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Individual pediatric hypertension trials support personalized care
The preferred medication in children with hypertension varied among three common medications in n-of-1 studies with repeated ambulatory blood pressure monitoring that allowed for individualized treatment plans.
“In usual care, the choice of specific antihypertensive regimen is based on physician preference with little or no systematic assessment of treatment benefits and hazards,” wrote Joyce P. Samuel, MD, of the University of Texas Health Science Center, Houston, and her colleagues.
In a study published in Pediatrics, the researchers assessed 32 hypertensive children who participated in n-of-1 studies at a single center. The children underwent repeated ambulatory blood pressure monitoring (APBM) to compare the effects of three medications: lisinopril, amlodipine, and hydrochlorothiazide. The children were at least 9 years old, and their primary referring physician had recommended antihypertensive treatment.
The preferred medication was defined as the one that yielded both a normal ambulatory blood pressure and the greatest reduction in average systolic blood pressure when awake for two treatment periods with no unacceptable side effects. If more than one medication met these criteria, the one with the least side effects was chosen.
Overall, the preferred medication was lisinopril for 16 patients (49%), amlodipine for 8 patients (24%), and hydrochlorothiazide for 4 patients (12%); 4 patients remained uncontrolled on monotherapy.
Each of the three medications was taken for 2 weeks, and patients were assessed with a 24-hour ABPM and a side-effect questionnaire during the final 24 hours of each treatment. A total of 27 patients reported at least one side effect during the study. Unacceptable side effects were most frequent on hydrochlorothiazide (25%), compared with 16% for lisinopril and 13% for amlodipine. None of the patients experienced hypertensive crisis, hypotension, hyperkalemia, or an increase in serum creatinine levels of more than 20% from baseline.
No single medication was preferred for at least 80% of the patients. “Within-patient variation in BP (blood pressure) response was considerable because the best-performing medication decreased the BP by about 12 mm Hg more than the worst-performing medication,” the researchers wrote.
The findings were limited by the possibility that a 2-week trial might be insufficient to evaluate medication effects, and more research is needed to refine the methods of the trials and the generalizability of the n-of-1 approach, the researchers noted. However, “this individualized approach to antihypertensive medication selection holds potential value by involving patients in their own care and facilitating informed treatment decisions,” they said.
“A randomized trial in which researchers compare usual care to routine use of n-of-1 trials with ABPM is needed to assess effects on treatment adherence, patient satisfaction, long-term BP control assessed with ABPM, and hypertensive target organ damage,” Dr. Samuel and her associates advised.
The study was supported in part by the National Center for Advancing Translational Sciences and the National Institutes of Health. The researchers had no financial conflicts to disclose.
SOURCE: Samuel JP et al. Pediatrics. 2019 Mar 6. doi: 10.1542/peds.2018-1818.
The preferred medication in children with hypertension varied among three common medications in n-of-1 studies with repeated ambulatory blood pressure monitoring that allowed for individualized treatment plans.
“In usual care, the choice of specific antihypertensive regimen is based on physician preference with little or no systematic assessment of treatment benefits and hazards,” wrote Joyce P. Samuel, MD, of the University of Texas Health Science Center, Houston, and her colleagues.
In a study published in Pediatrics, the researchers assessed 32 hypertensive children who participated in n-of-1 studies at a single center. The children underwent repeated ambulatory blood pressure monitoring (APBM) to compare the effects of three medications: lisinopril, amlodipine, and hydrochlorothiazide. The children were at least 9 years old, and their primary referring physician had recommended antihypertensive treatment.
The preferred medication was defined as the one that yielded both a normal ambulatory blood pressure and the greatest reduction in average systolic blood pressure when awake for two treatment periods with no unacceptable side effects. If more than one medication met these criteria, the one with the least side effects was chosen.
Overall, the preferred medication was lisinopril for 16 patients (49%), amlodipine for 8 patients (24%), and hydrochlorothiazide for 4 patients (12%); 4 patients remained uncontrolled on monotherapy.
Each of the three medications was taken for 2 weeks, and patients were assessed with a 24-hour ABPM and a side-effect questionnaire during the final 24 hours of each treatment. A total of 27 patients reported at least one side effect during the study. Unacceptable side effects were most frequent on hydrochlorothiazide (25%), compared with 16% for lisinopril and 13% for amlodipine. None of the patients experienced hypertensive crisis, hypotension, hyperkalemia, or an increase in serum creatinine levels of more than 20% from baseline.
No single medication was preferred for at least 80% of the patients. “Within-patient variation in BP (blood pressure) response was considerable because the best-performing medication decreased the BP by about 12 mm Hg more than the worst-performing medication,” the researchers wrote.
The findings were limited by the possibility that a 2-week trial might be insufficient to evaluate medication effects, and more research is needed to refine the methods of the trials and the generalizability of the n-of-1 approach, the researchers noted. However, “this individualized approach to antihypertensive medication selection holds potential value by involving patients in their own care and facilitating informed treatment decisions,” they said.
“A randomized trial in which researchers compare usual care to routine use of n-of-1 trials with ABPM is needed to assess effects on treatment adherence, patient satisfaction, long-term BP control assessed with ABPM, and hypertensive target organ damage,” Dr. Samuel and her associates advised.
The study was supported in part by the National Center for Advancing Translational Sciences and the National Institutes of Health. The researchers had no financial conflicts to disclose.
SOURCE: Samuel JP et al. Pediatrics. 2019 Mar 6. doi: 10.1542/peds.2018-1818.
The preferred medication in children with hypertension varied among three common medications in n-of-1 studies with repeated ambulatory blood pressure monitoring that allowed for individualized treatment plans.
“In usual care, the choice of specific antihypertensive regimen is based on physician preference with little or no systematic assessment of treatment benefits and hazards,” wrote Joyce P. Samuel, MD, of the University of Texas Health Science Center, Houston, and her colleagues.
In a study published in Pediatrics, the researchers assessed 32 hypertensive children who participated in n-of-1 studies at a single center. The children underwent repeated ambulatory blood pressure monitoring (APBM) to compare the effects of three medications: lisinopril, amlodipine, and hydrochlorothiazide. The children were at least 9 years old, and their primary referring physician had recommended antihypertensive treatment.
The preferred medication was defined as the one that yielded both a normal ambulatory blood pressure and the greatest reduction in average systolic blood pressure when awake for two treatment periods with no unacceptable side effects. If more than one medication met these criteria, the one with the least side effects was chosen.
Overall, the preferred medication was lisinopril for 16 patients (49%), amlodipine for 8 patients (24%), and hydrochlorothiazide for 4 patients (12%); 4 patients remained uncontrolled on monotherapy.
Each of the three medications was taken for 2 weeks, and patients were assessed with a 24-hour ABPM and a side-effect questionnaire during the final 24 hours of each treatment. A total of 27 patients reported at least one side effect during the study. Unacceptable side effects were most frequent on hydrochlorothiazide (25%), compared with 16% for lisinopril and 13% for amlodipine. None of the patients experienced hypertensive crisis, hypotension, hyperkalemia, or an increase in serum creatinine levels of more than 20% from baseline.
No single medication was preferred for at least 80% of the patients. “Within-patient variation in BP (blood pressure) response was considerable because the best-performing medication decreased the BP by about 12 mm Hg more than the worst-performing medication,” the researchers wrote.
The findings were limited by the possibility that a 2-week trial might be insufficient to evaluate medication effects, and more research is needed to refine the methods of the trials and the generalizability of the n-of-1 approach, the researchers noted. However, “this individualized approach to antihypertensive medication selection holds potential value by involving patients in their own care and facilitating informed treatment decisions,” they said.
“A randomized trial in which researchers compare usual care to routine use of n-of-1 trials with ABPM is needed to assess effects on treatment adherence, patient satisfaction, long-term BP control assessed with ABPM, and hypertensive target organ damage,” Dr. Samuel and her associates advised.
The study was supported in part by the National Center for Advancing Translational Sciences and the National Institutes of Health. The researchers had no financial conflicts to disclose.
SOURCE: Samuel JP et al. Pediatrics. 2019 Mar 6. doi: 10.1542/peds.2018-1818.
FROM PEDIATRICS
Comorbid skin conditions common in children with lichen nitidus
as is generalized disease, according to Selcen Kundak, MD, and Yasemin Çakır, MD, of Dr. Behcet Uz Children’s Research and Training Hospital in Izmir, Turkey.
In a retrospective study 10-year study of 17 children with biopsy-confirmed lichen nitidus (LN) who were diagnosed with the disease at a single tertiary care health center between January 2007 and March 2017, the mean age of onset was 9 years and 15 of 17 (88%) were male. The mean skin lesion duration period was 13 months (range 1-48 months).
The generalized form of LN was common in the study population, occurring in 7 of 17 (41%) patients, 2 of whom had severe pruritus. Comorbid skin conditions also occurred in seven (41%) patients; these conditions included lichen planus in one patient, lichen striatus in one patient, nail psoriasis in one patients, and cutaneous features of atopic skin in four patients. In addition, 11 of 17 (65%) patients had multinucleated giant cells.
“Seven of 17 had comorbid skin conditions. Lichen planus, lichen striatus, psoriasis, and atopy are also chronic inflammatory skin conditions, and possibly, there are common triggers for these and LN; however, this is speculative, not proven,” the investigators concluded in Pediatric Dermatology.
Mild to moderate corticosteroids were give to 16 patients; all showed some clinical improvement within 3 weeks. One patient was treated with systemic corticosteroids.
The study authors reported no relevant financial disclosures.
SOURCE: Kundak S et al. Pediatr Dermatol. 2019 Feb 11. doi: 10.1111/pde.13749.
as is generalized disease, according to Selcen Kundak, MD, and Yasemin Çakır, MD, of Dr. Behcet Uz Children’s Research and Training Hospital in Izmir, Turkey.
In a retrospective study 10-year study of 17 children with biopsy-confirmed lichen nitidus (LN) who were diagnosed with the disease at a single tertiary care health center between January 2007 and March 2017, the mean age of onset was 9 years and 15 of 17 (88%) were male. The mean skin lesion duration period was 13 months (range 1-48 months).
The generalized form of LN was common in the study population, occurring in 7 of 17 (41%) patients, 2 of whom had severe pruritus. Comorbid skin conditions also occurred in seven (41%) patients; these conditions included lichen planus in one patient, lichen striatus in one patient, nail psoriasis in one patients, and cutaneous features of atopic skin in four patients. In addition, 11 of 17 (65%) patients had multinucleated giant cells.
“Seven of 17 had comorbid skin conditions. Lichen planus, lichen striatus, psoriasis, and atopy are also chronic inflammatory skin conditions, and possibly, there are common triggers for these and LN; however, this is speculative, not proven,” the investigators concluded in Pediatric Dermatology.
Mild to moderate corticosteroids were give to 16 patients; all showed some clinical improvement within 3 weeks. One patient was treated with systemic corticosteroids.
The study authors reported no relevant financial disclosures.
SOURCE: Kundak S et al. Pediatr Dermatol. 2019 Feb 11. doi: 10.1111/pde.13749.
as is generalized disease, according to Selcen Kundak, MD, and Yasemin Çakır, MD, of Dr. Behcet Uz Children’s Research and Training Hospital in Izmir, Turkey.
In a retrospective study 10-year study of 17 children with biopsy-confirmed lichen nitidus (LN) who were diagnosed with the disease at a single tertiary care health center between January 2007 and March 2017, the mean age of onset was 9 years and 15 of 17 (88%) were male. The mean skin lesion duration period was 13 months (range 1-48 months).
The generalized form of LN was common in the study population, occurring in 7 of 17 (41%) patients, 2 of whom had severe pruritus. Comorbid skin conditions also occurred in seven (41%) patients; these conditions included lichen planus in one patient, lichen striatus in one patient, nail psoriasis in one patients, and cutaneous features of atopic skin in four patients. In addition, 11 of 17 (65%) patients had multinucleated giant cells.
“Seven of 17 had comorbid skin conditions. Lichen planus, lichen striatus, psoriasis, and atopy are also chronic inflammatory skin conditions, and possibly, there are common triggers for these and LN; however, this is speculative, not proven,” the investigators concluded in Pediatric Dermatology.
Mild to moderate corticosteroids were give to 16 patients; all showed some clinical improvement within 3 weeks. One patient was treated with systemic corticosteroids.
The study authors reported no relevant financial disclosures.
SOURCE: Kundak S et al. Pediatr Dermatol. 2019 Feb 11. doi: 10.1111/pde.13749.
FROM PEDIATRIC DERMATOLOGY
Atopic dermatitis at 1 year links with persistent food allergies
SAN FRANCISCO – Children diagnosed with atopic dermatitis when they were 1 year old were significantly more likely to have active food allergies and to have those allergies persist throughout childhood to age 18 years, based on findings from a prospective, longitudinal study of 287 Wisconsin children.
The link between atopic dermatitis (AD) and food allergy was especially strong in children who displayed early and recurrent AD; the link was weaker or essentially nonexistent for children with early transient AD or AD that first appeared later in childhood, Anne Marie Singh, MD, said while presenting a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
The results also showed that even mild AD linked with an increased prevalence of food allergy when it appeared early and persisted, but more severe AD with this onset and recurrence pattern led to an even greater prevalence of food allergy, said Dr. Singh, a pediatric allergist and asthma specialist at the University of Wisconsin–Madison.
“The data suggest that something about early, recurrent AD increases the risk for food allergy throughout childhood,” Dr. Singh said in an interview. The findings suggest that surveillance for food allergies need to be intensified in infants who present with AD by the time they’re 1 year old and that food allergy surveillance should continue as these children age as long as their AD recurs.
The results also hint that these children might potentially benefit from steps aimed at desensitizing the allergy, although this must be proven in a future intervention study, she said.
The results suggest that a food allergy prevention regimen like the one used in the Learning Early About Peanut Allergy (LEAP) trial (New Engl J Med. 2015 Feb 26;372[9]:803-13) to prevent peanut allergy may be appropriate for selected, high-risk children with early AD, but this hypothesis needs testing, Dr. Singh said. She noted that some important differences exist between the patients enrolled in LEAP and the children studied in the current report: In LEAP, all enrolled children had severe eczema, an established egg allergy, or both. The findings reported by Dr. Singh came from children with AD, but only about 30% had moderate or severe eczema, and her analysis did not subdivide the observed food allergies by the type of food that caused a reaction.
She and her associates used data collected in the Childhood Origins of Asthma (COAST) study, begun in 1998, which enrolled 287 infants prior to birth who had at least one parent who was allergic, asthmatic, or both (Pediatr Allergy Immunol. 2002 Dec;13[s15]:38-43). The data showed that 62% of the infants had either no AD or transient AD, 14% had late onset AD, and 24% had early, recurrent AD. Although the data showed a statistically significant link between AD at 1 year old and food allergies throughout childhood, further analysis that broke the population into three different patterns of AD showed that the link with food allergy primarily existed among children with the early, recurrent form. Children with early, recurrent atopic dermatitis had a food allergy prevalence of 12%-27% annually through the age of 18 years.
“The data suggest that immunologic changes early in life are critical to food allergy development and that these changes have long-lasting effects throughout childhood,” Dr. Singh concluded. “The immunologic mechanisms by which early AD affects food allergy development and disease expression require further investigation.”
COAST received no commercial funding. Dr. Singh reported no relevant financial disclosures.
SOURCE: Singh AM et al. J Allergy Clin Immunol. 2019 Feb;143[2]:AB125.
SAN FRANCISCO – Children diagnosed with atopic dermatitis when they were 1 year old were significantly more likely to have active food allergies and to have those allergies persist throughout childhood to age 18 years, based on findings from a prospective, longitudinal study of 287 Wisconsin children.
The link between atopic dermatitis (AD) and food allergy was especially strong in children who displayed early and recurrent AD; the link was weaker or essentially nonexistent for children with early transient AD or AD that first appeared later in childhood, Anne Marie Singh, MD, said while presenting a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
The results also showed that even mild AD linked with an increased prevalence of food allergy when it appeared early and persisted, but more severe AD with this onset and recurrence pattern led to an even greater prevalence of food allergy, said Dr. Singh, a pediatric allergist and asthma specialist at the University of Wisconsin–Madison.
“The data suggest that something about early, recurrent AD increases the risk for food allergy throughout childhood,” Dr. Singh said in an interview. The findings suggest that surveillance for food allergies need to be intensified in infants who present with AD by the time they’re 1 year old and that food allergy surveillance should continue as these children age as long as their AD recurs.
The results also hint that these children might potentially benefit from steps aimed at desensitizing the allergy, although this must be proven in a future intervention study, she said.
The results suggest that a food allergy prevention regimen like the one used in the Learning Early About Peanut Allergy (LEAP) trial (New Engl J Med. 2015 Feb 26;372[9]:803-13) to prevent peanut allergy may be appropriate for selected, high-risk children with early AD, but this hypothesis needs testing, Dr. Singh said. She noted that some important differences exist between the patients enrolled in LEAP and the children studied in the current report: In LEAP, all enrolled children had severe eczema, an established egg allergy, or both. The findings reported by Dr. Singh came from children with AD, but only about 30% had moderate or severe eczema, and her analysis did not subdivide the observed food allergies by the type of food that caused a reaction.
She and her associates used data collected in the Childhood Origins of Asthma (COAST) study, begun in 1998, which enrolled 287 infants prior to birth who had at least one parent who was allergic, asthmatic, or both (Pediatr Allergy Immunol. 2002 Dec;13[s15]:38-43). The data showed that 62% of the infants had either no AD or transient AD, 14% had late onset AD, and 24% had early, recurrent AD. Although the data showed a statistically significant link between AD at 1 year old and food allergies throughout childhood, further analysis that broke the population into three different patterns of AD showed that the link with food allergy primarily existed among children with the early, recurrent form. Children with early, recurrent atopic dermatitis had a food allergy prevalence of 12%-27% annually through the age of 18 years.
“The data suggest that immunologic changes early in life are critical to food allergy development and that these changes have long-lasting effects throughout childhood,” Dr. Singh concluded. “The immunologic mechanisms by which early AD affects food allergy development and disease expression require further investigation.”
COAST received no commercial funding. Dr. Singh reported no relevant financial disclosures.
SOURCE: Singh AM et al. J Allergy Clin Immunol. 2019 Feb;143[2]:AB125.
SAN FRANCISCO – Children diagnosed with atopic dermatitis when they were 1 year old were significantly more likely to have active food allergies and to have those allergies persist throughout childhood to age 18 years, based on findings from a prospective, longitudinal study of 287 Wisconsin children.
The link between atopic dermatitis (AD) and food allergy was especially strong in children who displayed early and recurrent AD; the link was weaker or essentially nonexistent for children with early transient AD or AD that first appeared later in childhood, Anne Marie Singh, MD, said while presenting a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
The results also showed that even mild AD linked with an increased prevalence of food allergy when it appeared early and persisted, but more severe AD with this onset and recurrence pattern led to an even greater prevalence of food allergy, said Dr. Singh, a pediatric allergist and asthma specialist at the University of Wisconsin–Madison.
“The data suggest that something about early, recurrent AD increases the risk for food allergy throughout childhood,” Dr. Singh said in an interview. The findings suggest that surveillance for food allergies need to be intensified in infants who present with AD by the time they’re 1 year old and that food allergy surveillance should continue as these children age as long as their AD recurs.
The results also hint that these children might potentially benefit from steps aimed at desensitizing the allergy, although this must be proven in a future intervention study, she said.
The results suggest that a food allergy prevention regimen like the one used in the Learning Early About Peanut Allergy (LEAP) trial (New Engl J Med. 2015 Feb 26;372[9]:803-13) to prevent peanut allergy may be appropriate for selected, high-risk children with early AD, but this hypothesis needs testing, Dr. Singh said. She noted that some important differences exist between the patients enrolled in LEAP and the children studied in the current report: In LEAP, all enrolled children had severe eczema, an established egg allergy, or both. The findings reported by Dr. Singh came from children with AD, but only about 30% had moderate or severe eczema, and her analysis did not subdivide the observed food allergies by the type of food that caused a reaction.
She and her associates used data collected in the Childhood Origins of Asthma (COAST) study, begun in 1998, which enrolled 287 infants prior to birth who had at least one parent who was allergic, asthmatic, or both (Pediatr Allergy Immunol. 2002 Dec;13[s15]:38-43). The data showed that 62% of the infants had either no AD or transient AD, 14% had late onset AD, and 24% had early, recurrent AD. Although the data showed a statistically significant link between AD at 1 year old and food allergies throughout childhood, further analysis that broke the population into three different patterns of AD showed that the link with food allergy primarily existed among children with the early, recurrent form. Children with early, recurrent atopic dermatitis had a food allergy prevalence of 12%-27% annually through the age of 18 years.
“The data suggest that immunologic changes early in life are critical to food allergy development and that these changes have long-lasting effects throughout childhood,” Dr. Singh concluded. “The immunologic mechanisms by which early AD affects food allergy development and disease expression require further investigation.”
COAST received no commercial funding. Dr. Singh reported no relevant financial disclosures.
SOURCE: Singh AM et al. J Allergy Clin Immunol. 2019 Feb;143[2]:AB125.
REPORTING FROM AAAAI 2019
Whole genome sequencing benefits pediatric ICU patients
SAN DIEGO – In the pediatric intensive care unit (PICU), rapid whole genome sequencing (rWGS) with targeted phenotype analysis often leads to specific changes in patient management, similar to what is seen when rWGS is applied to neonatal ICUs. The findings come from the first study to look at outcomes of rWGS in the PICU outside of infancy.
In the NICU, previous studies have shown an rWGS diagnostic rate ranging from 36% to 57%, and an estimated 49%-72% of these diagnoses result in changes to patient management; 38%-45% of those diagnoses had not been previously considered.
The researchers found similar benefits when the age of patients was extended to 18 years in the PICU. “We were happy to see we were able to make specific changes in ICU management, with three of those being medication changes based on the diagnosis, and one being in the transition to palliative care while the patient was still in the PICU,” Erica Sanford, MD, said in an interview.
Dr. Sanford is a pediatric clinical care fellow at the University of California, San Diego. She presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
Changes as a result of rWGS included factor replacement for a factor XIII deficiency, avoidance of renal biopsy because the diagnosis was made genetically, and use of serial MRI and other imaging methods to identify disorder-related sequela. “We’re hopeful as the turnaround for genome sequencing decreases that we’ll be able to offer this as a test when appropriate when a patient is presenting with an illness that doesn’t have a clear etiologic diagnosis,” said Dr. Sanford.
Certainly not every patient in the PICU should undergo rWGS, given its expense. Although the study was too small to identify candidate patients, there were some trends – patients in cardiac arrest were more likely to be receiving a genetic diagnosis. “We weren’t able to answer the question of which patients in the pediatric ICU should get whole genome sequencing – our next step is to have a larger group of patients so we can determine specifically which patients might benefit,” said Dr. Sanford. The team also plans to do a cost analysis of rWGS in the PICU setting.
The researchers examined data from a PICU at a tertiary children’s hospital, including records from 38 patients who underwent rWGS between July 2016 and May 2018. Based on the initial sequencing results, 18 underwent diagnostic rWGS. The average age of children was 5.7 years (median 3 years), with patients ranging from 4 months to 18 years old.
The most common reasons for PICU admission were shock (16% of all patients, 17% of patients who received diagnostic rWGS), respiratory failure (18% and 17%), cardiac arrest (13% and 22%), and altered mental status (13% and 11%).
Eleven of 18 patients (61%) who received an rWGS diagnosis experienced a subacute, non-ICU change in management. Four diagnoses (22%) led to a change in ICU management, and three led to no changes in patient management.
The National Institutes of Health funded the study. Dr. Sanford had no relevant financial disclosures.
SOURCE: Sanford E et al. CCC48, Abstract 373.
SAN DIEGO – In the pediatric intensive care unit (PICU), rapid whole genome sequencing (rWGS) with targeted phenotype analysis often leads to specific changes in patient management, similar to what is seen when rWGS is applied to neonatal ICUs. The findings come from the first study to look at outcomes of rWGS in the PICU outside of infancy.
In the NICU, previous studies have shown an rWGS diagnostic rate ranging from 36% to 57%, and an estimated 49%-72% of these diagnoses result in changes to patient management; 38%-45% of those diagnoses had not been previously considered.
The researchers found similar benefits when the age of patients was extended to 18 years in the PICU. “We were happy to see we were able to make specific changes in ICU management, with three of those being medication changes based on the diagnosis, and one being in the transition to palliative care while the patient was still in the PICU,” Erica Sanford, MD, said in an interview.
Dr. Sanford is a pediatric clinical care fellow at the University of California, San Diego. She presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
Changes as a result of rWGS included factor replacement for a factor XIII deficiency, avoidance of renal biopsy because the diagnosis was made genetically, and use of serial MRI and other imaging methods to identify disorder-related sequela. “We’re hopeful as the turnaround for genome sequencing decreases that we’ll be able to offer this as a test when appropriate when a patient is presenting with an illness that doesn’t have a clear etiologic diagnosis,” said Dr. Sanford.
Certainly not every patient in the PICU should undergo rWGS, given its expense. Although the study was too small to identify candidate patients, there were some trends – patients in cardiac arrest were more likely to be receiving a genetic diagnosis. “We weren’t able to answer the question of which patients in the pediatric ICU should get whole genome sequencing – our next step is to have a larger group of patients so we can determine specifically which patients might benefit,” said Dr. Sanford. The team also plans to do a cost analysis of rWGS in the PICU setting.
The researchers examined data from a PICU at a tertiary children’s hospital, including records from 38 patients who underwent rWGS between July 2016 and May 2018. Based on the initial sequencing results, 18 underwent diagnostic rWGS. The average age of children was 5.7 years (median 3 years), with patients ranging from 4 months to 18 years old.
The most common reasons for PICU admission were shock (16% of all patients, 17% of patients who received diagnostic rWGS), respiratory failure (18% and 17%), cardiac arrest (13% and 22%), and altered mental status (13% and 11%).
Eleven of 18 patients (61%) who received an rWGS diagnosis experienced a subacute, non-ICU change in management. Four diagnoses (22%) led to a change in ICU management, and three led to no changes in patient management.
The National Institutes of Health funded the study. Dr. Sanford had no relevant financial disclosures.
SOURCE: Sanford E et al. CCC48, Abstract 373.
SAN DIEGO – In the pediatric intensive care unit (PICU), rapid whole genome sequencing (rWGS) with targeted phenotype analysis often leads to specific changes in patient management, similar to what is seen when rWGS is applied to neonatal ICUs. The findings come from the first study to look at outcomes of rWGS in the PICU outside of infancy.
In the NICU, previous studies have shown an rWGS diagnostic rate ranging from 36% to 57%, and an estimated 49%-72% of these diagnoses result in changes to patient management; 38%-45% of those diagnoses had not been previously considered.
The researchers found similar benefits when the age of patients was extended to 18 years in the PICU. “We were happy to see we were able to make specific changes in ICU management, with three of those being medication changes based on the diagnosis, and one being in the transition to palliative care while the patient was still in the PICU,” Erica Sanford, MD, said in an interview.
Dr. Sanford is a pediatric clinical care fellow at the University of California, San Diego. She presented the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
Changes as a result of rWGS included factor replacement for a factor XIII deficiency, avoidance of renal biopsy because the diagnosis was made genetically, and use of serial MRI and other imaging methods to identify disorder-related sequela. “We’re hopeful as the turnaround for genome sequencing decreases that we’ll be able to offer this as a test when appropriate when a patient is presenting with an illness that doesn’t have a clear etiologic diagnosis,” said Dr. Sanford.
Certainly not every patient in the PICU should undergo rWGS, given its expense. Although the study was too small to identify candidate patients, there were some trends – patients in cardiac arrest were more likely to be receiving a genetic diagnosis. “We weren’t able to answer the question of which patients in the pediatric ICU should get whole genome sequencing – our next step is to have a larger group of patients so we can determine specifically which patients might benefit,” said Dr. Sanford. The team also plans to do a cost analysis of rWGS in the PICU setting.
The researchers examined data from a PICU at a tertiary children’s hospital, including records from 38 patients who underwent rWGS between July 2016 and May 2018. Based on the initial sequencing results, 18 underwent diagnostic rWGS. The average age of children was 5.7 years (median 3 years), with patients ranging from 4 months to 18 years old.
The most common reasons for PICU admission were shock (16% of all patients, 17% of patients who received diagnostic rWGS), respiratory failure (18% and 17%), cardiac arrest (13% and 22%), and altered mental status (13% and 11%).
Eleven of 18 patients (61%) who received an rWGS diagnosis experienced a subacute, non-ICU change in management. Four diagnoses (22%) led to a change in ICU management, and three led to no changes in patient management.
The National Institutes of Health funded the study. Dr. Sanford had no relevant financial disclosures.
SOURCE: Sanford E et al. CCC48, Abstract 373.
REPORTING FROM CCC48
What’s the price of rude behavior in the hospital?
SAN DIEGO – Does rudeness from a colleague prevent physicians from noticing a diagnostic error and challenging it? A new study suggests it might not, at least in the context of hand-offs from dismissive and insulting fellow doctors.
Instead, a simulation found that experience seems to be the key factor in giving physicians the guts – or the awareness – to change course. Still, the findings hint that rudeness may still have a negative effect on one group – resident physicians.
“It appears that we are building resilience somewhere in training,” said study lead author Michael Avesar, MD, a pediatric critical care medicine fellow at Children’s Hospital Los Angeles.
Dr. Avesar spoke in an interview following the presentation of the study findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The initial motivation of the study wasn’t to gain more understanding of rudeness in medicine. Instead, Dr. Avesar said, “We started off with trying to find ways to understand how physicians think during high-stakes decisions in stressful or time-limited situations. We wanted to see if people were able to challenge the momentum of diagnostic error. That’s when we learned more about the rudeness literature.”
Yes, it’s true: Researchers have devoted time to studying rudeness in medicine. After all, it’s quite common. A 2017 Israeli study in Pediatrics declared it’s “routinely experienced by medical teams.” That study, also based on simulations, determined that “rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety” (Pediatrics. 2017 Feb. doi: 10.1542/peds.2016-2305).
For the new study, Dr. Avesar and his colleagues ultimately decided to explore possible links between rudeness and diagnostic error. To explore the issue, they created a simulation of a hand-off of a pediatric patient from the operating team to the ICU.
In the simulation, the “physician” handing off the “patient” incorrectly noted a diagnosis of sepsis. In fact, the patient had cardiac tamponade.
The physician, played by an actor, was instructed to either act in a neutral fashion during the hand-off or be rude. But rudeness, it turns out, isn’t easy to define, even if we all think we know it when we see it.
“There’s a lot of debate as to what is ‘rude,’ ” Dr. Avesar said. The researchers settled on a level of rudeness that wasn’t “too mean” but was still inappropriate: It featured frequent interruptions during the hand-off, lack of eye contact, and abrupt departures. In some simulations, the actor insulted the colleagues of the recipient of the hand-off.
In other words, Dr. Avesar said, the actor was a jerk.
The researchers tested the “neutral” and “rude” hand-off scenarios in 41 simulations. The physicians who played the recipients of the hand-offs included 11 attendings, 14 fellows, and 16 residents.
Eighty-two percent of the attendings (9/11) challenged the diagnosis, as did 86% (12/14) of the fellows. Only 31% (5/16) of residents challenged the diagnosis; this difference from the other groups was statistically significant.
Half of the eight residents exposed to a “neutral” handoff challenged the correct diagnosis, while only 13% (1/8) of those who were treated rudely did. “While the P value was not significant, previous literature focused on residents supports this trend,” Dr. Avesar said.
It’s possible that certain residents gain the knowledge and experience to overcome rudeness over time, he said. That, he said, leads to an intriguing question: “Could we find out how resilience is learned and how to replicate it?”
Moving forward, he said, the team will try to figure out whether there’s a link between personality types and reactions to rudeness.
Eventually, he said, the team may test ways to reduce the effects of rudeness and boost critical thinking. “We see this as a long-term strategy to enhance medical education and patient safety,” he said.
No study funding is reported. Dr. Avesar reports no relevant disclosures.
SOURCE: Avesar M et al. Crit Care Med. 2019 Jan;47(1):682, Abstract 1412.
SAN DIEGO – Does rudeness from a colleague prevent physicians from noticing a diagnostic error and challenging it? A new study suggests it might not, at least in the context of hand-offs from dismissive and insulting fellow doctors.
Instead, a simulation found that experience seems to be the key factor in giving physicians the guts – or the awareness – to change course. Still, the findings hint that rudeness may still have a negative effect on one group – resident physicians.
“It appears that we are building resilience somewhere in training,” said study lead author Michael Avesar, MD, a pediatric critical care medicine fellow at Children’s Hospital Los Angeles.
Dr. Avesar spoke in an interview following the presentation of the study findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The initial motivation of the study wasn’t to gain more understanding of rudeness in medicine. Instead, Dr. Avesar said, “We started off with trying to find ways to understand how physicians think during high-stakes decisions in stressful or time-limited situations. We wanted to see if people were able to challenge the momentum of diagnostic error. That’s when we learned more about the rudeness literature.”
Yes, it’s true: Researchers have devoted time to studying rudeness in medicine. After all, it’s quite common. A 2017 Israeli study in Pediatrics declared it’s “routinely experienced by medical teams.” That study, also based on simulations, determined that “rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety” (Pediatrics. 2017 Feb. doi: 10.1542/peds.2016-2305).
For the new study, Dr. Avesar and his colleagues ultimately decided to explore possible links between rudeness and diagnostic error. To explore the issue, they created a simulation of a hand-off of a pediatric patient from the operating team to the ICU.
In the simulation, the “physician” handing off the “patient” incorrectly noted a diagnosis of sepsis. In fact, the patient had cardiac tamponade.
The physician, played by an actor, was instructed to either act in a neutral fashion during the hand-off or be rude. But rudeness, it turns out, isn’t easy to define, even if we all think we know it when we see it.
“There’s a lot of debate as to what is ‘rude,’ ” Dr. Avesar said. The researchers settled on a level of rudeness that wasn’t “too mean” but was still inappropriate: It featured frequent interruptions during the hand-off, lack of eye contact, and abrupt departures. In some simulations, the actor insulted the colleagues of the recipient of the hand-off.
In other words, Dr. Avesar said, the actor was a jerk.
The researchers tested the “neutral” and “rude” hand-off scenarios in 41 simulations. The physicians who played the recipients of the hand-offs included 11 attendings, 14 fellows, and 16 residents.
Eighty-two percent of the attendings (9/11) challenged the diagnosis, as did 86% (12/14) of the fellows. Only 31% (5/16) of residents challenged the diagnosis; this difference from the other groups was statistically significant.
Half of the eight residents exposed to a “neutral” handoff challenged the correct diagnosis, while only 13% (1/8) of those who were treated rudely did. “While the P value was not significant, previous literature focused on residents supports this trend,” Dr. Avesar said.
It’s possible that certain residents gain the knowledge and experience to overcome rudeness over time, he said. That, he said, leads to an intriguing question: “Could we find out how resilience is learned and how to replicate it?”
Moving forward, he said, the team will try to figure out whether there’s a link between personality types and reactions to rudeness.
Eventually, he said, the team may test ways to reduce the effects of rudeness and boost critical thinking. “We see this as a long-term strategy to enhance medical education and patient safety,” he said.
No study funding is reported. Dr. Avesar reports no relevant disclosures.
SOURCE: Avesar M et al. Crit Care Med. 2019 Jan;47(1):682, Abstract 1412.
SAN DIEGO – Does rudeness from a colleague prevent physicians from noticing a diagnostic error and challenging it? A new study suggests it might not, at least in the context of hand-offs from dismissive and insulting fellow doctors.
Instead, a simulation found that experience seems to be the key factor in giving physicians the guts – or the awareness – to change course. Still, the findings hint that rudeness may still have a negative effect on one group – resident physicians.
“It appears that we are building resilience somewhere in training,” said study lead author Michael Avesar, MD, a pediatric critical care medicine fellow at Children’s Hospital Los Angeles.
Dr. Avesar spoke in an interview following the presentation of the study findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
The initial motivation of the study wasn’t to gain more understanding of rudeness in medicine. Instead, Dr. Avesar said, “We started off with trying to find ways to understand how physicians think during high-stakes decisions in stressful or time-limited situations. We wanted to see if people were able to challenge the momentum of diagnostic error. That’s when we learned more about the rudeness literature.”
Yes, it’s true: Researchers have devoted time to studying rudeness in medicine. After all, it’s quite common. A 2017 Israeli study in Pediatrics declared it’s “routinely experienced by medical teams.” That study, also based on simulations, determined that “rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety” (Pediatrics. 2017 Feb. doi: 10.1542/peds.2016-2305).
For the new study, Dr. Avesar and his colleagues ultimately decided to explore possible links between rudeness and diagnostic error. To explore the issue, they created a simulation of a hand-off of a pediatric patient from the operating team to the ICU.
In the simulation, the “physician” handing off the “patient” incorrectly noted a diagnosis of sepsis. In fact, the patient had cardiac tamponade.
The physician, played by an actor, was instructed to either act in a neutral fashion during the hand-off or be rude. But rudeness, it turns out, isn’t easy to define, even if we all think we know it when we see it.
“There’s a lot of debate as to what is ‘rude,’ ” Dr. Avesar said. The researchers settled on a level of rudeness that wasn’t “too mean” but was still inappropriate: It featured frequent interruptions during the hand-off, lack of eye contact, and abrupt departures. In some simulations, the actor insulted the colleagues of the recipient of the hand-off.
In other words, Dr. Avesar said, the actor was a jerk.
The researchers tested the “neutral” and “rude” hand-off scenarios in 41 simulations. The physicians who played the recipients of the hand-offs included 11 attendings, 14 fellows, and 16 residents.
Eighty-two percent of the attendings (9/11) challenged the diagnosis, as did 86% (12/14) of the fellows. Only 31% (5/16) of residents challenged the diagnosis; this difference from the other groups was statistically significant.
Half of the eight residents exposed to a “neutral” handoff challenged the correct diagnosis, while only 13% (1/8) of those who were treated rudely did. “While the P value was not significant, previous literature focused on residents supports this trend,” Dr. Avesar said.
It’s possible that certain residents gain the knowledge and experience to overcome rudeness over time, he said. That, he said, leads to an intriguing question: “Could we find out how resilience is learned and how to replicate it?”
Moving forward, he said, the team will try to figure out whether there’s a link between personality types and reactions to rudeness.
Eventually, he said, the team may test ways to reduce the effects of rudeness and boost critical thinking. “We see this as a long-term strategy to enhance medical education and patient safety,” he said.
No study funding is reported. Dr. Avesar reports no relevant disclosures.
SOURCE: Avesar M et al. Crit Care Med. 2019 Jan;47(1):682, Abstract 1412.
REPORTING FROM CCC48
SPD president discusses pediatric research, and more
WASHINGTON – in an interview at the annual meeting of the American Academy of Dermatology.
Dr. Davis, a pediatric dermatologist at the Mayo Clinic, Rochester, Minn., said that the SPD had a strategic retreat prior to the AAD annual meeting to look at goals attained over the last 3 years “and where we’re going for the next 3 years.” Goals that have been accomplished “move us forward as a society for patient advocacy, specialty advocacy, workforce strengthening, research advancement, patient care, and education,” she noted. The education arena, for example, includes not only educating patients and their families, so they can get the best health care possible, “but we want to educate the pipeline of trainees coming through medical school so ... they have exposure to pediatric dermatology and they can hopefully develop an interest in pediatric dermatology as a future career.”
The SPD now has more than 1,200 members, and has a research arm, the Pediatric Dermatology Research Alliance (PeDRA), which has multiple projects, the largest of which is looking at the stigma of skin diseases, a study that involves patients with severe skin diseases and their families, said Dr. Davis. Watch the video above for more on PeDRA and SPD.
Dr. Davis disclosed that she is involved in a study for Regeneron but has not received any personal financial compensation.
WASHINGTON – in an interview at the annual meeting of the American Academy of Dermatology.
Dr. Davis, a pediatric dermatologist at the Mayo Clinic, Rochester, Minn., said that the SPD had a strategic retreat prior to the AAD annual meeting to look at goals attained over the last 3 years “and where we’re going for the next 3 years.” Goals that have been accomplished “move us forward as a society for patient advocacy, specialty advocacy, workforce strengthening, research advancement, patient care, and education,” she noted. The education arena, for example, includes not only educating patients and their families, so they can get the best health care possible, “but we want to educate the pipeline of trainees coming through medical school so ... they have exposure to pediatric dermatology and they can hopefully develop an interest in pediatric dermatology as a future career.”
The SPD now has more than 1,200 members, and has a research arm, the Pediatric Dermatology Research Alliance (PeDRA), which has multiple projects, the largest of which is looking at the stigma of skin diseases, a study that involves patients with severe skin diseases and their families, said Dr. Davis. Watch the video above for more on PeDRA and SPD.
Dr. Davis disclosed that she is involved in a study for Regeneron but has not received any personal financial compensation.
WASHINGTON – in an interview at the annual meeting of the American Academy of Dermatology.
Dr. Davis, a pediatric dermatologist at the Mayo Clinic, Rochester, Minn., said that the SPD had a strategic retreat prior to the AAD annual meeting to look at goals attained over the last 3 years “and where we’re going for the next 3 years.” Goals that have been accomplished “move us forward as a society for patient advocacy, specialty advocacy, workforce strengthening, research advancement, patient care, and education,” she noted. The education arena, for example, includes not only educating patients and their families, so they can get the best health care possible, “but we want to educate the pipeline of trainees coming through medical school so ... they have exposure to pediatric dermatology and they can hopefully develop an interest in pediatric dermatology as a future career.”
The SPD now has more than 1,200 members, and has a research arm, the Pediatric Dermatology Research Alliance (PeDRA), which has multiple projects, the largest of which is looking at the stigma of skin diseases, a study that involves patients with severe skin diseases and their families, said Dr. Davis. Watch the video above for more on PeDRA and SPD.
Dr. Davis disclosed that she is involved in a study for Regeneron but has not received any personal financial compensation.
REPORTING FROM AAD 2019
Don’t discount sleep disturbance for children with atopic dermatitis
The itching associated with atopic dermatitis (AD) may interfere with children’s sleep, and sleep studies suggest that children with active disease are more restless at night, wrote Faustine D. Ramirez of the University of California, San Francisco, and her colleagues. Their report is in JAMA Pediatrics.
“Acute and chronic sleep disturbances have been associated with a wide range of cognitive, mood, and behavioral impairments and have been linked to poor educational performance,” the researchers noted.
To determine the impact of active AD on children’s sleep, the researchers reviewed data from 13,988 children followed for a median of 11 years. Of these, 4,938 children met the definition for AD between age 2 and 16 years.
Overall, children with active AD were approximately 50% more likely to experience poor sleep quality than were those without AD (adjusted odds ratio, 1.48). Sleep quality was even worse for children with severe active AD (aOR, 1.68), and active AD plus asthma or allergic rhinitis (aOR 2.15). Sleep quality was significantly worse in children reporting mild AD (aOR, 1.40) or inactive AD (aOR, 1.41), compared with children without AD. Nighttime sleep duration was similar throughout childhood for children with and without AD.
“In addition to increased nighttime awakenings and difficulty falling asleep, we found that children with active atopic dermatitis were more likely to report nightmares and early morning awakenings, which has not been previously studied,” Ms. Ramirez and her associates said.
Total sleep duration was statistically shorter overall for children with AD, compared with those without AD, but the difference was not clinically significant, they noted.
The participants were from a longitudinal study in the United Kingdom in which pregnant women were recruited between 1990 and 1992. For those with children alive at 1 year, their children were followed for approximately 16 years. Sleep quality was assessed at six time points with four standardized questionnaires between ages 2 and 10 years, and sleep duration was assessed at eight time points between ages 2 and 16 years with standardized questionnaires.
The study findings were limited by several factors, including some missing data and patient attrition, as well as possible misclassification bias because of the use of parent and patient self-reports, and a possible lack of generalizability to other populations, the researchers noted.
However, the results support the need for developing clinical outcome measures to address sleep quality in children with AD, they said. “Additional work should investigate interventions to improve sleep quality and examine the association between atopic dermatitis treatment and children’s sleep.”
The study was funded primarily by a grant from the National Eczema Association. Ms. Ramirez disclosed a grant from the National Institutes of Health. Two other investigators received grants, one from NIH and the other Wellcome Senior Clinical Fellowship in Science. One coauthor reported receiving multiple grants, as well as paid consulting for TARGETPharma, a company developing a prospective atopic dermatitis registry.
SOURCE: Ramirez FD al. JAMA Pediatr. 2019 Mar 4. doi: 10.1001/jamapediatrics.2019.0025.
The itching associated with atopic dermatitis (AD) may interfere with children’s sleep, and sleep studies suggest that children with active disease are more restless at night, wrote Faustine D. Ramirez of the University of California, San Francisco, and her colleagues. Their report is in JAMA Pediatrics.
“Acute and chronic sleep disturbances have been associated with a wide range of cognitive, mood, and behavioral impairments and have been linked to poor educational performance,” the researchers noted.
To determine the impact of active AD on children’s sleep, the researchers reviewed data from 13,988 children followed for a median of 11 years. Of these, 4,938 children met the definition for AD between age 2 and 16 years.
Overall, children with active AD were approximately 50% more likely to experience poor sleep quality than were those without AD (adjusted odds ratio, 1.48). Sleep quality was even worse for children with severe active AD (aOR, 1.68), and active AD plus asthma or allergic rhinitis (aOR 2.15). Sleep quality was significantly worse in children reporting mild AD (aOR, 1.40) or inactive AD (aOR, 1.41), compared with children without AD. Nighttime sleep duration was similar throughout childhood for children with and without AD.
“In addition to increased nighttime awakenings and difficulty falling asleep, we found that children with active atopic dermatitis were more likely to report nightmares and early morning awakenings, which has not been previously studied,” Ms. Ramirez and her associates said.
Total sleep duration was statistically shorter overall for children with AD, compared with those without AD, but the difference was not clinically significant, they noted.
The participants were from a longitudinal study in the United Kingdom in which pregnant women were recruited between 1990 and 1992. For those with children alive at 1 year, their children were followed for approximately 16 years. Sleep quality was assessed at six time points with four standardized questionnaires between ages 2 and 10 years, and sleep duration was assessed at eight time points between ages 2 and 16 years with standardized questionnaires.
The study findings were limited by several factors, including some missing data and patient attrition, as well as possible misclassification bias because of the use of parent and patient self-reports, and a possible lack of generalizability to other populations, the researchers noted.
However, the results support the need for developing clinical outcome measures to address sleep quality in children with AD, they said. “Additional work should investigate interventions to improve sleep quality and examine the association between atopic dermatitis treatment and children’s sleep.”
The study was funded primarily by a grant from the National Eczema Association. Ms. Ramirez disclosed a grant from the National Institutes of Health. Two other investigators received grants, one from NIH and the other Wellcome Senior Clinical Fellowship in Science. One coauthor reported receiving multiple grants, as well as paid consulting for TARGETPharma, a company developing a prospective atopic dermatitis registry.
SOURCE: Ramirez FD al. JAMA Pediatr. 2019 Mar 4. doi: 10.1001/jamapediatrics.2019.0025.
The itching associated with atopic dermatitis (AD) may interfere with children’s sleep, and sleep studies suggest that children with active disease are more restless at night, wrote Faustine D. Ramirez of the University of California, San Francisco, and her colleagues. Their report is in JAMA Pediatrics.
“Acute and chronic sleep disturbances have been associated with a wide range of cognitive, mood, and behavioral impairments and have been linked to poor educational performance,” the researchers noted.
To determine the impact of active AD on children’s sleep, the researchers reviewed data from 13,988 children followed for a median of 11 years. Of these, 4,938 children met the definition for AD between age 2 and 16 years.
Overall, children with active AD were approximately 50% more likely to experience poor sleep quality than were those without AD (adjusted odds ratio, 1.48). Sleep quality was even worse for children with severe active AD (aOR, 1.68), and active AD plus asthma or allergic rhinitis (aOR 2.15). Sleep quality was significantly worse in children reporting mild AD (aOR, 1.40) or inactive AD (aOR, 1.41), compared with children without AD. Nighttime sleep duration was similar throughout childhood for children with and without AD.
“In addition to increased nighttime awakenings and difficulty falling asleep, we found that children with active atopic dermatitis were more likely to report nightmares and early morning awakenings, which has not been previously studied,” Ms. Ramirez and her associates said.
Total sleep duration was statistically shorter overall for children with AD, compared with those without AD, but the difference was not clinically significant, they noted.
The participants were from a longitudinal study in the United Kingdom in which pregnant women were recruited between 1990 and 1992. For those with children alive at 1 year, their children were followed for approximately 16 years. Sleep quality was assessed at six time points with four standardized questionnaires between ages 2 and 10 years, and sleep duration was assessed at eight time points between ages 2 and 16 years with standardized questionnaires.
The study findings were limited by several factors, including some missing data and patient attrition, as well as possible misclassification bias because of the use of parent and patient self-reports, and a possible lack of generalizability to other populations, the researchers noted.
However, the results support the need for developing clinical outcome measures to address sleep quality in children with AD, they said. “Additional work should investigate interventions to improve sleep quality and examine the association between atopic dermatitis treatment and children’s sleep.”
The study was funded primarily by a grant from the National Eczema Association. Ms. Ramirez disclosed a grant from the National Institutes of Health. Two other investigators received grants, one from NIH and the other Wellcome Senior Clinical Fellowship in Science. One coauthor reported receiving multiple grants, as well as paid consulting for TARGETPharma, a company developing a prospective atopic dermatitis registry.
SOURCE: Ramirez FD al. JAMA Pediatr. 2019 Mar 4. doi: 10.1001/jamapediatrics.2019.0025.
FROM JAMA PEDIATRICS
Viewing childhood autism as a whole body disorder
Intestinal inflammation, oxidative stress, immune problems affect subsets of patients.
LAS VEGAS – When parents of children with autism ask their primary physicians about complementary and integrative medical treatments, they often get stonewalled, according to Robert L. Hendren, DO.
“They find [clinicians] usually say, ‘Don’t try that stuff. It doesn’t work,’” Dr. Hendren said at an annual psychopharmacology update held by the Nevada Psychiatric Association.
“Parents then go to two different sets of providers,” he said. One provider “tells them about complementary and integrative medicine, but is likely not a traditional physician who’s treating their autism. It’s somebody who knows about these biomedical interventions but when parents tell them that they’re using traditional interventions ... that person also says, ‘Don’t use that. That’s doesn’t work.’ Then they go see their traditional provider who might be thinking about traditional medications. But they’ve learned that they don’t want to tell them, ‘I’m considering using omega 3s or zinc.’ Regrettably, most times physicians don’t say, ‘Let’s examine that. Let’s look at the literature and see if that’s the right decision for you.’ By shutting a family down saying, ‘I don’t want to hear about that,’ it often leads the family to think: ‘How do I make a decision about this? How do I know what to do?’ ”
Dr. Hendren said clinicians are beginning to embrace the notion that autism is not just a brain disorder, but rather a whole body disorder. For example, he noted that significant subsets of people with autism have intestinal inflammation, digestive enzyme abnormalities, metabolic impairments, oxidative stress, mitochondrial dysfunction, and immunity problems that range from immune deficiency to hypersensitivity to autoimmunity. “,” said Dr. Hendren, professor of child and adolescent psychiatry at the University of California, San Francisco. “I hope that by thinking about making the body healthier, we can help kids have the very best outcomes.”
Several biomedical treatments have adequate evidence to use for many patients, he said, including melatonin, probiotics, omega 3s, and possibly vitamin D3, methyl B12, oxytocin, restrictive diets, digestive enzymes, and choline. “There are strong anecdotal reports of gluten-free diet benefits,” said Dr. Hendren, who also directs the UCSF Program for Research on Neurodevelopmental and Translational Outcomes. “Some parents I greatly respect tell me it’s the single most important thing they’ve done in their child’s health, that their GI symptoms have improved, and their overall health has improved.”
In a multisite trial called aViation, researchers are evaluating the effects of an investigational vasopressin antagonist in autistic patients aged 5-17 years. The drug works by blocking a brain receptor of the vasopressin receptor that is associated with control of stress, anxiety, affection, and aggression. “The first trial in adults showed potential benefit,” Dr. Hendren said.
No robust studies exist to suggest that medical marijuana makes a difference for patients with autism, he said, but he has several patients whose parents give their affected child medical marijuana or cannabidiol. “I have a number of families who say it’s really made a big difference for their children and for how they’re doing,” he said.
In Marin County, Calif., the Oak Hill School serves a heterogeneous population of children, adolescents, and young adults, all of whom have autism spectrum disorder (ASD) or other neurologically based disorders of relating and communicating. Students receive special education instruction and customized on-site clinical programs that might include speech/language pathology, occupational therapy, and group and individual psychotherapy. Some of the students have received recent functional behavior analyses from Dr. Hendren and his colleagues, with school staff implementing positive behavior intervention programs.
The researchers also are using metabolomics as a biomarker of outcome. “We’re using metabolomics from the urine, where we can look at these processes in different clusters and see whether our interventions make a difference or not,” said Dr. Hendren, who is a past president of the American Academy of Child and Adolescent Psychiatry. “We did one trial with sulforaphane, which is a concentrated broccoli sprout extract that helps with oxidative stress. It was initially developed to treat oxidative stress in cancer,” he said. Upcoming trials in this cohort include the use of folinic acid and CM-AT, a pancreatic digestive enzyme intended to increase levels of chymotrypsin.
“I think of autism as being a disorder where you have this person and there’s a veil of autism that comes over the top of them,” he said. “That veil is not the kid, although the kid becomes more and more expressed through that. If we can do something to lift that veil, we can do more and more to pull that child out.”
Dr. Hendren disclosed that he has received grants from Curemark, Roche, Shire, and Sunovion. He is a member of the advisory boards for Curemark, BioMarin, Janssen, and Axial Biotherapeutics.
Intestinal inflammation, oxidative stress, immune problems affect subsets of patients.
Intestinal inflammation, oxidative stress, immune problems affect subsets of patients.
LAS VEGAS – When parents of children with autism ask their primary physicians about complementary and integrative medical treatments, they often get stonewalled, according to Robert L. Hendren, DO.
“They find [clinicians] usually say, ‘Don’t try that stuff. It doesn’t work,’” Dr. Hendren said at an annual psychopharmacology update held by the Nevada Psychiatric Association.
“Parents then go to two different sets of providers,” he said. One provider “tells them about complementary and integrative medicine, but is likely not a traditional physician who’s treating their autism. It’s somebody who knows about these biomedical interventions but when parents tell them that they’re using traditional interventions ... that person also says, ‘Don’t use that. That’s doesn’t work.’ Then they go see their traditional provider who might be thinking about traditional medications. But they’ve learned that they don’t want to tell them, ‘I’m considering using omega 3s or zinc.’ Regrettably, most times physicians don’t say, ‘Let’s examine that. Let’s look at the literature and see if that’s the right decision for you.’ By shutting a family down saying, ‘I don’t want to hear about that,’ it often leads the family to think: ‘How do I make a decision about this? How do I know what to do?’ ”
Dr. Hendren said clinicians are beginning to embrace the notion that autism is not just a brain disorder, but rather a whole body disorder. For example, he noted that significant subsets of people with autism have intestinal inflammation, digestive enzyme abnormalities, metabolic impairments, oxidative stress, mitochondrial dysfunction, and immunity problems that range from immune deficiency to hypersensitivity to autoimmunity. “,” said Dr. Hendren, professor of child and adolescent psychiatry at the University of California, San Francisco. “I hope that by thinking about making the body healthier, we can help kids have the very best outcomes.”
Several biomedical treatments have adequate evidence to use for many patients, he said, including melatonin, probiotics, omega 3s, and possibly vitamin D3, methyl B12, oxytocin, restrictive diets, digestive enzymes, and choline. “There are strong anecdotal reports of gluten-free diet benefits,” said Dr. Hendren, who also directs the UCSF Program for Research on Neurodevelopmental and Translational Outcomes. “Some parents I greatly respect tell me it’s the single most important thing they’ve done in their child’s health, that their GI symptoms have improved, and their overall health has improved.”
In a multisite trial called aViation, researchers are evaluating the effects of an investigational vasopressin antagonist in autistic patients aged 5-17 years. The drug works by blocking a brain receptor of the vasopressin receptor that is associated with control of stress, anxiety, affection, and aggression. “The first trial in adults showed potential benefit,” Dr. Hendren said.
No robust studies exist to suggest that medical marijuana makes a difference for patients with autism, he said, but he has several patients whose parents give their affected child medical marijuana or cannabidiol. “I have a number of families who say it’s really made a big difference for their children and for how they’re doing,” he said.
In Marin County, Calif., the Oak Hill School serves a heterogeneous population of children, adolescents, and young adults, all of whom have autism spectrum disorder (ASD) or other neurologically based disorders of relating and communicating. Students receive special education instruction and customized on-site clinical programs that might include speech/language pathology, occupational therapy, and group and individual psychotherapy. Some of the students have received recent functional behavior analyses from Dr. Hendren and his colleagues, with school staff implementing positive behavior intervention programs.
The researchers also are using metabolomics as a biomarker of outcome. “We’re using metabolomics from the urine, where we can look at these processes in different clusters and see whether our interventions make a difference or not,” said Dr. Hendren, who is a past president of the American Academy of Child and Adolescent Psychiatry. “We did one trial with sulforaphane, which is a concentrated broccoli sprout extract that helps with oxidative stress. It was initially developed to treat oxidative stress in cancer,” he said. Upcoming trials in this cohort include the use of folinic acid and CM-AT, a pancreatic digestive enzyme intended to increase levels of chymotrypsin.
“I think of autism as being a disorder where you have this person and there’s a veil of autism that comes over the top of them,” he said. “That veil is not the kid, although the kid becomes more and more expressed through that. If we can do something to lift that veil, we can do more and more to pull that child out.”
Dr. Hendren disclosed that he has received grants from Curemark, Roche, Shire, and Sunovion. He is a member of the advisory boards for Curemark, BioMarin, Janssen, and Axial Biotherapeutics.
LAS VEGAS – When parents of children with autism ask their primary physicians about complementary and integrative medical treatments, they often get stonewalled, according to Robert L. Hendren, DO.
“They find [clinicians] usually say, ‘Don’t try that stuff. It doesn’t work,’” Dr. Hendren said at an annual psychopharmacology update held by the Nevada Psychiatric Association.
“Parents then go to two different sets of providers,” he said. One provider “tells them about complementary and integrative medicine, but is likely not a traditional physician who’s treating their autism. It’s somebody who knows about these biomedical interventions but when parents tell them that they’re using traditional interventions ... that person also says, ‘Don’t use that. That’s doesn’t work.’ Then they go see their traditional provider who might be thinking about traditional medications. But they’ve learned that they don’t want to tell them, ‘I’m considering using omega 3s or zinc.’ Regrettably, most times physicians don’t say, ‘Let’s examine that. Let’s look at the literature and see if that’s the right decision for you.’ By shutting a family down saying, ‘I don’t want to hear about that,’ it often leads the family to think: ‘How do I make a decision about this? How do I know what to do?’ ”
Dr. Hendren said clinicians are beginning to embrace the notion that autism is not just a brain disorder, but rather a whole body disorder. For example, he noted that significant subsets of people with autism have intestinal inflammation, digestive enzyme abnormalities, metabolic impairments, oxidative stress, mitochondrial dysfunction, and immunity problems that range from immune deficiency to hypersensitivity to autoimmunity. “,” said Dr. Hendren, professor of child and adolescent psychiatry at the University of California, San Francisco. “I hope that by thinking about making the body healthier, we can help kids have the very best outcomes.”
Several biomedical treatments have adequate evidence to use for many patients, he said, including melatonin, probiotics, omega 3s, and possibly vitamin D3, methyl B12, oxytocin, restrictive diets, digestive enzymes, and choline. “There are strong anecdotal reports of gluten-free diet benefits,” said Dr. Hendren, who also directs the UCSF Program for Research on Neurodevelopmental and Translational Outcomes. “Some parents I greatly respect tell me it’s the single most important thing they’ve done in their child’s health, that their GI symptoms have improved, and their overall health has improved.”
In a multisite trial called aViation, researchers are evaluating the effects of an investigational vasopressin antagonist in autistic patients aged 5-17 years. The drug works by blocking a brain receptor of the vasopressin receptor that is associated with control of stress, anxiety, affection, and aggression. “The first trial in adults showed potential benefit,” Dr. Hendren said.
No robust studies exist to suggest that medical marijuana makes a difference for patients with autism, he said, but he has several patients whose parents give their affected child medical marijuana or cannabidiol. “I have a number of families who say it’s really made a big difference for their children and for how they’re doing,” he said.
In Marin County, Calif., the Oak Hill School serves a heterogeneous population of children, adolescents, and young adults, all of whom have autism spectrum disorder (ASD) or other neurologically based disorders of relating and communicating. Students receive special education instruction and customized on-site clinical programs that might include speech/language pathology, occupational therapy, and group and individual psychotherapy. Some of the students have received recent functional behavior analyses from Dr. Hendren and his colleagues, with school staff implementing positive behavior intervention programs.
The researchers also are using metabolomics as a biomarker of outcome. “We’re using metabolomics from the urine, where we can look at these processes in different clusters and see whether our interventions make a difference or not,” said Dr. Hendren, who is a past president of the American Academy of Child and Adolescent Psychiatry. “We did one trial with sulforaphane, which is a concentrated broccoli sprout extract that helps with oxidative stress. It was initially developed to treat oxidative stress in cancer,” he said. Upcoming trials in this cohort include the use of folinic acid and CM-AT, a pancreatic digestive enzyme intended to increase levels of chymotrypsin.
“I think of autism as being a disorder where you have this person and there’s a veil of autism that comes over the top of them,” he said. “That veil is not the kid, although the kid becomes more and more expressed through that. If we can do something to lift that veil, we can do more and more to pull that child out.”
Dr. Hendren disclosed that he has received grants from Curemark, Roche, Shire, and Sunovion. He is a member of the advisory boards for Curemark, BioMarin, Janssen, and Axial Biotherapeutics.
EXPERT ANALYSIS FROM NPA 2019
Intervention raises pediatric patient awareness of teratogenic rheumatology medications
While many medications in rheumatology are known or suspected to be teratogenic, there are no standards on educating rheumatology patients about this risk or on screening for pregnancy, wrote Ashley M. Cooper, MD, and her colleagues at Children’s Mercy Kansas City, Mo. Their report is in the April issue of Pediatrics.
“This is problematic in pediatric rheumatology because nearly half of adolescents report a history of sexual intercourse, but only 57% report condom use and 27% another form of contraception,” they wrote, pointing out that the United States also has one of the highest rates of teen pregnancy among industrialized nations; 80% are unplanned.
The intervention consisted of a number of approaches. Posters listing teratogenic medications were put in exam rooms, physicians received education about the Food and Drug Administration–mandated mycophenolate Risk Evaluation and Mitigation Strategy (REMS), and scripts were developed for staff to inform patients of teratogenic risks with medications, as well as prompts for referral to birth control clinics.
Researchers also implemented a standardized EHR template to allow clinical staff to review medication-specific teaching points and document the discussion with the patient. There also was a previsit planning process to review everything before the clinic day began, and identify patients for education or pregnancy screening.
After 8 months of the intervention – during which 1,366 eligible patient encounters occurred in rheumatology patients aged 10 years and older– researchers saw a significant increase in those encounters where teratogen education was recorded, from 25% before the intervention to 80% at 23 months after it. Pregnancy screening also increased among eligible patients, from 20% preintervention to 83% at 23 months after the first intervention.
Three patients became pregnant during the intervention period; all of the pregnancies were picked up by the screening process. In all cases, the teratogenic medication was immediately stopped; one patient underwent elective termination, one delivered a healthy term infant, and one patient was lost to follow-up. Two of the three had received education during the previous year.
“The strategies used in this project have implications that reach beyond rheumatology because teratogenic medications are commonly prescribed by other subspecialties,” the authors wrote.
Dr. Cooper and her associates noted that an original previsit checklist was later abandoned because it was viewed as being too much of a time imposition on staff at the beginning of a busy clinic day.
“The new process had higher staff buy-in because it was used to address multiple quality improvement projects and hospital requirements, some linked to provider remuneration,” they wrote.
No funding or conflicts of interest were declared.
SOURCE: Cooper AM et al. Pediatrics 2019; 143(4):e20180803. doi: 10.1542/peds.2018-0803.
While many medications in rheumatology are known or suspected to be teratogenic, there are no standards on educating rheumatology patients about this risk or on screening for pregnancy, wrote Ashley M. Cooper, MD, and her colleagues at Children’s Mercy Kansas City, Mo. Their report is in the April issue of Pediatrics.
“This is problematic in pediatric rheumatology because nearly half of adolescents report a history of sexual intercourse, but only 57% report condom use and 27% another form of contraception,” they wrote, pointing out that the United States also has one of the highest rates of teen pregnancy among industrialized nations; 80% are unplanned.
The intervention consisted of a number of approaches. Posters listing teratogenic medications were put in exam rooms, physicians received education about the Food and Drug Administration–mandated mycophenolate Risk Evaluation and Mitigation Strategy (REMS), and scripts were developed for staff to inform patients of teratogenic risks with medications, as well as prompts for referral to birth control clinics.
Researchers also implemented a standardized EHR template to allow clinical staff to review medication-specific teaching points and document the discussion with the patient. There also was a previsit planning process to review everything before the clinic day began, and identify patients for education or pregnancy screening.
After 8 months of the intervention – during which 1,366 eligible patient encounters occurred in rheumatology patients aged 10 years and older– researchers saw a significant increase in those encounters where teratogen education was recorded, from 25% before the intervention to 80% at 23 months after it. Pregnancy screening also increased among eligible patients, from 20% preintervention to 83% at 23 months after the first intervention.
Three patients became pregnant during the intervention period; all of the pregnancies were picked up by the screening process. In all cases, the teratogenic medication was immediately stopped; one patient underwent elective termination, one delivered a healthy term infant, and one patient was lost to follow-up. Two of the three had received education during the previous year.
“The strategies used in this project have implications that reach beyond rheumatology because teratogenic medications are commonly prescribed by other subspecialties,” the authors wrote.
Dr. Cooper and her associates noted that an original previsit checklist was later abandoned because it was viewed as being too much of a time imposition on staff at the beginning of a busy clinic day.
“The new process had higher staff buy-in because it was used to address multiple quality improvement projects and hospital requirements, some linked to provider remuneration,” they wrote.
No funding or conflicts of interest were declared.
SOURCE: Cooper AM et al. Pediatrics 2019; 143(4):e20180803. doi: 10.1542/peds.2018-0803.
While many medications in rheumatology are known or suspected to be teratogenic, there are no standards on educating rheumatology patients about this risk or on screening for pregnancy, wrote Ashley M. Cooper, MD, and her colleagues at Children’s Mercy Kansas City, Mo. Their report is in the April issue of Pediatrics.
“This is problematic in pediatric rheumatology because nearly half of adolescents report a history of sexual intercourse, but only 57% report condom use and 27% another form of contraception,” they wrote, pointing out that the United States also has one of the highest rates of teen pregnancy among industrialized nations; 80% are unplanned.
The intervention consisted of a number of approaches. Posters listing teratogenic medications were put in exam rooms, physicians received education about the Food and Drug Administration–mandated mycophenolate Risk Evaluation and Mitigation Strategy (REMS), and scripts were developed for staff to inform patients of teratogenic risks with medications, as well as prompts for referral to birth control clinics.
Researchers also implemented a standardized EHR template to allow clinical staff to review medication-specific teaching points and document the discussion with the patient. There also was a previsit planning process to review everything before the clinic day began, and identify patients for education or pregnancy screening.
After 8 months of the intervention – during which 1,366 eligible patient encounters occurred in rheumatology patients aged 10 years and older– researchers saw a significant increase in those encounters where teratogen education was recorded, from 25% before the intervention to 80% at 23 months after it. Pregnancy screening also increased among eligible patients, from 20% preintervention to 83% at 23 months after the first intervention.
Three patients became pregnant during the intervention period; all of the pregnancies were picked up by the screening process. In all cases, the teratogenic medication was immediately stopped; one patient underwent elective termination, one delivered a healthy term infant, and one patient was lost to follow-up. Two of the three had received education during the previous year.
“The strategies used in this project have implications that reach beyond rheumatology because teratogenic medications are commonly prescribed by other subspecialties,” the authors wrote.
Dr. Cooper and her associates noted that an original previsit checklist was later abandoned because it was viewed as being too much of a time imposition on staff at the beginning of a busy clinic day.
“The new process had higher staff buy-in because it was used to address multiple quality improvement projects and hospital requirements, some linked to provider remuneration,” they wrote.
No funding or conflicts of interest were declared.
SOURCE: Cooper AM et al. Pediatrics 2019; 143(4):e20180803. doi: 10.1542/peds.2018-0803.
FROM PEDIATRICS
Key clinical point: Intervention improves awareness of teratogenic rheumatology medications among pediatric patients, as well as pregnancy screening.
Major finding: Teratogen education increased from 25% before the intervention to 80% at 23 months after it. Pregnancy screening also increased among eligible patients, from 20% preintervention to 83% at 23 months after the first intervention.
Study details: Single-center trial of 1,366 patient encounters.
Disclosures: No funding or conflicts of interest were declared.
Source: Cooper AM et al. Pediatrics 2019;143(4):e20180803. doi: 10.1542/peds.2018-0803.
Pediatric pruritus requires distinct approach to assessment and management
WASHINGTON – Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.
Using special scales to measure itch in children and understanding that quality of life concerns may be different for children should also be kept in mind, said Dr. Chen, professor of dermatology at Emory University, Atlanta. Furthermore, several psychiatric comorbidities that have been associated with pediatric pruritus, such as ADHD and suicidal thoughts. Another consideration is that a child’s pruritus can have significant effects on his or her parents.
Measuring itch is challenging in children, who may have difficulty responding to visual analogue scales, verbal rating scales, and numerical rating scales. Dr. Chen and her colleagues developed the ItchyQuant scale as a self-report measure of itch severity (J Invest Dermatol. 2017 Jan;137[1]:57-61). It is a scale from 0 to 10 with cartoon illustrations depicting increasing itch severity, from no itch to the “worst itch imaginable.” Currently it is validated only in adults, but they are working towards getting it validated in children.
Another itch assessment scale for children, Itch Man, is available, but has only been studied in children who have survived burns.
The ItchyQOL scale measures the extent to which itch affects quality of life in adults. It examines the symptoms associated with itch, as well as its functional and emotional effects. But children’s concerns about quality of life are not the same as those of adults, so Dr. Chen and her colleagues used ItchyQOL as a basis for the “Tween ItchyQOL,” which is intended for children aged 8-17 years, and the “Kids ItchyQOL,” which is intended for children aged 6-7 years. The Tween ItchyQOL includes items (such as being made fun of) that are not in the ItchyQOL and eliminates items (such as working and spending money) that do not apply to children. The Kids ItchyQOL includes cartoons to help children understand the questions.
Dermatologists often use parents as proxies to measure their children’s itch, assuming that the latter’s responses might be unreliable. But when Dr. Chen and her colleagues administered the ItchyQuant to children with pruritus, parents, and their medical providers to evaluate the extent of agreement among assessors, they found that parents’ scores were higher than their children’s scores, although the difference was not significant.
Providers’ scores, however, were significantly lower than those of children and parents. All scores were in the moderate range. Dr. Chen and colleagues also found that, for each 1-point increase in the difference between children’s and parents’ responses, parents were 1.25 times less likely to have experience with chronic pruritus, outside of their children. This finding provides a gauge of how well a parent can serve as a proxy to characterize his or her child’s itch.
Adolescents are in general a troubled group, and caregivers have concerns about suicide in the adolescent population, Dr. Chen said. She referred to a large study of adolescents published in 2012, which indicated that the prevalence of suicidal ideation was 8.4% among adolescents with no itch, compared with 21.1% among adolescents with severe itch (Acta Derm Venereol. 2012 Sep;92[5]:543-6).
In the study, those with severe itch were three times more likely to have suicidal ideation than the general population, which Dr. Chen noted was comparable with that of suicidal ideation in patients with chronic pain in the study (odds ratio, 3.8).
Cross-sectional data suggest a link between itching and ADHD, but “it’s a chicken-and-egg phenomenon,” she said. “If you’re so itchy and squirmy, you’re not going to pay attention. Then again, if you’re not paying attention, maybe you’re that much more prone to scratch.” Longitudinal data indicate that improving itch correlates with improvement in ADHD symptoms.
In addition, pruritus affects the genders disproportionately. Girls report a significantly greater impact on quality of life than boys when itching is severe, with much of the difference in emotional impact, said Dr. Chen. Boys may report more functional impact than girls.
Chronic pruritus also affects parents, who may have disturbed sleep, feel stress about their own parenting, and have difficulty enforcing discipline. “They feel an incredible amount of guilt and blame for giving this to their child,” she commented. “As more and more places develop itch centers, it would be good to have a multidisciplinary approach bringing in mental health providers and social workers, because the impact of itch on parents can be quite profound.”
Dr. Chen reported disclosures with several companies, including BioPharmX, Dermecular Therapeutics, Leo Pharma, and Unilever.
WASHINGTON – Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.
Using special scales to measure itch in children and understanding that quality of life concerns may be different for children should also be kept in mind, said Dr. Chen, professor of dermatology at Emory University, Atlanta. Furthermore, several psychiatric comorbidities that have been associated with pediatric pruritus, such as ADHD and suicidal thoughts. Another consideration is that a child’s pruritus can have significant effects on his or her parents.
Measuring itch is challenging in children, who may have difficulty responding to visual analogue scales, verbal rating scales, and numerical rating scales. Dr. Chen and her colleagues developed the ItchyQuant scale as a self-report measure of itch severity (J Invest Dermatol. 2017 Jan;137[1]:57-61). It is a scale from 0 to 10 with cartoon illustrations depicting increasing itch severity, from no itch to the “worst itch imaginable.” Currently it is validated only in adults, but they are working towards getting it validated in children.
Another itch assessment scale for children, Itch Man, is available, but has only been studied in children who have survived burns.
The ItchyQOL scale measures the extent to which itch affects quality of life in adults. It examines the symptoms associated with itch, as well as its functional and emotional effects. But children’s concerns about quality of life are not the same as those of adults, so Dr. Chen and her colleagues used ItchyQOL as a basis for the “Tween ItchyQOL,” which is intended for children aged 8-17 years, and the “Kids ItchyQOL,” which is intended for children aged 6-7 years. The Tween ItchyQOL includes items (such as being made fun of) that are not in the ItchyQOL and eliminates items (such as working and spending money) that do not apply to children. The Kids ItchyQOL includes cartoons to help children understand the questions.
Dermatologists often use parents as proxies to measure their children’s itch, assuming that the latter’s responses might be unreliable. But when Dr. Chen and her colleagues administered the ItchyQuant to children with pruritus, parents, and their medical providers to evaluate the extent of agreement among assessors, they found that parents’ scores were higher than their children’s scores, although the difference was not significant.
Providers’ scores, however, were significantly lower than those of children and parents. All scores were in the moderate range. Dr. Chen and colleagues also found that, for each 1-point increase in the difference between children’s and parents’ responses, parents were 1.25 times less likely to have experience with chronic pruritus, outside of their children. This finding provides a gauge of how well a parent can serve as a proxy to characterize his or her child’s itch.
Adolescents are in general a troubled group, and caregivers have concerns about suicide in the adolescent population, Dr. Chen said. She referred to a large study of adolescents published in 2012, which indicated that the prevalence of suicidal ideation was 8.4% among adolescents with no itch, compared with 21.1% among adolescents with severe itch (Acta Derm Venereol. 2012 Sep;92[5]:543-6).
In the study, those with severe itch were three times more likely to have suicidal ideation than the general population, which Dr. Chen noted was comparable with that of suicidal ideation in patients with chronic pain in the study (odds ratio, 3.8).
Cross-sectional data suggest a link between itching and ADHD, but “it’s a chicken-and-egg phenomenon,” she said. “If you’re so itchy and squirmy, you’re not going to pay attention. Then again, if you’re not paying attention, maybe you’re that much more prone to scratch.” Longitudinal data indicate that improving itch correlates with improvement in ADHD symptoms.
In addition, pruritus affects the genders disproportionately. Girls report a significantly greater impact on quality of life than boys when itching is severe, with much of the difference in emotional impact, said Dr. Chen. Boys may report more functional impact than girls.
Chronic pruritus also affects parents, who may have disturbed sleep, feel stress about their own parenting, and have difficulty enforcing discipline. “They feel an incredible amount of guilt and blame for giving this to their child,” she commented. “As more and more places develop itch centers, it would be good to have a multidisciplinary approach bringing in mental health providers and social workers, because the impact of itch on parents can be quite profound.”
Dr. Chen reported disclosures with several companies, including BioPharmX, Dermecular Therapeutics, Leo Pharma, and Unilever.
WASHINGTON – Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.
Using special scales to measure itch in children and understanding that quality of life concerns may be different for children should also be kept in mind, said Dr. Chen, professor of dermatology at Emory University, Atlanta. Furthermore, several psychiatric comorbidities that have been associated with pediatric pruritus, such as ADHD and suicidal thoughts. Another consideration is that a child’s pruritus can have significant effects on his or her parents.
Measuring itch is challenging in children, who may have difficulty responding to visual analogue scales, verbal rating scales, and numerical rating scales. Dr. Chen and her colleagues developed the ItchyQuant scale as a self-report measure of itch severity (J Invest Dermatol. 2017 Jan;137[1]:57-61). It is a scale from 0 to 10 with cartoon illustrations depicting increasing itch severity, from no itch to the “worst itch imaginable.” Currently it is validated only in adults, but they are working towards getting it validated in children.
Another itch assessment scale for children, Itch Man, is available, but has only been studied in children who have survived burns.
The ItchyQOL scale measures the extent to which itch affects quality of life in adults. It examines the symptoms associated with itch, as well as its functional and emotional effects. But children’s concerns about quality of life are not the same as those of adults, so Dr. Chen and her colleagues used ItchyQOL as a basis for the “Tween ItchyQOL,” which is intended for children aged 8-17 years, and the “Kids ItchyQOL,” which is intended for children aged 6-7 years. The Tween ItchyQOL includes items (such as being made fun of) that are not in the ItchyQOL and eliminates items (such as working and spending money) that do not apply to children. The Kids ItchyQOL includes cartoons to help children understand the questions.
Dermatologists often use parents as proxies to measure their children’s itch, assuming that the latter’s responses might be unreliable. But when Dr. Chen and her colleagues administered the ItchyQuant to children with pruritus, parents, and their medical providers to evaluate the extent of agreement among assessors, they found that parents’ scores were higher than their children’s scores, although the difference was not significant.
Providers’ scores, however, were significantly lower than those of children and parents. All scores were in the moderate range. Dr. Chen and colleagues also found that, for each 1-point increase in the difference between children’s and parents’ responses, parents were 1.25 times less likely to have experience with chronic pruritus, outside of their children. This finding provides a gauge of how well a parent can serve as a proxy to characterize his or her child’s itch.
Adolescents are in general a troubled group, and caregivers have concerns about suicide in the adolescent population, Dr. Chen said. She referred to a large study of adolescents published in 2012, which indicated that the prevalence of suicidal ideation was 8.4% among adolescents with no itch, compared with 21.1% among adolescents with severe itch (Acta Derm Venereol. 2012 Sep;92[5]:543-6).
In the study, those with severe itch were three times more likely to have suicidal ideation than the general population, which Dr. Chen noted was comparable with that of suicidal ideation in patients with chronic pain in the study (odds ratio, 3.8).
Cross-sectional data suggest a link between itching and ADHD, but “it’s a chicken-and-egg phenomenon,” she said. “If you’re so itchy and squirmy, you’re not going to pay attention. Then again, if you’re not paying attention, maybe you’re that much more prone to scratch.” Longitudinal data indicate that improving itch correlates with improvement in ADHD symptoms.
In addition, pruritus affects the genders disproportionately. Girls report a significantly greater impact on quality of life than boys when itching is severe, with much of the difference in emotional impact, said Dr. Chen. Boys may report more functional impact than girls.
Chronic pruritus also affects parents, who may have disturbed sleep, feel stress about their own parenting, and have difficulty enforcing discipline. “They feel an incredible amount of guilt and blame for giving this to their child,” she commented. “As more and more places develop itch centers, it would be good to have a multidisciplinary approach bringing in mental health providers and social workers, because the impact of itch on parents can be quite profound.”
Dr. Chen reported disclosures with several companies, including BioPharmX, Dermecular Therapeutics, Leo Pharma, and Unilever.
REPORTING FROM AAD 2019