User login
Homelessness among LGBT youth in the United States
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
Confidential, parent-free discussion should occur by age 13
Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.
“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.
According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.
You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.
Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.
The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).
On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.
Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).
Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).
Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.
Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.
Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.
“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”
You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.
Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.
It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.
Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.
The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.
SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.
Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”
Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.
Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.
The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.
Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.
The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.
What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.
Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.
Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”
Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.
Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.
The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.
Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.
The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.
What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.
Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.
Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”
Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.
Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.
The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.
Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.
The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.
What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.
Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.
Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.
“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.
According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.
You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.
Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.
The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).
On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.
Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).
Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).
Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.
Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.
Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.
“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”
You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.
Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.
It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.
Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.
The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.
SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.
Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.
“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.
According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.
You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.
Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.
The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).
On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.
Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).
Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).
Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.
Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.
Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.
“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”
You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.
Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.
It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.
Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.
The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.
SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.
FROM PEDIATRICS
Key clinical point:
Major finding: The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%).
Study details: Self-report survey.
Disclosures: The authors had no financial relationships relevant to this article to disclose. The study was funded by an unrestricted research grant from the Merck Foundation.
Source: Santelli J. et. al. Pediatrics. 2019;143(2):e20181403.
Medicaid youth suicides include more females, younger kids, hanging deaths
Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.
Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.
“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.
Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.
Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.
Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.
Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.
Nevertheless, , Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.
This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.
The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.
SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.
Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.
“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.
Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.
Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.
Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.
Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.
Nevertheless, , Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.
This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.
The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.
SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.
Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.
“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.
Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.
Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.
Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.
Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.
Nevertheless, , Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.
This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.
The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.
SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point: Youth enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth.
Major finding: The Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, a 14% increased risk of suicide among females, and a 26% greater risk of death by hanging.
Study details: An observational study from the 16 most populous states that includes 4,045 youth who committed suicide during 2009-2013.
Disclosures: The authors reported no financial conflicts. The study was funded by the American Foundation for Suicide Prevention and the National Institutes of Health.
Source: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
Intrapartum molecular GBS screening reduced newborn early-onset disease, antibiotic use
Point-of-care intrapartum molecular screening of group B Streptococcus reduced the incidence of early-onset disease cases and antibiotic use, according to research published in Obstetrics & Gynecology.
Najoua El Helali, PharmD, from the Service de Microbiologie Clinique at Groupe Hospitalier Paris Saint-Joseph, and her colleagues measured the rate of early-onset disease group B Streptococcus (GBS) in a single-center study analyzing antenatal culture screening for 4 years prior to implementation (2006-2009) of polymerase chain reaction (PCR) screening (2010-2015). There were 11,226 deliveries (11,818 live births) during the antenatal screening period and 18,835 deliveries (18,980 live births) during the PCR screening period. Overall, 4% of deliveries during the antenatal period and 0.1% of deliveries during the intrapartum period were not screened for GBS (P less than .001).
During 2006-2015, the rate of early-onset disease of GBS decreased to 0.21/1,000 cases from 1.01/1,000 cases (risk ratio, 0.25; 95% confidence interval, 0.14-0.43; P = .026), while the rate of probable early-onset disease GBS decreased to 0.73/1,000 cases from 2.8/1,000 cases (RR, 0.25; (95% CI, 0.14-0.43; P less than .001).
For patients with early-onset GBS, length of stay in hospital decreased by 64%, and antibiotic therapy decreased by 60%, but there was no significant difference in average length of stay or duration of antibiotic therapy during the study period. There was a reduction in annual delivery- and treatment-associated costs of early-onset disease GBS from $41,875 to $11,945, while the estimated extra cost of PCR screening to avoid one additional case of early-onset disease GBS was $5,819 and a cost increase of $49 per newborn.
“The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs,” the investigators said.
“A randomized, controlled multicenter study is probably needed to evaluate the cost-effectiveness of this prevention strategy and demonstrate a better efficacy in populations where poorly followed women are of unknown GBS status at presentation for delivery,” the researchers said. “In term newborns, however, using infection rate as an endpoint is problematic given the sample size needed.”
The researchers said their study was potentially limited by lack of a control group and population selection, and described mothers in their center as “mostly well-informed and well-monitored during their pregnancy.”
The authors reported no relevant conflicts of interest.
SOURCE: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
Point-of-care intrapartum molecular screening of group B Streptococcus reduced the incidence of early-onset disease cases and antibiotic use, according to research published in Obstetrics & Gynecology.
Najoua El Helali, PharmD, from the Service de Microbiologie Clinique at Groupe Hospitalier Paris Saint-Joseph, and her colleagues measured the rate of early-onset disease group B Streptococcus (GBS) in a single-center study analyzing antenatal culture screening for 4 years prior to implementation (2006-2009) of polymerase chain reaction (PCR) screening (2010-2015). There were 11,226 deliveries (11,818 live births) during the antenatal screening period and 18,835 deliveries (18,980 live births) during the PCR screening period. Overall, 4% of deliveries during the antenatal period and 0.1% of deliveries during the intrapartum period were not screened for GBS (P less than .001).
During 2006-2015, the rate of early-onset disease of GBS decreased to 0.21/1,000 cases from 1.01/1,000 cases (risk ratio, 0.25; 95% confidence interval, 0.14-0.43; P = .026), while the rate of probable early-onset disease GBS decreased to 0.73/1,000 cases from 2.8/1,000 cases (RR, 0.25; (95% CI, 0.14-0.43; P less than .001).
For patients with early-onset GBS, length of stay in hospital decreased by 64%, and antibiotic therapy decreased by 60%, but there was no significant difference in average length of stay or duration of antibiotic therapy during the study period. There was a reduction in annual delivery- and treatment-associated costs of early-onset disease GBS from $41,875 to $11,945, while the estimated extra cost of PCR screening to avoid one additional case of early-onset disease GBS was $5,819 and a cost increase of $49 per newborn.
“The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs,” the investigators said.
“A randomized, controlled multicenter study is probably needed to evaluate the cost-effectiveness of this prevention strategy and demonstrate a better efficacy in populations where poorly followed women are of unknown GBS status at presentation for delivery,” the researchers said. “In term newborns, however, using infection rate as an endpoint is problematic given the sample size needed.”
The researchers said their study was potentially limited by lack of a control group and population selection, and described mothers in their center as “mostly well-informed and well-monitored during their pregnancy.”
The authors reported no relevant conflicts of interest.
SOURCE: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
Point-of-care intrapartum molecular screening of group B Streptococcus reduced the incidence of early-onset disease cases and antibiotic use, according to research published in Obstetrics & Gynecology.
Najoua El Helali, PharmD, from the Service de Microbiologie Clinique at Groupe Hospitalier Paris Saint-Joseph, and her colleagues measured the rate of early-onset disease group B Streptococcus (GBS) in a single-center study analyzing antenatal culture screening for 4 years prior to implementation (2006-2009) of polymerase chain reaction (PCR) screening (2010-2015). There were 11,226 deliveries (11,818 live births) during the antenatal screening period and 18,835 deliveries (18,980 live births) during the PCR screening period. Overall, 4% of deliveries during the antenatal period and 0.1% of deliveries during the intrapartum period were not screened for GBS (P less than .001).
During 2006-2015, the rate of early-onset disease of GBS decreased to 0.21/1,000 cases from 1.01/1,000 cases (risk ratio, 0.25; 95% confidence interval, 0.14-0.43; P = .026), while the rate of probable early-onset disease GBS decreased to 0.73/1,000 cases from 2.8/1,000 cases (RR, 0.25; (95% CI, 0.14-0.43; P less than .001).
For patients with early-onset GBS, length of stay in hospital decreased by 64%, and antibiotic therapy decreased by 60%, but there was no significant difference in average length of stay or duration of antibiotic therapy during the study period. There was a reduction in annual delivery- and treatment-associated costs of early-onset disease GBS from $41,875 to $11,945, while the estimated extra cost of PCR screening to avoid one additional case of early-onset disease GBS was $5,819 and a cost increase of $49 per newborn.
“The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs,” the investigators said.
“A randomized, controlled multicenter study is probably needed to evaluate the cost-effectiveness of this prevention strategy and demonstrate a better efficacy in populations where poorly followed women are of unknown GBS status at presentation for delivery,” the researchers said. “In term newborns, however, using infection rate as an endpoint is problematic given the sample size needed.”
The researchers said their study was potentially limited by lack of a control group and population selection, and described mothers in their center as “mostly well-informed and well-monitored during their pregnancy.”
The authors reported no relevant conflicts of interest.
SOURCE: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point:
Major finding: The rate of early-onset disease group B Streptococcus decreased from 1.01/1,000 cases to 0.21/1,000 cases across the antenatal and intrapartum periods.
Study details: A single-center study of antenatal culture screening for 11,226 deliveries during 2006-2009 and intrapartum PCR screening for 18,835 deliveries during 2010-2015.
Disclosures: The authors reported no relevant conflicts of interest.
Source: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
FDA approves generic version of vigabatrin
The drug is approved for the adjunctive treatment of focal seizures in patients aged 10 years and older who have not had an adequate response to other therapies.
The approval was granted to Teva Pharmaceuticals.
An FDA announcement noted that the agency has prioritized the approval of generic versions of drugs to improve access to treatments and to lower drug costs. Vigabatrin had been included on an FDA list of off-patent, off-exclusivity branded drugs without approved generics. The approval of generic vigabatrin “demonstrates that there is an open pathway to approving products like this one,” said FDA Commissioner Scott Gottlieb, MD.
The label for vigabatrin tablets includes a boxed warning for permanent vision loss. The generic vigabatrin tablets are part of a single shared-system Risk Evaluation and Mitigation Strategy (REMS) program with other drug products containing vigabatrin.
The most common side effects associated with vigabatrin tablets include dizziness, fatigue, sleepiness, involuntary eye movement, tremor, blurred vision, memory impairment, weight gain, joint pain, upper respiratory tract infection, aggression, double vision, abnormal coordination, and a confused state. Serious side effects associated with vigabatrin tablets include permanent vision loss and risk of suicidal thoughts or actions.
The drug is approved for the adjunctive treatment of focal seizures in patients aged 10 years and older who have not had an adequate response to other therapies.
The approval was granted to Teva Pharmaceuticals.
An FDA announcement noted that the agency has prioritized the approval of generic versions of drugs to improve access to treatments and to lower drug costs. Vigabatrin had been included on an FDA list of off-patent, off-exclusivity branded drugs without approved generics. The approval of generic vigabatrin “demonstrates that there is an open pathway to approving products like this one,” said FDA Commissioner Scott Gottlieb, MD.
The label for vigabatrin tablets includes a boxed warning for permanent vision loss. The generic vigabatrin tablets are part of a single shared-system Risk Evaluation and Mitigation Strategy (REMS) program with other drug products containing vigabatrin.
The most common side effects associated with vigabatrin tablets include dizziness, fatigue, sleepiness, involuntary eye movement, tremor, blurred vision, memory impairment, weight gain, joint pain, upper respiratory tract infection, aggression, double vision, abnormal coordination, and a confused state. Serious side effects associated with vigabatrin tablets include permanent vision loss and risk of suicidal thoughts or actions.
The drug is approved for the adjunctive treatment of focal seizures in patients aged 10 years and older who have not had an adequate response to other therapies.
The approval was granted to Teva Pharmaceuticals.
An FDA announcement noted that the agency has prioritized the approval of generic versions of drugs to improve access to treatments and to lower drug costs. Vigabatrin had been included on an FDA list of off-patent, off-exclusivity branded drugs without approved generics. The approval of generic vigabatrin “demonstrates that there is an open pathway to approving products like this one,” said FDA Commissioner Scott Gottlieb, MD.
The label for vigabatrin tablets includes a boxed warning for permanent vision loss. The generic vigabatrin tablets are part of a single shared-system Risk Evaluation and Mitigation Strategy (REMS) program with other drug products containing vigabatrin.
The most common side effects associated with vigabatrin tablets include dizziness, fatigue, sleepiness, involuntary eye movement, tremor, blurred vision, memory impairment, weight gain, joint pain, upper respiratory tract infection, aggression, double vision, abnormal coordination, and a confused state. Serious side effects associated with vigabatrin tablets include permanent vision loss and risk of suicidal thoughts or actions.
Delayed first contraception use raises unwanted pregnancy risk
Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy, according to data from a cross-sectional study of more than 26,000 women in the United States.
Unintended pregnancy in the United States is associated with delayed prenatal care, premature birth, and low birth weight and remains more common among African American and Hispanic women than among white women, and it also is more common among low-income women than among high income women, wrote Mara E. Murray Horwitz, MD, of Harvard Pilgrim Health Care Institute in Boston and her colleagues.
“Reducing unintended pregnancy and the associated socioeconomic disparities is a national public health priority,” they wrote.
In a study published in Pediatrics, the researchers reviewed data from four cycles of the National Survey of Family Growth between 2002 and 2015. They examined self-reported responses from 26,359 women aged 15-44 years with sexual debuts during 1970-2014, including the dates of sexual debut, initiation of contraceptives, and rates of unwanted pregnancy. Timely contraceptive initiation was defined as use within a month of starting sexual activity.
Overall, one in five women reported delayed initiation of contraception. This delay was significantly associated with an increased unwanted pregnancy risk within 3 months of starting sexual activity, compared with timely use of contraception (adjusted risk ratio, 3.7). The average age of sexual debut was 17 years.
When the researchers examined subgroups, they found that one in four respondents who were African American, Hispanic, or low income reported delayed contraceptive initiation.
No association with unwanted pregnancy was found between effective versus less effective contraception methods. Timely contraceptive use increased during the study period from less than 10% in the 1970s to more than 25% in the 2000s, but condoms accounted for most of this increase. Use of other methods including long-acting reversible and short-acting hormonal options was low, especially among African American, Hispanic, and low-income women, Dr. Murray Horwitz and her colleagues noted.
The study was limited by several factors including the use of self-reports, lack of data on the exact start of contraceptive initiation, and the lack of association between contraceptive method and unwanted pregnancy, the researchers noted. However, the findings suggest that clinicians can help by intervening with young patients and educating them about early adoption of pregnancy prevention strategies.
The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.
SOURCE: Murray Horwitz M et al. Pediatrics. 2019;143(2):e20182463.
Despite a declining teen birth rate in the last several decades, the United States has the highest teen birth rate among industrialized nations. While many factors play into this rate, we know that, in many European countries with low teen birth rates, adolescents often initiate contraceptive methods before their sexual debut. As we often tell teenagers, they can become pregnant the “first time,” which makes initiating contraception early – and preferably before sexual debut – an important strategy to preventing unplanned pregnancy.
This study identifies the trends over time in the initiation of contraception in relationship to sexual debut and examines its effects on unplanned teen pregnancy. Understanding these trends can help clinicians more effectively target teen pregnancy.
I was pleasantly surprised to see that rates of timely contraceptive initiation have increased since 1970. Sadly, this rise is largely because of condom use. Use of effective forms of contraception – especially long-acting reversible forms of contraception (LARC), such as the IUD or the etonogestrel rod – still remain low at the time of sexual debut. While we continue to encourage LARCs as first line for pregnancy prevention, many patients are not getting the message about these highly effective, safe methods. Unsurprisingly, there are significant differences based on race/ethnicity and socioeconomic status on timely initiation of contraceptive methods, especially highly effective methods. This supports prior research which has shown significant barriers in access to contraception to these groups, which leads to higher rates of unplanned pregnancies.
Dr. Kelly Curran, MD, specializes in adolescent medicine at the University of Oklahoma, Oklahoma City. She is a member of the Pediatric News editorial advisory board and was asked to comment on the study by Murray Horwitz et al. Dr. Curran had no relevant financial disclosures.
Despite a declining teen birth rate in the last several decades, the United States has the highest teen birth rate among industrialized nations. While many factors play into this rate, we know that, in many European countries with low teen birth rates, adolescents often initiate contraceptive methods before their sexual debut. As we often tell teenagers, they can become pregnant the “first time,” which makes initiating contraception early – and preferably before sexual debut – an important strategy to preventing unplanned pregnancy.
This study identifies the trends over time in the initiation of contraception in relationship to sexual debut and examines its effects on unplanned teen pregnancy. Understanding these trends can help clinicians more effectively target teen pregnancy.
I was pleasantly surprised to see that rates of timely contraceptive initiation have increased since 1970. Sadly, this rise is largely because of condom use. Use of effective forms of contraception – especially long-acting reversible forms of contraception (LARC), such as the IUD or the etonogestrel rod – still remain low at the time of sexual debut. While we continue to encourage LARCs as first line for pregnancy prevention, many patients are not getting the message about these highly effective, safe methods. Unsurprisingly, there are significant differences based on race/ethnicity and socioeconomic status on timely initiation of contraceptive methods, especially highly effective methods. This supports prior research which has shown significant barriers in access to contraception to these groups, which leads to higher rates of unplanned pregnancies.
Dr. Kelly Curran, MD, specializes in adolescent medicine at the University of Oklahoma, Oklahoma City. She is a member of the Pediatric News editorial advisory board and was asked to comment on the study by Murray Horwitz et al. Dr. Curran had no relevant financial disclosures.
Despite a declining teen birth rate in the last several decades, the United States has the highest teen birth rate among industrialized nations. While many factors play into this rate, we know that, in many European countries with low teen birth rates, adolescents often initiate contraceptive methods before their sexual debut. As we often tell teenagers, they can become pregnant the “first time,” which makes initiating contraception early – and preferably before sexual debut – an important strategy to preventing unplanned pregnancy.
This study identifies the trends over time in the initiation of contraception in relationship to sexual debut and examines its effects on unplanned teen pregnancy. Understanding these trends can help clinicians more effectively target teen pregnancy.
I was pleasantly surprised to see that rates of timely contraceptive initiation have increased since 1970. Sadly, this rise is largely because of condom use. Use of effective forms of contraception – especially long-acting reversible forms of contraception (LARC), such as the IUD or the etonogestrel rod – still remain low at the time of sexual debut. While we continue to encourage LARCs as first line for pregnancy prevention, many patients are not getting the message about these highly effective, safe methods. Unsurprisingly, there are significant differences based on race/ethnicity and socioeconomic status on timely initiation of contraceptive methods, especially highly effective methods. This supports prior research which has shown significant barriers in access to contraception to these groups, which leads to higher rates of unplanned pregnancies.
Dr. Kelly Curran, MD, specializes in adolescent medicine at the University of Oklahoma, Oklahoma City. She is a member of the Pediatric News editorial advisory board and was asked to comment on the study by Murray Horwitz et al. Dr. Curran had no relevant financial disclosures.
Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy, according to data from a cross-sectional study of more than 26,000 women in the United States.
Unintended pregnancy in the United States is associated with delayed prenatal care, premature birth, and low birth weight and remains more common among African American and Hispanic women than among white women, and it also is more common among low-income women than among high income women, wrote Mara E. Murray Horwitz, MD, of Harvard Pilgrim Health Care Institute in Boston and her colleagues.
“Reducing unintended pregnancy and the associated socioeconomic disparities is a national public health priority,” they wrote.
In a study published in Pediatrics, the researchers reviewed data from four cycles of the National Survey of Family Growth between 2002 and 2015. They examined self-reported responses from 26,359 women aged 15-44 years with sexual debuts during 1970-2014, including the dates of sexual debut, initiation of contraceptives, and rates of unwanted pregnancy. Timely contraceptive initiation was defined as use within a month of starting sexual activity.
Overall, one in five women reported delayed initiation of contraception. This delay was significantly associated with an increased unwanted pregnancy risk within 3 months of starting sexual activity, compared with timely use of contraception (adjusted risk ratio, 3.7). The average age of sexual debut was 17 years.
When the researchers examined subgroups, they found that one in four respondents who were African American, Hispanic, or low income reported delayed contraceptive initiation.
No association with unwanted pregnancy was found between effective versus less effective contraception methods. Timely contraceptive use increased during the study period from less than 10% in the 1970s to more than 25% in the 2000s, but condoms accounted for most of this increase. Use of other methods including long-acting reversible and short-acting hormonal options was low, especially among African American, Hispanic, and low-income women, Dr. Murray Horwitz and her colleagues noted.
The study was limited by several factors including the use of self-reports, lack of data on the exact start of contraceptive initiation, and the lack of association between contraceptive method and unwanted pregnancy, the researchers noted. However, the findings suggest that clinicians can help by intervening with young patients and educating them about early adoption of pregnancy prevention strategies.
The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.
SOURCE: Murray Horwitz M et al. Pediatrics. 2019;143(2):e20182463.
Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy, according to data from a cross-sectional study of more than 26,000 women in the United States.
Unintended pregnancy in the United States is associated with delayed prenatal care, premature birth, and low birth weight and remains more common among African American and Hispanic women than among white women, and it also is more common among low-income women than among high income women, wrote Mara E. Murray Horwitz, MD, of Harvard Pilgrim Health Care Institute in Boston and her colleagues.
“Reducing unintended pregnancy and the associated socioeconomic disparities is a national public health priority,” they wrote.
In a study published in Pediatrics, the researchers reviewed data from four cycles of the National Survey of Family Growth between 2002 and 2015. They examined self-reported responses from 26,359 women aged 15-44 years with sexual debuts during 1970-2014, including the dates of sexual debut, initiation of contraceptives, and rates of unwanted pregnancy. Timely contraceptive initiation was defined as use within a month of starting sexual activity.
Overall, one in five women reported delayed initiation of contraception. This delay was significantly associated with an increased unwanted pregnancy risk within 3 months of starting sexual activity, compared with timely use of contraception (adjusted risk ratio, 3.7). The average age of sexual debut was 17 years.
When the researchers examined subgroups, they found that one in four respondents who were African American, Hispanic, or low income reported delayed contraceptive initiation.
No association with unwanted pregnancy was found between effective versus less effective contraception methods. Timely contraceptive use increased during the study period from less than 10% in the 1970s to more than 25% in the 2000s, but condoms accounted for most of this increase. Use of other methods including long-acting reversible and short-acting hormonal options was low, especially among African American, Hispanic, and low-income women, Dr. Murray Horwitz and her colleagues noted.
The study was limited by several factors including the use of self-reports, lack of data on the exact start of contraceptive initiation, and the lack of association between contraceptive method and unwanted pregnancy, the researchers noted. However, the findings suggest that clinicians can help by intervening with young patients and educating them about early adoption of pregnancy prevention strategies.
The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.
SOURCE: Murray Horwitz M et al. Pediatrics. 2019;143(2):e20182463.
FROM PEDIATRICS
Key clinical point: Women who delayed using contraception were significantly more likely to become pregnant within 3 months of starting sexual activity than were those who had initiated contraception use, especially black, Hispanic, and low-income women.
Major finding: Unwanted pregnancy within 3 months of sexual debut was 3.7 times more likely in women who delayed initial contraception use, compared with those who had timely initiation.
Study details: The data come from a cross-sectional study including 26,359 women with sexual debuts between 1970 and 2014.
Disclosures: The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.
Source: Horwitz M et al. Pediatrics. 2019;143(2):e20182463.
Courts block Trump from eroding contraceptive mandate
Federal judges have blocked the Trump administration from weakening the Affordable Care Act’s contraceptive mandate in two separate orders that bar the President from letting more entities claim exemptions.
On Jan. 14, U.S. District Court Judge Wendy Beetlestone for the Eastern District of Pennsylvania issued a temporary nationwide ban on two rules that would have allowed an expanded group of employers and insurers to object to providing contraception coverage on either religious or moral grounds. The regulations, announced Nov. 7, 2018, were scheduled to take effect Jan. 14. The day before, U.S. District Judge Haywood Gilliam for the Northern District of California issued a similar temporary ban, but his order applied only to the 13 plaintiff states in the case, plus the District of Columbia.
While Pennsylvania and New Jersey are the only plaintiffs in the Judge Beetlestone case, she wrote that a nationwide injunction is required to protect numerous citizens from losing contraceptive coverage and resulting in “significant, direct, and proprietary harm” to states in the form of increased state-funded contraceptive services and increased costs associated with unintended pregnancies. Judge Gilliam provided similar reasoning in his Jan. 13 order, writing that the 13 plaintiff states have proven that rules promulgated by the U.S. Department of Health and Human Services would cause women to lose employer-sponsored contraceptive coverage, resulting in economic harm to the states.
California Attorney General Xavier Becerra, a plaintiff in the second case, said Judge Gilliam’s ruling will stop the Trump administration from denying millions of women and families access to co-pay birth control guaranteed by the Affordable Care Act.
“The law couldn’t be clearer – employers have no business interfering in women’s health care decisions,” Mr. Becerra said in the statement. “[The] court ruling stops another attempt by the Trump administration to trample on women’s access to basic reproductive care.”
At press time, the Trump administration officials had responded publicly to the court orders. The administration previously said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” HHS estimated that the rules would affect no more than 200 employers.
Mark Rienzi, president of the Becket Fund for Religious Liberty, a legal institute that defends religious freedoms, expressed disappointment at the court orders. Becket represents the Little Sisters of the Poor, an organization that has been fighting for several years for an exemption to the contraceptive mandate.
“Government bureaucrats should not be allowed to threaten the rights of the Little Sisters of the Poor to serve according to their Catholic beliefs,” Mr. Rienzi said in a statement. “Now the nuns are forced to keep fighting this unnecessary lawsuit to protect their ability to focus on caring for the poor. We are confident these decisions will be overturned.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
The Trump administration then announced new rules aimed at broadening exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. A second rule would protect nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions would apply to institutions of education, issuers, and individuals, but not to governmental entities.
Thirteen states and the District of Columbia then sued the Trump administration over the rules as well as Pennsylvania and New Jersey in a separate case.
The nationwide ban against the rules will remain in effect while the cases continue through the court system.
Federal judges have blocked the Trump administration from weakening the Affordable Care Act’s contraceptive mandate in two separate orders that bar the President from letting more entities claim exemptions.
On Jan. 14, U.S. District Court Judge Wendy Beetlestone for the Eastern District of Pennsylvania issued a temporary nationwide ban on two rules that would have allowed an expanded group of employers and insurers to object to providing contraception coverage on either religious or moral grounds. The regulations, announced Nov. 7, 2018, were scheduled to take effect Jan. 14. The day before, U.S. District Judge Haywood Gilliam for the Northern District of California issued a similar temporary ban, but his order applied only to the 13 plaintiff states in the case, plus the District of Columbia.
While Pennsylvania and New Jersey are the only plaintiffs in the Judge Beetlestone case, she wrote that a nationwide injunction is required to protect numerous citizens from losing contraceptive coverage and resulting in “significant, direct, and proprietary harm” to states in the form of increased state-funded contraceptive services and increased costs associated with unintended pregnancies. Judge Gilliam provided similar reasoning in his Jan. 13 order, writing that the 13 plaintiff states have proven that rules promulgated by the U.S. Department of Health and Human Services would cause women to lose employer-sponsored contraceptive coverage, resulting in economic harm to the states.
California Attorney General Xavier Becerra, a plaintiff in the second case, said Judge Gilliam’s ruling will stop the Trump administration from denying millions of women and families access to co-pay birth control guaranteed by the Affordable Care Act.
“The law couldn’t be clearer – employers have no business interfering in women’s health care decisions,” Mr. Becerra said in the statement. “[The] court ruling stops another attempt by the Trump administration to trample on women’s access to basic reproductive care.”
At press time, the Trump administration officials had responded publicly to the court orders. The administration previously said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” HHS estimated that the rules would affect no more than 200 employers.
Mark Rienzi, president of the Becket Fund for Religious Liberty, a legal institute that defends religious freedoms, expressed disappointment at the court orders. Becket represents the Little Sisters of the Poor, an organization that has been fighting for several years for an exemption to the contraceptive mandate.
“Government bureaucrats should not be allowed to threaten the rights of the Little Sisters of the Poor to serve according to their Catholic beliefs,” Mr. Rienzi said in a statement. “Now the nuns are forced to keep fighting this unnecessary lawsuit to protect their ability to focus on caring for the poor. We are confident these decisions will be overturned.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
The Trump administration then announced new rules aimed at broadening exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. A second rule would protect nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions would apply to institutions of education, issuers, and individuals, but not to governmental entities.
Thirteen states and the District of Columbia then sued the Trump administration over the rules as well as Pennsylvania and New Jersey in a separate case.
The nationwide ban against the rules will remain in effect while the cases continue through the court system.
Federal judges have blocked the Trump administration from weakening the Affordable Care Act’s contraceptive mandate in two separate orders that bar the President from letting more entities claim exemptions.
On Jan. 14, U.S. District Court Judge Wendy Beetlestone for the Eastern District of Pennsylvania issued a temporary nationwide ban on two rules that would have allowed an expanded group of employers and insurers to object to providing contraception coverage on either religious or moral grounds. The regulations, announced Nov. 7, 2018, were scheduled to take effect Jan. 14. The day before, U.S. District Judge Haywood Gilliam for the Northern District of California issued a similar temporary ban, but his order applied only to the 13 plaintiff states in the case, plus the District of Columbia.
While Pennsylvania and New Jersey are the only plaintiffs in the Judge Beetlestone case, she wrote that a nationwide injunction is required to protect numerous citizens from losing contraceptive coverage and resulting in “significant, direct, and proprietary harm” to states in the form of increased state-funded contraceptive services and increased costs associated with unintended pregnancies. Judge Gilliam provided similar reasoning in his Jan. 13 order, writing that the 13 plaintiff states have proven that rules promulgated by the U.S. Department of Health and Human Services would cause women to lose employer-sponsored contraceptive coverage, resulting in economic harm to the states.
California Attorney General Xavier Becerra, a plaintiff in the second case, said Judge Gilliam’s ruling will stop the Trump administration from denying millions of women and families access to co-pay birth control guaranteed by the Affordable Care Act.
“The law couldn’t be clearer – employers have no business interfering in women’s health care decisions,” Mr. Becerra said in the statement. “[The] court ruling stops another attempt by the Trump administration to trample on women’s access to basic reproductive care.”
At press time, the Trump administration officials had responded publicly to the court orders. The administration previously said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” HHS estimated that the rules would affect no more than 200 employers.
Mark Rienzi, president of the Becket Fund for Religious Liberty, a legal institute that defends religious freedoms, expressed disappointment at the court orders. Becket represents the Little Sisters of the Poor, an organization that has been fighting for several years for an exemption to the contraceptive mandate.
“Government bureaucrats should not be allowed to threaten the rights of the Little Sisters of the Poor to serve according to their Catholic beliefs,” Mr. Rienzi said in a statement. “Now the nuns are forced to keep fighting this unnecessary lawsuit to protect their ability to focus on caring for the poor. We are confident these decisions will be overturned.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
The Trump administration then announced new rules aimed at broadening exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. A second rule would protect nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions would apply to institutions of education, issuers, and individuals, but not to governmental entities.
Thirteen states and the District of Columbia then sued the Trump administration over the rules as well as Pennsylvania and New Jersey in a separate case.
The nationwide ban against the rules will remain in effect while the cases continue through the court system.
Consider caffeine effects on children and adolescents
Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.
Caffeine usage in children and adolescents
Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:
- Soda (12 oz). About 40 mg caffeine.
- Coffee (8 oz). About 100 mg caffeine.
- Tea (8 oz). About 48 mg caffeine.
- Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.
It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.
With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
Effects of caffeine
As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.
Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.
There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.
A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.
There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
Conclusions
This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at [email protected]. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).
Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.
Caffeine usage in children and adolescents
Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:
- Soda (12 oz). About 40 mg caffeine.
- Coffee (8 oz). About 100 mg caffeine.
- Tea (8 oz). About 48 mg caffeine.
- Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.
It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.
With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
Effects of caffeine
As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.
Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.
There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.
A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.
There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
Conclusions
This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at [email protected]. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).
Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.
Caffeine usage in children and adolescents
Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:
- Soda (12 oz). About 40 mg caffeine.
- Coffee (8 oz). About 100 mg caffeine.
- Tea (8 oz). About 48 mg caffeine.
- Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.
It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.
With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
Effects of caffeine
As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.
Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.
There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.
A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.
There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
Conclusions
This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at [email protected]. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).
Prenatal valproate and ADHD
Also today, one expert calls for better ways to preserve beta cell function in youth, synthetic opioids drive a spike in the number of fatal overdoses, and mothers may play a role in the link between depression in fathers and daughters.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, one expert calls for better ways to preserve beta cell function in youth, synthetic opioids drive a spike in the number of fatal overdoses, and mothers may play a role in the link between depression in fathers and daughters.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, one expert calls for better ways to preserve beta cell function in youth, synthetic opioids drive a spike in the number of fatal overdoses, and mothers may play a role in the link between depression in fathers and daughters.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Expert calls for better ways to preserve beta cell function in youth
LOS ANGELES –
At the same time, the SEARCH for Diabetes in Youth trial showed that the incidence of T2DM in U.S. youth continues to rise, especially among Native Americans and non-Hispanic blacks (P less than .001 for both associations; N Engl J Med. 2017;376:1419-29). In addition, the earlier Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study showed that rapid treatment failure in youth-onset T2DM was associated with loss of beta cell function (N Engl J Med. 2012;366:2247-56).
“Early treatment of youth with impaired glucose tolerance or type 2 diabetes may require other medications alone or in combination or for longer periods of time to combat the severe insulin resistance of puberty and arrest progressive loss of beta cell function,” Sonia Caprio, MD, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease.
She based her remarks on a review of the recently completed multicenter Restoring Insulin Secretion (RISE) Pediatric Medication Study, (Diabetes Care 2018;41[8]:1717-25). It set out to answer the following question: In adolescents with impaired glucose tolerance or recently diagnosed T2DM, can beta cell function be preserved or improved during 12 months of active treatment and maintained for 3 months following the withdrawal of therapy?
To find out, Dr. Caprio, a pediatric endocrinologist at Yale University, New Haven, Conn., and her colleagues enrolled 91 youth who were randomized to one of two treatment arms: metformin alone titrated over 4 weeks from 500 mg/day to a 1,000 mg twice daily dose (modified if necessary due to GI symptoms), or to glargine followed by metformin. This group received once-daily insulin glargine, titrated twice weekly over 1 month based on daily self-monitoring of blood glucose to a goal of 80-90 mg/dL. Glargine was discontinued after 3 months and metformin was titrated. Beta-cell function (insulin sensitivity paired with beta-cell responses) was assessed by the two-step hyperglycemic clamp at baseline, 12 months (on treatment), and 15 months (3 months off treatment). All clinical data were collected 3 months after discontinuation of active treatment.
Dr. Caprio described the two-step hyperglycemic clamp as “a robust approach to quantification of insulin sensitivity and beta-cell responses to both glucose and the nonglucose secretagogue arginine. It provides mechanistic insights into how the tested interventions affected two key metabolic defects of type 2 diabetes: insulin sensitivity and beta cell responses.”
The mean age of patients was 14 years, 71% were female, their mean body mass index was 37 kg/m2. The researchers observed no significant differences between treatment groups at baseline, 12 months, or 15 months in beta cell function, BMI percentile, hemoglobin A1c, fasting glucose, or oral glucose tolerance test 2-hour glucose results. In both treatment groups, clamp-measured beta cell function was significantly lower at 12 and 15 months, compared with baseline. HbA1c fell transiently at 6 months within both groups. BMI was higher in the glargine followed by metformin versus metformin alone group between 3 and 9 months. Only 5% of participants discontinued the interventions, and both treatments were well tolerated.
“These findings are discouraging,” Dr. Caprio said. “They contrast with previous studies in adults showing an improvement in beta cell function with metformin or insulin for type 2 diabetes prevention and treatment.” Results of the RISE Pediatric Medication Study “call for further studies to better understand the physiology underlying beta cell dysfunction in youth to identify effective treatment options. Better approaches to prevent and treat obesity in youth are critically needed.”
Dr. Caprio reported having no disclosures.
LOS ANGELES –
At the same time, the SEARCH for Diabetes in Youth trial showed that the incidence of T2DM in U.S. youth continues to rise, especially among Native Americans and non-Hispanic blacks (P less than .001 for both associations; N Engl J Med. 2017;376:1419-29). In addition, the earlier Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study showed that rapid treatment failure in youth-onset T2DM was associated with loss of beta cell function (N Engl J Med. 2012;366:2247-56).
“Early treatment of youth with impaired glucose tolerance or type 2 diabetes may require other medications alone or in combination or for longer periods of time to combat the severe insulin resistance of puberty and arrest progressive loss of beta cell function,” Sonia Caprio, MD, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease.
She based her remarks on a review of the recently completed multicenter Restoring Insulin Secretion (RISE) Pediatric Medication Study, (Diabetes Care 2018;41[8]:1717-25). It set out to answer the following question: In adolescents with impaired glucose tolerance or recently diagnosed T2DM, can beta cell function be preserved or improved during 12 months of active treatment and maintained for 3 months following the withdrawal of therapy?
To find out, Dr. Caprio, a pediatric endocrinologist at Yale University, New Haven, Conn., and her colleagues enrolled 91 youth who were randomized to one of two treatment arms: metformin alone titrated over 4 weeks from 500 mg/day to a 1,000 mg twice daily dose (modified if necessary due to GI symptoms), or to glargine followed by metformin. This group received once-daily insulin glargine, titrated twice weekly over 1 month based on daily self-monitoring of blood glucose to a goal of 80-90 mg/dL. Glargine was discontinued after 3 months and metformin was titrated. Beta-cell function (insulin sensitivity paired with beta-cell responses) was assessed by the two-step hyperglycemic clamp at baseline, 12 months (on treatment), and 15 months (3 months off treatment). All clinical data were collected 3 months after discontinuation of active treatment.
Dr. Caprio described the two-step hyperglycemic clamp as “a robust approach to quantification of insulin sensitivity and beta-cell responses to both glucose and the nonglucose secretagogue arginine. It provides mechanistic insights into how the tested interventions affected two key metabolic defects of type 2 diabetes: insulin sensitivity and beta cell responses.”
The mean age of patients was 14 years, 71% were female, their mean body mass index was 37 kg/m2. The researchers observed no significant differences between treatment groups at baseline, 12 months, or 15 months in beta cell function, BMI percentile, hemoglobin A1c, fasting glucose, or oral glucose tolerance test 2-hour glucose results. In both treatment groups, clamp-measured beta cell function was significantly lower at 12 and 15 months, compared with baseline. HbA1c fell transiently at 6 months within both groups. BMI was higher in the glargine followed by metformin versus metformin alone group between 3 and 9 months. Only 5% of participants discontinued the interventions, and both treatments were well tolerated.
“These findings are discouraging,” Dr. Caprio said. “They contrast with previous studies in adults showing an improvement in beta cell function with metformin or insulin for type 2 diabetes prevention and treatment.” Results of the RISE Pediatric Medication Study “call for further studies to better understand the physiology underlying beta cell dysfunction in youth to identify effective treatment options. Better approaches to prevent and treat obesity in youth are critically needed.”
Dr. Caprio reported having no disclosures.
LOS ANGELES –
At the same time, the SEARCH for Diabetes in Youth trial showed that the incidence of T2DM in U.S. youth continues to rise, especially among Native Americans and non-Hispanic blacks (P less than .001 for both associations; N Engl J Med. 2017;376:1419-29). In addition, the earlier Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study showed that rapid treatment failure in youth-onset T2DM was associated with loss of beta cell function (N Engl J Med. 2012;366:2247-56).
“Early treatment of youth with impaired glucose tolerance or type 2 diabetes may require other medications alone or in combination or for longer periods of time to combat the severe insulin resistance of puberty and arrest progressive loss of beta cell function,” Sonia Caprio, MD, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease.
She based her remarks on a review of the recently completed multicenter Restoring Insulin Secretion (RISE) Pediatric Medication Study, (Diabetes Care 2018;41[8]:1717-25). It set out to answer the following question: In adolescents with impaired glucose tolerance or recently diagnosed T2DM, can beta cell function be preserved or improved during 12 months of active treatment and maintained for 3 months following the withdrawal of therapy?
To find out, Dr. Caprio, a pediatric endocrinologist at Yale University, New Haven, Conn., and her colleagues enrolled 91 youth who were randomized to one of two treatment arms: metformin alone titrated over 4 weeks from 500 mg/day to a 1,000 mg twice daily dose (modified if necessary due to GI symptoms), or to glargine followed by metformin. This group received once-daily insulin glargine, titrated twice weekly over 1 month based on daily self-monitoring of blood glucose to a goal of 80-90 mg/dL. Glargine was discontinued after 3 months and metformin was titrated. Beta-cell function (insulin sensitivity paired with beta-cell responses) was assessed by the two-step hyperglycemic clamp at baseline, 12 months (on treatment), and 15 months (3 months off treatment). All clinical data were collected 3 months after discontinuation of active treatment.
Dr. Caprio described the two-step hyperglycemic clamp as “a robust approach to quantification of insulin sensitivity and beta-cell responses to both glucose and the nonglucose secretagogue arginine. It provides mechanistic insights into how the tested interventions affected two key metabolic defects of type 2 diabetes: insulin sensitivity and beta cell responses.”
The mean age of patients was 14 years, 71% were female, their mean body mass index was 37 kg/m2. The researchers observed no significant differences between treatment groups at baseline, 12 months, or 15 months in beta cell function, BMI percentile, hemoglobin A1c, fasting glucose, or oral glucose tolerance test 2-hour glucose results. In both treatment groups, clamp-measured beta cell function was significantly lower at 12 and 15 months, compared with baseline. HbA1c fell transiently at 6 months within both groups. BMI was higher in the glargine followed by metformin versus metformin alone group between 3 and 9 months. Only 5% of participants discontinued the interventions, and both treatments were well tolerated.
“These findings are discouraging,” Dr. Caprio said. “They contrast with previous studies in adults showing an improvement in beta cell function with metformin or insulin for type 2 diabetes prevention and treatment.” Results of the RISE Pediatric Medication Study “call for further studies to better understand the physiology underlying beta cell dysfunction in youth to identify effective treatment options. Better approaches to prevent and treat obesity in youth are critically needed.”
Dr. Caprio reported having no disclosures.
EXPERT ANALYSIS FROM WCIRDC 2018