Pediatrics

Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin, Madison, teaches patients how to breathe mindfully. So does Kathy Farah, MD, an integrative family physician who practices in Roberts, Wis.

Mindful breathing is the most basic mind-body skill and one that can help interrupt the itch-scratch cycle and relieve pain, stress, and distress often experienced by children, teens, and adults with dermatologic conditions, they said at the annual Integrative Dermatology Symposium.

“As with any integrative modality, if it’s safe and effective, then let’s use it,” Dr. Farah said in a presentation on the mind-body approach to pain and itch.

“A breathwork session can literally take 1 minute,” said Dr. Bodemer, associate professor of dermatology at the University of Wisconsin and director of an integrative dermatology clinic. Dr. Bodemer, who completed a fellowship in integrative medicine at the Andrew Weil Center for Integrative Medicine at the University of Arizona and sits on the American Board of Integrative Medicine, spoke on a mindfulness panel at the meeting.

Her favorite breathing practice is the “4-7-8” breath taught by Andrew Weil, MD, founder and director of the center. This involves inhaling through the nose for a count of 4, holding for 7, and exhaling through the mouth for a count of 8. “It doesn’t matter how slow or fast, it’s the tempo that matters ... On exhale, squeeze your abs in to engage your core and get air out of your lungs as much as you can,” she said, advising a cycle of three at a time.

A technique known as “square breathing” (breath in 4, hold for 4, breath out for 4, hold for 4) is another helpful technique to “reset the nervous system” said Dr. Farah, who worked for many years in a children’s hospital. With children, she said, “I often do five finger breathing.”

For five finger breathing, the children spread their fingers apart in front of them or on the ground and use the pointer finger of the opposite hand to trace each finger, inhaling while tracing upward, and exhaling while tracing down.

Dr. Farah, associate clinical director of The Center for Mind-Body Medicine in Washington, DC, said her commitment to mindfulness was influenced by a “seminal” study published over 20 years ago showing that patients with moderate to severe psoriasis who used a meditation-based, audiotape-guided stress reduction intervention during phototherapy sessions had more rapid resolution of psoriatic lesions than did patients who didn’t use the mindfulness exercise.

Among more recent findings: A cross-sectional study of 120 adult dermatology patients, published in the British Journal of Dermatology in 2016, assessed skin shame, social anxiety, anxiety, depression, dermatological quality of life, and levels of mindfulness, and found that higher levels of mindfulness were associated with lower levels of psychosocial distress.

Another cross-sectional questionnaire study looked at mindfulness and “itch catastrophizing” in 155 adult patients with atopic dermatitis. Higher levels of a specific facet of mindfulness termed “acting with awareness” were associated with lower levels of itch catastrophizing, the researchers found. “Catastrophizing is a negative way of thinking, this itching will never stop,” Dr. Farah explained. The study shows that “mindfulness can actually help reduce some of the automatic scratching and response to itch. So it’s a great adjunct to pharmaceuticals.”

Affirmations – phrases and statements that are repeated to oneself to help challenge negative thoughts – can also help reverse itch catastrophizing. Statements such as “I can breathe through this feeling of itching,” or “I can move to feel comfortable and relaxed” encourage positive change, she said.

“I teach [mindfulness skills like breathing] a lot, without any expectations. I’ll say ‘give it a try and see what you think.’ If patients feel even a micron better, then they’re invested” and can then find numerous tools online, Dr. Farah said. “Can I do this [in a busy schedule] with every patient? Absolutely not. But can I do it with every 10th patient? Maybe.”

Dr. Bodemer’s experience has shown her that “breathing with your patient builds rapport,” she said. “There’s something very powerful in that in terms of building trust. ... I’ll just do it [during a visit, to show them] and almost always, patients start breathing with me, with an invitation or without.”

For her own health, 4-7-8 breathing has “been a gateway to meditation and deeper practices,” she said. “But even without going very deep, it has a long history of being able to modulate the stress response. It’s the parasympathetic-sympathetic rebalancing I’m interested in.”

Mindful breathing and other mind-body practices also can be helpful for parents of children with eczema, she and Dr. Farah said.

Dr. Bodemer and Dr. Farah reported no financial relationships to disclose.

Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin, Madison, teaches patients how to breathe mindfully. So does Kathy Farah, MD, an integrative family physician who practices in Roberts, Wis.

Mindful breathing is the most basic mind-body skill and one that can help interrupt the itch-scratch cycle and relieve pain, stress, and distress often experienced by children, teens, and adults with dermatologic conditions, they said at the annual Integrative Dermatology Symposium.

“As with any integrative modality, if it’s safe and effective, then let’s use it,” Dr. Farah said in a presentation on the mind-body approach to pain and itch.

“A breathwork session can literally take 1 minute,” said Dr. Bodemer, associate professor of dermatology at the University of Wisconsin and director of an integrative dermatology clinic. Dr. Bodemer, who completed a fellowship in integrative medicine at the Andrew Weil Center for Integrative Medicine at the University of Arizona and sits on the American Board of Integrative Medicine, spoke on a mindfulness panel at the meeting.

Her favorite breathing practice is the “4-7-8” breath taught by Andrew Weil, MD, founder and director of the center. This involves inhaling through the nose for a count of 4, holding for 7, and exhaling through the mouth for a count of 8. “It doesn’t matter how slow or fast, it’s the tempo that matters ... On exhale, squeeze your abs in to engage your core and get air out of your lungs as much as you can,” she said, advising a cycle of three at a time.

A technique known as “square breathing” (breath in 4, hold for 4, breath out for 4, hold for 4) is another helpful technique to “reset the nervous system” said Dr. Farah, who worked for many years in a children’s hospital. With children, she said, “I often do five finger breathing.”

For five finger breathing, the children spread their fingers apart in front of them or on the ground and use the pointer finger of the opposite hand to trace each finger, inhaling while tracing upward, and exhaling while tracing down.

Dr. Farah, associate clinical director of The Center for Mind-Body Medicine in Washington, DC, said her commitment to mindfulness was influenced by a “seminal” study published over 20 years ago showing that patients with moderate to severe psoriasis who used a meditation-based, audiotape-guided stress reduction intervention during phototherapy sessions had more rapid resolution of psoriatic lesions than did patients who didn’t use the mindfulness exercise.

Among more recent findings: A cross-sectional study of 120 adult dermatology patients, published in the British Journal of Dermatology in 2016, assessed skin shame, social anxiety, anxiety, depression, dermatological quality of life, and levels of mindfulness, and found that higher levels of mindfulness were associated with lower levels of psychosocial distress.

Another cross-sectional questionnaire study looked at mindfulness and “itch catastrophizing” in 155 adult patients with atopic dermatitis. Higher levels of a specific facet of mindfulness termed “acting with awareness” were associated with lower levels of itch catastrophizing, the researchers found. “Catastrophizing is a negative way of thinking, this itching will never stop,” Dr. Farah explained. The study shows that “mindfulness can actually help reduce some of the automatic scratching and response to itch. So it’s a great adjunct to pharmaceuticals.”

Affirmations – phrases and statements that are repeated to oneself to help challenge negative thoughts – can also help reverse itch catastrophizing. Statements such as “I can breathe through this feeling of itching,” or “I can move to feel comfortable and relaxed” encourage positive change, she said.

“I teach [mindfulness skills like breathing] a lot, without any expectations. I’ll say ‘give it a try and see what you think.’ If patients feel even a micron better, then they’re invested” and can then find numerous tools online, Dr. Farah said. “Can I do this [in a busy schedule] with every patient? Absolutely not. But can I do it with every 10th patient? Maybe.”

Dr. Bodemer’s experience has shown her that “breathing with your patient builds rapport,” she said. “There’s something very powerful in that in terms of building trust. ... I’ll just do it [during a visit, to show them] and almost always, patients start breathing with me, with an invitation or without.”

For her own health, 4-7-8 breathing has “been a gateway to meditation and deeper practices,” she said. “But even without going very deep, it has a long history of being able to modulate the stress response. It’s the parasympathetic-sympathetic rebalancing I’m interested in.”

Mindful breathing and other mind-body practices also can be helpful for parents of children with eczema, she and Dr. Farah said.

Dr. Bodemer and Dr. Farah reported no financial relationships to disclose.

Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin, Madison, teaches patients how to breathe mindfully. So does Kathy Farah, MD, an integrative family physician who practices in Roberts, Wis.

Mindful breathing is the most basic mind-body skill and one that can help interrupt the itch-scratch cycle and relieve pain, stress, and distress often experienced by children, teens, and adults with dermatologic conditions, they said at the annual Integrative Dermatology Symposium.

“As with any integrative modality, if it’s safe and effective, then let’s use it,” Dr. Farah said in a presentation on the mind-body approach to pain and itch.

“A breathwork session can literally take 1 minute,” said Dr. Bodemer, associate professor of dermatology at the University of Wisconsin and director of an integrative dermatology clinic. Dr. Bodemer, who completed a fellowship in integrative medicine at the Andrew Weil Center for Integrative Medicine at the University of Arizona and sits on the American Board of Integrative Medicine, spoke on a mindfulness panel at the meeting.

Her favorite breathing practice is the “4-7-8” breath taught by Andrew Weil, MD, founder and director of the center. This involves inhaling through the nose for a count of 4, holding for 7, and exhaling through the mouth for a count of 8. “It doesn’t matter how slow or fast, it’s the tempo that matters ... On exhale, squeeze your abs in to engage your core and get air out of your lungs as much as you can,” she said, advising a cycle of three at a time.

A technique known as “square breathing” (breath in 4, hold for 4, breath out for 4, hold for 4) is another helpful technique to “reset the nervous system” said Dr. Farah, who worked for many years in a children’s hospital. With children, she said, “I often do five finger breathing.”

For five finger breathing, the children spread their fingers apart in front of them or on the ground and use the pointer finger of the opposite hand to trace each finger, inhaling while tracing upward, and exhaling while tracing down.

Dr. Farah, associate clinical director of The Center for Mind-Body Medicine in Washington, DC, said her commitment to mindfulness was influenced by a “seminal” study published over 20 years ago showing that patients with moderate to severe psoriasis who used a meditation-based, audiotape-guided stress reduction intervention during phototherapy sessions had more rapid resolution of psoriatic lesions than did patients who didn’t use the mindfulness exercise.

Among more recent findings: A cross-sectional study of 120 adult dermatology patients, published in the British Journal of Dermatology in 2016, assessed skin shame, social anxiety, anxiety, depression, dermatological quality of life, and levels of mindfulness, and found that higher levels of mindfulness were associated with lower levels of psychosocial distress.

Another cross-sectional questionnaire study looked at mindfulness and “itch catastrophizing” in 155 adult patients with atopic dermatitis. Higher levels of a specific facet of mindfulness termed “acting with awareness” were associated with lower levels of itch catastrophizing, the researchers found. “Catastrophizing is a negative way of thinking, this itching will never stop,” Dr. Farah explained. The study shows that “mindfulness can actually help reduce some of the automatic scratching and response to itch. So it’s a great adjunct to pharmaceuticals.”

Affirmations – phrases and statements that are repeated to oneself to help challenge negative thoughts – can also help reverse itch catastrophizing. Statements such as “I can breathe through this feeling of itching,” or “I can move to feel comfortable and relaxed” encourage positive change, she said.

“I teach [mindfulness skills like breathing] a lot, without any expectations. I’ll say ‘give it a try and see what you think.’ If patients feel even a micron better, then they’re invested” and can then find numerous tools online, Dr. Farah said. “Can I do this [in a busy schedule] with every patient? Absolutely not. But can I do it with every 10th patient? Maybe.”

Dr. Bodemer’s experience has shown her that “breathing with your patient builds rapport,” she said. “There’s something very powerful in that in terms of building trust. ... I’ll just do it [during a visit, to show them] and almost always, patients start breathing with me, with an invitation or without.”

For her own health, 4-7-8 breathing has “been a gateway to meditation and deeper practices,” she said. “But even without going very deep, it has a long history of being able to modulate the stress response. It’s the parasympathetic-sympathetic rebalancing I’m interested in.”

Mindful breathing and other mind-body practices also can be helpful for parents of children with eczema, she and Dr. Farah said.

Dr. Bodemer and Dr. Farah reported no financial relationships to disclose.

The successful treatment of Pompe disease in utero for the first time may be the start of a new chapter for fetal therapy, researchers said.

A report published online in the New England Journal of Medicine describes in utero enzyme-replacement therapy (ERT) for infantile-onset Pompe disease.

The patient, now a toddler, is thriving, according to the researchers. Her parents previously had children with the same disorder who died.

“This treatment expands the repertoire of fetal therapies in a new direction,” Tippi MacKenzie, MD, a pediatric surgeon with University of California, San Francisco, Benioff Children’s Hospitals and a coauthor of the report, said in a news release. “As new treatments become available for children with genetic conditions, we are developing protocols to apply them before birth.”

Dr. MacKenzie codirects the University of California, San Francisco’s center for maternal-fetal precision medicine and directs the Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research.

Pompe disease is caused by mutations in a gene that makes acid alpha-glucosidase. With limited amounts of this enzyme, dangerous amounts of glycogen accumulate in the body. Babies with infantile-onset disease typically have enlarged hearts and die by age 2 years.

The condition, which occurs in an estimated 1 in 40,000 births, is one of several early-onset lysosomal storage disorders. Patients with these diseases “are ideal candidates for prenatal therapy because organ damage starts in utero,” the researchers said.

Newborn screening can lead to early initiation of treatment with recombinant enzymes, “but this strategy does not completely prevent irreversible organ damage,” the authors said.

The patient in the new report received six prenatal ERT treatments at the Ottawa Hospital and is receiving postnatal enzyme therapy at CHEO, a pediatric hospital and research center in Ottawa.

Investigators administered alglucosidase alfa through the umbilical vein. They delivered the first infusion to the fetus at 24 weeks 5 days of gestation. They continued providing infusions at 2-week intervals through 34 weeks 5 days of gestation.

She is doing well at age 16 months, with normal cardiac and motor function, and is meeting developmental milestones, according to the news release.

The successful treatment involved collaboration among the University of California, San Francisco, where researchers are conducting a clinical trial of this treatment approach; CHEO and the Ottawa Hospital; and Duke University, Durham, N.C.

Under normal circumstances, the patient’s family would have traveled to Benioff Children’s Hospitals fetal treatment center to participate in the clinical trial, but COVID-19 restrictions led the researchers to deliver the therapy to Ottawa as part of the trial.

The University of California, San Francisco, has received U.S. Food and Drug Administration approval to treat Pompe disease and several other lysosomal storage disorders in utero as part of a phase 1 clinical trial with 10 patients. The other diseases are mucopolysaccharidosis types 1, 2, 4a, 6, and 7; Gaucher disease types 2 and 3; and Wolman disease.

Patients with Pompe disease might typically be diagnosed clinically at age 3-6 months, said study coauthor Paul Harmatz, MD, with the University of California, San Francisco. With newborn screening, the disease might be diagnosed at 1 week. But intervening before birth may be optimal, Dr. Harmatz said.

Fetal treatment appears to be “revolutionary at this point,” Dr. Harmatz said.

The research was supported by a grant from the National Institutes of Health. Sanofi Genzyme provided the enzyme for the patient.

A version of this article first appeared on Medscape.com.

The successful treatment of Pompe disease in utero for the first time may be the start of a new chapter for fetal therapy, researchers said.

A report published online in the New England Journal of Medicine describes in utero enzyme-replacement therapy (ERT) for infantile-onset Pompe disease.

The patient, now a toddler, is thriving, according to the researchers. Her parents previously had children with the same disorder who died.

“This treatment expands the repertoire of fetal therapies in a new direction,” Tippi MacKenzie, MD, a pediatric surgeon with University of California, San Francisco, Benioff Children’s Hospitals and a coauthor of the report, said in a news release. “As new treatments become available for children with genetic conditions, we are developing protocols to apply them before birth.”

Dr. MacKenzie codirects the University of California, San Francisco’s center for maternal-fetal precision medicine and directs the Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research.

Pompe disease is caused by mutations in a gene that makes acid alpha-glucosidase. With limited amounts of this enzyme, dangerous amounts of glycogen accumulate in the body. Babies with infantile-onset disease typically have enlarged hearts and die by age 2 years.

The condition, which occurs in an estimated 1 in 40,000 births, is one of several early-onset lysosomal storage disorders. Patients with these diseases “are ideal candidates for prenatal therapy because organ damage starts in utero,” the researchers said.

Newborn screening can lead to early initiation of treatment with recombinant enzymes, “but this strategy does not completely prevent irreversible organ damage,” the authors said.

The patient in the new report received six prenatal ERT treatments at the Ottawa Hospital and is receiving postnatal enzyme therapy at CHEO, a pediatric hospital and research center in Ottawa.

Investigators administered alglucosidase alfa through the umbilical vein. They delivered the first infusion to the fetus at 24 weeks 5 days of gestation. They continued providing infusions at 2-week intervals through 34 weeks 5 days of gestation.

She is doing well at age 16 months, with normal cardiac and motor function, and is meeting developmental milestones, according to the news release.

The successful treatment involved collaboration among the University of California, San Francisco, where researchers are conducting a clinical trial of this treatment approach; CHEO and the Ottawa Hospital; and Duke University, Durham, N.C.

Under normal circumstances, the patient’s family would have traveled to Benioff Children’s Hospitals fetal treatment center to participate in the clinical trial, but COVID-19 restrictions led the researchers to deliver the therapy to Ottawa as part of the trial.

The University of California, San Francisco, has received U.S. Food and Drug Administration approval to treat Pompe disease and several other lysosomal storage disorders in utero as part of a phase 1 clinical trial with 10 patients. The other diseases are mucopolysaccharidosis types 1, 2, 4a, 6, and 7; Gaucher disease types 2 and 3; and Wolman disease.

Patients with Pompe disease might typically be diagnosed clinically at age 3-6 months, said study coauthor Paul Harmatz, MD, with the University of California, San Francisco. With newborn screening, the disease might be diagnosed at 1 week. But intervening before birth may be optimal, Dr. Harmatz said.

Fetal treatment appears to be “revolutionary at this point,” Dr. Harmatz said.

The research was supported by a grant from the National Institutes of Health. Sanofi Genzyme provided the enzyme for the patient.

A version of this article first appeared on Medscape.com.

The successful treatment of Pompe disease in utero for the first time may be the start of a new chapter for fetal therapy, researchers said.

A report published online in the New England Journal of Medicine describes in utero enzyme-replacement therapy (ERT) for infantile-onset Pompe disease.

The patient, now a toddler, is thriving, according to the researchers. Her parents previously had children with the same disorder who died.

“This treatment expands the repertoire of fetal therapies in a new direction,” Tippi MacKenzie, MD, a pediatric surgeon with University of California, San Francisco, Benioff Children’s Hospitals and a coauthor of the report, said in a news release. “As new treatments become available for children with genetic conditions, we are developing protocols to apply them before birth.”

Dr. MacKenzie codirects the University of California, San Francisco’s center for maternal-fetal precision medicine and directs the Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research.

Pompe disease is caused by mutations in a gene that makes acid alpha-glucosidase. With limited amounts of this enzyme, dangerous amounts of glycogen accumulate in the body. Babies with infantile-onset disease typically have enlarged hearts and die by age 2 years.

The condition, which occurs in an estimated 1 in 40,000 births, is one of several early-onset lysosomal storage disorders. Patients with these diseases “are ideal candidates for prenatal therapy because organ damage starts in utero,” the researchers said.

Newborn screening can lead to early initiation of treatment with recombinant enzymes, “but this strategy does not completely prevent irreversible organ damage,” the authors said.

The patient in the new report received six prenatal ERT treatments at the Ottawa Hospital and is receiving postnatal enzyme therapy at CHEO, a pediatric hospital and research center in Ottawa.

Investigators administered alglucosidase alfa through the umbilical vein. They delivered the first infusion to the fetus at 24 weeks 5 days of gestation. They continued providing infusions at 2-week intervals through 34 weeks 5 days of gestation.

She is doing well at age 16 months, with normal cardiac and motor function, and is meeting developmental milestones, according to the news release.

The successful treatment involved collaboration among the University of California, San Francisco, where researchers are conducting a clinical trial of this treatment approach; CHEO and the Ottawa Hospital; and Duke University, Durham, N.C.

Under normal circumstances, the patient’s family would have traveled to Benioff Children’s Hospitals fetal treatment center to participate in the clinical trial, but COVID-19 restrictions led the researchers to deliver the therapy to Ottawa as part of the trial.

The University of California, San Francisco, has received U.S. Food and Drug Administration approval to treat Pompe disease and several other lysosomal storage disorders in utero as part of a phase 1 clinical trial with 10 patients. The other diseases are mucopolysaccharidosis types 1, 2, 4a, 6, and 7; Gaucher disease types 2 and 3; and Wolman disease.

Patients with Pompe disease might typically be diagnosed clinically at age 3-6 months, said study coauthor Paul Harmatz, MD, with the University of California, San Francisco. With newborn screening, the disease might be diagnosed at 1 week. But intervening before birth may be optimal, Dr. Harmatz said.

Fetal treatment appears to be “revolutionary at this point,” Dr. Harmatz said.

The research was supported by a grant from the National Institutes of Health. Sanofi Genzyme provided the enzyme for the patient.

A version of this article first appeared on Medscape.com.

Cold and flu season came early in 2022.

On Nov. 4, 2022, the Centers for Disease Control and Prevention issued a Health Alert Network Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses other than SARS-CoV-2.

Interseasonal spread of respiratory syncytial virus has continued in 2022, with RSV-associated hospitalizations increasing in the late spring and continuing throughout the summer and into the fall. In October, some regions of the country were seeing RSV activity near the peak seasonal levels typically observed in December and January.

Cases of severe respiratory infection in children who tested positive for rhinovirus or enterovirus spiked in August; further testing confirmed the presence of EV-D68 in some children. Rhinovirus and enterovirus continue to circulate and are isolated in hospitalized children with respiratory illness.

In some parts of the country, influenza cases have rapidly increased ahead of what we normally anticipate. According to preliminary estimates from the CDC, between Oct. 1 and Oct. 22, 880,000 people were sickened with flu, 420,000 people visited a health care provider for flu illness, and 6,900 people were hospitalized for flu. The cumulative hospitalization rate is higher than observed at this time of year in every previous flu season since 2010-2011. Hospitalization rates are highest in children aged 0-4 years and adults 65 years and older.

Of course, this report came as no surprise to pediatric health care providers. Many children’s hospitals had been operating at or over capacity for weeks. While a systematic assessment of the surge on children’s hospitals has not been published, anecdotally, hospitals from around the country have described record emergency department visits and inpatient census numbers. Some have set up tents or other temporary facilities to see ambulatory patients and have canceled elective surgeries because of a lack of beds.

There is no quick or easy solution to stem the tide of RSV-related or enterovirus/rhinovirus admissions, but many flu-related hospitalizations are vaccine preventable. Unfortunately, too few children are receiving influenza vaccine. As of the week ending Oct. 15, only about 22.1% of eligible children had been immunized. The American Academy of Pediatrics and the CDC recommend that all children are vaccinated, preferably by the end of October so they have time to develop immunity before influenza starts circulating. As it stands now, the majority of the nation’s children are facing a flu season without the benefits of vaccine.

There is still time to take steps to prevent this flu season from becoming one of the worst in recent memory. A strong provider recommendation for influenza vaccine is consistently associated with higher rates of vaccine acceptance. We need to recommend influenza vaccine to all eligible patients at every visit and in every setting. It will help if we can say it like we mean it. Some of us are tired of debating the merits of COVID-19 vaccine with families and may be leery of additional debates about flu. Some of us may just be tired, as many practices have already expanded office hours to care for the influx of kids with respiratory illness. On the heels of two atypical flu seasons, a few of us may be quietly complacent about the importance of flu vaccines for children.

Anyone in need of a little motivation should check out a paper recently published in Clinical Infectious Diseases that reinforces the value of flu vaccine, even in a year when there is a poor match between the vaccine and circulating viruses.

The 2019-2020 flu season was a bad flu season for children. Two antigenically drifted influenza viruses predominated and cases of influenza soared, resulting in the largest influenza epidemic in children in the United States since 1992. Pediatric Intensive Care Influenza Study investigators used a test-negative design to estimate the effectiveness of influenza vaccine in preventing critical and life-threatening influenza in children during that season. The good news: vaccination reduced the risk of critical influenza by 78% against H1N1pdm09 viruses that were well-matched to vaccine and by 47% against mismatched viruses. Vaccination was estimated to be 75% protective against antigenically drifted B-Victoria viruses. Overall vaccine effectiveness against critical illness from any influenza virus was 63% (95% confidence interval, 38%-78%).

While it might be tempting to attribute suboptimal immunization rates to vaccine hesitancy, ready availability remains an issue for some families. We need to eliminate barriers to access. While the AAP continues to emphasize immunization in the medical home, especially for the youngest infants, the 2022 policy statement suggests that vaccinating children in schools, pharmacies, and other nontraditional settings could improve immunization rates. To the extent feasible, we need to work with partners to support community-based initiatives and promote these to families who struggle to make it into the office.

Improving access is just one potential way to reduce health disparities related to influenza and influenza vaccination. Over 10 influenza seasons, higher rates of influenza-associated hospitalizations and intensive care unit admissions were observed in Black, Hispanic, and American Indian/Alaska Native people. These disparities were highest in children aged younger than 4 years and influenza-associated in-hospital deaths were three- to fourfold higher in Black, Hispanic, and Asian/Pacific Islander children, compared with White children. The reason for the disparities isn’t completely clear but increasing immunization rates may be part of the solution. During the 2020-2021 influenza season, flu immunization rates in Black children (51.6%) were lower than those seen in White (57.4%) and Hispanic children (58.9%).

The AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023, highlight a variety of evidence-based strategies to increase influenza immunization rates. These may provide a little inspiration for clinicians looking to try a new approach. If you wish to share your experience with increasing influenza immunization rates in your practice setting, please email me at [email protected].

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead.

Cold and flu season came early in 2022.

On Nov. 4, 2022, the Centers for Disease Control and Prevention issued a Health Alert Network Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses other than SARS-CoV-2.

Interseasonal spread of respiratory syncytial virus has continued in 2022, with RSV-associated hospitalizations increasing in the late spring and continuing throughout the summer and into the fall. In October, some regions of the country were seeing RSV activity near the peak seasonal levels typically observed in December and January.

Cases of severe respiratory infection in children who tested positive for rhinovirus or enterovirus spiked in August; further testing confirmed the presence of EV-D68 in some children. Rhinovirus and enterovirus continue to circulate and are isolated in hospitalized children with respiratory illness.

In some parts of the country, influenza cases have rapidly increased ahead of what we normally anticipate. According to preliminary estimates from the CDC, between Oct. 1 and Oct. 22, 880,000 people were sickened with flu, 420,000 people visited a health care provider for flu illness, and 6,900 people were hospitalized for flu. The cumulative hospitalization rate is higher than observed at this time of year in every previous flu season since 2010-2011. Hospitalization rates are highest in children aged 0-4 years and adults 65 years and older.

Of course, this report came as no surprise to pediatric health care providers. Many children’s hospitals had been operating at or over capacity for weeks. While a systematic assessment of the surge on children’s hospitals has not been published, anecdotally, hospitals from around the country have described record emergency department visits and inpatient census numbers. Some have set up tents or other temporary facilities to see ambulatory patients and have canceled elective surgeries because of a lack of beds.

There is no quick or easy solution to stem the tide of RSV-related or enterovirus/rhinovirus admissions, but many flu-related hospitalizations are vaccine preventable. Unfortunately, too few children are receiving influenza vaccine. As of the week ending Oct. 15, only about 22.1% of eligible children had been immunized. The American Academy of Pediatrics and the CDC recommend that all children are vaccinated, preferably by the end of October so they have time to develop immunity before influenza starts circulating. As it stands now, the majority of the nation’s children are facing a flu season without the benefits of vaccine.

There is still time to take steps to prevent this flu season from becoming one of the worst in recent memory. A strong provider recommendation for influenza vaccine is consistently associated with higher rates of vaccine acceptance. We need to recommend influenza vaccine to all eligible patients at every visit and in every setting. It will help if we can say it like we mean it. Some of us are tired of debating the merits of COVID-19 vaccine with families and may be leery of additional debates about flu. Some of us may just be tired, as many practices have already expanded office hours to care for the influx of kids with respiratory illness. On the heels of two atypical flu seasons, a few of us may be quietly complacent about the importance of flu vaccines for children.

Anyone in need of a little motivation should check out a paper recently published in Clinical Infectious Diseases that reinforces the value of flu vaccine, even in a year when there is a poor match between the vaccine and circulating viruses.

The 2019-2020 flu season was a bad flu season for children. Two antigenically drifted influenza viruses predominated and cases of influenza soared, resulting in the largest influenza epidemic in children in the United States since 1992. Pediatric Intensive Care Influenza Study investigators used a test-negative design to estimate the effectiveness of influenza vaccine in preventing critical and life-threatening influenza in children during that season. The good news: vaccination reduced the risk of critical influenza by 78% against H1N1pdm09 viruses that were well-matched to vaccine and by 47% against mismatched viruses. Vaccination was estimated to be 75% protective against antigenically drifted B-Victoria viruses. Overall vaccine effectiveness against critical illness from any influenza virus was 63% (95% confidence interval, 38%-78%).

While it might be tempting to attribute suboptimal immunization rates to vaccine hesitancy, ready availability remains an issue for some families. We need to eliminate barriers to access. While the AAP continues to emphasize immunization in the medical home, especially for the youngest infants, the 2022 policy statement suggests that vaccinating children in schools, pharmacies, and other nontraditional settings could improve immunization rates. To the extent feasible, we need to work with partners to support community-based initiatives and promote these to families who struggle to make it into the office.

Improving access is just one potential way to reduce health disparities related to influenza and influenza vaccination. Over 10 influenza seasons, higher rates of influenza-associated hospitalizations and intensive care unit admissions were observed in Black, Hispanic, and American Indian/Alaska Native people. These disparities were highest in children aged younger than 4 years and influenza-associated in-hospital deaths were three- to fourfold higher in Black, Hispanic, and Asian/Pacific Islander children, compared with White children. The reason for the disparities isn’t completely clear but increasing immunization rates may be part of the solution. During the 2020-2021 influenza season, flu immunization rates in Black children (51.6%) were lower than those seen in White (57.4%) and Hispanic children (58.9%).

The AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023, highlight a variety of evidence-based strategies to increase influenza immunization rates. These may provide a little inspiration for clinicians looking to try a new approach. If you wish to share your experience with increasing influenza immunization rates in your practice setting, please email me at [email protected].

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead.

Cold and flu season came early in 2022.

On Nov. 4, 2022, the Centers for Disease Control and Prevention issued a Health Alert Network Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses other than SARS-CoV-2.

Interseasonal spread of respiratory syncytial virus has continued in 2022, with RSV-associated hospitalizations increasing in the late spring and continuing throughout the summer and into the fall. In October, some regions of the country were seeing RSV activity near the peak seasonal levels typically observed in December and January.

Cases of severe respiratory infection in children who tested positive for rhinovirus or enterovirus spiked in August; further testing confirmed the presence of EV-D68 in some children. Rhinovirus and enterovirus continue to circulate and are isolated in hospitalized children with respiratory illness.

In some parts of the country, influenza cases have rapidly increased ahead of what we normally anticipate. According to preliminary estimates from the CDC, between Oct. 1 and Oct. 22, 880,000 people were sickened with flu, 420,000 people visited a health care provider for flu illness, and 6,900 people were hospitalized for flu. The cumulative hospitalization rate is higher than observed at this time of year in every previous flu season since 2010-2011. Hospitalization rates are highest in children aged 0-4 years and adults 65 years and older.

Of course, this report came as no surprise to pediatric health care providers. Many children’s hospitals had been operating at or over capacity for weeks. While a systematic assessment of the surge on children’s hospitals has not been published, anecdotally, hospitals from around the country have described record emergency department visits and inpatient census numbers. Some have set up tents or other temporary facilities to see ambulatory patients and have canceled elective surgeries because of a lack of beds.

There is no quick or easy solution to stem the tide of RSV-related or enterovirus/rhinovirus admissions, but many flu-related hospitalizations are vaccine preventable. Unfortunately, too few children are receiving influenza vaccine. As of the week ending Oct. 15, only about 22.1% of eligible children had been immunized. The American Academy of Pediatrics and the CDC recommend that all children are vaccinated, preferably by the end of October so they have time to develop immunity before influenza starts circulating. As it stands now, the majority of the nation’s children are facing a flu season without the benefits of vaccine.

There is still time to take steps to prevent this flu season from becoming one of the worst in recent memory. A strong provider recommendation for influenza vaccine is consistently associated with higher rates of vaccine acceptance. We need to recommend influenza vaccine to all eligible patients at every visit and in every setting. It will help if we can say it like we mean it. Some of us are tired of debating the merits of COVID-19 vaccine with families and may be leery of additional debates about flu. Some of us may just be tired, as many practices have already expanded office hours to care for the influx of kids with respiratory illness. On the heels of two atypical flu seasons, a few of us may be quietly complacent about the importance of flu vaccines for children.

Anyone in need of a little motivation should check out a paper recently published in Clinical Infectious Diseases that reinforces the value of flu vaccine, even in a year when there is a poor match between the vaccine and circulating viruses.

The 2019-2020 flu season was a bad flu season for children. Two antigenically drifted influenza viruses predominated and cases of influenza soared, resulting in the largest influenza epidemic in children in the United States since 1992. Pediatric Intensive Care Influenza Study investigators used a test-negative design to estimate the effectiveness of influenza vaccine in preventing critical and life-threatening influenza in children during that season. The good news: vaccination reduced the risk of critical influenza by 78% against H1N1pdm09 viruses that were well-matched to vaccine and by 47% against mismatched viruses. Vaccination was estimated to be 75% protective against antigenically drifted B-Victoria viruses. Overall vaccine effectiveness against critical illness from any influenza virus was 63% (95% confidence interval, 38%-78%).

While it might be tempting to attribute suboptimal immunization rates to vaccine hesitancy, ready availability remains an issue for some families. We need to eliminate barriers to access. While the AAP continues to emphasize immunization in the medical home, especially for the youngest infants, the 2022 policy statement suggests that vaccinating children in schools, pharmacies, and other nontraditional settings could improve immunization rates. To the extent feasible, we need to work with partners to support community-based initiatives and promote these to families who struggle to make it into the office.

Improving access is just one potential way to reduce health disparities related to influenza and influenza vaccination. Over 10 influenza seasons, higher rates of influenza-associated hospitalizations and intensive care unit admissions were observed in Black, Hispanic, and American Indian/Alaska Native people. These disparities were highest in children aged younger than 4 years and influenza-associated in-hospital deaths were three- to fourfold higher in Black, Hispanic, and Asian/Pacific Islander children, compared with White children. The reason for the disparities isn’t completely clear but increasing immunization rates may be part of the solution. During the 2020-2021 influenza season, flu immunization rates in Black children (51.6%) were lower than those seen in White (57.4%) and Hispanic children (58.9%).

The AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023, highlight a variety of evidence-based strategies to increase influenza immunization rates. These may provide a little inspiration for clinicians looking to try a new approach. If you wish to share your experience with increasing influenza immunization rates in your practice setting, please email me at [email protected].

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead.

As a physician in the heart of the opioid epidemic, Pavirthra R. Ellison, MD, has watched for years as her patients have lost parents to overdoses. More than 1,400 adults in West Virginia, where she practices, died of opioid abuse in 2021 alone, government statistics show.

The grim toll made Ellison wonder: What was happening to children in the state? The answer, according to a new study, is not reassuring.

Ellison and her colleagues have found a troubling link between a surge in critical head and neck injuries among youth in West Virginia and a spike in positive tests for opioids and benzodiazepines among children who arrive at emergency departments in the state. They don’t think the pattern is a coincidence.

“What we found was really kind of scary,” said Dr. Ellison, a professor of anesthesiology and pediatrics at West Virginia University, Morgantown. “Children in this region often get exposure to these drugs early on.”
 

A region in crisis

According to a 2020 report from the Department of Health & Human Services, about 9.9 million Americans abused prescription opioids in 2018. That same year, almost 47,000 died following an overdose of the painkillers. In 2017, Appalachian counties experienced a death rate from opioid overdoses that was 72% higher than that of the rest of the country.

Dr. Ellison and associates who presented their findings recently at the 2022 annual meeting of the American Society of Anesthesiologists, examined rates of pediatric trauma injuries, injury severity, and results of drug screenings throughout West Virginia between 2009 and 2019.

The study included 4,538 children and adolescents younger than 18 years who had been treated for head and neck trauma. The youth were divided into two groups: 3,356 who were treated from 2009 to 2016, and 1,182 who were treated between 2017 and 2019.

The incidence of critical head injuries increased from 3.7% in the period 2009-2016 to 7.2% in the period 2017-2019 (P = .007). The incidence of serious neck injuries increased from 12.2% to 27.1% (P = .007) during that period, according to the researchers. The number of days that these patients spent on ventilators more than doubled, from 3.1 to 6.3 (P < .001), they reported.

At the same time, the rate of positive urine drug tests rose sharply, from 0.8% to 1.8% (P < .001) for benzodiazepines and from 1% to 4.9% for opioids (P < .001).

Drug testing of children hospitalized for trauma rose more than threefold, from 6.9% to 23.2% (P < .001). Dr. Ellison’s group was unable to match positive drug screens with patients who came in with injuries.

Dr. Ellison said her research “warrants further evaluation of current policies and protocols targeting substance use in children and adolescents.” To that end, her team is planning to conduct a prospective study in mid 2023 to further illuminate the trends.

“I hope early next year we can put together a group of physicians, pediatric general surgeons, neurosurgeons, and anesthesiologists,” she said. “I want to look at what we can do to reduce the severity of injury.”

She also wants to reach the population that these findings directly affect.

“The next step that we are currently working on is community awareness of the issue,” Dr. Ellison said. “Our trauma institute is partnering with middle school and high school kids to create material to raise awareness.”

Rural Appalachia faces several other endemic problems that affect the health and well-being of children and families, including limited access to health care, poverty, and minimal community support, according to Dr. Ellison. Children and teens in the region who live with parents who abuse opioids are more likely to experience family conflict, mental health challenges, legal troubles, and negative health effects, including physical trauma.
 

A call to action

Toufic Jildeh, MD, assistant professor of orthopedics, Michigan State University Health Care, East Lansing, who has studied ways to reduce opioid use among surgery patients, called the new findings “alarming.”

After reviewing the study, Dr. Jildeh said that in his opinion, the results support standardized drug testing of children, particularly in the context of severe trauma.

Bruce Bassi, MD, an addiction psychiatrist and owner of TelepsychHealth, a private, online psychiatric practice, agreed. “The main take-home message is that drug screening should be the standard of care for pediatric patients in this region, because it changes the management of those individuals,” Dr. Bassi said.

But identifying these patients is just the first step. “We should continue to educate and raise awareness, not only in the health care system,” Dr. Bassi said. “We also need to let parents know that the possibility of children obtaining access to medications is high.”

The study was independently supported. Dr. Ellison and Dr. Jildeh reported no relevant financial relationships. Dr. Bassi owns a private psychiatry practice called Telepsychhealth but has no other relevant financial relationships.

A version of this article first appeared on Medscape.com.

As a physician in the heart of the opioid epidemic, Pavirthra R. Ellison, MD, has watched for years as her patients have lost parents to overdoses. More than 1,400 adults in West Virginia, where she practices, died of opioid abuse in 2021 alone, government statistics show.

The grim toll made Ellison wonder: What was happening to children in the state? The answer, according to a new study, is not reassuring.

Ellison and her colleagues have found a troubling link between a surge in critical head and neck injuries among youth in West Virginia and a spike in positive tests for opioids and benzodiazepines among children who arrive at emergency departments in the state. They don’t think the pattern is a coincidence.

“What we found was really kind of scary,” said Dr. Ellison, a professor of anesthesiology and pediatrics at West Virginia University, Morgantown. “Children in this region often get exposure to these drugs early on.”
 

A region in crisis

According to a 2020 report from the Department of Health & Human Services, about 9.9 million Americans abused prescription opioids in 2018. That same year, almost 47,000 died following an overdose of the painkillers. In 2017, Appalachian counties experienced a death rate from opioid overdoses that was 72% higher than that of the rest of the country.

Dr. Ellison and associates who presented their findings recently at the 2022 annual meeting of the American Society of Anesthesiologists, examined rates of pediatric trauma injuries, injury severity, and results of drug screenings throughout West Virginia between 2009 and 2019.

The study included 4,538 children and adolescents younger than 18 years who had been treated for head and neck trauma. The youth were divided into two groups: 3,356 who were treated from 2009 to 2016, and 1,182 who were treated between 2017 and 2019.

The incidence of critical head injuries increased from 3.7% in the period 2009-2016 to 7.2% in the period 2017-2019 (P = .007). The incidence of serious neck injuries increased from 12.2% to 27.1% (P = .007) during that period, according to the researchers. The number of days that these patients spent on ventilators more than doubled, from 3.1 to 6.3 (P < .001), they reported.

At the same time, the rate of positive urine drug tests rose sharply, from 0.8% to 1.8% (P < .001) for benzodiazepines and from 1% to 4.9% for opioids (P < .001).

Drug testing of children hospitalized for trauma rose more than threefold, from 6.9% to 23.2% (P < .001). Dr. Ellison’s group was unable to match positive drug screens with patients who came in with injuries.

Dr. Ellison said her research “warrants further evaluation of current policies and protocols targeting substance use in children and adolescents.” To that end, her team is planning to conduct a prospective study in mid 2023 to further illuminate the trends.

“I hope early next year we can put together a group of physicians, pediatric general surgeons, neurosurgeons, and anesthesiologists,” she said. “I want to look at what we can do to reduce the severity of injury.”

She also wants to reach the population that these findings directly affect.

“The next step that we are currently working on is community awareness of the issue,” Dr. Ellison said. “Our trauma institute is partnering with middle school and high school kids to create material to raise awareness.”

Rural Appalachia faces several other endemic problems that affect the health and well-being of children and families, including limited access to health care, poverty, and minimal community support, according to Dr. Ellison. Children and teens in the region who live with parents who abuse opioids are more likely to experience family conflict, mental health challenges, legal troubles, and negative health effects, including physical trauma.
 

A call to action

Toufic Jildeh, MD, assistant professor of orthopedics, Michigan State University Health Care, East Lansing, who has studied ways to reduce opioid use among surgery patients, called the new findings “alarming.”

After reviewing the study, Dr. Jildeh said that in his opinion, the results support standardized drug testing of children, particularly in the context of severe trauma.

Bruce Bassi, MD, an addiction psychiatrist and owner of TelepsychHealth, a private, online psychiatric practice, agreed. “The main take-home message is that drug screening should be the standard of care for pediatric patients in this region, because it changes the management of those individuals,” Dr. Bassi said.

But identifying these patients is just the first step. “We should continue to educate and raise awareness, not only in the health care system,” Dr. Bassi said. “We also need to let parents know that the possibility of children obtaining access to medications is high.”

The study was independently supported. Dr. Ellison and Dr. Jildeh reported no relevant financial relationships. Dr. Bassi owns a private psychiatry practice called Telepsychhealth but has no other relevant financial relationships.

A version of this article first appeared on Medscape.com.

As a physician in the heart of the opioid epidemic, Pavirthra R. Ellison, MD, has watched for years as her patients have lost parents to overdoses. More than 1,400 adults in West Virginia, where she practices, died of opioid abuse in 2021 alone, government statistics show.

The grim toll made Ellison wonder: What was happening to children in the state? The answer, according to a new study, is not reassuring.

Ellison and her colleagues have found a troubling link between a surge in critical head and neck injuries among youth in West Virginia and a spike in positive tests for opioids and benzodiazepines among children who arrive at emergency departments in the state. They don’t think the pattern is a coincidence.

“What we found was really kind of scary,” said Dr. Ellison, a professor of anesthesiology and pediatrics at West Virginia University, Morgantown. “Children in this region often get exposure to these drugs early on.”
 

A region in crisis

According to a 2020 report from the Department of Health & Human Services, about 9.9 million Americans abused prescription opioids in 2018. That same year, almost 47,000 died following an overdose of the painkillers. In 2017, Appalachian counties experienced a death rate from opioid overdoses that was 72% higher than that of the rest of the country.

Dr. Ellison and associates who presented their findings recently at the 2022 annual meeting of the American Society of Anesthesiologists, examined rates of pediatric trauma injuries, injury severity, and results of drug screenings throughout West Virginia between 2009 and 2019.

The study included 4,538 children and adolescents younger than 18 years who had been treated for head and neck trauma. The youth were divided into two groups: 3,356 who were treated from 2009 to 2016, and 1,182 who were treated between 2017 and 2019.

The incidence of critical head injuries increased from 3.7% in the period 2009-2016 to 7.2% in the period 2017-2019 (P = .007). The incidence of serious neck injuries increased from 12.2% to 27.1% (P = .007) during that period, according to the researchers. The number of days that these patients spent on ventilators more than doubled, from 3.1 to 6.3 (P < .001), they reported.

At the same time, the rate of positive urine drug tests rose sharply, from 0.8% to 1.8% (P < .001) for benzodiazepines and from 1% to 4.9% for opioids (P < .001).

Drug testing of children hospitalized for trauma rose more than threefold, from 6.9% to 23.2% (P < .001). Dr. Ellison’s group was unable to match positive drug screens with patients who came in with injuries.

Dr. Ellison said her research “warrants further evaluation of current policies and protocols targeting substance use in children and adolescents.” To that end, her team is planning to conduct a prospective study in mid 2023 to further illuminate the trends.

“I hope early next year we can put together a group of physicians, pediatric general surgeons, neurosurgeons, and anesthesiologists,” she said. “I want to look at what we can do to reduce the severity of injury.”

She also wants to reach the population that these findings directly affect.

“The next step that we are currently working on is community awareness of the issue,” Dr. Ellison said. “Our trauma institute is partnering with middle school and high school kids to create material to raise awareness.”

Rural Appalachia faces several other endemic problems that affect the health and well-being of children and families, including limited access to health care, poverty, and minimal community support, according to Dr. Ellison. Children and teens in the region who live with parents who abuse opioids are more likely to experience family conflict, mental health challenges, legal troubles, and negative health effects, including physical trauma.
 

A call to action

Toufic Jildeh, MD, assistant professor of orthopedics, Michigan State University Health Care, East Lansing, who has studied ways to reduce opioid use among surgery patients, called the new findings “alarming.”

After reviewing the study, Dr. Jildeh said that in his opinion, the results support standardized drug testing of children, particularly in the context of severe trauma.

Bruce Bassi, MD, an addiction psychiatrist and owner of TelepsychHealth, a private, online psychiatric practice, agreed. “The main take-home message is that drug screening should be the standard of care for pediatric patients in this region, because it changes the management of those individuals,” Dr. Bassi said.

But identifying these patients is just the first step. “We should continue to educate and raise awareness, not only in the health care system,” Dr. Bassi said. “We also need to let parents know that the possibility of children obtaining access to medications is high.”

The study was independently supported. Dr. Ellison and Dr. Jildeh reported no relevant financial relationships. Dr. Bassi owns a private psychiatry practice called Telepsychhealth but has no other relevant financial relationships.

A version of this article first appeared on Medscape.com.

The spotlight continues to shine on vitiligo as Lego has released the first-ever mini-character featuring the hallmark dark and light skin patches of the disease.

The character appears with the customizable array of players to assemble for a table football team.

It’s the latest representation of the disease as toymakers diversify their lines.

In May 2022, Mattel released a Ken doll with vitiligo after a Barbie with vitiligo was released in 2020. Rainbow High and other toy makers also have character versions.

The Lego addition follows a big summer medically for vitiligo as the first treatment was approved for repigmentation. In July, a cream formulation of ruxolitinib (Opzelura), a Janus kinase inhibitor, became the first repigmentation treatment approved by the Food and Drug Administration for nonsegmental vitiligo, the most common form of the disease.

Vitiligo is estimated to affect 1.9 million–2.8 million adults in the United States and more than 100 million people worldwide. It cuts across races and genders and can be psychologically painful for many who live with it.

John E. Harris, MD, director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester, wrote about the Lego character in his blog “Speaking of Vitiligo ...” saying: “I could not be more excited. This new minifigure also serves as a way to educate both children and adults who are not familiar with vitiligo about the disease.”

He noted that until recently vitiligo representation in kids’ toys has been limited. “By adding diversity such as representations of vitiligo in toys, it can help remove stigmas associated with vitiligo and give children more options that they can relate to.”

Erika Page of Richmond, Va., who founded and edits the vitiligo blog “Living Dappled,” told this news organization she was thrilled to see the new Lego character.

“Growing up I didn’t know anyone who looked like me, let alone a toy or a character,” she said. The message the representations send is important not just for the kids but for the parents of kids with vitiligo who want to help their kids in any way they can.

Ms. Page was diagnosed with vitiligo at age 7 and struggled emotionally in her high school and college years when she often looked in the mirror, saw “giraffe-like” spots, and cried. Over time she lost 100% of her pigment to the condition and today at age 33, lives with universal vitiligo or overall very pale skin.

She founded the Living Dappled blog 6 years ago to help people with the disease feel less alone. The Lego character will also help with that, she said.

“Growing up with vitiligo was so isolating and you felt so different,” Ms. Page said. “Today we see billboards and models and dolls and now Legos that look like us. I hope this is a first of many to come for Lego.”

Dr. Harris and Ms. Page declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The spotlight continues to shine on vitiligo as Lego has released the first-ever mini-character featuring the hallmark dark and light skin patches of the disease.

The character appears with the customizable array of players to assemble for a table football team.

It’s the latest representation of the disease as toymakers diversify their lines.

In May 2022, Mattel released a Ken doll with vitiligo after a Barbie with vitiligo was released in 2020. Rainbow High and other toy makers also have character versions.

The Lego addition follows a big summer medically for vitiligo as the first treatment was approved for repigmentation. In July, a cream formulation of ruxolitinib (Opzelura), a Janus kinase inhibitor, became the first repigmentation treatment approved by the Food and Drug Administration for nonsegmental vitiligo, the most common form of the disease.

Vitiligo is estimated to affect 1.9 million–2.8 million adults in the United States and more than 100 million people worldwide. It cuts across races and genders and can be psychologically painful for many who live with it.

John E. Harris, MD, director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester, wrote about the Lego character in his blog “Speaking of Vitiligo ...” saying: “I could not be more excited. This new minifigure also serves as a way to educate both children and adults who are not familiar with vitiligo about the disease.”

He noted that until recently vitiligo representation in kids’ toys has been limited. “By adding diversity such as representations of vitiligo in toys, it can help remove stigmas associated with vitiligo and give children more options that they can relate to.”

Erika Page of Richmond, Va., who founded and edits the vitiligo blog “Living Dappled,” told this news organization she was thrilled to see the new Lego character.

“Growing up I didn’t know anyone who looked like me, let alone a toy or a character,” she said. The message the representations send is important not just for the kids but for the parents of kids with vitiligo who want to help their kids in any way they can.

Ms. Page was diagnosed with vitiligo at age 7 and struggled emotionally in her high school and college years when she often looked in the mirror, saw “giraffe-like” spots, and cried. Over time she lost 100% of her pigment to the condition and today at age 33, lives with universal vitiligo or overall very pale skin.

She founded the Living Dappled blog 6 years ago to help people with the disease feel less alone. The Lego character will also help with that, she said.

“Growing up with vitiligo was so isolating and you felt so different,” Ms. Page said. “Today we see billboards and models and dolls and now Legos that look like us. I hope this is a first of many to come for Lego.”

Dr. Harris and Ms. Page declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The spotlight continues to shine on vitiligo as Lego has released the first-ever mini-character featuring the hallmark dark and light skin patches of the disease.

The character appears with the customizable array of players to assemble for a table football team.

It’s the latest representation of the disease as toymakers diversify their lines.

In May 2022, Mattel released a Ken doll with vitiligo after a Barbie with vitiligo was released in 2020. Rainbow High and other toy makers also have character versions.

The Lego addition follows a big summer medically for vitiligo as the first treatment was approved for repigmentation. In July, a cream formulation of ruxolitinib (Opzelura), a Janus kinase inhibitor, became the first repigmentation treatment approved by the Food and Drug Administration for nonsegmental vitiligo, the most common form of the disease.

Vitiligo is estimated to affect 1.9 million–2.8 million adults in the United States and more than 100 million people worldwide. It cuts across races and genders and can be psychologically painful for many who live with it.

John E. Harris, MD, director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester, wrote about the Lego character in his blog “Speaking of Vitiligo ...” saying: “I could not be more excited. This new minifigure also serves as a way to educate both children and adults who are not familiar with vitiligo about the disease.”

He noted that until recently vitiligo representation in kids’ toys has been limited. “By adding diversity such as representations of vitiligo in toys, it can help remove stigmas associated with vitiligo and give children more options that they can relate to.”

Erika Page of Richmond, Va., who founded and edits the vitiligo blog “Living Dappled,” told this news organization she was thrilled to see the new Lego character.

“Growing up I didn’t know anyone who looked like me, let alone a toy or a character,” she said. The message the representations send is important not just for the kids but for the parents of kids with vitiligo who want to help their kids in any way they can.

Ms. Page was diagnosed with vitiligo at age 7 and struggled emotionally in her high school and college years when she often looked in the mirror, saw “giraffe-like” spots, and cried. Over time she lost 100% of her pigment to the condition and today at age 33, lives with universal vitiligo or overall very pale skin.

She founded the Living Dappled blog 6 years ago to help people with the disease feel less alone. The Lego character will also help with that, she said.

“Growing up with vitiligo was so isolating and you felt so different,” Ms. Page said. “Today we see billboards and models and dolls and now Legos that look like us. I hope this is a first of many to come for Lego.”

Dr. Harris and Ms. Page declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The incidence of new celiac disease with onset by age 10 appears to be rising and varies widely by region, suggesting different environmental, genetic, and epigenetic influences within the United States, according to a new report.

The overall high incidence among pediatric patients warrants a low threshold for screening and additional research on region-specific celiac disease triggers, the authors write.

“Determining the true incidence of celiac disease (CD) is not possible without nonbiased screening for the disease. This is because many cases occur with neither a family history nor with classic symptoms,” write Edwin Liu, MD, a pediatric gastroenterologist at the Children’s Hospital Colorado Anschutz Medical Campus and director of the Colorado Center for Celiac Disease, and colleagues.

“Individuals may have celiac disease autoimmunity without having CD if they have transient or fluctuating antibody levels, low antibody levels without biopsy evaluation, dietary modification influencing further evaluation, or potential celiac disease,” they write.

The study was published online in The American Journal of Gastroenterology.
 

Celiac disease incidence

The Environmental Determinants of Diabetes in the Young (TEDDY) study prospectively follows children born between 2004 and 2010 who are at genetic risk for both type 1 diabetes and CD at six clinical sites in four countries: the United States, Finland, Germany, and Sweden. In the United States, patients are enrolled in Colorado, Georgia, and Washington.

As part of TEDDY, children are longitudinally monitored for celiac disease autoimmunity (CDA) by assessment of autoantibodies to tissue transglutaminase (tTGA). The protocol is designed to analyze the development of persistent tTGA positivity, CDA, and subsequent CD. The study population contains various DQ2.5 and DQ8.1 combinations, which represent the highest-risk human leukocyte antigen (HLA) DQ haplogentotypes for CD.

From September 2004 through February 2010, more than 424,000 newborns were screened for specific HLA haplogenotypes, and 8,676 children were enrolled in TEDDY at the six clinical sites. The eligible haplogenotypes included DQ2.5/DQ2.5, DQ2.5/DQ8.1, DQ8.1/DQ8.1, and DQ8.1/DQ4.2.

Blood samples were obtained and stored every 3 months until age 48 months and at least every 6 months after that. At age 2, participants were screened annually for tTGA. With the first tTGA-positive result, all prior collected samples from the patient were tested for tTGA to determine the earliest time point of autoimmunity.

CDA, a primary study outcome, was defined as positivity in two consecutive tTGA tests at least 3 months apart.

In seropositive children, CD was defined on the basis of a duodenal biopsy with a Marsh score of 2 or higher. The decision to perform a biopsy was determined by the clinical gastroenterologist and was outside of the study protocol. When a biopsy wasn’t performed, participants with an average tTGA of 100 units or greater from two positive tests were considered to have CD for the study purposes.

As of July 2020, among the children who had undergone one or more tTGA tests, 6,628 HLA-typed eligible children were found to carry the DQ2.5, the D8.1, or both haplogenotypes and were included in the analysis. The median follow-up period was 11.5 years.

Overall, 580 children (9%) had a first-degree relative with type 1 diabetes, and 317 children (5%) reported a first-degree relative with CD.

Among the 6,628 children, 1,299 (20%) met the CDA outcome, and 529 (8%) met the study diagnostic criteria for CD on the basis of biopsy or persistently high tTGA levels. The median age at CDA across all sites was 41 months. Most children with CDA were asymptomatic.

Overall, the 10-year cumulative incidence was highest in Sweden, at 8.4% for CDA and 3% for CD. Within the United States, Colorado had the highest cumulative incidence for both endpoints, at 6.5% for CDA and 2.4% for CD. Washington had the lowest incidence across all sites, at 4.6% for CDA and 0.9% for CD.

“CDA and CD risk varied substantially by haplogenotype and by clinical center, but the relative risk by region was preserved regardless of the haplogenotype,” the authors write. “For example, the disease burden for each region remained highest in Sweden and lowest in Washington state for all haplogenotypes.”
 

Site-specific risks

In the HLA, sex, and family-adjusted model, Colorado children had a 2.5-fold higher risk of CD, compared with Washington children. Likewise, Swedish children had a 1.8-fold higher risk of CD than children in Germany, a 1.7-fold higher than children in the United States, and a 1.4-fold higher risk than children in Finland.

Among DQ2.5 participants, Sweden demonstrated the highest risk, with 63.1% of patients developing CDA by age 10 and 28.3% developing CD by age 10. Finland consistently had a higher incidence of CDA than Colorado, at 60.4% versus 50.9%, for DQ2.5 participants but a lower incidence of CD than Colorado, at 20.3% versus 22.6%.

The research team performed a post hoc sensitivity analysis using a lower tTGA cutoff to reduce bias in site differences for biopsy referral and to increase sensitivity of the CD definition for incidence estimation. When the tTGA cutoff was lowered to an average two-visit tTGA of 67.4 or higher, more children met the serologic criteria for CD.

“Even with this lower cutoff, the differences in the risk of CD between clinical sites and countries were still observed with statistical significance,” the authors write. “This indicates that the regional differences in CD incidence could not be solely attributed to detection biases posed by differential biopsy rates.”

Multiple environmental factors likely account for the differences in autoimmunity among regions, the authors write. These variables include diet, chemical exposures, vaccination patterns, early-life gastrointestinal infections, and interactions among these factors. For instance, the Swedish site has the lowest rotavirus vaccination rates and the highest median gluten intake among the TEDDY sites.

Future prospective studies should capture environmental, genetic, and epigenetic exposures to assess causal pathways and plan for preventive strategies, the authors write. The TEDDY study is pursuing this research.

“From a policy standpoint, this informs future screening practices and supports efforts toward mass screening, at least in some areas,” the authors write. “In the clinical setting, this points to the importance for clinicians to have a low threshold for CD screening in the appropriate clinical setting.”

The TEDDY study is funded by several grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the Centers for Disease Control and Prevention, and the Juvenile Diabetes Research Foundation. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The incidence of new celiac disease with onset by age 10 appears to be rising and varies widely by region, suggesting different environmental, genetic, and epigenetic influences within the United States, according to a new report.

The overall high incidence among pediatric patients warrants a low threshold for screening and additional research on region-specific celiac disease triggers, the authors write.

“Determining the true incidence of celiac disease (CD) is not possible without nonbiased screening for the disease. This is because many cases occur with neither a family history nor with classic symptoms,” write Edwin Liu, MD, a pediatric gastroenterologist at the Children’s Hospital Colorado Anschutz Medical Campus and director of the Colorado Center for Celiac Disease, and colleagues.

“Individuals may have celiac disease autoimmunity without having CD if they have transient or fluctuating antibody levels, low antibody levels without biopsy evaluation, dietary modification influencing further evaluation, or potential celiac disease,” they write.

The study was published online in The American Journal of Gastroenterology.
 

Celiac disease incidence

The Environmental Determinants of Diabetes in the Young (TEDDY) study prospectively follows children born between 2004 and 2010 who are at genetic risk for both type 1 diabetes and CD at six clinical sites in four countries: the United States, Finland, Germany, and Sweden. In the United States, patients are enrolled in Colorado, Georgia, and Washington.

As part of TEDDY, children are longitudinally monitored for celiac disease autoimmunity (CDA) by assessment of autoantibodies to tissue transglutaminase (tTGA). The protocol is designed to analyze the development of persistent tTGA positivity, CDA, and subsequent CD. The study population contains various DQ2.5 and DQ8.1 combinations, which represent the highest-risk human leukocyte antigen (HLA) DQ haplogentotypes for CD.

From September 2004 through February 2010, more than 424,000 newborns were screened for specific HLA haplogenotypes, and 8,676 children were enrolled in TEDDY at the six clinical sites. The eligible haplogenotypes included DQ2.5/DQ2.5, DQ2.5/DQ8.1, DQ8.1/DQ8.1, and DQ8.1/DQ4.2.

Blood samples were obtained and stored every 3 months until age 48 months and at least every 6 months after that. At age 2, participants were screened annually for tTGA. With the first tTGA-positive result, all prior collected samples from the patient were tested for tTGA to determine the earliest time point of autoimmunity.

CDA, a primary study outcome, was defined as positivity in two consecutive tTGA tests at least 3 months apart.

In seropositive children, CD was defined on the basis of a duodenal biopsy with a Marsh score of 2 or higher. The decision to perform a biopsy was determined by the clinical gastroenterologist and was outside of the study protocol. When a biopsy wasn’t performed, participants with an average tTGA of 100 units or greater from two positive tests were considered to have CD for the study purposes.

As of July 2020, among the children who had undergone one or more tTGA tests, 6,628 HLA-typed eligible children were found to carry the DQ2.5, the D8.1, or both haplogenotypes and were included in the analysis. The median follow-up period was 11.5 years.

Overall, 580 children (9%) had a first-degree relative with type 1 diabetes, and 317 children (5%) reported a first-degree relative with CD.

Among the 6,628 children, 1,299 (20%) met the CDA outcome, and 529 (8%) met the study diagnostic criteria for CD on the basis of biopsy or persistently high tTGA levels. The median age at CDA across all sites was 41 months. Most children with CDA were asymptomatic.

Overall, the 10-year cumulative incidence was highest in Sweden, at 8.4% for CDA and 3% for CD. Within the United States, Colorado had the highest cumulative incidence for both endpoints, at 6.5% for CDA and 2.4% for CD. Washington had the lowest incidence across all sites, at 4.6% for CDA and 0.9% for CD.

“CDA and CD risk varied substantially by haplogenotype and by clinical center, but the relative risk by region was preserved regardless of the haplogenotype,” the authors write. “For example, the disease burden for each region remained highest in Sweden and lowest in Washington state for all haplogenotypes.”
 

Site-specific risks

In the HLA, sex, and family-adjusted model, Colorado children had a 2.5-fold higher risk of CD, compared with Washington children. Likewise, Swedish children had a 1.8-fold higher risk of CD than children in Germany, a 1.7-fold higher than children in the United States, and a 1.4-fold higher risk than children in Finland.

Among DQ2.5 participants, Sweden demonstrated the highest risk, with 63.1% of patients developing CDA by age 10 and 28.3% developing CD by age 10. Finland consistently had a higher incidence of CDA than Colorado, at 60.4% versus 50.9%, for DQ2.5 participants but a lower incidence of CD than Colorado, at 20.3% versus 22.6%.

The research team performed a post hoc sensitivity analysis using a lower tTGA cutoff to reduce bias in site differences for biopsy referral and to increase sensitivity of the CD definition for incidence estimation. When the tTGA cutoff was lowered to an average two-visit tTGA of 67.4 or higher, more children met the serologic criteria for CD.

“Even with this lower cutoff, the differences in the risk of CD between clinical sites and countries were still observed with statistical significance,” the authors write. “This indicates that the regional differences in CD incidence could not be solely attributed to detection biases posed by differential biopsy rates.”

Multiple environmental factors likely account for the differences in autoimmunity among regions, the authors write. These variables include diet, chemical exposures, vaccination patterns, early-life gastrointestinal infections, and interactions among these factors. For instance, the Swedish site has the lowest rotavirus vaccination rates and the highest median gluten intake among the TEDDY sites.

Future prospective studies should capture environmental, genetic, and epigenetic exposures to assess causal pathways and plan for preventive strategies, the authors write. The TEDDY study is pursuing this research.

“From a policy standpoint, this informs future screening practices and supports efforts toward mass screening, at least in some areas,” the authors write. “In the clinical setting, this points to the importance for clinicians to have a low threshold for CD screening in the appropriate clinical setting.”

The TEDDY study is funded by several grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the Centers for Disease Control and Prevention, and the Juvenile Diabetes Research Foundation. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The incidence of new celiac disease with onset by age 10 appears to be rising and varies widely by region, suggesting different environmental, genetic, and epigenetic influences within the United States, according to a new report.

The overall high incidence among pediatric patients warrants a low threshold for screening and additional research on region-specific celiac disease triggers, the authors write.

“Determining the true incidence of celiac disease (CD) is not possible without nonbiased screening for the disease. This is because many cases occur with neither a family history nor with classic symptoms,” write Edwin Liu, MD, a pediatric gastroenterologist at the Children’s Hospital Colorado Anschutz Medical Campus and director of the Colorado Center for Celiac Disease, and colleagues.

“Individuals may have celiac disease autoimmunity without having CD if they have transient or fluctuating antibody levels, low antibody levels without biopsy evaluation, dietary modification influencing further evaluation, or potential celiac disease,” they write.

The study was published online in The American Journal of Gastroenterology.
 

Celiac disease incidence

The Environmental Determinants of Diabetes in the Young (TEDDY) study prospectively follows children born between 2004 and 2010 who are at genetic risk for both type 1 diabetes and CD at six clinical sites in four countries: the United States, Finland, Germany, and Sweden. In the United States, patients are enrolled in Colorado, Georgia, and Washington.

As part of TEDDY, children are longitudinally monitored for celiac disease autoimmunity (CDA) by assessment of autoantibodies to tissue transglutaminase (tTGA). The protocol is designed to analyze the development of persistent tTGA positivity, CDA, and subsequent CD. The study population contains various DQ2.5 and DQ8.1 combinations, which represent the highest-risk human leukocyte antigen (HLA) DQ haplogentotypes for CD.

From September 2004 through February 2010, more than 424,000 newborns were screened for specific HLA haplogenotypes, and 8,676 children were enrolled in TEDDY at the six clinical sites. The eligible haplogenotypes included DQ2.5/DQ2.5, DQ2.5/DQ8.1, DQ8.1/DQ8.1, and DQ8.1/DQ4.2.

Blood samples were obtained and stored every 3 months until age 48 months and at least every 6 months after that. At age 2, participants were screened annually for tTGA. With the first tTGA-positive result, all prior collected samples from the patient were tested for tTGA to determine the earliest time point of autoimmunity.

CDA, a primary study outcome, was defined as positivity in two consecutive tTGA tests at least 3 months apart.

In seropositive children, CD was defined on the basis of a duodenal biopsy with a Marsh score of 2 or higher. The decision to perform a biopsy was determined by the clinical gastroenterologist and was outside of the study protocol. When a biopsy wasn’t performed, participants with an average tTGA of 100 units or greater from two positive tests were considered to have CD for the study purposes.

As of July 2020, among the children who had undergone one or more tTGA tests, 6,628 HLA-typed eligible children were found to carry the DQ2.5, the D8.1, or both haplogenotypes and were included in the analysis. The median follow-up period was 11.5 years.

Overall, 580 children (9%) had a first-degree relative with type 1 diabetes, and 317 children (5%) reported a first-degree relative with CD.

Among the 6,628 children, 1,299 (20%) met the CDA outcome, and 529 (8%) met the study diagnostic criteria for CD on the basis of biopsy or persistently high tTGA levels. The median age at CDA across all sites was 41 months. Most children with CDA were asymptomatic.

Overall, the 10-year cumulative incidence was highest in Sweden, at 8.4% for CDA and 3% for CD. Within the United States, Colorado had the highest cumulative incidence for both endpoints, at 6.5% for CDA and 2.4% for CD. Washington had the lowest incidence across all sites, at 4.6% for CDA and 0.9% for CD.

“CDA and CD risk varied substantially by haplogenotype and by clinical center, but the relative risk by region was preserved regardless of the haplogenotype,” the authors write. “For example, the disease burden for each region remained highest in Sweden and lowest in Washington state for all haplogenotypes.”
 

Site-specific risks

In the HLA, sex, and family-adjusted model, Colorado children had a 2.5-fold higher risk of CD, compared with Washington children. Likewise, Swedish children had a 1.8-fold higher risk of CD than children in Germany, a 1.7-fold higher than children in the United States, and a 1.4-fold higher risk than children in Finland.

Among DQ2.5 participants, Sweden demonstrated the highest risk, with 63.1% of patients developing CDA by age 10 and 28.3% developing CD by age 10. Finland consistently had a higher incidence of CDA than Colorado, at 60.4% versus 50.9%, for DQ2.5 participants but a lower incidence of CD than Colorado, at 20.3% versus 22.6%.

The research team performed a post hoc sensitivity analysis using a lower tTGA cutoff to reduce bias in site differences for biopsy referral and to increase sensitivity of the CD definition for incidence estimation. When the tTGA cutoff was lowered to an average two-visit tTGA of 67.4 or higher, more children met the serologic criteria for CD.

“Even with this lower cutoff, the differences in the risk of CD between clinical sites and countries were still observed with statistical significance,” the authors write. “This indicates that the regional differences in CD incidence could not be solely attributed to detection biases posed by differential biopsy rates.”

Multiple environmental factors likely account for the differences in autoimmunity among regions, the authors write. These variables include diet, chemical exposures, vaccination patterns, early-life gastrointestinal infections, and interactions among these factors. For instance, the Swedish site has the lowest rotavirus vaccination rates and the highest median gluten intake among the TEDDY sites.

Future prospective studies should capture environmental, genetic, and epigenetic exposures to assess causal pathways and plan for preventive strategies, the authors write. The TEDDY study is pursuing this research.

“From a policy standpoint, this informs future screening practices and supports efforts toward mass screening, at least in some areas,” the authors write. “In the clinical setting, this points to the importance for clinicians to have a low threshold for CD screening in the appropriate clinical setting.”

The TEDDY study is funded by several grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the Centers for Disease Control and Prevention, and the Juvenile Diabetes Research Foundation. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It is unsurprising that food frequently is thought to be the culprit behind an eczema flare, especially in infants. Indeed, it often is said that infants do only 3 things: eat, sleep, and poop.¹ For those unfortunate enough to develop the signs and symptoms of atopic dermatitis (AD), food quickly emerges as a potential culprit from the tiny pool of suspects, which is against a cultural backdrop of unprecedented focus on foods and food reactions.² The prevalence of food allergies in children, though admittedly fraught with methodological difficulties, is estimated to have more than doubled from 3.4% in 1999 to 7.6% in 2018.³ As expected, prevalence rates were higher among children with other atopic comorbidities including AD, with up to 50% of children with AD demonstrating convincing food allergy.⁴ It is easy to imagine a patient conflating these 2 entities and mistaking their correlation for causation. Thus, it follows that more than 90% of parents/guardians have reported that their children have had food-induced AD, and understandably—at least according to one study—75% of parents/guardians were found to have manipulated the diet in an attempt to manage the disease.^5,6

Patients and parents/guardians are not the only ones who have suspected food as a driving force in AD. An article in the British Medical Journal from the 1800s beautifully encapsulated the depth and duration of this quandary: “There is probably no subject in which more deeply rooted convictions have been held, not only in the profession but by the laity, than the connection between diet and disease, both as regards the causation and treatment of the latter.”⁷ Herein, a wide range of food reactions is examined to highlight evidence for the role of diet in AD, which may contradict what patients—and even some clinicians—believe.

No Easy Answers

A definitive statement that food allergy is not the root cause of AD would put this issue to rest, but such simplicity does not reflect the complex reality. First, we must agree on definitions for certain terms. What do we mean by food allergy? A broader category—adverse food reactions—covers a wide range of entities, some immune mediated and some not, including lactose intolerance, irritant contact dermatitis around the mouth, and even dermatitis herpetiformis (the cutaneous manifestation of celiac disease).⁸ Although the term food allergy often is used synonymously with adverse food reactions, the exact definition of a food allergy is specific: “adverse immune responses to food proteins that result in typical clinical symptoms.”⁸ The fact that many patients and even health care practitioners seem to frequently misapply this term makes it even more confusing. 

The current focus is on foods that could trigger a flare of AD, which clearly is a broader question than food allergy sensu stricto. It seems self-evident, for example, that if an infant with AD were to (messily) eat an acidic food such as an orange, a flare-up of AD around the mouth and on the cheeks and hands would be a forgone conclusion. Similar nonimmunologic scenarios unambiguously can occur with many foods, including citrus; corn; radish; mustard; garlic; onion; pineapple; and many spices, food additives, and preservatives.⁹ Clearly there are some scenarios whereby food could trigger an AD flare, and yet this more limited vignette generally is not what patients are referring to when suggesting that food is the root cause of their AD.

The Labyrinth of Testing for Food Allergies

Although there is no reliable method for testing for irritant dermatitis, understanding the other types of tests may help guide our thinking. Testing for IgE-mediated food allergies generally is done via an immunoenzymatic serum assay that can document sensitization to a food protein; however, this testing by itself is not sufficient to diagnose a clinical food allergy.¹⁰ Similarly, skin prick testing allows for intradermal administration of a food extract to evaluate for an urticarial reaction within 10 to 15 minutes. Although the sensitivity and specificity vary by age, population, and the specific allergen being tested, these are limited to immediate-type reactions and do not reflect the potential to drive an eczematous flare.

The gold standard, if there is one, is likely the double-blind, placebo-controlled food challenge (DBPCFC), ideally with a long enough observation period to capture later-occurring reactions such as an AD flare. However, given the nature of the test—having patients eat the foods of concern and then carefully following them for reactions—it remains time consuming, expensive, and labor intensive.¹¹ 

To further complicate matters, several unvalidated tests exist such as IgG testing, atopy patch testing, kinesiology, and hair and gastric juice analysis, which remain investigational but continue to be used and may further confuse patients and clinicians.¹²

It is useful to first separate out the classic IgE-mediated food allergy reactions that are common. In these immediate-type reactions, a person sensitized to a food protein will develop characteristic cutaneous and/or extracutaneous reactions such as urticaria, angioedema, and even anaphylaxis, usually within minutes of exposure. Although it is possible that an IgE-mediated reaction could trigger an AD flare—perhaps simply by causing pruritus, which could initiate the itch-scratch cycle—because of the near simultaneity with ingestion of the offending food and the often dramatic clinical presentations, such foods clearly do not represent “hidden” triggers for AD flares.³ The concept of food-triggered AD (FTAD) is crucial for thinking about foods that could result in true eczematous flares, which historically have been classified as early-type (<2 hours after food challenge) and late-type (≥2 hours after food challenge) reactions.^13,14 

A study of more than 1000 DBPCFCs performed in patients with AD was illustrative.¹⁵ Immediate reactions other than AD were fairly common and were observed in 40% of the food challenges compared to only 9% in the placebo group. These reactions included urticaria, angioedema, and gastrointestinal and respiratory tract symptoms. Immediate reactions of AD alone were exceedingly rare at only 0.7% and not significantly elevated compared to placebo. Just over 4% experienced both an immediate AD exacerbation along with other non-AD findings, which was significantly greater than placebo (P<.01). Although intermediate and late reactions manifesting as AD exacerbations did occur after food ingestion, they were rare (2.2% or less) and not significantly different from placebo. The authors concluded that an exacerbation of AD in the absence of other allergic symptoms in children was unlikely to be due to food,¹⁵ which is an important finding.

A recent retrospective review of 372 children with AD reported similar results.⁴ The authors defined FTAD in a different way; instead of showing a flare after a DBPCFC, they looked for “physician-noted sustained improvement in AD upon removal of a food (typically after 2–6-wk follow-up), to which the child was sensitized without any other changes in skin care.” Despite this fundamentally different approach, they similarly concluded that while food allergies were common, FTAD was relatively uncommon—found in 2% of those with mild AD, 6% of those with moderate AD, and 4% of those with severe AD.⁴ 

There are other ways that foods could contribute to disease flares, however, and one of the most compelling is that there may be broader concepts at play; perhaps some diets are not specifically driving the AD but rather are affecting inflammation in the body at large. Although somewhat speculative, there is evidence that some foods may simply be proinflammatory, working to exacerbate the disease outside of a specific mechanism, which has been seen in a variety of other conditions such as acne or rheumatoid arthritis.^16,17 To speculate further, it is possible that there may be a threshold effect such that when the AD is poorly controlled, certain factors such as inflammatory foods could lead to a flare, while when under better control, these same factors may not cause an effect.

Finally, it is important to also consider the emotional and/or psychological aspects related to food and diet. The power of the placebo in dietary change has been documented in several diseases, though this certainly is not to be dismissive of the patient’s symptoms; it seems reasonable that the very act of changing such a fundamental aspect of daily life could result in a placebo effect.^18,19 In the context of relapsing and remitting conditions such as AD, this effect may be magnified. A landmark study by Thompson and Hanifin²⁰ illustrates this possibility. The authors found that in 80% of cases in which patients were convinced that food was a major contributing factor to their AD, such concerns diminished markedly once better control of the eczema was achieved.²⁰

This brings us to what to do with an individual patient in the examination room. Because there is such widespread concern and discussion around this topic, it is important to at least briefly address it. If there are known food allergens that are being avoided, it is important to underscore the importance of continuing to avoid those foods, especially when there is actual evidence of true food allergy rather than sensitization alone. Historically, elimination diets often were recommended empirically, though more recent studies, meta-analyses, and guidance documents increasingly have recommended against them.³ In particular, there are major concerns for iatrogenic harm. 

First, heavily restricted diets may result in nutritional and/or caloric deficiencies that can be dangerous and lead to poor growth.²¹ Practices such as drinking unpasteurized milk can expose children to dangerous infections, while feeding them exclusively rice milk can lead to severe malnutrition.²² 

Second, there is a dawning realization that children with AD placed on elimination diets may actually develop true IgE-mediated allergies, including fatal anaphylaxis, to the excluded foods. In fact, one retrospective review of 298 patients with a history of AD and no prior immediate reactions found that 19% of patients developed new immediate-type hypersensitivity reactions after starting an elimination diet, presumably due to the loss of tolerance to these foods. A striking one-third of these reactions were classified as anaphylaxis, with cow’s milk and egg being the most common offenders.²³

It also is crucial to acknowledge that recommending sweeping lifestyle changes is not easy for patients, especially pediatric patients. Onerous dietary restrictions may add considerable stress, ironically a known trigger for AD itself. 

Finally, dietary modifications can be a distraction from conventional therapy and may result in treatment delays while the patient continues to experience uncontrolled symptoms of AD. 

Final Thoughts

Diet is intimately related to AD. Although the narrative continues to unfold in fascinating domains, such as the skin barrier and the microbiome, it is increasingly clear that these are intertwined and always have been. Despite the rarity of true food-triggered AD, the perception of dietary triggers is so widespread and addressing the topic is important and may help avoid unnecessary harm from unfounded extreme dietary changes. A recent multispecialty workgroup report on AD and food allergy succinctly summarized this as: “AD has many triggers and comorbidities, and food allergy is only one of the potential triggers and comorbid conditions. With regard to AD management, education and skin care are most important.”³ With proper testing, guidance, and both topical and systemic therapies, most AD can be brought under control, and for at least some patients, this may allay concerns about foods triggering their AD. 

It is unsurprising that food frequently is thought to be the culprit behind an eczema flare, especially in infants. Indeed, it often is said that infants do only 3 things: eat, sleep, and poop.¹ For those unfortunate enough to develop the signs and symptoms of atopic dermatitis (AD), food quickly emerges as a potential culprit from the tiny pool of suspects, which is against a cultural backdrop of unprecedented focus on foods and food reactions.² The prevalence of food allergies in children, though admittedly fraught with methodological difficulties, is estimated to have more than doubled from 3.4% in 1999 to 7.6% in 2018.³ As expected, prevalence rates were higher among children with other atopic comorbidities including AD, with up to 50% of children with AD demonstrating convincing food allergy.⁴ It is easy to imagine a patient conflating these 2 entities and mistaking their correlation for causation. Thus, it follows that more than 90% of parents/guardians have reported that their children have had food-induced AD, and understandably—at least according to one study—75% of parents/guardians were found to have manipulated the diet in an attempt to manage the disease.^5,6

Patients and parents/guardians are not the only ones who have suspected food as a driving force in AD. An article in the British Medical Journal from the 1800s beautifully encapsulated the depth and duration of this quandary: “There is probably no subject in which more deeply rooted convictions have been held, not only in the profession but by the laity, than the connection between diet and disease, both as regards the causation and treatment of the latter.”⁷ Herein, a wide range of food reactions is examined to highlight evidence for the role of diet in AD, which may contradict what patients—and even some clinicians—believe.

No Easy Answers

A definitive statement that food allergy is not the root cause of AD would put this issue to rest, but such simplicity does not reflect the complex reality. First, we must agree on definitions for certain terms. What do we mean by food allergy? A broader category—adverse food reactions—covers a wide range of entities, some immune mediated and some not, including lactose intolerance, irritant contact dermatitis around the mouth, and even dermatitis herpetiformis (the cutaneous manifestation of celiac disease).⁸ Although the term food allergy often is used synonymously with adverse food reactions, the exact definition of a food allergy is specific: “adverse immune responses to food proteins that result in typical clinical symptoms.”⁸ The fact that many patients and even health care practitioners seem to frequently misapply this term makes it even more confusing. 

The current focus is on foods that could trigger a flare of AD, which clearly is a broader question than food allergy sensu stricto. It seems self-evident, for example, that if an infant with AD were to (messily) eat an acidic food such as an orange, a flare-up of AD around the mouth and on the cheeks and hands would be a forgone conclusion. Similar nonimmunologic scenarios unambiguously can occur with many foods, including citrus; corn; radish; mustard; garlic; onion; pineapple; and many spices, food additives, and preservatives.⁹ Clearly there are some scenarios whereby food could trigger an AD flare, and yet this more limited vignette generally is not what patients are referring to when suggesting that food is the root cause of their AD.

The Labyrinth of Testing for Food Allergies

Although there is no reliable method for testing for irritant dermatitis, understanding the other types of tests may help guide our thinking. Testing for IgE-mediated food allergies generally is done via an immunoenzymatic serum assay that can document sensitization to a food protein; however, this testing by itself is not sufficient to diagnose a clinical food allergy.¹⁰ Similarly, skin prick testing allows for intradermal administration of a food extract to evaluate for an urticarial reaction within 10 to 15 minutes. Although the sensitivity and specificity vary by age, population, and the specific allergen being tested, these are limited to immediate-type reactions and do not reflect the potential to drive an eczematous flare.

The gold standard, if there is one, is likely the double-blind, placebo-controlled food challenge (DBPCFC), ideally with a long enough observation period to capture later-occurring reactions such as an AD flare. However, given the nature of the test—having patients eat the foods of concern and then carefully following them for reactions—it remains time consuming, expensive, and labor intensive.¹¹ 

To further complicate matters, several unvalidated tests exist such as IgG testing, atopy patch testing, kinesiology, and hair and gastric juice analysis, which remain investigational but continue to be used and may further confuse patients and clinicians.¹²

It is useful to first separate out the classic IgE-mediated food allergy reactions that are common. In these immediate-type reactions, a person sensitized to a food protein will develop characteristic cutaneous and/or extracutaneous reactions such as urticaria, angioedema, and even anaphylaxis, usually within minutes of exposure. Although it is possible that an IgE-mediated reaction could trigger an AD flare—perhaps simply by causing pruritus, which could initiate the itch-scratch cycle—because of the near simultaneity with ingestion of the offending food and the often dramatic clinical presentations, such foods clearly do not represent “hidden” triggers for AD flares.³ The concept of food-triggered AD (FTAD) is crucial for thinking about foods that could result in true eczematous flares, which historically have been classified as early-type (<2 hours after food challenge) and late-type (≥2 hours after food challenge) reactions.^13,14 

A study of more than 1000 DBPCFCs performed in patients with AD was illustrative.¹⁵ Immediate reactions other than AD were fairly common and were observed in 40% of the food challenges compared to only 9% in the placebo group. These reactions included urticaria, angioedema, and gastrointestinal and respiratory tract symptoms. Immediate reactions of AD alone were exceedingly rare at only 0.7% and not significantly elevated compared to placebo. Just over 4% experienced both an immediate AD exacerbation along with other non-AD findings, which was significantly greater than placebo (P<.01). Although intermediate and late reactions manifesting as AD exacerbations did occur after food ingestion, they were rare (2.2% or less) and not significantly different from placebo. The authors concluded that an exacerbation of AD in the absence of other allergic symptoms in children was unlikely to be due to food,¹⁵ which is an important finding.

A recent retrospective review of 372 children with AD reported similar results.⁴ The authors defined FTAD in a different way; instead of showing a flare after a DBPCFC, they looked for “physician-noted sustained improvement in AD upon removal of a food (typically after 2–6-wk follow-up), to which the child was sensitized without any other changes in skin care.” Despite this fundamentally different approach, they similarly concluded that while food allergies were common, FTAD was relatively uncommon—found in 2% of those with mild AD, 6% of those with moderate AD, and 4% of those with severe AD.⁴ 

There are other ways that foods could contribute to disease flares, however, and one of the most compelling is that there may be broader concepts at play; perhaps some diets are not specifically driving the AD but rather are affecting inflammation in the body at large. Although somewhat speculative, there is evidence that some foods may simply be proinflammatory, working to exacerbate the disease outside of a specific mechanism, which has been seen in a variety of other conditions such as acne or rheumatoid arthritis.^16,17 To speculate further, it is possible that there may be a threshold effect such that when the AD is poorly controlled, certain factors such as inflammatory foods could lead to a flare, while when under better control, these same factors may not cause an effect.

Finally, it is important to also consider the emotional and/or psychological aspects related to food and diet. The power of the placebo in dietary change has been documented in several diseases, though this certainly is not to be dismissive of the patient’s symptoms; it seems reasonable that the very act of changing such a fundamental aspect of daily life could result in a placebo effect.^18,19 In the context of relapsing and remitting conditions such as AD, this effect may be magnified. A landmark study by Thompson and Hanifin²⁰ illustrates this possibility. The authors found that in 80% of cases in which patients were convinced that food was a major contributing factor to their AD, such concerns diminished markedly once better control of the eczema was achieved.²⁰

This brings us to what to do with an individual patient in the examination room. Because there is such widespread concern and discussion around this topic, it is important to at least briefly address it. If there are known food allergens that are being avoided, it is important to underscore the importance of continuing to avoid those foods, especially when there is actual evidence of true food allergy rather than sensitization alone. Historically, elimination diets often were recommended empirically, though more recent studies, meta-analyses, and guidance documents increasingly have recommended against them.³ In particular, there are major concerns for iatrogenic harm. 

First, heavily restricted diets may result in nutritional and/or caloric deficiencies that can be dangerous and lead to poor growth.²¹ Practices such as drinking unpasteurized milk can expose children to dangerous infections, while feeding them exclusively rice milk can lead to severe malnutrition.²² 

Second, there is a dawning realization that children with AD placed on elimination diets may actually develop true IgE-mediated allergies, including fatal anaphylaxis, to the excluded foods. In fact, one retrospective review of 298 patients with a history of AD and no prior immediate reactions found that 19% of patients developed new immediate-type hypersensitivity reactions after starting an elimination diet, presumably due to the loss of tolerance to these foods. A striking one-third of these reactions were classified as anaphylaxis, with cow’s milk and egg being the most common offenders.²³

It also is crucial to acknowledge that recommending sweeping lifestyle changes is not easy for patients, especially pediatric patients. Onerous dietary restrictions may add considerable stress, ironically a known trigger for AD itself. 

Finally, dietary modifications can be a distraction from conventional therapy and may result in treatment delays while the patient continues to experience uncontrolled symptoms of AD. 

Final Thoughts

Diet is intimately related to AD. Although the narrative continues to unfold in fascinating domains, such as the skin barrier and the microbiome, it is increasingly clear that these are intertwined and always have been. Despite the rarity of true food-triggered AD, the perception of dietary triggers is so widespread and addressing the topic is important and may help avoid unnecessary harm from unfounded extreme dietary changes. A recent multispecialty workgroup report on AD and food allergy succinctly summarized this as: “AD has many triggers and comorbidities, and food allergy is only one of the potential triggers and comorbid conditions. With regard to AD management, education and skin care are most important.”³ With proper testing, guidance, and both topical and systemic therapies, most AD can be brought under control, and for at least some patients, this may allay concerns about foods triggering their AD. 

It is unsurprising that food frequently is thought to be the culprit behind an eczema flare, especially in infants. Indeed, it often is said that infants do only 3 things: eat, sleep, and poop.¹ For those unfortunate enough to develop the signs and symptoms of atopic dermatitis (AD), food quickly emerges as a potential culprit from the tiny pool of suspects, which is against a cultural backdrop of unprecedented focus on foods and food reactions.² The prevalence of food allergies in children, though admittedly fraught with methodological difficulties, is estimated to have more than doubled from 3.4% in 1999 to 7.6% in 2018.³ As expected, prevalence rates were higher among children with other atopic comorbidities including AD, with up to 50% of children with AD demonstrating convincing food allergy.⁴ It is easy to imagine a patient conflating these 2 entities and mistaking their correlation for causation. Thus, it follows that more than 90% of parents/guardians have reported that their children have had food-induced AD, and understandably—at least according to one study—75% of parents/guardians were found to have manipulated the diet in an attempt to manage the disease.^5,6

Patients and parents/guardians are not the only ones who have suspected food as a driving force in AD. An article in the British Medical Journal from the 1800s beautifully encapsulated the depth and duration of this quandary: “There is probably no subject in which more deeply rooted convictions have been held, not only in the profession but by the laity, than the connection between diet and disease, both as regards the causation and treatment of the latter.”⁷ Herein, a wide range of food reactions is examined to highlight evidence for the role of diet in AD, which may contradict what patients—and even some clinicians—believe.

No Easy Answers

A definitive statement that food allergy is not the root cause of AD would put this issue to rest, but such simplicity does not reflect the complex reality. First, we must agree on definitions for certain terms. What do we mean by food allergy? A broader category—adverse food reactions—covers a wide range of entities, some immune mediated and some not, including lactose intolerance, irritant contact dermatitis around the mouth, and even dermatitis herpetiformis (the cutaneous manifestation of celiac disease).⁸ Although the term food allergy often is used synonymously with adverse food reactions, the exact definition of a food allergy is specific: “adverse immune responses to food proteins that result in typical clinical symptoms.”⁸ The fact that many patients and even health care practitioners seem to frequently misapply this term makes it even more confusing. 

The current focus is on foods that could trigger a flare of AD, which clearly is a broader question than food allergy sensu stricto. It seems self-evident, for example, that if an infant with AD were to (messily) eat an acidic food such as an orange, a flare-up of AD around the mouth and on the cheeks and hands would be a forgone conclusion. Similar nonimmunologic scenarios unambiguously can occur with many foods, including citrus; corn; radish; mustard; garlic; onion; pineapple; and many spices, food additives, and preservatives.⁹ Clearly there are some scenarios whereby food could trigger an AD flare, and yet this more limited vignette generally is not what patients are referring to when suggesting that food is the root cause of their AD.

The Labyrinth of Testing for Food Allergies

Although there is no reliable method for testing for irritant dermatitis, understanding the other types of tests may help guide our thinking. Testing for IgE-mediated food allergies generally is done via an immunoenzymatic serum assay that can document sensitization to a food protein; however, this testing by itself is not sufficient to diagnose a clinical food allergy.¹⁰ Similarly, skin prick testing allows for intradermal administration of a food extract to evaluate for an urticarial reaction within 10 to 15 minutes. Although the sensitivity and specificity vary by age, population, and the specific allergen being tested, these are limited to immediate-type reactions and do not reflect the potential to drive an eczematous flare.

The gold standard, if there is one, is likely the double-blind, placebo-controlled food challenge (DBPCFC), ideally with a long enough observation period to capture later-occurring reactions such as an AD flare. However, given the nature of the test—having patients eat the foods of concern and then carefully following them for reactions—it remains time consuming, expensive, and labor intensive.¹¹ 

To further complicate matters, several unvalidated tests exist such as IgG testing, atopy patch testing, kinesiology, and hair and gastric juice analysis, which remain investigational but continue to be used and may further confuse patients and clinicians.¹²

It is useful to first separate out the classic IgE-mediated food allergy reactions that are common. In these immediate-type reactions, a person sensitized to a food protein will develop characteristic cutaneous and/or extracutaneous reactions such as urticaria, angioedema, and even anaphylaxis, usually within minutes of exposure. Although it is possible that an IgE-mediated reaction could trigger an AD flare—perhaps simply by causing pruritus, which could initiate the itch-scratch cycle—because of the near simultaneity with ingestion of the offending food and the often dramatic clinical presentations, such foods clearly do not represent “hidden” triggers for AD flares.³ The concept of food-triggered AD (FTAD) is crucial for thinking about foods that could result in true eczematous flares, which historically have been classified as early-type (<2 hours after food challenge) and late-type (≥2 hours after food challenge) reactions.^13,14 

A study of more than 1000 DBPCFCs performed in patients with AD was illustrative.¹⁵ Immediate reactions other than AD were fairly common and were observed in 40% of the food challenges compared to only 9% in the placebo group. These reactions included urticaria, angioedema, and gastrointestinal and respiratory tract symptoms. Immediate reactions of AD alone were exceedingly rare at only 0.7% and not significantly elevated compared to placebo. Just over 4% experienced both an immediate AD exacerbation along with other non-AD findings, which was significantly greater than placebo (P<.01). Although intermediate and late reactions manifesting as AD exacerbations did occur after food ingestion, they were rare (2.2% or less) and not significantly different from placebo. The authors concluded that an exacerbation of AD in the absence of other allergic symptoms in children was unlikely to be due to food,¹⁵ which is an important finding.

A recent retrospective review of 372 children with AD reported similar results.⁴ The authors defined FTAD in a different way; instead of showing a flare after a DBPCFC, they looked for “physician-noted sustained improvement in AD upon removal of a food (typically after 2–6-wk follow-up), to which the child was sensitized without any other changes in skin care.” Despite this fundamentally different approach, they similarly concluded that while food allergies were common, FTAD was relatively uncommon—found in 2% of those with mild AD, 6% of those with moderate AD, and 4% of those with severe AD.⁴ 

There are other ways that foods could contribute to disease flares, however, and one of the most compelling is that there may be broader concepts at play; perhaps some diets are not specifically driving the AD but rather are affecting inflammation in the body at large. Although somewhat speculative, there is evidence that some foods may simply be proinflammatory, working to exacerbate the disease outside of a specific mechanism, which has been seen in a variety of other conditions such as acne or rheumatoid arthritis.^16,17 To speculate further, it is possible that there may be a threshold effect such that when the AD is poorly controlled, certain factors such as inflammatory foods could lead to a flare, while when under better control, these same factors may not cause an effect.

Finally, it is important to also consider the emotional and/or psychological aspects related to food and diet. The power of the placebo in dietary change has been documented in several diseases, though this certainly is not to be dismissive of the patient’s symptoms; it seems reasonable that the very act of changing such a fundamental aspect of daily life could result in a placebo effect.^18,19 In the context of relapsing and remitting conditions such as AD, this effect may be magnified. A landmark study by Thompson and Hanifin²⁰ illustrates this possibility. The authors found that in 80% of cases in which patients were convinced that food was a major contributing factor to their AD, such concerns diminished markedly once better control of the eczema was achieved.²⁰

This brings us to what to do with an individual patient in the examination room. Because there is such widespread concern and discussion around this topic, it is important to at least briefly address it. If there are known food allergens that are being avoided, it is important to underscore the importance of continuing to avoid those foods, especially when there is actual evidence of true food allergy rather than sensitization alone. Historically, elimination diets often were recommended empirically, though more recent studies, meta-analyses, and guidance documents increasingly have recommended against them.³ In particular, there are major concerns for iatrogenic harm. 

First, heavily restricted diets may result in nutritional and/or caloric deficiencies that can be dangerous and lead to poor growth.²¹ Practices such as drinking unpasteurized milk can expose children to dangerous infections, while feeding them exclusively rice milk can lead to severe malnutrition.²² 

Second, there is a dawning realization that children with AD placed on elimination diets may actually develop true IgE-mediated allergies, including fatal anaphylaxis, to the excluded foods. In fact, one retrospective review of 298 patients with a history of AD and no prior immediate reactions found that 19% of patients developed new immediate-type hypersensitivity reactions after starting an elimination diet, presumably due to the loss of tolerance to these foods. A striking one-third of these reactions were classified as anaphylaxis, with cow’s milk and egg being the most common offenders.²³

It also is crucial to acknowledge that recommending sweeping lifestyle changes is not easy for patients, especially pediatric patients. Onerous dietary restrictions may add considerable stress, ironically a known trigger for AD itself. 

Finally, dietary modifications can be a distraction from conventional therapy and may result in treatment delays while the patient continues to experience uncontrolled symptoms of AD. 

Final Thoughts

Diet is intimately related to AD. Although the narrative continues to unfold in fascinating domains, such as the skin barrier and the microbiome, it is increasingly clear that these are intertwined and always have been. Despite the rarity of true food-triggered AD, the perception of dietary triggers is so widespread and addressing the topic is important and may help avoid unnecessary harm from unfounded extreme dietary changes. A recent multispecialty workgroup report on AD and food allergy succinctly summarized this as: “AD has many triggers and comorbidities, and food allergy is only one of the potential triggers and comorbid conditions. With regard to AD management, education and skin care are most important.”³ With proper testing, guidance, and both topical and systemic therapies, most AD can be brought under control, and for at least some patients, this may allay concerns about foods triggering their AD. 

New COVID-19 cases rose among U.S. children for the second consecutive week, while hospitals saw signs of renewed activity on the part of SARS-CoV-2.

The total for new cases reported during the week of Oct. 28 to Nov. 3, while still low at just under 30,000, was 21% higher than the previous week and 31% higher than 2 weeks ago (Oct. 14-20), when the count fell to its lowest level in more than a year, the American Academy of Pediatrics and the Children’s Hospital Association said in their joint report.

The trend is discernible, however, when looking at hospitalizations of children with confirmed COVID. The rate of new admissions of children aged 0-17 years was 0.16 per 100,000 population as late as Oct. 23 but ticked up a notch after that and has been 0.17 per 100,000 since, according to the CDC. As with the ED rate, hospitalizations had been steadily declining since late August.

Vaccine initiation continues to slow

During the week of Oct. 27 to Nov. 2, about 30,000 children under 5 years of age received their initial COVID vaccination. A month earlier (Sept. 29 to Oct. 5), that number was about 40,000. A month before that, about 53,000 children aged 0-5 years received their initial dose, the AAP said in a separate vaccination report based on CDC data.

All of that reduced interest adds up to 7.4% of the age group having received at least one dose and just 3.2% being fully vaccinated as of Nov. 2. Among children aged 5-11 years, the corresponding vaccination rates are 38.9% and 31.8%, while those aged 12-17 years are at 71.3% and 61.1%, the CDC said.

Looking at just the first 20 weeks of the vaccination experience for each age group shows that 1.6 million children under 5 years of age had received at least an initial dose, compared with 8.1 million children aged 5-11 years and 8.1 million children aged 12-15, the AAP said.

New COVID-19 cases rose among U.S. children for the second consecutive week, while hospitals saw signs of renewed activity on the part of SARS-CoV-2.

The total for new cases reported during the week of Oct. 28 to Nov. 3, while still low at just under 30,000, was 21% higher than the previous week and 31% higher than 2 weeks ago (Oct. 14-20), when the count fell to its lowest level in more than a year, the American Academy of Pediatrics and the Children’s Hospital Association said in their joint report.

The trend is discernible, however, when looking at hospitalizations of children with confirmed COVID. The rate of new admissions of children aged 0-17 years was 0.16 per 100,000 population as late as Oct. 23 but ticked up a notch after that and has been 0.17 per 100,000 since, according to the CDC. As with the ED rate, hospitalizations had been steadily declining since late August.

Vaccine initiation continues to slow

During the week of Oct. 27 to Nov. 2, about 30,000 children under 5 years of age received their initial COVID vaccination. A month earlier (Sept. 29 to Oct. 5), that number was about 40,000. A month before that, about 53,000 children aged 0-5 years received their initial dose, the AAP said in a separate vaccination report based on CDC data.

All of that reduced interest adds up to 7.4% of the age group having received at least one dose and just 3.2% being fully vaccinated as of Nov. 2. Among children aged 5-11 years, the corresponding vaccination rates are 38.9% and 31.8%, while those aged 12-17 years are at 71.3% and 61.1%, the CDC said.

Looking at just the first 20 weeks of the vaccination experience for each age group shows that 1.6 million children under 5 years of age had received at least an initial dose, compared with 8.1 million children aged 5-11 years and 8.1 million children aged 12-15, the AAP said.

New COVID-19 cases rose among U.S. children for the second consecutive week, while hospitals saw signs of renewed activity on the part of SARS-CoV-2.

The total for new cases reported during the week of Oct. 28 to Nov. 3, while still low at just under 30,000, was 21% higher than the previous week and 31% higher than 2 weeks ago (Oct. 14-20), when the count fell to its lowest level in more than a year, the American Academy of Pediatrics and the Children’s Hospital Association said in their joint report.

The trend is discernible, however, when looking at hospitalizations of children with confirmed COVID. The rate of new admissions of children aged 0-17 years was 0.16 per 100,000 population as late as Oct. 23 but ticked up a notch after that and has been 0.17 per 100,000 since, according to the CDC. As with the ED rate, hospitalizations had been steadily declining since late August.

Vaccine initiation continues to slow

During the week of Oct. 27 to Nov. 2, about 30,000 children under 5 years of age received their initial COVID vaccination. A month earlier (Sept. 29 to Oct. 5), that number was about 40,000. A month before that, about 53,000 children aged 0-5 years received their initial dose, the AAP said in a separate vaccination report based on CDC data.

All of that reduced interest adds up to 7.4% of the age group having received at least one dose and just 3.2% being fully vaccinated as of Nov. 2. Among children aged 5-11 years, the corresponding vaccination rates are 38.9% and 31.8%, while those aged 12-17 years are at 71.3% and 61.1%, the CDC said.

Looking at just the first 20 weeks of the vaccination experience for each age group shows that 1.6 million children under 5 years of age had received at least an initial dose, compared with 8.1 million children aged 5-11 years and 8.1 million children aged 12-15, the AAP said.

Recent findings from a study examining mothers’ recall of doctors’ advice on early-child nutrition suggest that key feeding messages may not be heard, remembered, or even delivered.

During a typical child wellness visit, pediatricians provide parents with anticipatory guidance on all aspects of child development and safety, up to the age of 5 years.

The analysis of data from a subset of 1,302 mothers participating in the 2017-2019 National Survey of Family Growth showed that those older than 31 years of age and those who identified as non-Hispanic White were more likely to recall discussion of certain child nutrition topics compared with younger mothers or those who identified as Hispanic.

Of the six child-feeding topics referenced from the American Academy of Pediatrics’ “Bright Futures Guidelines,” less than half of the mothers, all of whom had a child between the ages of 6 months and 5 years, recalled guidance on limiting meals in front of the television or other electronic devices. Similarly, fewer than 50% remembered being told not to force their child to finish a bottle or food, the analysis showed.

When it came to the best time to introduce solid foods, 37% didn’t recall being told to wait at least 4 months and preferably, 6 months. In fact, these mothers reported being advised to introduce solid foods before 6 months, said Andrea McGowan, MPH, of the National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention, Atlanta, and colleagues.

The study was published in the Journal of Nutrition Education and Behavior.

“All in all, this research draws attention to certain nutrition guidance topics or subpopulations that might be prioritized to improve receipt and recall of guidance,” said Ms. McGowan, now a first-year medical student at the University of Michigan, Ann Arbor, in a podcast. “This research ... implores us to consider ways to revamp the existing standard practice for pediatric well-child care to improve recall of messages.”

The analysis also included data on mothers’ recall of advice on offering foods with different tastes and textures; offering a variety of fruits and vegetables; and limiting added sugar. More than half of mothers remembered discussing four or five child nutrition topics, but 31% recalled talking about only one or two. Offering a variety of fruits and vegetables had the highest percentage of recall.

The study wasn’t powered to determine whether the nutrition guidance provided at a well-child visit was not remembered or not provided, Ms. McGowan said, adding: “So exploring this is definitely the goal of future research.”

However, pediatricians report spending an average of 18 minutes with children and their parents, she noted. “This is definitely not enough time to cover every single topic a pediatrician or a parent might want to discuss.” Other barriers, such as a lack of insurance or transportation, may limit parents’ access to this kind of anticipatory guidance, the researchers said.

Priority should be given to certain topics and to certain mothers, they suggested. “Innovative strategies tailored to families’ needs might alleviate the HCP [health care provider] burden and could enhance parental recall, especially when messaging is culturally relevant and personalized,” Ms. McGowan said.

Two independent experts agreed in interviews. Pediatricians must do their best to tailor advice to each particular family so that parents can engage in the conversation, said Lauren Fiechtner, MD, director of the center for pediatric nutrition at Mass General for Children, Boston. “As the authors suggest, we should seek to understand the cultural relevance of our recommendations and to understand the barriers our patient families might face in implementing our advice,” said Dr. Fiechtner, who is also an assistant professor at Harvard Medical School, also in Boston.

“Much of the instructions we as pediatricians give to parents must be repeated and reinforced,” said Rebecca S. Fisk, MD, a pediatrician at Lenox Hill Hospital, Northwell Health, in New York. Often, the doctor’s advice runs counter to what family and friends recommend, she pointed out. Some parents may believe that “the baby who starts solid food earlier will sleep through the night earlier or that eating in front of the TV relaxes the child or allows them to eat more,” Dr. Fisk explained. In her practice, a nurse goes over her instructions, answers questions, and provides specific examples and written information.

Sometimes, even that’s not enough, Dr. Fisk admitted. “I, myself, have fielded many repeated questions about feeding, when to start, how much to give, and so on, despite printed guidance given to parents at well-child visits.”

This study was funded by the U.S. Centers for Disease Control and Prevention. Ms. McGowan and study coauthors reported having no potential conflicts of interest. Dr. Fiechtner and Dr. Fisk disclosed having no potential conflicts of interest.
 

Recent findings from a study examining mothers’ recall of doctors’ advice on early-child nutrition suggest that key feeding messages may not be heard, remembered, or even delivered.

During a typical child wellness visit, pediatricians provide parents with anticipatory guidance on all aspects of child development and safety, up to the age of 5 years.

The analysis of data from a subset of 1,302 mothers participating in the 2017-2019 National Survey of Family Growth showed that those older than 31 years of age and those who identified as non-Hispanic White were more likely to recall discussion of certain child nutrition topics compared with younger mothers or those who identified as Hispanic.

Of the six child-feeding topics referenced from the American Academy of Pediatrics’ “Bright Futures Guidelines,” less than half of the mothers, all of whom had a child between the ages of 6 months and 5 years, recalled guidance on limiting meals in front of the television or other electronic devices. Similarly, fewer than 50% remembered being told not to force their child to finish a bottle or food, the analysis showed.

When it came to the best time to introduce solid foods, 37% didn’t recall being told to wait at least 4 months and preferably, 6 months. In fact, these mothers reported being advised to introduce solid foods before 6 months, said Andrea McGowan, MPH, of the National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention, Atlanta, and colleagues.

The study was published in the Journal of Nutrition Education and Behavior.

“All in all, this research draws attention to certain nutrition guidance topics or subpopulations that might be prioritized to improve receipt and recall of guidance,” said Ms. McGowan, now a first-year medical student at the University of Michigan, Ann Arbor, in a podcast. “This research ... implores us to consider ways to revamp the existing standard practice for pediatric well-child care to improve recall of messages.”

The analysis also included data on mothers’ recall of advice on offering foods with different tastes and textures; offering a variety of fruits and vegetables; and limiting added sugar. More than half of mothers remembered discussing four or five child nutrition topics, but 31% recalled talking about only one or two. Offering a variety of fruits and vegetables had the highest percentage of recall.

The study wasn’t powered to determine whether the nutrition guidance provided at a well-child visit was not remembered or not provided, Ms. McGowan said, adding: “So exploring this is definitely the goal of future research.”

However, pediatricians report spending an average of 18 minutes with children and their parents, she noted. “This is definitely not enough time to cover every single topic a pediatrician or a parent might want to discuss.” Other barriers, such as a lack of insurance or transportation, may limit parents’ access to this kind of anticipatory guidance, the researchers said.

Priority should be given to certain topics and to certain mothers, they suggested. “Innovative strategies tailored to families’ needs might alleviate the HCP [health care provider] burden and could enhance parental recall, especially when messaging is culturally relevant and personalized,” Ms. McGowan said.

Two independent experts agreed in interviews. Pediatricians must do their best to tailor advice to each particular family so that parents can engage in the conversation, said Lauren Fiechtner, MD, director of the center for pediatric nutrition at Mass General for Children, Boston. “As the authors suggest, we should seek to understand the cultural relevance of our recommendations and to understand the barriers our patient families might face in implementing our advice,” said Dr. Fiechtner, who is also an assistant professor at Harvard Medical School, also in Boston.

“Much of the instructions we as pediatricians give to parents must be repeated and reinforced,” said Rebecca S. Fisk, MD, a pediatrician at Lenox Hill Hospital, Northwell Health, in New York. Often, the doctor’s advice runs counter to what family and friends recommend, she pointed out. Some parents may believe that “the baby who starts solid food earlier will sleep through the night earlier or that eating in front of the TV relaxes the child or allows them to eat more,” Dr. Fisk explained. In her practice, a nurse goes over her instructions, answers questions, and provides specific examples and written information.

Sometimes, even that’s not enough, Dr. Fisk admitted. “I, myself, have fielded many repeated questions about feeding, when to start, how much to give, and so on, despite printed guidance given to parents at well-child visits.”

This study was funded by the U.S. Centers for Disease Control and Prevention. Ms. McGowan and study coauthors reported having no potential conflicts of interest. Dr. Fiechtner and Dr. Fisk disclosed having no potential conflicts of interest.
 

Recent findings from a study examining mothers’ recall of doctors’ advice on early-child nutrition suggest that key feeding messages may not be heard, remembered, or even delivered.

During a typical child wellness visit, pediatricians provide parents with anticipatory guidance on all aspects of child development and safety, up to the age of 5 years.

The analysis of data from a subset of 1,302 mothers participating in the 2017-2019 National Survey of Family Growth showed that those older than 31 years of age and those who identified as non-Hispanic White were more likely to recall discussion of certain child nutrition topics compared with younger mothers or those who identified as Hispanic.

Of the six child-feeding topics referenced from the American Academy of Pediatrics’ “Bright Futures Guidelines,” less than half of the mothers, all of whom had a child between the ages of 6 months and 5 years, recalled guidance on limiting meals in front of the television or other electronic devices. Similarly, fewer than 50% remembered being told not to force their child to finish a bottle or food, the analysis showed.

When it came to the best time to introduce solid foods, 37% didn’t recall being told to wait at least 4 months and preferably, 6 months. In fact, these mothers reported being advised to introduce solid foods before 6 months, said Andrea McGowan, MPH, of the National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention, Atlanta, and colleagues.

The study was published in the Journal of Nutrition Education and Behavior.

“All in all, this research draws attention to certain nutrition guidance topics or subpopulations that might be prioritized to improve receipt and recall of guidance,” said Ms. McGowan, now a first-year medical student at the University of Michigan, Ann Arbor, in a podcast. “This research ... implores us to consider ways to revamp the existing standard practice for pediatric well-child care to improve recall of messages.”

The analysis also included data on mothers’ recall of advice on offering foods with different tastes and textures; offering a variety of fruits and vegetables; and limiting added sugar. More than half of mothers remembered discussing four or five child nutrition topics, but 31% recalled talking about only one or two. Offering a variety of fruits and vegetables had the highest percentage of recall.

The study wasn’t powered to determine whether the nutrition guidance provided at a well-child visit was not remembered or not provided, Ms. McGowan said, adding: “So exploring this is definitely the goal of future research.”

However, pediatricians report spending an average of 18 minutes with children and their parents, she noted. “This is definitely not enough time to cover every single topic a pediatrician or a parent might want to discuss.” Other barriers, such as a lack of insurance or transportation, may limit parents’ access to this kind of anticipatory guidance, the researchers said.

Priority should be given to certain topics and to certain mothers, they suggested. “Innovative strategies tailored to families’ needs might alleviate the HCP [health care provider] burden and could enhance parental recall, especially when messaging is culturally relevant and personalized,” Ms. McGowan said.

Two independent experts agreed in interviews. Pediatricians must do their best to tailor advice to each particular family so that parents can engage in the conversation, said Lauren Fiechtner, MD, director of the center for pediatric nutrition at Mass General for Children, Boston. “As the authors suggest, we should seek to understand the cultural relevance of our recommendations and to understand the barriers our patient families might face in implementing our advice,” said Dr. Fiechtner, who is also an assistant professor at Harvard Medical School, also in Boston.

“Much of the instructions we as pediatricians give to parents must be repeated and reinforced,” said Rebecca S. Fisk, MD, a pediatrician at Lenox Hill Hospital, Northwell Health, in New York. Often, the doctor’s advice runs counter to what family and friends recommend, she pointed out. Some parents may believe that “the baby who starts solid food earlier will sleep through the night earlier or that eating in front of the TV relaxes the child or allows them to eat more,” Dr. Fisk explained. In her practice, a nurse goes over her instructions, answers questions, and provides specific examples and written information.

Sometimes, even that’s not enough, Dr. Fisk admitted. “I, myself, have fielded many repeated questions about feeding, when to start, how much to give, and so on, despite printed guidance given to parents at well-child visits.”

This study was funded by the U.S. Centers for Disease Control and Prevention. Ms. McGowan and study coauthors reported having no potential conflicts of interest. Dr. Fiechtner and Dr. Fisk disclosed having no potential conflicts of interest.
 

Case: You are talking with one of your teenage patients, who has a history of significant suicidal ideation and an aborted attempt, and you ask her if there is someone she can talk with if she is feeling suicidal. “I call a friend,” she says. “That’s the only thing that works when I’m feeling bad.”

During difficult times, it is important to have a repertoire of coping skills to address stress, tension, frustration, anxiety, anger, sadness, and to help avoid dangerous behaviors. It is also important to have someone to talk to. For many youth, talking with friends is their preferred coping skill and contact when struggling with intense feelings.

This is hardly surprising. Peer relations are central to adolescent development. The ongoing individuation-separation process means that adolescents are peeling away from the family and into a community of their peers, where they figure out who they are through social interactions in subtle and complex ways. Adolescents are often profoundly immersed in the world of their peers; they often spend more time with their peers in educational and social settings than with their parents or other adults; and their connections with peers are often pleasurable, engaging, supportive, and intense. It is natural that they would want to communicate with their peers during stressful times.

At the same time, they may also want to avoid talking with adults. They may identify adult figures with authority, expectations, and control. So much adolescent psychic suffering and so many mental health crises involve shame, guilt, and fear, and are associated with romance, love, disappointment, and trauma – all of which may be difficult to share with parents and adult figures.

Adults also struggle with these kinds of conversations. Even benign attempts at comforting the youth (“Don’t worry, it’ll get better,” “Everyone feels this way sometimes”) can be seen as invalidating. And in stressful times, a difficult conversation can be ignited by the fuel of adult anxieties about the independence and autonomy of the child that is coming, which can make charged conversations all the more inflammatory.

Reaching out to peers during stressful times is therefore developmentally appropriate and often feels far more comfortable, validating, and sympathetic.

One of the most important things we can do is to help kids understand when, how, and why they can support each other – and when they cannot. Whether we like it or not, for many youth, peers are peer mental health counselors. They have shared vocabularies and can share experiences in the mental health care system. In addition to relying on their peers, a great many youth we work with also see themselves as supports to their peers, so it’s not just a one-way street.

So we talk with them frankly about when, how, and why talking with their friends can be an effective way of getting through a hard time and when, how, and why they need to reach out to an adult.

Recognizing how positive peer support can be, we ask them to identify problems with it. Kids often recognize the drawbacks of relying on their peers for support. They can see how it can be a burden to their friends. They often acknowledge that their friends may be experts in some aspects of their lives but not in others. For example, they can have shared stressors in school, can have similar understandings of the drama in their lives, and can relate to each other’s worlds, but will also not necessarily know what to do if a situation becomes dangerous.

The youth also tend to understand that the stakes in these conversations are high. We have seen peer groups suffer terribly when the youth have felt responsible – and even been the last preceding contact – in bad or even fatal outcomes.

We need to open up conversations about different forms of communication: when teens need understanding, compassion, patience; when they need a good understanding of local, cultural contexts, and a sense of support without anxieties and stressors; and when they need support and adult capacities and connections to solve problems. We can help them understand how to access people – both peers and adults – but also discuss responsibility: who you are responsible for, how you cannot be responsible alone for your friends’ mental health, how they cannot be responsible for yours, and who can be responsible for you.

To this end, we validate the importance of peers and ask more specifically when the adolescent thinks it is helpful to contact peers and when they think it would not be helpful. Having teens explain the difference may help them identify the right times to connect with peers or adults.

We can then talk about how to understand that there are different kinds of crisis: the kind where comfort, understanding, and support from friends can alleviate the crisis, and times when it is imperative to involve adults.

We can then identify which adults in their lives they can contact and how they would do so, both in terms of method of communication (texting an older sister, speaking in person with a parent, calling a therapist) and what they could say.

Then comes a more difficult step. We help them think about how to identify adults whom they do not know: how to contact a hotline or go to an emergency room or call 911. It is important not just to provide the numbers or address, but to help them run through a brief script so they know what to say and would be comfortable saying in their own words (but effectively saying, “I really need to speak with someone right now, I’m not safe.”)

Helping youth understand the advantages and disadvantages of reaching out to peers, and when and how to reach out to adults, can be a constructive conversation. It is a chance not only to speak with and hear about a youth’s life and relationships but also a chance to give them a stronger and safer support network.

Dr. Henderson is a psychiatrist who treats children and adolescents at NYU Langone Health, New York.

Case: You are talking with one of your teenage patients, who has a history of significant suicidal ideation and an aborted attempt, and you ask her if there is someone she can talk with if she is feeling suicidal. “I call a friend,” she says. “That’s the only thing that works when I’m feeling bad.”

During difficult times, it is important to have a repertoire of coping skills to address stress, tension, frustration, anxiety, anger, sadness, and to help avoid dangerous behaviors. It is also important to have someone to talk to. For many youth, talking with friends is their preferred coping skill and contact when struggling with intense feelings.

This is hardly surprising. Peer relations are central to adolescent development. The ongoing individuation-separation process means that adolescents are peeling away from the family and into a community of their peers, where they figure out who they are through social interactions in subtle and complex ways. Adolescents are often profoundly immersed in the world of their peers; they often spend more time with their peers in educational and social settings than with their parents or other adults; and their connections with peers are often pleasurable, engaging, supportive, and intense. It is natural that they would want to communicate with their peers during stressful times.

At the same time, they may also want to avoid talking with adults. They may identify adult figures with authority, expectations, and control. So much adolescent psychic suffering and so many mental health crises involve shame, guilt, and fear, and are associated with romance, love, disappointment, and trauma – all of which may be difficult to share with parents and adult figures.

Adults also struggle with these kinds of conversations. Even benign attempts at comforting the youth (“Don’t worry, it’ll get better,” “Everyone feels this way sometimes”) can be seen as invalidating. And in stressful times, a difficult conversation can be ignited by the fuel of adult anxieties about the independence and autonomy of the child that is coming, which can make charged conversations all the more inflammatory.

Reaching out to peers during stressful times is therefore developmentally appropriate and often feels far more comfortable, validating, and sympathetic.

One of the most important things we can do is to help kids understand when, how, and why they can support each other – and when they cannot. Whether we like it or not, for many youth, peers are peer mental health counselors. They have shared vocabularies and can share experiences in the mental health care system. In addition to relying on their peers, a great many youth we work with also see themselves as supports to their peers, so it’s not just a one-way street.

So we talk with them frankly about when, how, and why talking with their friends can be an effective way of getting through a hard time and when, how, and why they need to reach out to an adult.

Recognizing how positive peer support can be, we ask them to identify problems with it. Kids often recognize the drawbacks of relying on their peers for support. They can see how it can be a burden to their friends. They often acknowledge that their friends may be experts in some aspects of their lives but not in others. For example, they can have shared stressors in school, can have similar understandings of the drama in their lives, and can relate to each other’s worlds, but will also not necessarily know what to do if a situation becomes dangerous.

The youth also tend to understand that the stakes in these conversations are high. We have seen peer groups suffer terribly when the youth have felt responsible – and even been the last preceding contact – in bad or even fatal outcomes.

We need to open up conversations about different forms of communication: when teens need understanding, compassion, patience; when they need a good understanding of local, cultural contexts, and a sense of support without anxieties and stressors; and when they need support and adult capacities and connections to solve problems. We can help them understand how to access people – both peers and adults – but also discuss responsibility: who you are responsible for, how you cannot be responsible alone for your friends’ mental health, how they cannot be responsible for yours, and who can be responsible for you.

To this end, we validate the importance of peers and ask more specifically when the adolescent thinks it is helpful to contact peers and when they think it would not be helpful. Having teens explain the difference may help them identify the right times to connect with peers or adults.

We can then talk about how to understand that there are different kinds of crisis: the kind where comfort, understanding, and support from friends can alleviate the crisis, and times when it is imperative to involve adults.

We can then identify which adults in their lives they can contact and how they would do so, both in terms of method of communication (texting an older sister, speaking in person with a parent, calling a therapist) and what they could say.

Then comes a more difficult step. We help them think about how to identify adults whom they do not know: how to contact a hotline or go to an emergency room or call 911. It is important not just to provide the numbers or address, but to help them run through a brief script so they know what to say and would be comfortable saying in their own words (but effectively saying, “I really need to speak with someone right now, I’m not safe.”)

Helping youth understand the advantages and disadvantages of reaching out to peers, and when and how to reach out to adults, can be a constructive conversation. It is a chance not only to speak with and hear about a youth’s life and relationships but also a chance to give them a stronger and safer support network.

Dr. Henderson is a psychiatrist who treats children and adolescents at NYU Langone Health, New York.

Case: You are talking with one of your teenage patients, who has a history of significant suicidal ideation and an aborted attempt, and you ask her if there is someone she can talk with if she is feeling suicidal. “I call a friend,” she says. “That’s the only thing that works when I’m feeling bad.”

During difficult times, it is important to have a repertoire of coping skills to address stress, tension, frustration, anxiety, anger, sadness, and to help avoid dangerous behaviors. It is also important to have someone to talk to. For many youth, talking with friends is their preferred coping skill and contact when struggling with intense feelings.

This is hardly surprising. Peer relations are central to adolescent development. The ongoing individuation-separation process means that adolescents are peeling away from the family and into a community of their peers, where they figure out who they are through social interactions in subtle and complex ways. Adolescents are often profoundly immersed in the world of their peers; they often spend more time with their peers in educational and social settings than with their parents or other adults; and their connections with peers are often pleasurable, engaging, supportive, and intense. It is natural that they would want to communicate with their peers during stressful times.

At the same time, they may also want to avoid talking with adults. They may identify adult figures with authority, expectations, and control. So much adolescent psychic suffering and so many mental health crises involve shame, guilt, and fear, and are associated with romance, love, disappointment, and trauma – all of which may be difficult to share with parents and adult figures.

Adults also struggle with these kinds of conversations. Even benign attempts at comforting the youth (“Don’t worry, it’ll get better,” “Everyone feels this way sometimes”) can be seen as invalidating. And in stressful times, a difficult conversation can be ignited by the fuel of adult anxieties about the independence and autonomy of the child that is coming, which can make charged conversations all the more inflammatory.

Reaching out to peers during stressful times is therefore developmentally appropriate and often feels far more comfortable, validating, and sympathetic.

One of the most important things we can do is to help kids understand when, how, and why they can support each other – and when they cannot. Whether we like it or not, for many youth, peers are peer mental health counselors. They have shared vocabularies and can share experiences in the mental health care system. In addition to relying on their peers, a great many youth we work with also see themselves as supports to their peers, so it’s not just a one-way street.

So we talk with them frankly about when, how, and why talking with their friends can be an effective way of getting through a hard time and when, how, and why they need to reach out to an adult.

Recognizing how positive peer support can be, we ask them to identify problems with it. Kids often recognize the drawbacks of relying on their peers for support. They can see how it can be a burden to their friends. They often acknowledge that their friends may be experts in some aspects of their lives but not in others. For example, they can have shared stressors in school, can have similar understandings of the drama in their lives, and can relate to each other’s worlds, but will also not necessarily know what to do if a situation becomes dangerous.

The youth also tend to understand that the stakes in these conversations are high. We have seen peer groups suffer terribly when the youth have felt responsible – and even been the last preceding contact – in bad or even fatal outcomes.

We need to open up conversations about different forms of communication: when teens need understanding, compassion, patience; when they need a good understanding of local, cultural contexts, and a sense of support without anxieties and stressors; and when they need support and adult capacities and connections to solve problems. We can help them understand how to access people – both peers and adults – but also discuss responsibility: who you are responsible for, how you cannot be responsible alone for your friends’ mental health, how they cannot be responsible for yours, and who can be responsible for you.

To this end, we validate the importance of peers and ask more specifically when the adolescent thinks it is helpful to contact peers and when they think it would not be helpful. Having teens explain the difference may help them identify the right times to connect with peers or adults.

We can then talk about how to understand that there are different kinds of crisis: the kind where comfort, understanding, and support from friends can alleviate the crisis, and times when it is imperative to involve adults.

We can then identify which adults in their lives they can contact and how they would do so, both in terms of method of communication (texting an older sister, speaking in person with a parent, calling a therapist) and what they could say.

Then comes a more difficult step. We help them think about how to identify adults whom they do not know: how to contact a hotline or go to an emergency room or call 911. It is important not just to provide the numbers or address, but to help them run through a brief script so they know what to say and would be comfortable saying in their own words (but effectively saying, “I really need to speak with someone right now, I’m not safe.”)

Helping youth understand the advantages and disadvantages of reaching out to peers, and when and how to reach out to adults, can be a constructive conversation. It is a chance not only to speak with and hear about a youth’s life and relationships but also a chance to give them a stronger and safer support network.

Dr. Henderson is a psychiatrist who treats children and adolescents at NYU Langone Health, New York.