: What can we do to reduce the severity of disease? Or what can we do within the role that we play in maternal health that can reduce that?
We know that there are societal issues absolutely that increase women’s risks and there are public health issues. But there’s a role that hospitals play in helping reduce that risk. Ten years ago, I was on the maternal mortality review committee for the state of California when we started reviewing cases of women who died within hospital systems to see, “Is there a role that we can play in a hospital system to reduce that risk?”
We recognized that sometimes there were conditions that were not recognized early enough so that there was a delay in the care. Sometimes there was a misdiagnosis. Or in some hospital systems, especially rural systems where there aren’t as many resources, sometimes there was the lack of specialists available. So, we’ve identified these risks and said, “We can do something about them.”
Q: You served on a federal panel 20 years ago that published a groundbreaking report identifying racism in health care. It seems as if we could be much further along.
A. The purpose of that committee was to really answer the question: Do patients receive a different level of care based on race? Looking back, we knew there was something there, but we really didn’t know. And it took months for the committee to come to that agreement, that there was a difference. I mean, that was honestly monumental, because we just didn’t have that level of consensus before. And so just to say “That treatment is unequal and it’s unacceptable” was really profound.
We thought that the 700-page report was going to be a time period where there was going to be tremendous movement, and I think I’ve learned over 20 years that change doesn’t happen quickly, especially when providers and health systems don’t see that they play a role. It’s like … “OK, so maybe it exists, but not for me.”
We all saw George Floyd and how he was treated. And during COVID we saw a tremendous difference in who was dying, right? Underrepresented minorities – certainly much higher. It was that culmination that made us realize the elephant in the room. We can’t ignore that this does exist, that there is a difference in how people are treated, even in our health care system.
Q: When addressing racism in health care, you talk about diversifying not just the health care workforce, but also the boardrooms of hospitals and health systems. Why is that important?
A. At the board level, change is hard. But we all play a role because leadership really helps determine much of what’s carried out. So, to have a leadership that is understanding and representative of the communities they serve, I think it has been demonstrated that we do make a difference.
Q: As a health care provider, do you have a wish list of policies you’d like the government to take up?
A. There was tremendous effort around offering preventive health services as a part of what was covered under the Affordable Care Act. And individuals exhaled, finally thinking this is a tremendous win, especially for women in pregnancy. Because we fought for preventive health services to help them have access so they can prepare for their pregnancy. So, for women, this was huge. But now with the Texas federal court ruling that the U.S. Preventive Services Task Force didn’t have any authority, it is a tremendous step backward.
We have culturally, linguistically appropriate standards in place, but it’s a matter in terms of how they’re carried out by state and by individual hospital systems. My wish list is that we really do listen to our patients, speak to them in a language of their choice, and provide them written materials in the language of their choice. We don’t fully do that.
Q: You mentioned one Texas ruling on the ACA. What’s your take on the ruling by another Texas judge suspending the abortion pill? And the U.S. Supreme Court’s overturning of Roe v. Wade?A. As a maternal-fetal medicine specialist who tries to help women plan for pregnancies, those rulings are a tremendous setback.
Q: And what about women of color? Will they find access to abortion services more difficult?
A. Oh, absolutely. When we speak of underrepresented minorities or those with less resources, they have less resources to then seek the appropriate care. Some women may have the opportunity to go to a different state or seek care elsewhere if their state doesn’t provide it. Many women just don’t have those resources to devote to them and don’t have a choice. So, we will see that disparity widen.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
She’s seen progress, albeit slow, over three decades, yet the number of maternal deaths each year continues to rise.
Luckily, she’s got the ear of President Joe Biden’s health secretary.
Dr. Reyes, 64, is married to Health and Human Services Secretary Xavier Becerra, who is championing the administration’s initiative to require all states to provide Medicaid coverage to mothers for a year after giving birth. In March, the Centers for Disease Control and Prevention released data showing a 40% increase in U.S. maternal deaths from 2020 to 2021. The mortality rate among Black women was 2.6 times that of white women, no matter their economic status.
Over the years, Mr. Becerra has spoken highly of his wife’s expertise, but she downplays her influence, saying her husband of nearly 35 years “had it in him to begin with” to improve health care for women and to demand fewer pregnancy-related deaths. She, too, describes the nation’s high maternal mortality rate as unacceptable and preventable.
Dr. Reyes, a Latina who grew up as one of eight children in California’s agricultural heartland, now practices perinatology at the University of California, Davis. She is a member of a California Department of Public Health panel that reviews cases of maternal deaths and recommends improvements. And she chairs the board of the California Health Care Foundation, a nonprofit that works to increase health care access. (California Healthline is an editorially independent service of the California Health Care Foundation.)
Her work has been a blend of medicine and advocacy, and she worries recent federal court rulings will erode hard-fought victories regarding the safety of pregnant women and their babies. She discussed the nation’s maternal health crisis and health care disparities in an interview, which has been edited for length and clarity.
Question: When did you first realize there are disparities in the health care system?
Answer: When I was in high school in the Fresno Unified School District, we were under a consent decree to desegregate. And I was, at the time, student body president at Roosevelt High School. I was asked to be on this unified school district desegregation task force, where the district had to come up with a plan.
It was a time when I really had incredible exposure to how policies are made at a larger level, societal level, that really determine where people live, where they can seek health care, where they go to school. That experience had a tremendous impact on my life in terms of what I wanted to do in a career and how to give back.
Q: The U.S. has one of the best health care systems in the world, yet the maternal mortality rate is high compared with other developed countries. Why do think that is?
A. What we know by the CDC and maternal mortality review committees is that about 60% of maternal deaths are considered preventable. And that’s really been a lot of what I’ve tried to focus on: What can we do to reduce the severity of disease? Or what can we do within the role that we play in maternal health that can reduce that?
We know that there are societal issues absolutely that increase women’s risks and there are public health issues. But there’s a role that hospitals play in helping reduce that risk. Ten years ago, I was on the maternal mortality review committee for the state of California when we started reviewing cases of women who died within hospital systems to see, “Is there a role that we can play in a hospital system to reduce that risk?”
We recognized that sometimes there were conditions that were not recognized early enough so that there was a delay in the care. Sometimes there was a misdiagnosis. Or in some hospital systems, especially rural systems where there aren’t as many resources, sometimes there was the lack of specialists available. So, we’ve identified these risks and said, “We can do something about them.”
Q: You served on a federal panel 20 years ago that published a groundbreaking report identifying racism in health care. It seems as if we could be much further along.
A. The purpose of that committee was to really answer the question: Do patients receive a different level of care based on race? Looking back, we knew there was something there, but we really didn’t know. And it took months for the committee to come to that agreement, that there was a difference. I mean, that was honestly monumental, because we just didn’t have that level of consensus before. And so just to say “That treatment is unequal and it’s unacceptable” was really profound.
We thought that the 700-page report was going to be a time period where there was going to be tremendous movement, and I think I’ve learned over 20 years that change doesn’t happen quickly, especially when providers and health systems don’t see that they play a role. It’s like … “OK, so maybe it exists, but not for me.”
We all saw George Floyd and how he was treated. And during COVID we saw a tremendous difference in who was dying, right? Underrepresented minorities – certainly much higher. It was that culmination that made us realize the elephant in the room. We can’t ignore that this does exist, that there is a difference in how people are treated, even in our health care system.
Q: When addressing racism in health care, you talk about diversifying not just the health care workforce, but also the boardrooms of hospitals and health systems. Why is that important?
A. At the board level, change is hard. But we all play a role because leadership really helps determine much of what’s carried out. So, to have a leadership that is understanding and representative of the communities they serve, I think it has been demonstrated that we do make a difference.
Q: As a health care provider, do you have a wish list of policies you’d like the government to take up?
A. There was tremendous effort around offering preventive health services as a part of what was covered under the Affordable Care Act. And individuals exhaled, finally thinking this is a tremendous win, especially for women in pregnancy. Because we fought for preventive health services to help them have access so they can prepare for their pregnancy. So, for women, this was huge. But now with the Texas federal court ruling that the U.S. Preventive Services Task Force didn’t have any authority, it is a tremendous step backward.
We have culturally, linguistically appropriate standards in place, but it’s a matter in terms of how they’re carried out by state and by individual hospital systems. My wish list is that we really do listen to our patients, speak to them in a language of their choice, and provide them written materials in the language of their choice. We don’t fully do that.
Q: You mentioned one Texas ruling on the ACA. What’s your take on the ruling by another Texas judge suspending the abortion pill? And the U.S. Supreme Court’s overturning of Roe v. Wade?A. As a maternal-fetal medicine specialist who tries to help women plan for pregnancies, those rulings are a tremendous setback.
Q: And what about women of color? Will they find access to abortion services more difficult?
A. Oh, absolutely. When we speak of underrepresented minorities or those with less resources, they have less resources to then seek the appropriate care. Some women may have the opportunity to go to a different state or seek care elsewhere if their state doesn’t provide it. Many women just don’t have those resources to devote to them and don’t have a choice. So, we will see that disparity widen.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
She’s seen progress, albeit slow, over three decades, yet the number of maternal deaths each year continues to rise.
Luckily, she’s got the ear of President Joe Biden’s health secretary.
Dr. Reyes, 64, is married to Health and Human Services Secretary Xavier Becerra, who is championing the administration’s initiative to require all states to provide Medicaid coverage to mothers for a year after giving birth. In March, the Centers for Disease Control and Prevention released data showing a 40% increase in U.S. maternal deaths from 2020 to 2021. The mortality rate among Black women was 2.6 times that of white women, no matter their economic status.
Over the years, Mr. Becerra has spoken highly of his wife’s expertise, but she downplays her influence, saying her husband of nearly 35 years “had it in him to begin with” to improve health care for women and to demand fewer pregnancy-related deaths. She, too, describes the nation’s high maternal mortality rate as unacceptable and preventable.
Dr. Reyes, a Latina who grew up as one of eight children in California’s agricultural heartland, now practices perinatology at the University of California, Davis. She is a member of a California Department of Public Health panel that reviews cases of maternal deaths and recommends improvements. And she chairs the board of the California Health Care Foundation, a nonprofit that works to increase health care access. (California Healthline is an editorially independent service of the California Health Care Foundation.)
Her work has been a blend of medicine and advocacy, and she worries recent federal court rulings will erode hard-fought victories regarding the safety of pregnant women and their babies. She discussed the nation’s maternal health crisis and health care disparities in an interview, which has been edited for length and clarity.
Question: When did you first realize there are disparities in the health care system?
Answer: When I was in high school in the Fresno Unified School District, we were under a consent decree to desegregate. And I was, at the time, student body president at Roosevelt High School. I was asked to be on this unified school district desegregation task force, where the district had to come up with a plan.
It was a time when I really had incredible exposure to how policies are made at a larger level, societal level, that really determine where people live, where they can seek health care, where they go to school. That experience had a tremendous impact on my life in terms of what I wanted to do in a career and how to give back.
Q: The U.S. has one of the best health care systems in the world, yet the maternal mortality rate is high compared with other developed countries. Why do think that is?
A. What we know by the CDC and maternal mortality review committees is that about 60% of maternal deaths are considered preventable. And that’s really been a lot of what I’ve tried to focus on: What can we do to reduce the severity of disease? Or what can we do within the role that we play in maternal health that can reduce that?
We know that there are societal issues absolutely that increase women’s risks and there are public health issues. But there’s a role that hospitals play in helping reduce that risk. Ten years ago, I was on the maternal mortality review committee for the state of California when we started reviewing cases of women who died within hospital systems to see, “Is there a role that we can play in a hospital system to reduce that risk?”
We recognized that sometimes there were conditions that were not recognized early enough so that there was a delay in the care. Sometimes there was a misdiagnosis. Or in some hospital systems, especially rural systems where there aren’t as many resources, sometimes there was the lack of specialists available. So, we’ve identified these risks and said, “We can do something about them.”
Q: You served on a federal panel 20 years ago that published a groundbreaking report identifying racism in health care. It seems as if we could be much further along.
A. The purpose of that committee was to really answer the question: Do patients receive a different level of care based on race? Looking back, we knew there was something there, but we really didn’t know. And it took months for the committee to come to that agreement, that there was a difference. I mean, that was honestly monumental, because we just didn’t have that level of consensus before. And so just to say “That treatment is unequal and it’s unacceptable” was really profound.
We thought that the 700-page report was going to be a time period where there was going to be tremendous movement, and I think I’ve learned over 20 years that change doesn’t happen quickly, especially when providers and health systems don’t see that they play a role. It’s like … “OK, so maybe it exists, but not for me.”
We all saw George Floyd and how he was treated. And during COVID we saw a tremendous difference in who was dying, right? Underrepresented minorities – certainly much higher. It was that culmination that made us realize the elephant in the room. We can’t ignore that this does exist, that there is a difference in how people are treated, even in our health care system.
Q: When addressing racism in health care, you talk about diversifying not just the health care workforce, but also the boardrooms of hospitals and health systems. Why is that important?
A. At the board level, change is hard. But we all play a role because leadership really helps determine much of what’s carried out. So, to have a leadership that is understanding and representative of the communities they serve, I think it has been demonstrated that we do make a difference.
Q: As a health care provider, do you have a wish list of policies you’d like the government to take up?
A. There was tremendous effort around offering preventive health services as a part of what was covered under the Affordable Care Act. And individuals exhaled, finally thinking this is a tremendous win, especially for women in pregnancy. Because we fought for preventive health services to help them have access so they can prepare for their pregnancy. So, for women, this was huge. But now with the Texas federal court ruling that the U.S. Preventive Services Task Force didn’t have any authority, it is a tremendous step backward.
We have culturally, linguistically appropriate standards in place, but it’s a matter in terms of how they’re carried out by state and by individual hospital systems. My wish list is that we really do listen to our patients, speak to them in a language of their choice, and provide them written materials in the language of their choice. We don’t fully do that.
Q: You mentioned one Texas ruling on the ACA. What’s your take on the ruling by another Texas judge suspending the abortion pill? And the U.S. Supreme Court’s overturning of Roe v. Wade?A. As a maternal-fetal medicine specialist who tries to help women plan for pregnancies, those rulings are a tremendous setback.
Q: And what about women of color? Will they find access to abortion services more difficult?
A. Oh, absolutely. When we speak of underrepresented minorities or those with less resources, they have less resources to then seek the appropriate care. Some women may have the opportunity to go to a different state or seek care elsewhere if their state doesn’t provide it. Many women just don’t have those resources to devote to them and don’t have a choice. So, we will see that disparity widen.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Gender-diverse teens face barriers to physical activity
WASHINGTON – in a poster presented at the Pediatric Academic Societies annual meeting. Other barriers included body dissatisfaction and discomfort or pain from binding or tucking, based on data from 160 individuals.
Previous studies suggest that gender-diverse teens have lower levels of physical activity than cisgender teens, but data on the specific barriers to physical activity reported by gender-diverse adolescents are lacking, according to Karishma Desai, BA, a medical student at Northwestern University, Chicago, and colleagues.
The researchers reviewed data from adolescents aged 13-18 years who identified as transgender or nonbinary and lived in the United States. Participants were recruited through flyers, wallet cards, email, and social media. They completed an online survey that included questions on preferred types of physical activity and potential barriers to physical activity. Major barriers were defined as items that “almost always” or “always” got in the way of physical activity.
Overall, 51% of the participants identified as female/transfeminine, 31% as male/transmasculine, 9% as genderqueer or agender, 8% as nonbinary, and 1% as unsure. A total of 86 participants were assigned male at birth, 73 were assigned female, and 1 was assigned intersex or other. Nearly all of the participants (96%) had begun social transition; approximately half (48%) reported using a chest binder, and 75% had been or were currently taking gender-affirming hormones.
Potential negative judgment from others was the top barrier to physical activity (cited by 39% of participants), followed by body dissatisfaction from gender dysphoria (38%) and discomfort with the available options for locker rooms or changing rooms (38%). Approximately one-third (36%) of respondents reported physical discomfort or pain from binding or tucking as a barrier to physical activity, and 34% cited discomfort with requirements for a physical activity uniform or athletic clothing at school. Other gender-diverse specific barriers to physical activity included bullying related to being transgender (31%) and the inability to participate in a group of choice because of gender identity (24%).
In addition, participants cited general barriers to physical activity including bullying related to weight (33%), dissatisfaction with weight or size (31%), and bullying in general or for reasons other than gender status (29%).
However, more than 50% of respondents said they were comfortable or very comfortable (4 or 5 on a 5-point Likert Scale) with physical activity in the settings of coed or all-gender teams (61%) or engaging in individual activities (71%). By contrast, 36% were comfortable or very comfortable with a team, group, or class that aligned with sex assignment at birth.
The majority of participants (81%) were comfortable or very comfortable with their homes or a private location as a setting for physical activity, 54% with a public space such as a park, and 43% with a school setting.
Increasing gender congruence was the biggest facilitator of physical activity, reported by 53% of participants, the researchers noted. Other facilitators of physical activity included increasing body satisfaction (43%), staying healthy to avoid long-term health problems in the future (43%), and staying healthy to prepare for gender-related surgery in the future (18%).
The study findings were limited by the use of self-reports and the use of a convenience sample, as well as the lack of data on race, the researchers noted. However, the results suggest that access to all-gender teams, standardizing physical activity clothing, and increasing inclusive facilities may promote greater physical activity participation by gender-diverse adolescents, and offering private or individual options may increase comfort with physical activity, they concluded.
Study provides teens’ perspectives
The current study is especially timely given the recent passage by the U.S. House of Representatives of the anti-trans sports bill preventing transgender women and girls from playing on sports teams “consistent with their gender identity,” said Margaret Thew, DNP, medical director of adolescent medicine at Children’s Wisconsin in Milwaukee, in an interview. Ms. Thew was not involved in the current study.
“The House bill seeks to amend federal law to require that sex shall be recognized based solely on a person’s reproductive biology and genetics at birth, for the purpose of determining compliance with Title IX in athletics,” Ms. Thew said.
“Despite political responses to sports participation for transgender adolescents, we have not heard the perspective of the teens themselves,” she emphasized. “It is imperative for parents, coaches, and clinicians to hear the adolescents’ concerns so they can advocate for the students and provide the needed support.” In addition, Ms. Thew noted, “these concerns may also provide overdue changes to the required uniforms described for specific sports.”
Ms. Thew said she was surprised by the finding of transgender teens’ comfort with coed teams and individual activities, both of which may be opportunities to promote physical activity for transgender adolescents.
However, she added that she was not surprised by some of the results. “Many transgender adolescents experience the discomfort and further body dysmorphia of being put into gender-conforming attire such as swimwear, spandex shorts for female volleyball players, or field hockey skirts, for example.”
Although many schools are establishing safe, comfortable places for all adolescents to change clothing prior to physical education and sports participation, “resources are limited, and students and parents need to advocate within the school system,” Ms. Thew noted.
“We as a society, including athletic clothing makers, need to hear the testimony of transgender adolescents on the discomfort from body modifications to better support and innovate attire to meet their needs,” she added.
“The take-home message for clinicians is twofold,” said Ms. Thew. “Clinicians need to advocate for transgender patients to have the same opportunities as all teens when it comes to sports participation and physical activity. Also, clinicians need to ask all adolescents about their comfort in participating in physical activity both on club/school teams and independently,” she said. “If barriers are identified, clinicians need to work to support the adolescent with alternative activities/attire that will promote healthy physical activities for overall health.”
The current study also suggests that transgender adolescents who may have interest in, but discomfort with, physical activity should be redirected to coed or individual sports available in their communities, Ms. Thew added.
More research is needed on innovative sports attire that would improve comfort for transgender adolescents and thereby encourage physical activity, Ms. Thew told this news organization. More data also are needed on which sports transgender adolescents participate in and why, and how these activities might be promoted, she said.
Finally, more research will be needed to examine the impact of the recent House bills on physical activity for transgender youth, Ms. Thew said.
The study was supported by the Potocsnak Family Division of Adolescent and Young Adult Medicine at Ann and Robert H. Lurie’s Children’s Hospital of Chicago. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose, but she serves on the Editorial Advisory Board of Pediatric News.
WASHINGTON – in a poster presented at the Pediatric Academic Societies annual meeting. Other barriers included body dissatisfaction and discomfort or pain from binding or tucking, based on data from 160 individuals.
Previous studies suggest that gender-diverse teens have lower levels of physical activity than cisgender teens, but data on the specific barriers to physical activity reported by gender-diverse adolescents are lacking, according to Karishma Desai, BA, a medical student at Northwestern University, Chicago, and colleagues.
The researchers reviewed data from adolescents aged 13-18 years who identified as transgender or nonbinary and lived in the United States. Participants were recruited through flyers, wallet cards, email, and social media. They completed an online survey that included questions on preferred types of physical activity and potential barriers to physical activity. Major barriers were defined as items that “almost always” or “always” got in the way of physical activity.
Overall, 51% of the participants identified as female/transfeminine, 31% as male/transmasculine, 9% as genderqueer or agender, 8% as nonbinary, and 1% as unsure. A total of 86 participants were assigned male at birth, 73 were assigned female, and 1 was assigned intersex or other. Nearly all of the participants (96%) had begun social transition; approximately half (48%) reported using a chest binder, and 75% had been or were currently taking gender-affirming hormones.
Potential negative judgment from others was the top barrier to physical activity (cited by 39% of participants), followed by body dissatisfaction from gender dysphoria (38%) and discomfort with the available options for locker rooms or changing rooms (38%). Approximately one-third (36%) of respondents reported physical discomfort or pain from binding or tucking as a barrier to physical activity, and 34% cited discomfort with requirements for a physical activity uniform or athletic clothing at school. Other gender-diverse specific barriers to physical activity included bullying related to being transgender (31%) and the inability to participate in a group of choice because of gender identity (24%).
In addition, participants cited general barriers to physical activity including bullying related to weight (33%), dissatisfaction with weight or size (31%), and bullying in general or for reasons other than gender status (29%).
However, more than 50% of respondents said they were comfortable or very comfortable (4 or 5 on a 5-point Likert Scale) with physical activity in the settings of coed or all-gender teams (61%) or engaging in individual activities (71%). By contrast, 36% were comfortable or very comfortable with a team, group, or class that aligned with sex assignment at birth.
The majority of participants (81%) were comfortable or very comfortable with their homes or a private location as a setting for physical activity, 54% with a public space such as a park, and 43% with a school setting.
Increasing gender congruence was the biggest facilitator of physical activity, reported by 53% of participants, the researchers noted. Other facilitators of physical activity included increasing body satisfaction (43%), staying healthy to avoid long-term health problems in the future (43%), and staying healthy to prepare for gender-related surgery in the future (18%).
The study findings were limited by the use of self-reports and the use of a convenience sample, as well as the lack of data on race, the researchers noted. However, the results suggest that access to all-gender teams, standardizing physical activity clothing, and increasing inclusive facilities may promote greater physical activity participation by gender-diverse adolescents, and offering private or individual options may increase comfort with physical activity, they concluded.
Study provides teens’ perspectives
The current study is especially timely given the recent passage by the U.S. House of Representatives of the anti-trans sports bill preventing transgender women and girls from playing on sports teams “consistent with their gender identity,” said Margaret Thew, DNP, medical director of adolescent medicine at Children’s Wisconsin in Milwaukee, in an interview. Ms. Thew was not involved in the current study.
“The House bill seeks to amend federal law to require that sex shall be recognized based solely on a person’s reproductive biology and genetics at birth, for the purpose of determining compliance with Title IX in athletics,” Ms. Thew said.
“Despite political responses to sports participation for transgender adolescents, we have not heard the perspective of the teens themselves,” she emphasized. “It is imperative for parents, coaches, and clinicians to hear the adolescents’ concerns so they can advocate for the students and provide the needed support.” In addition, Ms. Thew noted, “these concerns may also provide overdue changes to the required uniforms described for specific sports.”
Ms. Thew said she was surprised by the finding of transgender teens’ comfort with coed teams and individual activities, both of which may be opportunities to promote physical activity for transgender adolescents.
However, she added that she was not surprised by some of the results. “Many transgender adolescents experience the discomfort and further body dysmorphia of being put into gender-conforming attire such as swimwear, spandex shorts for female volleyball players, or field hockey skirts, for example.”
Although many schools are establishing safe, comfortable places for all adolescents to change clothing prior to physical education and sports participation, “resources are limited, and students and parents need to advocate within the school system,” Ms. Thew noted.
“We as a society, including athletic clothing makers, need to hear the testimony of transgender adolescents on the discomfort from body modifications to better support and innovate attire to meet their needs,” she added.
“The take-home message for clinicians is twofold,” said Ms. Thew. “Clinicians need to advocate for transgender patients to have the same opportunities as all teens when it comes to sports participation and physical activity. Also, clinicians need to ask all adolescents about their comfort in participating in physical activity both on club/school teams and independently,” she said. “If barriers are identified, clinicians need to work to support the adolescent with alternative activities/attire that will promote healthy physical activities for overall health.”
The current study also suggests that transgender adolescents who may have interest in, but discomfort with, physical activity should be redirected to coed or individual sports available in their communities, Ms. Thew added.
More research is needed on innovative sports attire that would improve comfort for transgender adolescents and thereby encourage physical activity, Ms. Thew told this news organization. More data also are needed on which sports transgender adolescents participate in and why, and how these activities might be promoted, she said.
Finally, more research will be needed to examine the impact of the recent House bills on physical activity for transgender youth, Ms. Thew said.
The study was supported by the Potocsnak Family Division of Adolescent and Young Adult Medicine at Ann and Robert H. Lurie’s Children’s Hospital of Chicago. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose, but she serves on the Editorial Advisory Board of Pediatric News.
WASHINGTON – in a poster presented at the Pediatric Academic Societies annual meeting. Other barriers included body dissatisfaction and discomfort or pain from binding or tucking, based on data from 160 individuals.
Previous studies suggest that gender-diverse teens have lower levels of physical activity than cisgender teens, but data on the specific barriers to physical activity reported by gender-diverse adolescents are lacking, according to Karishma Desai, BA, a medical student at Northwestern University, Chicago, and colleagues.
The researchers reviewed data from adolescents aged 13-18 years who identified as transgender or nonbinary and lived in the United States. Participants were recruited through flyers, wallet cards, email, and social media. They completed an online survey that included questions on preferred types of physical activity and potential barriers to physical activity. Major barriers were defined as items that “almost always” or “always” got in the way of physical activity.
Overall, 51% of the participants identified as female/transfeminine, 31% as male/transmasculine, 9% as genderqueer or agender, 8% as nonbinary, and 1% as unsure. A total of 86 participants were assigned male at birth, 73 were assigned female, and 1 was assigned intersex or other. Nearly all of the participants (96%) had begun social transition; approximately half (48%) reported using a chest binder, and 75% had been or were currently taking gender-affirming hormones.
Potential negative judgment from others was the top barrier to physical activity (cited by 39% of participants), followed by body dissatisfaction from gender dysphoria (38%) and discomfort with the available options for locker rooms or changing rooms (38%). Approximately one-third (36%) of respondents reported physical discomfort or pain from binding or tucking as a barrier to physical activity, and 34% cited discomfort with requirements for a physical activity uniform or athletic clothing at school. Other gender-diverse specific barriers to physical activity included bullying related to being transgender (31%) and the inability to participate in a group of choice because of gender identity (24%).
In addition, participants cited general barriers to physical activity including bullying related to weight (33%), dissatisfaction with weight or size (31%), and bullying in general or for reasons other than gender status (29%).
However, more than 50% of respondents said they were comfortable or very comfortable (4 or 5 on a 5-point Likert Scale) with physical activity in the settings of coed or all-gender teams (61%) or engaging in individual activities (71%). By contrast, 36% were comfortable or very comfortable with a team, group, or class that aligned with sex assignment at birth.
The majority of participants (81%) were comfortable or very comfortable with their homes or a private location as a setting for physical activity, 54% with a public space such as a park, and 43% with a school setting.
Increasing gender congruence was the biggest facilitator of physical activity, reported by 53% of participants, the researchers noted. Other facilitators of physical activity included increasing body satisfaction (43%), staying healthy to avoid long-term health problems in the future (43%), and staying healthy to prepare for gender-related surgery in the future (18%).
The study findings were limited by the use of self-reports and the use of a convenience sample, as well as the lack of data on race, the researchers noted. However, the results suggest that access to all-gender teams, standardizing physical activity clothing, and increasing inclusive facilities may promote greater physical activity participation by gender-diverse adolescents, and offering private or individual options may increase comfort with physical activity, they concluded.
Study provides teens’ perspectives
The current study is especially timely given the recent passage by the U.S. House of Representatives of the anti-trans sports bill preventing transgender women and girls from playing on sports teams “consistent with their gender identity,” said Margaret Thew, DNP, medical director of adolescent medicine at Children’s Wisconsin in Milwaukee, in an interview. Ms. Thew was not involved in the current study.
“The House bill seeks to amend federal law to require that sex shall be recognized based solely on a person’s reproductive biology and genetics at birth, for the purpose of determining compliance with Title IX in athletics,” Ms. Thew said.
“Despite political responses to sports participation for transgender adolescents, we have not heard the perspective of the teens themselves,” she emphasized. “It is imperative for parents, coaches, and clinicians to hear the adolescents’ concerns so they can advocate for the students and provide the needed support.” In addition, Ms. Thew noted, “these concerns may also provide overdue changes to the required uniforms described for specific sports.”
Ms. Thew said she was surprised by the finding of transgender teens’ comfort with coed teams and individual activities, both of which may be opportunities to promote physical activity for transgender adolescents.
However, she added that she was not surprised by some of the results. “Many transgender adolescents experience the discomfort and further body dysmorphia of being put into gender-conforming attire such as swimwear, spandex shorts for female volleyball players, or field hockey skirts, for example.”
Although many schools are establishing safe, comfortable places for all adolescents to change clothing prior to physical education and sports participation, “resources are limited, and students and parents need to advocate within the school system,” Ms. Thew noted.
“We as a society, including athletic clothing makers, need to hear the testimony of transgender adolescents on the discomfort from body modifications to better support and innovate attire to meet their needs,” she added.
“The take-home message for clinicians is twofold,” said Ms. Thew. “Clinicians need to advocate for transgender patients to have the same opportunities as all teens when it comes to sports participation and physical activity. Also, clinicians need to ask all adolescents about their comfort in participating in physical activity both on club/school teams and independently,” she said. “If barriers are identified, clinicians need to work to support the adolescent with alternative activities/attire that will promote healthy physical activities for overall health.”
The current study also suggests that transgender adolescents who may have interest in, but discomfort with, physical activity should be redirected to coed or individual sports available in their communities, Ms. Thew added.
More research is needed on innovative sports attire that would improve comfort for transgender adolescents and thereby encourage physical activity, Ms. Thew told this news organization. More data also are needed on which sports transgender adolescents participate in and why, and how these activities might be promoted, she said.
Finally, more research will be needed to examine the impact of the recent House bills on physical activity for transgender youth, Ms. Thew said.
The study was supported by the Potocsnak Family Division of Adolescent and Young Adult Medicine at Ann and Robert H. Lurie’s Children’s Hospital of Chicago. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose, but she serves on the Editorial Advisory Board of Pediatric News.
AT PAS 2023
UTI imaging falls short in some primary care settings
WASHINGTON –
“Timely imaging is recommended after febrile UTI (fUTI) in young children to identify treatable urologic conditions,” wrote Jonathan Hatoun, MD, of Boston Children’s Hospital, and colleagues in a poster presented at the Pediatric Academic Societies annual meeting.
The American Academy of Pediatrics (AAP) currently recommends renal-bladder ultrasound (RBUS) after fUTI with voiding cystourethrogram (VCUG) after abnormal RBUS or second fUTI, but data on clinician adherence to these recommendations are limited, the researchers said.
To characterize practice patterns regarding fUTI, the researchers reviewed data from children younger than 24 months of age with fUTI who were treated at a primary care network in Massachusetts in 2019. The definition of fUTI was temperature of 38° C or higher, positive urinalysis, and more than 50,000 CFU on urine culture. The median age of the patients was 9 months; 84% were female.
In a multivariate analysis, post-UTI imaging followed the AAP guidelines in 82 cases (69.5%). The main reasons for nonadherence were lack of RBUS in 21 patients, VCUG despite normal RBUS in 9 patients, no VCUG after abnormal RBUS in 4 patients, and no VCUG after a second fUTI in 2 patients.
Overall, nonadherence was a result of not ordering a recommended study in 23% of cases (errors of omission) and ordering an unnecessary study in 8% of cases (errors of commission).
Commercial insurance, larger number of providers in practice, and younger provider age were significant independent predictors of adherence (odds ratios 2.82, 1.38, and 0.96, respectively).
The findings were limited by the use of data from a single center; however, the results suggest that targeted training may improve guideline adherence, the researchers wrote. Additional research and quality improvement studies are needed to understand and address the impact of insurance on guideline adherence for imaging after febrile UTIs, they noted.
Provider education is essential to continued quality of care
When it comes to febrile UTIs, “it is important to stay focused on the quality of care being provided, as opposed to the usual benchmark of quantity of care,” Tim Joos, MD, a Seattle-based clinician with a combination internal medicine/pediatrics practice, said in an interview.
“This is a very simple but interesting study on provider compliance with practice guidelines,” said Dr. Joos, who was not involved in the study. “I was surprised that the providers did so well in ordering the correct imaging in 70% of the cases,” he said.
Of particular interest, Dr. Joos noted, was that “the authors also showed that older providers and those working in smaller practices are less likely to comply with this particular imaging guideline. This can be summed up as the ‘I didn’t know the guideline’ effect.”
To improve quality of care, “more research and effort should be directed at updating providers when strong new evidence changes previous practices and guidelines,” Dr. Joos told this news organization.
The study received no outside funding. The researchers and Dr. Joos had no financial conflicts to disclose.
WASHINGTON –
“Timely imaging is recommended after febrile UTI (fUTI) in young children to identify treatable urologic conditions,” wrote Jonathan Hatoun, MD, of Boston Children’s Hospital, and colleagues in a poster presented at the Pediatric Academic Societies annual meeting.
The American Academy of Pediatrics (AAP) currently recommends renal-bladder ultrasound (RBUS) after fUTI with voiding cystourethrogram (VCUG) after abnormal RBUS or second fUTI, but data on clinician adherence to these recommendations are limited, the researchers said.
To characterize practice patterns regarding fUTI, the researchers reviewed data from children younger than 24 months of age with fUTI who were treated at a primary care network in Massachusetts in 2019. The definition of fUTI was temperature of 38° C or higher, positive urinalysis, and more than 50,000 CFU on urine culture. The median age of the patients was 9 months; 84% were female.
In a multivariate analysis, post-UTI imaging followed the AAP guidelines in 82 cases (69.5%). The main reasons for nonadherence were lack of RBUS in 21 patients, VCUG despite normal RBUS in 9 patients, no VCUG after abnormal RBUS in 4 patients, and no VCUG after a second fUTI in 2 patients.
Overall, nonadherence was a result of not ordering a recommended study in 23% of cases (errors of omission) and ordering an unnecessary study in 8% of cases (errors of commission).
Commercial insurance, larger number of providers in practice, and younger provider age were significant independent predictors of adherence (odds ratios 2.82, 1.38, and 0.96, respectively).
The findings were limited by the use of data from a single center; however, the results suggest that targeted training may improve guideline adherence, the researchers wrote. Additional research and quality improvement studies are needed to understand and address the impact of insurance on guideline adherence for imaging after febrile UTIs, they noted.
Provider education is essential to continued quality of care
When it comes to febrile UTIs, “it is important to stay focused on the quality of care being provided, as opposed to the usual benchmark of quantity of care,” Tim Joos, MD, a Seattle-based clinician with a combination internal medicine/pediatrics practice, said in an interview.
“This is a very simple but interesting study on provider compliance with practice guidelines,” said Dr. Joos, who was not involved in the study. “I was surprised that the providers did so well in ordering the correct imaging in 70% of the cases,” he said.
Of particular interest, Dr. Joos noted, was that “the authors also showed that older providers and those working in smaller practices are less likely to comply with this particular imaging guideline. This can be summed up as the ‘I didn’t know the guideline’ effect.”
To improve quality of care, “more research and effort should be directed at updating providers when strong new evidence changes previous practices and guidelines,” Dr. Joos told this news organization.
The study received no outside funding. The researchers and Dr. Joos had no financial conflicts to disclose.
WASHINGTON –
“Timely imaging is recommended after febrile UTI (fUTI) in young children to identify treatable urologic conditions,” wrote Jonathan Hatoun, MD, of Boston Children’s Hospital, and colleagues in a poster presented at the Pediatric Academic Societies annual meeting.
The American Academy of Pediatrics (AAP) currently recommends renal-bladder ultrasound (RBUS) after fUTI with voiding cystourethrogram (VCUG) after abnormal RBUS or second fUTI, but data on clinician adherence to these recommendations are limited, the researchers said.
To characterize practice patterns regarding fUTI, the researchers reviewed data from children younger than 24 months of age with fUTI who were treated at a primary care network in Massachusetts in 2019. The definition of fUTI was temperature of 38° C or higher, positive urinalysis, and more than 50,000 CFU on urine culture. The median age of the patients was 9 months; 84% were female.
In a multivariate analysis, post-UTI imaging followed the AAP guidelines in 82 cases (69.5%). The main reasons for nonadherence were lack of RBUS in 21 patients, VCUG despite normal RBUS in 9 patients, no VCUG after abnormal RBUS in 4 patients, and no VCUG after a second fUTI in 2 patients.
Overall, nonadherence was a result of not ordering a recommended study in 23% of cases (errors of omission) and ordering an unnecessary study in 8% of cases (errors of commission).
Commercial insurance, larger number of providers in practice, and younger provider age were significant independent predictors of adherence (odds ratios 2.82, 1.38, and 0.96, respectively).
The findings were limited by the use of data from a single center; however, the results suggest that targeted training may improve guideline adherence, the researchers wrote. Additional research and quality improvement studies are needed to understand and address the impact of insurance on guideline adherence for imaging after febrile UTIs, they noted.
Provider education is essential to continued quality of care
When it comes to febrile UTIs, “it is important to stay focused on the quality of care being provided, as opposed to the usual benchmark of quantity of care,” Tim Joos, MD, a Seattle-based clinician with a combination internal medicine/pediatrics practice, said in an interview.
“This is a very simple but interesting study on provider compliance with practice guidelines,” said Dr. Joos, who was not involved in the study. “I was surprised that the providers did so well in ordering the correct imaging in 70% of the cases,” he said.
Of particular interest, Dr. Joos noted, was that “the authors also showed that older providers and those working in smaller practices are less likely to comply with this particular imaging guideline. This can be summed up as the ‘I didn’t know the guideline’ effect.”
To improve quality of care, “more research and effort should be directed at updating providers when strong new evidence changes previous practices and guidelines,” Dr. Joos told this news organization.
The study received no outside funding. The researchers and Dr. Joos had no financial conflicts to disclose.
AT PAS 2023
Four profiles help identify kids at risk for suicide
The profiles were developed from their study of children and adolescents aged 5-18 years who had been admitted with a neuropsychiatric event to two children’s hospitals.
The researchers used Bayesian regression to identify the profiles developed from 32 covariates: age, sex, and 30 mental health diagnostic groups from April 2016 to March 2020. The profiles include low-, moderate-, high- and very-high-risk categories.
The study, led by Mert Sekmen with the division of hospital medicine at Monroe Carell Jr. Children’s Hospital, and a student at Vanderbilt University Medical Center in Nashville, Tenn., included 1,098 children, average age 14. Of those, 406 (37%) were diagnosed with a self-harm event.
Traditionally, single diagnoses have been linked with risk of self-harm, independent of other comorbidities, but this study gauges risk for a set of diagnoses.
Findings were published online in Pediatrics.
The risk groups were described as follows:
- Low risk. (45% of the study population; median risk of 0.04 (interquartile range, 0.03-0.04; odds ratio, 0.08). The group included children aged 5-9 years with a non–mental health diagnosis, and without mood, behavioral, psychotic, developmental, trauma, or substance-related disorders.
- Moderate risk. (8% of the study group). This group had the same risk as the baseline risk for the entire cohort (37%) and served as the reference group, with a median risk of 0.30 (IQR, 0.27-0.33). This profile was characterized by several mood disorders and behavioral disorders but without depressive disorders.
- High risk. (36%) This group had an average risk of 0.69 (IQR, 0.67-0.71; OR, 5.09). This profile included female adolescents ages 14-17 with depression and anxiety in conjunction with substance- and trauma-related disorders. Personality and eating disorders were significant in this group. Importantly, the authors wrote, the high-risk group did not include behavioral and developmental disorders.
- Very high risk. (11%) The very-high-risk profile had the highest average risk of 0.79 (IQR, 0.73-0.79; OR, 7.21) and included male children aged 10-13. This profile, like the high-risk profile, included anxiety and depressive disorders. The very-high-risk profile differed from the high-risk with its inclusion of bipolar disorder; attention-deficit/hyperactivity disorder; and trauma-related and developmental disorders such as autism spectrum disorder or intellectual disability, along with conduct disorders. Neither the high- nor the very-high-risk profiles included a concurrent non–mental health diagnosis.
Differences by sex
The authors explained some of the differences by sex. They noted that in a study of children aged 5-11, deaths by suicide were more prevalent among boys. A mental health diagnosis was identified in 31%, the most common being ADHD, depression, and other unspecified co-occurring disorders.
“The very-high-risk group also reflects a concerning rise in death by suicide among (males) aged 10-13, who have seen rates nearly triple from 2007 to 2017,” the authors wrote.
The authors pointed out that, although incidence of anxiety and depressive disorders between male and female children is much the same before adolescence, “female adolescents are twice as likely to be diagnosed with either disorder during adolescence. Girls also have higher rates of suicidal ideation and attempts after puberty.”
Eating disorders were also included in the high-risk profile. A study showed that emergency department visits for adolescent girls attempting suicide were 51% higher from February to March 2021, compared with the same period in the pre-COVID-19 year 2019.
Jason Lewis, PhD, psychologist and section director of mood, anxiety and trauma disorders in the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia, who was not part of the research team, said the “constellations of risk factors put into acuity levels” helps to better project risk than knowing the risk associated with a particular diagnosis.
Gap closing between young children, adolescents
Dr. Lewis said he was surprised by the young age of 10-13 among the boys in the highest-risk category. That speaks to the differences from standard thinking this paper points out, he said. “Generally, we think about adolescents as being at the highest risk of suicide death and suicidal behavior,” he said.
Dr. Lewis said it’s important to note that the authors acknowledge these profiles are not static. He gave an example that the rate of suicide deaths among females is rising.
“As things like that change, some of these risk profiles will change as well.”
Dr. Lewis said the profiles may be especially helpful to medical providers in emergency departments or those making discharge decisions who don’t have an ongoing relationship with a patient.
The information could also help educators and lay people, “think about suicide in the youth population in ways we don’t normally think about it,” Dr. Lewis said.
Covariates considered for profiles were determined through expert consensus between pediatric psychiatrists, general pediatricians, pediatric hospitalists, pediatric complex care physicians, and pediatric pharmacoepidemiologists.
Age was broken into three groups: 5-9 years, 10-13 years, and 14-17 years based on Centers for Disease Control and Prevention reporting and previous studies that showed significant increases in suicide rates in these age-based subgroups.
Results are preliminary
The authors note that the profiles were developed using data from 1,000 children with neuropsychiatric complaints at two academic children’s hospitals and are thus preliminary.
“Future studies should focus on validating these risk profiles in a larger, more heterogeneous population of children and adolescents,” the authors write.
They also acknowledge that they were not able to include factors such as medication use, previous suicidal behavior, and family and social support, which also factor into risk.
The study authors and Dr. Lewis report no relevant financial relationships.
The profiles were developed from their study of children and adolescents aged 5-18 years who had been admitted with a neuropsychiatric event to two children’s hospitals.
The researchers used Bayesian regression to identify the profiles developed from 32 covariates: age, sex, and 30 mental health diagnostic groups from April 2016 to March 2020. The profiles include low-, moderate-, high- and very-high-risk categories.
The study, led by Mert Sekmen with the division of hospital medicine at Monroe Carell Jr. Children’s Hospital, and a student at Vanderbilt University Medical Center in Nashville, Tenn., included 1,098 children, average age 14. Of those, 406 (37%) were diagnosed with a self-harm event.
Traditionally, single diagnoses have been linked with risk of self-harm, independent of other comorbidities, but this study gauges risk for a set of diagnoses.
Findings were published online in Pediatrics.
The risk groups were described as follows:
- Low risk. (45% of the study population; median risk of 0.04 (interquartile range, 0.03-0.04; odds ratio, 0.08). The group included children aged 5-9 years with a non–mental health diagnosis, and without mood, behavioral, psychotic, developmental, trauma, or substance-related disorders.
- Moderate risk. (8% of the study group). This group had the same risk as the baseline risk for the entire cohort (37%) and served as the reference group, with a median risk of 0.30 (IQR, 0.27-0.33). This profile was characterized by several mood disorders and behavioral disorders but without depressive disorders.
- High risk. (36%) This group had an average risk of 0.69 (IQR, 0.67-0.71; OR, 5.09). This profile included female adolescents ages 14-17 with depression and anxiety in conjunction with substance- and trauma-related disorders. Personality and eating disorders were significant in this group. Importantly, the authors wrote, the high-risk group did not include behavioral and developmental disorders.
- Very high risk. (11%) The very-high-risk profile had the highest average risk of 0.79 (IQR, 0.73-0.79; OR, 7.21) and included male children aged 10-13. This profile, like the high-risk profile, included anxiety and depressive disorders. The very-high-risk profile differed from the high-risk with its inclusion of bipolar disorder; attention-deficit/hyperactivity disorder; and trauma-related and developmental disorders such as autism spectrum disorder or intellectual disability, along with conduct disorders. Neither the high- nor the very-high-risk profiles included a concurrent non–mental health diagnosis.
Differences by sex
The authors explained some of the differences by sex. They noted that in a study of children aged 5-11, deaths by suicide were more prevalent among boys. A mental health diagnosis was identified in 31%, the most common being ADHD, depression, and other unspecified co-occurring disorders.
“The very-high-risk group also reflects a concerning rise in death by suicide among (males) aged 10-13, who have seen rates nearly triple from 2007 to 2017,” the authors wrote.
The authors pointed out that, although incidence of anxiety and depressive disorders between male and female children is much the same before adolescence, “female adolescents are twice as likely to be diagnosed with either disorder during adolescence. Girls also have higher rates of suicidal ideation and attempts after puberty.”
Eating disorders were also included in the high-risk profile. A study showed that emergency department visits for adolescent girls attempting suicide were 51% higher from February to March 2021, compared with the same period in the pre-COVID-19 year 2019.
Jason Lewis, PhD, psychologist and section director of mood, anxiety and trauma disorders in the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia, who was not part of the research team, said the “constellations of risk factors put into acuity levels” helps to better project risk than knowing the risk associated with a particular diagnosis.
Gap closing between young children, adolescents
Dr. Lewis said he was surprised by the young age of 10-13 among the boys in the highest-risk category. That speaks to the differences from standard thinking this paper points out, he said. “Generally, we think about adolescents as being at the highest risk of suicide death and suicidal behavior,” he said.
Dr. Lewis said it’s important to note that the authors acknowledge these profiles are not static. He gave an example that the rate of suicide deaths among females is rising.
“As things like that change, some of these risk profiles will change as well.”
Dr. Lewis said the profiles may be especially helpful to medical providers in emergency departments or those making discharge decisions who don’t have an ongoing relationship with a patient.
The information could also help educators and lay people, “think about suicide in the youth population in ways we don’t normally think about it,” Dr. Lewis said.
Covariates considered for profiles were determined through expert consensus between pediatric psychiatrists, general pediatricians, pediatric hospitalists, pediatric complex care physicians, and pediatric pharmacoepidemiologists.
Age was broken into three groups: 5-9 years, 10-13 years, and 14-17 years based on Centers for Disease Control and Prevention reporting and previous studies that showed significant increases in suicide rates in these age-based subgroups.
Results are preliminary
The authors note that the profiles were developed using data from 1,000 children with neuropsychiatric complaints at two academic children’s hospitals and are thus preliminary.
“Future studies should focus on validating these risk profiles in a larger, more heterogeneous population of children and adolescents,” the authors write.
They also acknowledge that they were not able to include factors such as medication use, previous suicidal behavior, and family and social support, which also factor into risk.
The study authors and Dr. Lewis report no relevant financial relationships.
The profiles were developed from their study of children and adolescents aged 5-18 years who had been admitted with a neuropsychiatric event to two children’s hospitals.
The researchers used Bayesian regression to identify the profiles developed from 32 covariates: age, sex, and 30 mental health diagnostic groups from April 2016 to March 2020. The profiles include low-, moderate-, high- and very-high-risk categories.
The study, led by Mert Sekmen with the division of hospital medicine at Monroe Carell Jr. Children’s Hospital, and a student at Vanderbilt University Medical Center in Nashville, Tenn., included 1,098 children, average age 14. Of those, 406 (37%) were diagnosed with a self-harm event.
Traditionally, single diagnoses have been linked with risk of self-harm, independent of other comorbidities, but this study gauges risk for a set of diagnoses.
Findings were published online in Pediatrics.
The risk groups were described as follows:
- Low risk. (45% of the study population; median risk of 0.04 (interquartile range, 0.03-0.04; odds ratio, 0.08). The group included children aged 5-9 years with a non–mental health diagnosis, and without mood, behavioral, psychotic, developmental, trauma, or substance-related disorders.
- Moderate risk. (8% of the study group). This group had the same risk as the baseline risk for the entire cohort (37%) and served as the reference group, with a median risk of 0.30 (IQR, 0.27-0.33). This profile was characterized by several mood disorders and behavioral disorders but without depressive disorders.
- High risk. (36%) This group had an average risk of 0.69 (IQR, 0.67-0.71; OR, 5.09). This profile included female adolescents ages 14-17 with depression and anxiety in conjunction with substance- and trauma-related disorders. Personality and eating disorders were significant in this group. Importantly, the authors wrote, the high-risk group did not include behavioral and developmental disorders.
- Very high risk. (11%) The very-high-risk profile had the highest average risk of 0.79 (IQR, 0.73-0.79; OR, 7.21) and included male children aged 10-13. This profile, like the high-risk profile, included anxiety and depressive disorders. The very-high-risk profile differed from the high-risk with its inclusion of bipolar disorder; attention-deficit/hyperactivity disorder; and trauma-related and developmental disorders such as autism spectrum disorder or intellectual disability, along with conduct disorders. Neither the high- nor the very-high-risk profiles included a concurrent non–mental health diagnosis.
Differences by sex
The authors explained some of the differences by sex. They noted that in a study of children aged 5-11, deaths by suicide were more prevalent among boys. A mental health diagnosis was identified in 31%, the most common being ADHD, depression, and other unspecified co-occurring disorders.
“The very-high-risk group also reflects a concerning rise in death by suicide among (males) aged 10-13, who have seen rates nearly triple from 2007 to 2017,” the authors wrote.
The authors pointed out that, although incidence of anxiety and depressive disorders between male and female children is much the same before adolescence, “female adolescents are twice as likely to be diagnosed with either disorder during adolescence. Girls also have higher rates of suicidal ideation and attempts after puberty.”
Eating disorders were also included in the high-risk profile. A study showed that emergency department visits for adolescent girls attempting suicide were 51% higher from February to March 2021, compared with the same period in the pre-COVID-19 year 2019.
Jason Lewis, PhD, psychologist and section director of mood, anxiety and trauma disorders in the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia, who was not part of the research team, said the “constellations of risk factors put into acuity levels” helps to better project risk than knowing the risk associated with a particular diagnosis.
Gap closing between young children, adolescents
Dr. Lewis said he was surprised by the young age of 10-13 among the boys in the highest-risk category. That speaks to the differences from standard thinking this paper points out, he said. “Generally, we think about adolescents as being at the highest risk of suicide death and suicidal behavior,” he said.
Dr. Lewis said it’s important to note that the authors acknowledge these profiles are not static. He gave an example that the rate of suicide deaths among females is rising.
“As things like that change, some of these risk profiles will change as well.”
Dr. Lewis said the profiles may be especially helpful to medical providers in emergency departments or those making discharge decisions who don’t have an ongoing relationship with a patient.
The information could also help educators and lay people, “think about suicide in the youth population in ways we don’t normally think about it,” Dr. Lewis said.
Covariates considered for profiles were determined through expert consensus between pediatric psychiatrists, general pediatricians, pediatric hospitalists, pediatric complex care physicians, and pediatric pharmacoepidemiologists.
Age was broken into three groups: 5-9 years, 10-13 years, and 14-17 years based on Centers for Disease Control and Prevention reporting and previous studies that showed significant increases in suicide rates in these age-based subgroups.
Results are preliminary
The authors note that the profiles were developed using data from 1,000 children with neuropsychiatric complaints at two academic children’s hospitals and are thus preliminary.
“Future studies should focus on validating these risk profiles in a larger, more heterogeneous population of children and adolescents,” the authors write.
They also acknowledge that they were not able to include factors such as medication use, previous suicidal behavior, and family and social support, which also factor into risk.
The study authors and Dr. Lewis report no relevant financial relationships.
FROM PEDIATRICS
Researchers seek to understand post-COVID autoimmune disease risk
Since the COVID-19 pandemic started more than 3 years ago, the longer-lasting effects of SARS-CoV-2 infection have continued to reveal themselves. Approximately 28% of Americans report having ever experienced post-COVID conditions, such as brain fog, postexertional malaise, and joint pain, and 11% say they are still experiencing these long-term effects. Now, new research is showing that people who have had COVID are more likely to newly develop an autoimmune disease. Exactly why this is happening is less clear, experts say.
Two preprint studies and one study published in a peer-reviewed journal provide strong evidence that patients who have been infected with SARS-CoV-2 are at elevated risk of developing an autoimmune disease. The studies retrospectively reviewed medical records from three countries and compared the incidence of new-onset autoimmune disease among patients who had polymerase chain reaction–confirmed COVID-19 and those who had never been diagnosed with the virus.
A study analyzing the health records of 3.8 million U.S. patients – more than 888,460 with confirmed COVID-19 – found that the COVID-19 group was two to three times as likely to develop various autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. A U.K. preprint study that included more than 458,000 people with confirmed COVID found that those who had previously been infected with SARS-CoV-2 were 22% more likely to develop an autoimmune disease compared with the control group. In this cohort, the diseases most strongly associated with COVID-19 were type 1 diabetes, inflammatory bowel disease, and psoriasis. A preprint study from German researchers found that COVID-19 patients were almost 43% more likely to develop an autoimmune disease, compared with those who had never been infected. COVID-19 was most strongly linked to vasculitis.
These large studies are telling us, “Yes, this link is there, so we have to accept it,” Sonia Sharma, PhD, of the Center for Autoimmunity and Inflammation at the La Jolla (Calif.) Institute for Immunology, told this news organization. But this is not the first time that autoimmune diseases have been linked to previous infections.
Researchers have known for decades that Epstein-Barr virus infection is linked to several autoimmune diseases, including systemic lupus erythematosus, multiple sclerosis, and rheumatoid arthritis. More recent research suggests the virus may activate certain genes associated with these immune disorders. Hepatitis C virus can induce cryoglobulinemia, and infection with cytomegalovirus has been implicated in several autoimmune diseases. Bacterial infections have also been linked to autoimmunity, such as group A streptococcus and rheumatic fever, as well as salmonella and reactive arthritis, to name only a few.
“In a way, this isn’t necessarily a new concept to physicians, particularly rheumatologists,” said Jeffrey A. Sparks, MD, a rheumatologist at Brigham and Women’s Hospital in Boston. “There’s a fine line between appropriately clearing an infection and the body overreacting and setting off a cascade where the immune system is chronically overactive that can manifest as an autoimmune disease,” he told this news organization.
A dysregulated response to infection
It takes the immune system a week or two to develop antigen-specific antibodies to a new pathogen. But for patients with serious infections – in this instance, COVID-19 – that’s time they don’t have. Therefore, the immune system has an alternative pathway, called extrafollicular activation, that creates fast-acting antibodies, explained Matthew Woodruff, PhD, an instructor of immunology and rheumatology at Emory University, Atlanta.
The trade-off is that these antibodies are not as specific and can target the body’s own tissues. This dysregulation of antibody selection is generally short lived and fades when more targeted antibodies are produced and take over, but in some cases, this process can lead to high levels of self-targeting antibodies that can harm the body’s organs and tissues. Research also suggests that for patients who experience long COVID, the same autoantibodies that drive the initial immune response are detectable in the body months after infection, though it is not known whether these lingering immune cells cause these longer-lasting symptoms.
“If you have a virus that causes hyperinflammation plus organ damage, that is a recipe for disaster,” Dr. Sharma said. “It’s a recipe for autoantibodies and autoreactive T cells that down the road can attack the body’s own tissues, especially in people whose immune system is trained in such a way to cause self-reactivity,” she added.
This hyperinflammation can result in rare but serious complications, such as multisystem inflammatory syndrome in children and adults, which can occur 2-6 weeks after SARS-CoV-2 infection. But even in these patients with severe illness, organ-specific complications tend to resolve in 6 months with “no significant sequelae 1 year after diagnosis,” according to the Centers for Disease Control and Prevention. And while long COVID can last for a year or longer, data suggest that symptoms do eventually resolve for most people. What is not clear is why acute autoimmunity triggered by COVID-19 can become a chronic condition in certain patients.
Predisposition to autoimmunity
P. J. Utz, MD, PhD, professor of immunology and rheumatology at Stanford (Calif.) University, said that people who develop autoimmune disease after SARS-CoV-2 infection may have already been predisposed toward autoimmunity. Especially for autoimmune diseases such as type 1 diabetes and lupus, autoantibodies can appear and circulate in the body for more than a decade in some people before they present with any clinical symptoms. “Their immune system is primed such that if they get infected with something – or they have some other environmental trigger that maybe we don’t know about yet – that is enough to then push them over the edge so that they get full-blown autoimmunity,” he said. What is not known is whether these patients’ conditions would have advanced to true clinical disease had they not been infected, he said.
He also noted that the presence of autoantibodies does not necessarily mean someone has autoimmune disease; healthy people can also have autoantibodies, and everyone develops them with age. “My advice would be, ‘Don’t lose sleep over this,’ “ he said.
Dr. Sparks agreed that while these retrospective studies did show an elevated risk of autoimmune disease after COVID-19, that risk appears to be relatively small. “As a practicing rheumatologist, we aren’t seeing a stampede of patients with new-onset rheumatic diseases,” he said. “It’s not like we’re overwhelmed with autoimmune patients, even though almost everyone’s had COVID. So, if there is a risk, it’s very modest.”
Dr. Sparks is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the R. Bruce and Joan M. Mickey Research Scholar Fund, and the Llura Gund Award for Rheumatoid Arthritis Research and Care. Dr. Utz receives research funding from Pfizer. Dr. Sharma and Dr. Woodruff have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Since the COVID-19 pandemic started more than 3 years ago, the longer-lasting effects of SARS-CoV-2 infection have continued to reveal themselves. Approximately 28% of Americans report having ever experienced post-COVID conditions, such as brain fog, postexertional malaise, and joint pain, and 11% say they are still experiencing these long-term effects. Now, new research is showing that people who have had COVID are more likely to newly develop an autoimmune disease. Exactly why this is happening is less clear, experts say.
Two preprint studies and one study published in a peer-reviewed journal provide strong evidence that patients who have been infected with SARS-CoV-2 are at elevated risk of developing an autoimmune disease. The studies retrospectively reviewed medical records from three countries and compared the incidence of new-onset autoimmune disease among patients who had polymerase chain reaction–confirmed COVID-19 and those who had never been diagnosed with the virus.
A study analyzing the health records of 3.8 million U.S. patients – more than 888,460 with confirmed COVID-19 – found that the COVID-19 group was two to three times as likely to develop various autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. A U.K. preprint study that included more than 458,000 people with confirmed COVID found that those who had previously been infected with SARS-CoV-2 were 22% more likely to develop an autoimmune disease compared with the control group. In this cohort, the diseases most strongly associated with COVID-19 were type 1 diabetes, inflammatory bowel disease, and psoriasis. A preprint study from German researchers found that COVID-19 patients were almost 43% more likely to develop an autoimmune disease, compared with those who had never been infected. COVID-19 was most strongly linked to vasculitis.
These large studies are telling us, “Yes, this link is there, so we have to accept it,” Sonia Sharma, PhD, of the Center for Autoimmunity and Inflammation at the La Jolla (Calif.) Institute for Immunology, told this news organization. But this is not the first time that autoimmune diseases have been linked to previous infections.
Researchers have known for decades that Epstein-Barr virus infection is linked to several autoimmune diseases, including systemic lupus erythematosus, multiple sclerosis, and rheumatoid arthritis. More recent research suggests the virus may activate certain genes associated with these immune disorders. Hepatitis C virus can induce cryoglobulinemia, and infection with cytomegalovirus has been implicated in several autoimmune diseases. Bacterial infections have also been linked to autoimmunity, such as group A streptococcus and rheumatic fever, as well as salmonella and reactive arthritis, to name only a few.
“In a way, this isn’t necessarily a new concept to physicians, particularly rheumatologists,” said Jeffrey A. Sparks, MD, a rheumatologist at Brigham and Women’s Hospital in Boston. “There’s a fine line between appropriately clearing an infection and the body overreacting and setting off a cascade where the immune system is chronically overactive that can manifest as an autoimmune disease,” he told this news organization.
A dysregulated response to infection
It takes the immune system a week or two to develop antigen-specific antibodies to a new pathogen. But for patients with serious infections – in this instance, COVID-19 – that’s time they don’t have. Therefore, the immune system has an alternative pathway, called extrafollicular activation, that creates fast-acting antibodies, explained Matthew Woodruff, PhD, an instructor of immunology and rheumatology at Emory University, Atlanta.
The trade-off is that these antibodies are not as specific and can target the body’s own tissues. This dysregulation of antibody selection is generally short lived and fades when more targeted antibodies are produced and take over, but in some cases, this process can lead to high levels of self-targeting antibodies that can harm the body’s organs and tissues. Research also suggests that for patients who experience long COVID, the same autoantibodies that drive the initial immune response are detectable in the body months after infection, though it is not known whether these lingering immune cells cause these longer-lasting symptoms.
“If you have a virus that causes hyperinflammation plus organ damage, that is a recipe for disaster,” Dr. Sharma said. “It’s a recipe for autoantibodies and autoreactive T cells that down the road can attack the body’s own tissues, especially in people whose immune system is trained in such a way to cause self-reactivity,” she added.
This hyperinflammation can result in rare but serious complications, such as multisystem inflammatory syndrome in children and adults, which can occur 2-6 weeks after SARS-CoV-2 infection. But even in these patients with severe illness, organ-specific complications tend to resolve in 6 months with “no significant sequelae 1 year after diagnosis,” according to the Centers for Disease Control and Prevention. And while long COVID can last for a year or longer, data suggest that symptoms do eventually resolve for most people. What is not clear is why acute autoimmunity triggered by COVID-19 can become a chronic condition in certain patients.
Predisposition to autoimmunity
P. J. Utz, MD, PhD, professor of immunology and rheumatology at Stanford (Calif.) University, said that people who develop autoimmune disease after SARS-CoV-2 infection may have already been predisposed toward autoimmunity. Especially for autoimmune diseases such as type 1 diabetes and lupus, autoantibodies can appear and circulate in the body for more than a decade in some people before they present with any clinical symptoms. “Their immune system is primed such that if they get infected with something – or they have some other environmental trigger that maybe we don’t know about yet – that is enough to then push them over the edge so that they get full-blown autoimmunity,” he said. What is not known is whether these patients’ conditions would have advanced to true clinical disease had they not been infected, he said.
He also noted that the presence of autoantibodies does not necessarily mean someone has autoimmune disease; healthy people can also have autoantibodies, and everyone develops them with age. “My advice would be, ‘Don’t lose sleep over this,’ “ he said.
Dr. Sparks agreed that while these retrospective studies did show an elevated risk of autoimmune disease after COVID-19, that risk appears to be relatively small. “As a practicing rheumatologist, we aren’t seeing a stampede of patients with new-onset rheumatic diseases,” he said. “It’s not like we’re overwhelmed with autoimmune patients, even though almost everyone’s had COVID. So, if there is a risk, it’s very modest.”
Dr. Sparks is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the R. Bruce and Joan M. Mickey Research Scholar Fund, and the Llura Gund Award for Rheumatoid Arthritis Research and Care. Dr. Utz receives research funding from Pfizer. Dr. Sharma and Dr. Woodruff have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Since the COVID-19 pandemic started more than 3 years ago, the longer-lasting effects of SARS-CoV-2 infection have continued to reveal themselves. Approximately 28% of Americans report having ever experienced post-COVID conditions, such as brain fog, postexertional malaise, and joint pain, and 11% say they are still experiencing these long-term effects. Now, new research is showing that people who have had COVID are more likely to newly develop an autoimmune disease. Exactly why this is happening is less clear, experts say.
Two preprint studies and one study published in a peer-reviewed journal provide strong evidence that patients who have been infected with SARS-CoV-2 are at elevated risk of developing an autoimmune disease. The studies retrospectively reviewed medical records from three countries and compared the incidence of new-onset autoimmune disease among patients who had polymerase chain reaction–confirmed COVID-19 and those who had never been diagnosed with the virus.
A study analyzing the health records of 3.8 million U.S. patients – more than 888,460 with confirmed COVID-19 – found that the COVID-19 group was two to three times as likely to develop various autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. A U.K. preprint study that included more than 458,000 people with confirmed COVID found that those who had previously been infected with SARS-CoV-2 were 22% more likely to develop an autoimmune disease compared with the control group. In this cohort, the diseases most strongly associated with COVID-19 were type 1 diabetes, inflammatory bowel disease, and psoriasis. A preprint study from German researchers found that COVID-19 patients were almost 43% more likely to develop an autoimmune disease, compared with those who had never been infected. COVID-19 was most strongly linked to vasculitis.
These large studies are telling us, “Yes, this link is there, so we have to accept it,” Sonia Sharma, PhD, of the Center for Autoimmunity and Inflammation at the La Jolla (Calif.) Institute for Immunology, told this news organization. But this is not the first time that autoimmune diseases have been linked to previous infections.
Researchers have known for decades that Epstein-Barr virus infection is linked to several autoimmune diseases, including systemic lupus erythematosus, multiple sclerosis, and rheumatoid arthritis. More recent research suggests the virus may activate certain genes associated with these immune disorders. Hepatitis C virus can induce cryoglobulinemia, and infection with cytomegalovirus has been implicated in several autoimmune diseases. Bacterial infections have also been linked to autoimmunity, such as group A streptococcus and rheumatic fever, as well as salmonella and reactive arthritis, to name only a few.
“In a way, this isn’t necessarily a new concept to physicians, particularly rheumatologists,” said Jeffrey A. Sparks, MD, a rheumatologist at Brigham and Women’s Hospital in Boston. “There’s a fine line between appropriately clearing an infection and the body overreacting and setting off a cascade where the immune system is chronically overactive that can manifest as an autoimmune disease,” he told this news organization.
A dysregulated response to infection
It takes the immune system a week or two to develop antigen-specific antibodies to a new pathogen. But for patients with serious infections – in this instance, COVID-19 – that’s time they don’t have. Therefore, the immune system has an alternative pathway, called extrafollicular activation, that creates fast-acting antibodies, explained Matthew Woodruff, PhD, an instructor of immunology and rheumatology at Emory University, Atlanta.
The trade-off is that these antibodies are not as specific and can target the body’s own tissues. This dysregulation of antibody selection is generally short lived and fades when more targeted antibodies are produced and take over, but in some cases, this process can lead to high levels of self-targeting antibodies that can harm the body’s organs and tissues. Research also suggests that for patients who experience long COVID, the same autoantibodies that drive the initial immune response are detectable in the body months after infection, though it is not known whether these lingering immune cells cause these longer-lasting symptoms.
“If you have a virus that causes hyperinflammation plus organ damage, that is a recipe for disaster,” Dr. Sharma said. “It’s a recipe for autoantibodies and autoreactive T cells that down the road can attack the body’s own tissues, especially in people whose immune system is trained in such a way to cause self-reactivity,” she added.
This hyperinflammation can result in rare but serious complications, such as multisystem inflammatory syndrome in children and adults, which can occur 2-6 weeks after SARS-CoV-2 infection. But even in these patients with severe illness, organ-specific complications tend to resolve in 6 months with “no significant sequelae 1 year after diagnosis,” according to the Centers for Disease Control and Prevention. And while long COVID can last for a year or longer, data suggest that symptoms do eventually resolve for most people. What is not clear is why acute autoimmunity triggered by COVID-19 can become a chronic condition in certain patients.
Predisposition to autoimmunity
P. J. Utz, MD, PhD, professor of immunology and rheumatology at Stanford (Calif.) University, said that people who develop autoimmune disease after SARS-CoV-2 infection may have already been predisposed toward autoimmunity. Especially for autoimmune diseases such as type 1 diabetes and lupus, autoantibodies can appear and circulate in the body for more than a decade in some people before they present with any clinical symptoms. “Their immune system is primed such that if they get infected with something – or they have some other environmental trigger that maybe we don’t know about yet – that is enough to then push them over the edge so that they get full-blown autoimmunity,” he said. What is not known is whether these patients’ conditions would have advanced to true clinical disease had they not been infected, he said.
He also noted that the presence of autoantibodies does not necessarily mean someone has autoimmune disease; healthy people can also have autoantibodies, and everyone develops them with age. “My advice would be, ‘Don’t lose sleep over this,’ “ he said.
Dr. Sparks agreed that while these retrospective studies did show an elevated risk of autoimmune disease after COVID-19, that risk appears to be relatively small. “As a practicing rheumatologist, we aren’t seeing a stampede of patients with new-onset rheumatic diseases,” he said. “It’s not like we’re overwhelmed with autoimmune patients, even though almost everyone’s had COVID. So, if there is a risk, it’s very modest.”
Dr. Sparks is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the R. Bruce and Joan M. Mickey Research Scholar Fund, and the Llura Gund Award for Rheumatoid Arthritis Research and Care. Dr. Utz receives research funding from Pfizer. Dr. Sharma and Dr. Woodruff have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
New hope for adult children with ‘failure to launch’ syndrome
WASHINGTON – , a new pilot study shows.
Known as failure to launch (FTL) syndrome, the criteria for this condition include the absence of a neurodevelopmental, mental, or intellectual condition, difficulty adapting to the challenges of adulthood, and living with or at the expense of parents.
Results suggest that the program benefits families dealing with FTL, said study investigator Uri Berger, PhD, postdoctoral associate, Yale Child Study Center Anxiety and Mood Disorders Program, New Haven, Conn.
“If you encounter parents who are say 50-60 years old who have a child with FTL, you can tell them there’s something they can do; there’s work they can do even if their child is refusing to go to therapy,” he said.
The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
Anxious, isolated
Estimates suggest that there are 3.3 million physically able adults with FTL and that the disorder may be on the rise. These individuals often present with mental health symptoms including anxiety, depression, and suicidality, and tend to be socially isolated.
The investigators noted that intervening is often challenging because individuals with the syndrome are frequently noncompliant with therapy, and currently there is no standard of care.
“The longer you’re isolated, the harder it is getting out of your cocoon, and when these adult children get to the point where they seek help, they’re less likely to comply,” he said. However, he noted, this is not because they are lazy; it’s that they’re “very, very anxious.”
Parents and other family members are also negatively affected. Dr. Berger noted that 15% of parents of a child with FTL equate their caregiver burden with having a family member with a chronic physical illness. “It’s huge; parents go through hell and it’s very hard on them. Many believe it is their fault and they feel a lot of shame.”
Supportive Parenting for Anxious Childhood Emotions (SPACE) is a manualized, parent-based program for childhood anxiety and obsessive-compulsive disorder. It has been tested in clinical trials and found to be noninferior to cognitive behavioral therapy for childhood anxiety.
The research adapted it to treat FTL. SPACE-FTL focuses on reducing parents’ family accommodation (FA), a descriptor for a child’s excessive dependence on their parents to help them avoid anxiety-provoking situations.
The study examined the feasibility, acceptability, and treatment satisfaction and its effect on adult child psychopathology symptoms, parents’ FA, and the paternal burden of caring for adult children.
The study included parents (mean age, 59.46 years; 85% female) of 40 adult children with FTL (mean age, 23.51 years; 20% female) from across the United States.
Parents were randomized to a 13-week wait-list or the SPACE-FTL program, which involves 13-20 therapy sessions, depending on the need. The average number of sessions in the study was 15. The program has five key components:
- Providing information emphasizing FTL as not a character flaw but a problem with anxiety.
- Helping parents identify how they accommodate their child’s behavior, and facilitating an environment that encourages independence.
- Getting parents to show acceptance and confidence in their child who’s trying to overcome anxiety when, for example, they seek employment, instead of being overprotective and demanding.
- Focusing on change nonconfrontationally.
- Involving other family, community members, and professionals who can support the parent, child, or both.
The recruitment, treatment sessions, and assessments were all done online. Most participants rated the intervention as highly satisfactory on the Client Satisfaction Questionnaire (CSQ-8; mean score, 27.7 out of a maximum of 32). About 60% of the offspring no longer met full criteria for FTL (P < .001; Cohen’s D = 1.76).
All children of the wait-listed parents still met criteria for FTL.
FTL symptoms decreased significantly in the offspring of the intervention group, as seen in both in the Adult Entitled Dependence Scale (AED; P < .05; Cohen’s D = 0.84); and the Adaptive Behaviors Scale (ABS; P < .05; Cohen’s D = 0.70).
There was no change in anxiety as assessed by the Adult Behavior Checklist (ABCL). But Dr. Berger noted that child anxiety is difficult to assess through parental report.
“This population is self-isolating and parents sometimes don’t know what’s going on,” and ABCL measures may not be “as sensitive as we would have liked them to be,” Dr. Berger said.
Parental burden was significantly decreased as measured by the Zarit Burden Interview (ZBI; P < .05; Cohen’s D = 0.70). In addition, family accommodation decreased significantly as determined by the Family Accommodation Scale–Anxiety (FASA; P < .05; Cohen’s D = 0.70).
Innovative work
In a comment, Jonathan E. Alpert, MD, PhD, chair, department of psychiatry and behavioral sciences, and professor of psychiatry, neuroscience, and pediatrics, Albert Einstein College of Medicine, New York, described the program as “innovative.”
He noted that the SPACE-FTL approach provides parents with education and skills to reduce behaviors that reinforce their child’s avoidance of independent activities. Such behaviors “may inadvertently contribute to the adult child remaining stuck,” he said.
“Through its involvement of parents and use of a structured approach, SPACE-FTL is a very interesting step toward more evidence-based therapies.”
However, he noted that the number of study participants is still “very low” and further work is needed to better characterize this condition and develop effective therapies.
He noted that parents of adult children with FTL should not be judged or blamed. “They have been living with a worrisome problem for years and are simply doing their best to cope as any of us would do.”
In addition, he noted that some adult children aren’t capable of launching because of a serious mental illness or substance use disorder that needs treatment.
It’s unclear just how many adult children have FTL, as the condition lacks formal, agreed-upon clinical and research criteria and a reliable evidence base for treatment, Dr. Alpert said.
“Whatever the actual numbers of FTL, my anecdotal clinical experience suggests that it is a very common problem which is understudied.”
He added that the definitions of FTL should include cultural context. In some groups, it’s quite normal for adults in their 20s, 30s, or even older to live with their parents, Dr. Alpert said.
Dr. Berger and Dr. Albert report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
WASHINGTON – , a new pilot study shows.
Known as failure to launch (FTL) syndrome, the criteria for this condition include the absence of a neurodevelopmental, mental, or intellectual condition, difficulty adapting to the challenges of adulthood, and living with or at the expense of parents.
Results suggest that the program benefits families dealing with FTL, said study investigator Uri Berger, PhD, postdoctoral associate, Yale Child Study Center Anxiety and Mood Disorders Program, New Haven, Conn.
“If you encounter parents who are say 50-60 years old who have a child with FTL, you can tell them there’s something they can do; there’s work they can do even if their child is refusing to go to therapy,” he said.
The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
Anxious, isolated
Estimates suggest that there are 3.3 million physically able adults with FTL and that the disorder may be on the rise. These individuals often present with mental health symptoms including anxiety, depression, and suicidality, and tend to be socially isolated.
The investigators noted that intervening is often challenging because individuals with the syndrome are frequently noncompliant with therapy, and currently there is no standard of care.
“The longer you’re isolated, the harder it is getting out of your cocoon, and when these adult children get to the point where they seek help, they’re less likely to comply,” he said. However, he noted, this is not because they are lazy; it’s that they’re “very, very anxious.”
Parents and other family members are also negatively affected. Dr. Berger noted that 15% of parents of a child with FTL equate their caregiver burden with having a family member with a chronic physical illness. “It’s huge; parents go through hell and it’s very hard on them. Many believe it is their fault and they feel a lot of shame.”
Supportive Parenting for Anxious Childhood Emotions (SPACE) is a manualized, parent-based program for childhood anxiety and obsessive-compulsive disorder. It has been tested in clinical trials and found to be noninferior to cognitive behavioral therapy for childhood anxiety.
The research adapted it to treat FTL. SPACE-FTL focuses on reducing parents’ family accommodation (FA), a descriptor for a child’s excessive dependence on their parents to help them avoid anxiety-provoking situations.
The study examined the feasibility, acceptability, and treatment satisfaction and its effect on adult child psychopathology symptoms, parents’ FA, and the paternal burden of caring for adult children.
The study included parents (mean age, 59.46 years; 85% female) of 40 adult children with FTL (mean age, 23.51 years; 20% female) from across the United States.
Parents were randomized to a 13-week wait-list or the SPACE-FTL program, which involves 13-20 therapy sessions, depending on the need. The average number of sessions in the study was 15. The program has five key components:
- Providing information emphasizing FTL as not a character flaw but a problem with anxiety.
- Helping parents identify how they accommodate their child’s behavior, and facilitating an environment that encourages independence.
- Getting parents to show acceptance and confidence in their child who’s trying to overcome anxiety when, for example, they seek employment, instead of being overprotective and demanding.
- Focusing on change nonconfrontationally.
- Involving other family, community members, and professionals who can support the parent, child, or both.
The recruitment, treatment sessions, and assessments were all done online. Most participants rated the intervention as highly satisfactory on the Client Satisfaction Questionnaire (CSQ-8; mean score, 27.7 out of a maximum of 32). About 60% of the offspring no longer met full criteria for FTL (P < .001; Cohen’s D = 1.76).
All children of the wait-listed parents still met criteria for FTL.
FTL symptoms decreased significantly in the offspring of the intervention group, as seen in both in the Adult Entitled Dependence Scale (AED; P < .05; Cohen’s D = 0.84); and the Adaptive Behaviors Scale (ABS; P < .05; Cohen’s D = 0.70).
There was no change in anxiety as assessed by the Adult Behavior Checklist (ABCL). But Dr. Berger noted that child anxiety is difficult to assess through parental report.
“This population is self-isolating and parents sometimes don’t know what’s going on,” and ABCL measures may not be “as sensitive as we would have liked them to be,” Dr. Berger said.
Parental burden was significantly decreased as measured by the Zarit Burden Interview (ZBI; P < .05; Cohen’s D = 0.70). In addition, family accommodation decreased significantly as determined by the Family Accommodation Scale–Anxiety (FASA; P < .05; Cohen’s D = 0.70).
Innovative work
In a comment, Jonathan E. Alpert, MD, PhD, chair, department of psychiatry and behavioral sciences, and professor of psychiatry, neuroscience, and pediatrics, Albert Einstein College of Medicine, New York, described the program as “innovative.”
He noted that the SPACE-FTL approach provides parents with education and skills to reduce behaviors that reinforce their child’s avoidance of independent activities. Such behaviors “may inadvertently contribute to the adult child remaining stuck,” he said.
“Through its involvement of parents and use of a structured approach, SPACE-FTL is a very interesting step toward more evidence-based therapies.”
However, he noted that the number of study participants is still “very low” and further work is needed to better characterize this condition and develop effective therapies.
He noted that parents of adult children with FTL should not be judged or blamed. “They have been living with a worrisome problem for years and are simply doing their best to cope as any of us would do.”
In addition, he noted that some adult children aren’t capable of launching because of a serious mental illness or substance use disorder that needs treatment.
It’s unclear just how many adult children have FTL, as the condition lacks formal, agreed-upon clinical and research criteria and a reliable evidence base for treatment, Dr. Alpert said.
“Whatever the actual numbers of FTL, my anecdotal clinical experience suggests that it is a very common problem which is understudied.”
He added that the definitions of FTL should include cultural context. In some groups, it’s quite normal for adults in their 20s, 30s, or even older to live with their parents, Dr. Alpert said.
Dr. Berger and Dr. Albert report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
WASHINGTON – , a new pilot study shows.
Known as failure to launch (FTL) syndrome, the criteria for this condition include the absence of a neurodevelopmental, mental, or intellectual condition, difficulty adapting to the challenges of adulthood, and living with or at the expense of parents.
Results suggest that the program benefits families dealing with FTL, said study investigator Uri Berger, PhD, postdoctoral associate, Yale Child Study Center Anxiety and Mood Disorders Program, New Haven, Conn.
“If you encounter parents who are say 50-60 years old who have a child with FTL, you can tell them there’s something they can do; there’s work they can do even if their child is refusing to go to therapy,” he said.
The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
Anxious, isolated
Estimates suggest that there are 3.3 million physically able adults with FTL and that the disorder may be on the rise. These individuals often present with mental health symptoms including anxiety, depression, and suicidality, and tend to be socially isolated.
The investigators noted that intervening is often challenging because individuals with the syndrome are frequently noncompliant with therapy, and currently there is no standard of care.
“The longer you’re isolated, the harder it is getting out of your cocoon, and when these adult children get to the point where they seek help, they’re less likely to comply,” he said. However, he noted, this is not because they are lazy; it’s that they’re “very, very anxious.”
Parents and other family members are also negatively affected. Dr. Berger noted that 15% of parents of a child with FTL equate their caregiver burden with having a family member with a chronic physical illness. “It’s huge; parents go through hell and it’s very hard on them. Many believe it is their fault and they feel a lot of shame.”
Supportive Parenting for Anxious Childhood Emotions (SPACE) is a manualized, parent-based program for childhood anxiety and obsessive-compulsive disorder. It has been tested in clinical trials and found to be noninferior to cognitive behavioral therapy for childhood anxiety.
The research adapted it to treat FTL. SPACE-FTL focuses on reducing parents’ family accommodation (FA), a descriptor for a child’s excessive dependence on their parents to help them avoid anxiety-provoking situations.
The study examined the feasibility, acceptability, and treatment satisfaction and its effect on adult child psychopathology symptoms, parents’ FA, and the paternal burden of caring for adult children.
The study included parents (mean age, 59.46 years; 85% female) of 40 adult children with FTL (mean age, 23.51 years; 20% female) from across the United States.
Parents were randomized to a 13-week wait-list or the SPACE-FTL program, which involves 13-20 therapy sessions, depending on the need. The average number of sessions in the study was 15. The program has five key components:
- Providing information emphasizing FTL as not a character flaw but a problem with anxiety.
- Helping parents identify how they accommodate their child’s behavior, and facilitating an environment that encourages independence.
- Getting parents to show acceptance and confidence in their child who’s trying to overcome anxiety when, for example, they seek employment, instead of being overprotective and demanding.
- Focusing on change nonconfrontationally.
- Involving other family, community members, and professionals who can support the parent, child, or both.
The recruitment, treatment sessions, and assessments were all done online. Most participants rated the intervention as highly satisfactory on the Client Satisfaction Questionnaire (CSQ-8; mean score, 27.7 out of a maximum of 32). About 60% of the offspring no longer met full criteria for FTL (P < .001; Cohen’s D = 1.76).
All children of the wait-listed parents still met criteria for FTL.
FTL symptoms decreased significantly in the offspring of the intervention group, as seen in both in the Adult Entitled Dependence Scale (AED; P < .05; Cohen’s D = 0.84); and the Adaptive Behaviors Scale (ABS; P < .05; Cohen’s D = 0.70).
There was no change in anxiety as assessed by the Adult Behavior Checklist (ABCL). But Dr. Berger noted that child anxiety is difficult to assess through parental report.
“This population is self-isolating and parents sometimes don’t know what’s going on,” and ABCL measures may not be “as sensitive as we would have liked them to be,” Dr. Berger said.
Parental burden was significantly decreased as measured by the Zarit Burden Interview (ZBI; P < .05; Cohen’s D = 0.70). In addition, family accommodation decreased significantly as determined by the Family Accommodation Scale–Anxiety (FASA; P < .05; Cohen’s D = 0.70).
Innovative work
In a comment, Jonathan E. Alpert, MD, PhD, chair, department of psychiatry and behavioral sciences, and professor of psychiatry, neuroscience, and pediatrics, Albert Einstein College of Medicine, New York, described the program as “innovative.”
He noted that the SPACE-FTL approach provides parents with education and skills to reduce behaviors that reinforce their child’s avoidance of independent activities. Such behaviors “may inadvertently contribute to the adult child remaining stuck,” he said.
“Through its involvement of parents and use of a structured approach, SPACE-FTL is a very interesting step toward more evidence-based therapies.”
However, he noted that the number of study participants is still “very low” and further work is needed to better characterize this condition and develop effective therapies.
He noted that parents of adult children with FTL should not be judged or blamed. “They have been living with a worrisome problem for years and are simply doing their best to cope as any of us would do.”
In addition, he noted that some adult children aren’t capable of launching because of a serious mental illness or substance use disorder that needs treatment.
It’s unclear just how many adult children have FTL, as the condition lacks formal, agreed-upon clinical and research criteria and a reliable evidence base for treatment, Dr. Alpert said.
“Whatever the actual numbers of FTL, my anecdotal clinical experience suggests that it is a very common problem which is understudied.”
He added that the definitions of FTL should include cultural context. In some groups, it’s quite normal for adults in their 20s, 30s, or even older to live with their parents, Dr. Alpert said.
Dr. Berger and Dr. Albert report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT ADAA 2023
Remote weight monitoring minimizes office visits for newborns
WASHINGTON, D.C. – according to a new study presented at the Pediatric Academic Societies annual meeting.
The pilot trial compared the frequency of office visits for healthy babies born at 37 weeks’ gestation or later. One group of 20 infants had their weight monitored at home by parents, and another group of 20 infants received usual care, which included two in-person office visits over the first 6 weeks of life.
Researchers found that visits for infants in the intervention group decreased by 25% after the first week of life and by 23% after the second week.
The remote method can help alert physicians earlier to insufficient weight because parents report gains or losses three times a week over the 6 weeks, resulting in more data for providers.
“You’re going to see fewer visits with people who have scales because the docs are getting the information they need, which is: ‘Is this baby doing okay or not?’ ” said Diane DiTomasso, PhD, RN, a professor at the University of Rhode Island, South Kingstown, who was not involved with the study. “I think it’s a very necessary study because, to my knowledge, nobody has done a randomized controlled trial on this topic.”
Keeping infants at home can also protect babies from infections they might catch in the clinic.
“There are a lot of other kids in an office setting, and kids like touching things,” said Anirudha Das, MD, MPH, a neonatologist at Cleveland Clinic Children’s and the lead author of the study. “When there are a lot of other kids, there are a lot of viruses. It’s a very dangerous environment.”
Parents in the intervention group were given scales and asked to enter their infant’s weight into a patient portal app three times per week for 6 weeks. Physicians then determined if in-office visits were necessary.
The benefits of home weight checks can include helping to allow for breastfeeding for a longer duration.
Weight is more closely monitored for breastfed infants. Waiting weeks for office checks can heighten parental anxiety and lead to prematurely stopping breastfeeding. With regular at-home checks, parents receive up-to-date information from physicians that can alleviate concerns and empower them with more control over the process, according to Dr. DiTomasso.
Breastfeeding is associated with a lower risk for cardiovascular disease, diabetes, obesity, cancer in later life, and a lower risk of breast cancer for breastfeeding parents.
Office weight checks can also alleviate a significant and unnecessary burden for parents, Dr. Das said.
“You shouldn’t have to put your baby in a car, possibly in freezing temperatures, hire someone to take care of your other kids, drive to the hospital, pay for parking, and walk to the office for a weight check,” Dr. Das said.
Dr. Das noted that, because of technical errors, parents weren’t able to use remote monitoring and had in-person visits during the first 5 days of life. The intervention group had more visits during that period than the usual-care group.
The study was funded by the American Academy of Pediatrics. The authors and Dr. Das reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
WASHINGTON, D.C. – according to a new study presented at the Pediatric Academic Societies annual meeting.
The pilot trial compared the frequency of office visits for healthy babies born at 37 weeks’ gestation or later. One group of 20 infants had their weight monitored at home by parents, and another group of 20 infants received usual care, which included two in-person office visits over the first 6 weeks of life.
Researchers found that visits for infants in the intervention group decreased by 25% after the first week of life and by 23% after the second week.
The remote method can help alert physicians earlier to insufficient weight because parents report gains or losses three times a week over the 6 weeks, resulting in more data for providers.
“You’re going to see fewer visits with people who have scales because the docs are getting the information they need, which is: ‘Is this baby doing okay or not?’ ” said Diane DiTomasso, PhD, RN, a professor at the University of Rhode Island, South Kingstown, who was not involved with the study. “I think it’s a very necessary study because, to my knowledge, nobody has done a randomized controlled trial on this topic.”
Keeping infants at home can also protect babies from infections they might catch in the clinic.
“There are a lot of other kids in an office setting, and kids like touching things,” said Anirudha Das, MD, MPH, a neonatologist at Cleveland Clinic Children’s and the lead author of the study. “When there are a lot of other kids, there are a lot of viruses. It’s a very dangerous environment.”
Parents in the intervention group were given scales and asked to enter their infant’s weight into a patient portal app three times per week for 6 weeks. Physicians then determined if in-office visits were necessary.
The benefits of home weight checks can include helping to allow for breastfeeding for a longer duration.
Weight is more closely monitored for breastfed infants. Waiting weeks for office checks can heighten parental anxiety and lead to prematurely stopping breastfeeding. With regular at-home checks, parents receive up-to-date information from physicians that can alleviate concerns and empower them with more control over the process, according to Dr. DiTomasso.
Breastfeeding is associated with a lower risk for cardiovascular disease, diabetes, obesity, cancer in later life, and a lower risk of breast cancer for breastfeeding parents.
Office weight checks can also alleviate a significant and unnecessary burden for parents, Dr. Das said.
“You shouldn’t have to put your baby in a car, possibly in freezing temperatures, hire someone to take care of your other kids, drive to the hospital, pay for parking, and walk to the office for a weight check,” Dr. Das said.
Dr. Das noted that, because of technical errors, parents weren’t able to use remote monitoring and had in-person visits during the first 5 days of life. The intervention group had more visits during that period than the usual-care group.
The study was funded by the American Academy of Pediatrics. The authors and Dr. Das reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
WASHINGTON, D.C. – according to a new study presented at the Pediatric Academic Societies annual meeting.
The pilot trial compared the frequency of office visits for healthy babies born at 37 weeks’ gestation or later. One group of 20 infants had their weight monitored at home by parents, and another group of 20 infants received usual care, which included two in-person office visits over the first 6 weeks of life.
Researchers found that visits for infants in the intervention group decreased by 25% after the first week of life and by 23% after the second week.
The remote method can help alert physicians earlier to insufficient weight because parents report gains or losses three times a week over the 6 weeks, resulting in more data for providers.
“You’re going to see fewer visits with people who have scales because the docs are getting the information they need, which is: ‘Is this baby doing okay or not?’ ” said Diane DiTomasso, PhD, RN, a professor at the University of Rhode Island, South Kingstown, who was not involved with the study. “I think it’s a very necessary study because, to my knowledge, nobody has done a randomized controlled trial on this topic.”
Keeping infants at home can also protect babies from infections they might catch in the clinic.
“There are a lot of other kids in an office setting, and kids like touching things,” said Anirudha Das, MD, MPH, a neonatologist at Cleveland Clinic Children’s and the lead author of the study. “When there are a lot of other kids, there are a lot of viruses. It’s a very dangerous environment.”
Parents in the intervention group were given scales and asked to enter their infant’s weight into a patient portal app three times per week for 6 weeks. Physicians then determined if in-office visits were necessary.
The benefits of home weight checks can include helping to allow for breastfeeding for a longer duration.
Weight is more closely monitored for breastfed infants. Waiting weeks for office checks can heighten parental anxiety and lead to prematurely stopping breastfeeding. With regular at-home checks, parents receive up-to-date information from physicians that can alleviate concerns and empower them with more control over the process, according to Dr. DiTomasso.
Breastfeeding is associated with a lower risk for cardiovascular disease, diabetes, obesity, cancer in later life, and a lower risk of breast cancer for breastfeeding parents.
Office weight checks can also alleviate a significant and unnecessary burden for parents, Dr. Das said.
“You shouldn’t have to put your baby in a car, possibly in freezing temperatures, hire someone to take care of your other kids, drive to the hospital, pay for parking, and walk to the office for a weight check,” Dr. Das said.
Dr. Das noted that, because of technical errors, parents weren’t able to use remote monitoring and had in-person visits during the first 5 days of life. The intervention group had more visits during that period than the usual-care group.
The study was funded by the American Academy of Pediatrics. The authors and Dr. Das reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
AT PAS 2023
A clash of expectations
A few weeks ago I asked what changes would have to occur to return urgent care to its former place under the umbrella of the primary care pediatrician. Several responses that I received and the recent story about screenings in this magazine (April 2023) have prompted me to ask the broader question of what is a pediatrician? More specifically, what is the role of a primary care pediatrician?
I think we can agree that a pediatrician is someone who has dedicated his or her training to learning about and then treating the diseases of children. There are pediatricians whose focus is on newborns. There are others who specialize by organ system or by the intensity of the disease (for example, hospitalists and ED physicians). In Great Britain, and to some extent Canada, “paediatricians” serve primarily as consultants to other health care providers. In this country, however, we tend to think of a pediatrician as a frontline primary care physician with general expertise in children. It is those providers (myself included) to whom I address my questions: “What is our role? What is our primary mission?” Are the expectations that we and others have for us realistic given the realities of 21st-century America? And, is our failure to meet some of those expectations contributing to our burnout?
Are we preventionists? I have always thought that one of the things that sets us apart from other specialties is our focus on prevention. We’ve done a pretty good job with infectious diseases thanks to vaccines and antibiotics. But, when I look at the children who grew to be obese adults under my care I have to say that I and my peers have done an abysmal job of prevention. And that is just one example.
Are we educators responsible for helping parents learn what we consider to be the best child-rearing practices? The Latin root of the word “doctor” means teacher. But, education done well is a very time-consuming process. How many of us have time in the office to really teach? Furthermore, some recent studies on managing vaccine deniers suggests that education doesn’t work with people who have long-held beliefs.
Are we data-entry clerks tasked with documenting our every professional step to validate our value to society and the correctness of our methods? It seems that there are some folks who believe we should be.
Are we screeners? TSA agents with white coats and stethoscopes responsible for screening the entire population for potential threats that weren’t obvious to our thoughtful history taking and careful physical examinations?
And finally, are we healers? If you haven’t already disabused yourself of that myth please take a moment to consider the number of cures you have orchestrated in the last 10 years.
The answer is that we can and maybe should be all of those things but we and those who advise us and support us must have reasonable expectations of how difficult it can be to be all those things to all of our patients in the real world of primary care pediatrics. We aren’t social engineers who can level every inequality nor can we orchestrate changes in a society that leans toward enabling unhealthy lifestyles.
The American Academy of Pediatrics must shoulder some of the blame for this discrepancy between expectations and reality. In the Pediatric News article on screening, Susan Kressly, MD, the chair of the American Academy of Pediatrics’s Section on Administration and Practice shares some common-sense observations on how screening can be applied thoughtfully. However, this isn’t how it is usually portrayed in the top-down rollout as each advocacy group releases its next best screening recommendations.
Faced with this clash or expectations I have always chosen to think small. I live in a small town in a small state. I look at each patient and each family, one at a time, with its strengths and its vulnerabilities as a given. I try to educate and prevent as their needs and my time allows. I screen when something makes me feel uncomfortable. Long ago I retired my aspirations as a healer and instead have focussed on being a soother.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
A few weeks ago I asked what changes would have to occur to return urgent care to its former place under the umbrella of the primary care pediatrician. Several responses that I received and the recent story about screenings in this magazine (April 2023) have prompted me to ask the broader question of what is a pediatrician? More specifically, what is the role of a primary care pediatrician?
I think we can agree that a pediatrician is someone who has dedicated his or her training to learning about and then treating the diseases of children. There are pediatricians whose focus is on newborns. There are others who specialize by organ system or by the intensity of the disease (for example, hospitalists and ED physicians). In Great Britain, and to some extent Canada, “paediatricians” serve primarily as consultants to other health care providers. In this country, however, we tend to think of a pediatrician as a frontline primary care physician with general expertise in children. It is those providers (myself included) to whom I address my questions: “What is our role? What is our primary mission?” Are the expectations that we and others have for us realistic given the realities of 21st-century America? And, is our failure to meet some of those expectations contributing to our burnout?
Are we preventionists? I have always thought that one of the things that sets us apart from other specialties is our focus on prevention. We’ve done a pretty good job with infectious diseases thanks to vaccines and antibiotics. But, when I look at the children who grew to be obese adults under my care I have to say that I and my peers have done an abysmal job of prevention. And that is just one example.
Are we educators responsible for helping parents learn what we consider to be the best child-rearing practices? The Latin root of the word “doctor” means teacher. But, education done well is a very time-consuming process. How many of us have time in the office to really teach? Furthermore, some recent studies on managing vaccine deniers suggests that education doesn’t work with people who have long-held beliefs.
Are we data-entry clerks tasked with documenting our every professional step to validate our value to society and the correctness of our methods? It seems that there are some folks who believe we should be.
Are we screeners? TSA agents with white coats and stethoscopes responsible for screening the entire population for potential threats that weren’t obvious to our thoughtful history taking and careful physical examinations?
And finally, are we healers? If you haven’t already disabused yourself of that myth please take a moment to consider the number of cures you have orchestrated in the last 10 years.
The answer is that we can and maybe should be all of those things but we and those who advise us and support us must have reasonable expectations of how difficult it can be to be all those things to all of our patients in the real world of primary care pediatrics. We aren’t social engineers who can level every inequality nor can we orchestrate changes in a society that leans toward enabling unhealthy lifestyles.
The American Academy of Pediatrics must shoulder some of the blame for this discrepancy between expectations and reality. In the Pediatric News article on screening, Susan Kressly, MD, the chair of the American Academy of Pediatrics’s Section on Administration and Practice shares some common-sense observations on how screening can be applied thoughtfully. However, this isn’t how it is usually portrayed in the top-down rollout as each advocacy group releases its next best screening recommendations.
Faced with this clash or expectations I have always chosen to think small. I live in a small town in a small state. I look at each patient and each family, one at a time, with its strengths and its vulnerabilities as a given. I try to educate and prevent as their needs and my time allows. I screen when something makes me feel uncomfortable. Long ago I retired my aspirations as a healer and instead have focussed on being a soother.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
A few weeks ago I asked what changes would have to occur to return urgent care to its former place under the umbrella of the primary care pediatrician. Several responses that I received and the recent story about screenings in this magazine (April 2023) have prompted me to ask the broader question of what is a pediatrician? More specifically, what is the role of a primary care pediatrician?
I think we can agree that a pediatrician is someone who has dedicated his or her training to learning about and then treating the diseases of children. There are pediatricians whose focus is on newborns. There are others who specialize by organ system or by the intensity of the disease (for example, hospitalists and ED physicians). In Great Britain, and to some extent Canada, “paediatricians” serve primarily as consultants to other health care providers. In this country, however, we tend to think of a pediatrician as a frontline primary care physician with general expertise in children. It is those providers (myself included) to whom I address my questions: “What is our role? What is our primary mission?” Are the expectations that we and others have for us realistic given the realities of 21st-century America? And, is our failure to meet some of those expectations contributing to our burnout?
Are we preventionists? I have always thought that one of the things that sets us apart from other specialties is our focus on prevention. We’ve done a pretty good job with infectious diseases thanks to vaccines and antibiotics. But, when I look at the children who grew to be obese adults under my care I have to say that I and my peers have done an abysmal job of prevention. And that is just one example.
Are we educators responsible for helping parents learn what we consider to be the best child-rearing practices? The Latin root of the word “doctor” means teacher. But, education done well is a very time-consuming process. How many of us have time in the office to really teach? Furthermore, some recent studies on managing vaccine deniers suggests that education doesn’t work with people who have long-held beliefs.
Are we data-entry clerks tasked with documenting our every professional step to validate our value to society and the correctness of our methods? It seems that there are some folks who believe we should be.
Are we screeners? TSA agents with white coats and stethoscopes responsible for screening the entire population for potential threats that weren’t obvious to our thoughtful history taking and careful physical examinations?
And finally, are we healers? If you haven’t already disabused yourself of that myth please take a moment to consider the number of cures you have orchestrated in the last 10 years.
The answer is that we can and maybe should be all of those things but we and those who advise us and support us must have reasonable expectations of how difficult it can be to be all those things to all of our patients in the real world of primary care pediatrics. We aren’t social engineers who can level every inequality nor can we orchestrate changes in a society that leans toward enabling unhealthy lifestyles.
The American Academy of Pediatrics must shoulder some of the blame for this discrepancy between expectations and reality. In the Pediatric News article on screening, Susan Kressly, MD, the chair of the American Academy of Pediatrics’s Section on Administration and Practice shares some common-sense observations on how screening can be applied thoughtfully. However, this isn’t how it is usually portrayed in the top-down rollout as each advocacy group releases its next best screening recommendations.
Faced with this clash or expectations I have always chosen to think small. I live in a small town in a small state. I look at each patient and each family, one at a time, with its strengths and its vulnerabilities as a given. I try to educate and prevent as their needs and my time allows. I screen when something makes me feel uncomfortable. Long ago I retired my aspirations as a healer and instead have focussed on being a soother.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].