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Study shows evidence of herd immunity with HPV vaccine
Introduction of the quadrivalent human papillomavirus (HPV) vaccine was associated with significant declines in the incidence of vaccine-type virus both in vaccinated and unvaccinated young women, according to a study published in Pediatrics.
Four surveillance studies, conducted between 2006 and 2017, examined the rate of positive tests for vaccine-type HPV among 1,580 vaccinated and unvaccinated women aged 13-26 years. The majority of participants identified as African American or multiracial.
Overall, 97% of study participants received the quadrivalent vaccine, with vaccination rates increasing from 0% to 84% over the four waves of vaccination. Vaccine effectiveness – representing the relative risk of infection in vaccinated individuals, compared with unvaccinated risk before introduction of the vaccine – increased by 72% from wave 1 to wave 2, 91% from wave 1 to wave 3, and 80% from wave 1 to wave 4.
Among women who were vaccinated, rates of the quadrivalent vaccine–type HPV decreased by 81%, from 35% to 7%. But even among women who were unvaccinated, detection of the vaccine-targeted strains of HPV decreased by 40%, from 32% to 19%.
Chelse Spinner of the University of Cincinnati and her coauthors wrote that the decline in the quadrivalent vaccine–type HPV provided evidence of direct protection and high vaccine effectiveness in this real-world setting.
“This degree of effectiveness is remarkable given the fact that vaccination was defined as having received one or more doses (i.e., was not defined as having completed the vaccination series) and that women in this study were likely at a substantially higher risk for preexisting HPV infection than [were] those in the HPV vaccine clinical trials because of their reported sexual behaviors,” they wrote. “As noted in a recent review, evidence about herd protection will be a key component of cost-effectiveness analysis evaluating cervical cancer screening strategies.”
Twelve percent of women in the studies received the nine-valent HPV vaccine, and among these women, the rate of infection with the nine-valent vaccine-type HPV decreased from 47% in the first wave of vaccination to 14% in the last wave, representing a 71% decline.
The proportion of vaccinated women in the study who were infected with one or more of the five viral subtypes included in the nine-valent but not in the quadrivalent vaccine decreased significantly by 69%, from 23% to 7%.
However, these data also suggested a nonsignificant 58% increase among unvaccinated women in infections with one of the five subtypes covered by the nine-valent vaccine but not the quadrivalent vaccine.
Ms. Spinner and her associates noted this increase was unexpected and suggested the increase may be caused by the differences between vaccinated and unvaccinated women.
“For example, if women who are unvaccinated versus women who are vaccinated are more likely to practice riskier behaviors that would increase their risk of acquiring HPV, they would be more likely to acquire non–vaccine-type HPV,” they wrote.
Ms. Spinner graduated from the University of Cincinnati and now is a graduate student at the University of South Florida, Tampa. The study was funded by the National Institutes of Health. Darron R. Brown declared shares of Merck, but the other coauthors declared no other relevant financial disclosures.
SOURCE: Spinner C et al. Pediatrics. 2019, Jan 22. doi: 10.1542/peds.2018-1902.
This study of the real-world effectiveness of the HPV vaccine adds to the growing body of literature, and has produced three important results.
The first is that women who had received at least one dose of the vaccine were considered vaccinated, and because of their level of sexual activity, many likely would have already been infected with some HPV subtypes. The high vaccine effectiveness seen in this study despite these factors adds weight to evidence that this HPV vaccine is highly protective.
The study also showed evidence of cross-protection, in that even women who had received only the quadrivalent vaccine still had significantly reduced rates of infection with the HPV subtypes included in the nine-valent vaccine.
It also provides significant evidence of the herd immunity effect against the subtypes included in the quadrivalent vaccine.
Amanda F. Dempsey, MD, PhD, is from the adult and child consortium for health outcomes research and delivery science at the University of Colorado, Denver. These comments are taken from an accompanying editorial (Pediatrics. 2019 Jan 22. doi: 10.1542/peds.2018-3427). Dr. Dempsey declared advisory board roles for Merck, Sanofi, and Pfizer and a consultancy for Pfizer. She received no external funding.
This study of the real-world effectiveness of the HPV vaccine adds to the growing body of literature, and has produced three important results.
The first is that women who had received at least one dose of the vaccine were considered vaccinated, and because of their level of sexual activity, many likely would have already been infected with some HPV subtypes. The high vaccine effectiveness seen in this study despite these factors adds weight to evidence that this HPV vaccine is highly protective.
The study also showed evidence of cross-protection, in that even women who had received only the quadrivalent vaccine still had significantly reduced rates of infection with the HPV subtypes included in the nine-valent vaccine.
It also provides significant evidence of the herd immunity effect against the subtypes included in the quadrivalent vaccine.
Amanda F. Dempsey, MD, PhD, is from the adult and child consortium for health outcomes research and delivery science at the University of Colorado, Denver. These comments are taken from an accompanying editorial (Pediatrics. 2019 Jan 22. doi: 10.1542/peds.2018-3427). Dr. Dempsey declared advisory board roles for Merck, Sanofi, and Pfizer and a consultancy for Pfizer. She received no external funding.
This study of the real-world effectiveness of the HPV vaccine adds to the growing body of literature, and has produced three important results.
The first is that women who had received at least one dose of the vaccine were considered vaccinated, and because of their level of sexual activity, many likely would have already been infected with some HPV subtypes. The high vaccine effectiveness seen in this study despite these factors adds weight to evidence that this HPV vaccine is highly protective.
The study also showed evidence of cross-protection, in that even women who had received only the quadrivalent vaccine still had significantly reduced rates of infection with the HPV subtypes included in the nine-valent vaccine.
It also provides significant evidence of the herd immunity effect against the subtypes included in the quadrivalent vaccine.
Amanda F. Dempsey, MD, PhD, is from the adult and child consortium for health outcomes research and delivery science at the University of Colorado, Denver. These comments are taken from an accompanying editorial (Pediatrics. 2019 Jan 22. doi: 10.1542/peds.2018-3427). Dr. Dempsey declared advisory board roles for Merck, Sanofi, and Pfizer and a consultancy for Pfizer. She received no external funding.
Introduction of the quadrivalent human papillomavirus (HPV) vaccine was associated with significant declines in the incidence of vaccine-type virus both in vaccinated and unvaccinated young women, according to a study published in Pediatrics.
Four surveillance studies, conducted between 2006 and 2017, examined the rate of positive tests for vaccine-type HPV among 1,580 vaccinated and unvaccinated women aged 13-26 years. The majority of participants identified as African American or multiracial.
Overall, 97% of study participants received the quadrivalent vaccine, with vaccination rates increasing from 0% to 84% over the four waves of vaccination. Vaccine effectiveness – representing the relative risk of infection in vaccinated individuals, compared with unvaccinated risk before introduction of the vaccine – increased by 72% from wave 1 to wave 2, 91% from wave 1 to wave 3, and 80% from wave 1 to wave 4.
Among women who were vaccinated, rates of the quadrivalent vaccine–type HPV decreased by 81%, from 35% to 7%. But even among women who were unvaccinated, detection of the vaccine-targeted strains of HPV decreased by 40%, from 32% to 19%.
Chelse Spinner of the University of Cincinnati and her coauthors wrote that the decline in the quadrivalent vaccine–type HPV provided evidence of direct protection and high vaccine effectiveness in this real-world setting.
“This degree of effectiveness is remarkable given the fact that vaccination was defined as having received one or more doses (i.e., was not defined as having completed the vaccination series) and that women in this study were likely at a substantially higher risk for preexisting HPV infection than [were] those in the HPV vaccine clinical trials because of their reported sexual behaviors,” they wrote. “As noted in a recent review, evidence about herd protection will be a key component of cost-effectiveness analysis evaluating cervical cancer screening strategies.”
Twelve percent of women in the studies received the nine-valent HPV vaccine, and among these women, the rate of infection with the nine-valent vaccine-type HPV decreased from 47% in the first wave of vaccination to 14% in the last wave, representing a 71% decline.
The proportion of vaccinated women in the study who were infected with one or more of the five viral subtypes included in the nine-valent but not in the quadrivalent vaccine decreased significantly by 69%, from 23% to 7%.
However, these data also suggested a nonsignificant 58% increase among unvaccinated women in infections with one of the five subtypes covered by the nine-valent vaccine but not the quadrivalent vaccine.
Ms. Spinner and her associates noted this increase was unexpected and suggested the increase may be caused by the differences between vaccinated and unvaccinated women.
“For example, if women who are unvaccinated versus women who are vaccinated are more likely to practice riskier behaviors that would increase their risk of acquiring HPV, they would be more likely to acquire non–vaccine-type HPV,” they wrote.
Ms. Spinner graduated from the University of Cincinnati and now is a graduate student at the University of South Florida, Tampa. The study was funded by the National Institutes of Health. Darron R. Brown declared shares of Merck, but the other coauthors declared no other relevant financial disclosures.
SOURCE: Spinner C et al. Pediatrics. 2019, Jan 22. doi: 10.1542/peds.2018-1902.
Introduction of the quadrivalent human papillomavirus (HPV) vaccine was associated with significant declines in the incidence of vaccine-type virus both in vaccinated and unvaccinated young women, according to a study published in Pediatrics.
Four surveillance studies, conducted between 2006 and 2017, examined the rate of positive tests for vaccine-type HPV among 1,580 vaccinated and unvaccinated women aged 13-26 years. The majority of participants identified as African American or multiracial.
Overall, 97% of study participants received the quadrivalent vaccine, with vaccination rates increasing from 0% to 84% over the four waves of vaccination. Vaccine effectiveness – representing the relative risk of infection in vaccinated individuals, compared with unvaccinated risk before introduction of the vaccine – increased by 72% from wave 1 to wave 2, 91% from wave 1 to wave 3, and 80% from wave 1 to wave 4.
Among women who were vaccinated, rates of the quadrivalent vaccine–type HPV decreased by 81%, from 35% to 7%. But even among women who were unvaccinated, detection of the vaccine-targeted strains of HPV decreased by 40%, from 32% to 19%.
Chelse Spinner of the University of Cincinnati and her coauthors wrote that the decline in the quadrivalent vaccine–type HPV provided evidence of direct protection and high vaccine effectiveness in this real-world setting.
“This degree of effectiveness is remarkable given the fact that vaccination was defined as having received one or more doses (i.e., was not defined as having completed the vaccination series) and that women in this study were likely at a substantially higher risk for preexisting HPV infection than [were] those in the HPV vaccine clinical trials because of their reported sexual behaviors,” they wrote. “As noted in a recent review, evidence about herd protection will be a key component of cost-effectiveness analysis evaluating cervical cancer screening strategies.”
Twelve percent of women in the studies received the nine-valent HPV vaccine, and among these women, the rate of infection with the nine-valent vaccine-type HPV decreased from 47% in the first wave of vaccination to 14% in the last wave, representing a 71% decline.
The proportion of vaccinated women in the study who were infected with one or more of the five viral subtypes included in the nine-valent but not in the quadrivalent vaccine decreased significantly by 69%, from 23% to 7%.
However, these data also suggested a nonsignificant 58% increase among unvaccinated women in infections with one of the five subtypes covered by the nine-valent vaccine but not the quadrivalent vaccine.
Ms. Spinner and her associates noted this increase was unexpected and suggested the increase may be caused by the differences between vaccinated and unvaccinated women.
“For example, if women who are unvaccinated versus women who are vaccinated are more likely to practice riskier behaviors that would increase their risk of acquiring HPV, they would be more likely to acquire non–vaccine-type HPV,” they wrote.
Ms. Spinner graduated from the University of Cincinnati and now is a graduate student at the University of South Florida, Tampa. The study was funded by the National Institutes of Health. Darron R. Brown declared shares of Merck, but the other coauthors declared no other relevant financial disclosures.
SOURCE: Spinner C et al. Pediatrics. 2019, Jan 22. doi: 10.1542/peds.2018-1902.
FROM PEDIATRICS
Key clinical point:
Major finding: Infection rates for quadrivalent vaccine-covered HPV strains declined by 81% among vaccinated women.
Study details: Surveillance studies in 1,580 vaccinated and unvaccinated young women.
Disclosures: The study was funded by the National Institutes of Health. One author declared shares of Merck, but no other conflicts of interest were declared.
Source: Spinner C et al. Pediatrics. 2019, Jan 22. doi: 10.1542/peds.2018-1902.
Emphasize disease prevention in communications about HPV vaccine
Parents were much more confident about vaccinating their children against the human papillomavirus (HPV) when they were told about the diseases that the vaccine prevents rather than about safety, new research found.
In Pediatrics, researchers reported the outcomes of an online video-messaging study that attempted to address the most common parental questions and concerns about the HPV vaccine. They surveyed a national sample of 1,196 parents of children (aged 9-17 years) who watched four brief videos of a pediatrician talking about one of seven common concerns regarding HPV vaccination. The parents then were asked how each video affected them.
Parents who were exposed to messages about the diseases that the HPV vaccine prevented had the highest confidence in the HPV vaccine (46%). These messages included “HPV is a common virus that millions of people get every year. The HPV vaccine will protect your child from some cancers and genital warts” and “HPV infection can cause cancer in both men and women. The HPV vaccine will protect your child from many of these cancers.”
Similarly, parents exposed to messages about the need for HPV vaccination for both boys and girls also had the highest levels of confidence about HPV vaccination (44%).
Confidence was lower in parents exposed to messages about safety and side effects (30%)
“As such, reiterating vaccination benefits (including cancer prevention) when addressing concerns may also improve the impact of messages,” wrote Parth D. Shah, PhD, from the Fred Hutchinson Cancer Research Center, Seattle, and his coauthors.
Parents who received messages that expressed urgency about vaccination had lower confidence in the HPV vaccine.
“One reason may be that parents who are hesitant feel inappropriately rushed or that their concerns are not being treated with appropriate care,” the authors wrote.
However, messages that required a higher reading grade level and messages that were longer also seemed to inspire more confidence among parents. Parents who were exposed to messages about cancer prevention additionally were even more confident in HPV vaccine, Dr. Shah and his associates reported.
The study also found that 84% of parents wanted to talk to their children’s doctor about the diseases that the HPV vaccine prevented, while 68% wanted to talk about safety and side effects.
The study was funded by the Centers for Disease Control and Prevention and the National Cancer Institute. Dr. Shah was partially supported by an Agency for Healthcare Research and Quality grant. Another author declared being on paid advisory boards of research grants from Merck, Pfizer, and GlaxoSmithKline. No other conflicts of interest were declared.
SOURCE: Shah PD et al. Pediatrics. 2019 Feb. doi: 10.1542/peds.2018-1872.
Parents were much more confident about vaccinating their children against the human papillomavirus (HPV) when they were told about the diseases that the vaccine prevents rather than about safety, new research found.
In Pediatrics, researchers reported the outcomes of an online video-messaging study that attempted to address the most common parental questions and concerns about the HPV vaccine. They surveyed a national sample of 1,196 parents of children (aged 9-17 years) who watched four brief videos of a pediatrician talking about one of seven common concerns regarding HPV vaccination. The parents then were asked how each video affected them.
Parents who were exposed to messages about the diseases that the HPV vaccine prevented had the highest confidence in the HPV vaccine (46%). These messages included “HPV is a common virus that millions of people get every year. The HPV vaccine will protect your child from some cancers and genital warts” and “HPV infection can cause cancer in both men and women. The HPV vaccine will protect your child from many of these cancers.”
Similarly, parents exposed to messages about the need for HPV vaccination for both boys and girls also had the highest levels of confidence about HPV vaccination (44%).
Confidence was lower in parents exposed to messages about safety and side effects (30%)
“As such, reiterating vaccination benefits (including cancer prevention) when addressing concerns may also improve the impact of messages,” wrote Parth D. Shah, PhD, from the Fred Hutchinson Cancer Research Center, Seattle, and his coauthors.
Parents who received messages that expressed urgency about vaccination had lower confidence in the HPV vaccine.
“One reason may be that parents who are hesitant feel inappropriately rushed or that their concerns are not being treated with appropriate care,” the authors wrote.
However, messages that required a higher reading grade level and messages that were longer also seemed to inspire more confidence among parents. Parents who were exposed to messages about cancer prevention additionally were even more confident in HPV vaccine, Dr. Shah and his associates reported.
The study also found that 84% of parents wanted to talk to their children’s doctor about the diseases that the HPV vaccine prevented, while 68% wanted to talk about safety and side effects.
The study was funded by the Centers for Disease Control and Prevention and the National Cancer Institute. Dr. Shah was partially supported by an Agency for Healthcare Research and Quality grant. Another author declared being on paid advisory boards of research grants from Merck, Pfizer, and GlaxoSmithKline. No other conflicts of interest were declared.
SOURCE: Shah PD et al. Pediatrics. 2019 Feb. doi: 10.1542/peds.2018-1872.
Parents were much more confident about vaccinating their children against the human papillomavirus (HPV) when they were told about the diseases that the vaccine prevents rather than about safety, new research found.
In Pediatrics, researchers reported the outcomes of an online video-messaging study that attempted to address the most common parental questions and concerns about the HPV vaccine. They surveyed a national sample of 1,196 parents of children (aged 9-17 years) who watched four brief videos of a pediatrician talking about one of seven common concerns regarding HPV vaccination. The parents then were asked how each video affected them.
Parents who were exposed to messages about the diseases that the HPV vaccine prevented had the highest confidence in the HPV vaccine (46%). These messages included “HPV is a common virus that millions of people get every year. The HPV vaccine will protect your child from some cancers and genital warts” and “HPV infection can cause cancer in both men and women. The HPV vaccine will protect your child from many of these cancers.”
Similarly, parents exposed to messages about the need for HPV vaccination for both boys and girls also had the highest levels of confidence about HPV vaccination (44%).
Confidence was lower in parents exposed to messages about safety and side effects (30%)
“As such, reiterating vaccination benefits (including cancer prevention) when addressing concerns may also improve the impact of messages,” wrote Parth D. Shah, PhD, from the Fred Hutchinson Cancer Research Center, Seattle, and his coauthors.
Parents who received messages that expressed urgency about vaccination had lower confidence in the HPV vaccine.
“One reason may be that parents who are hesitant feel inappropriately rushed or that their concerns are not being treated with appropriate care,” the authors wrote.
However, messages that required a higher reading grade level and messages that were longer also seemed to inspire more confidence among parents. Parents who were exposed to messages about cancer prevention additionally were even more confident in HPV vaccine, Dr. Shah and his associates reported.
The study also found that 84% of parents wanted to talk to their children’s doctor about the diseases that the HPV vaccine prevented, while 68% wanted to talk about safety and side effects.
The study was funded by the Centers for Disease Control and Prevention and the National Cancer Institute. Dr. Shah was partially supported by an Agency for Healthcare Research and Quality grant. Another author declared being on paid advisory boards of research grants from Merck, Pfizer, and GlaxoSmithKline. No other conflicts of interest were declared.
SOURCE: Shah PD et al. Pediatrics. 2019 Feb. doi: 10.1542/peds.2018-1872.
FROM PEDIATRICS
Key clinical point: Information on the benefits of HPV vaccination can improve parent confidence.
Major finding: Messages about the disease and cancer prevention benefits of HPV vaccination inspired greater parent confidence.
Study details: Study in 1,196 parents of children aged 9-17 years.
Disclosures: The study was funded by the Centers for Disease Control and Prevention and the National Cancer Institute. Dr. Shah was partially supported by an Agency for Healthcare Research and Quality grant. Another author declared being on paid advisory boards of research grants from Merck, Pfizer, and GlaxoSmithKline. No other conflicts of interest were declared.
Source: Shah P et al. Pediatrics. 2019 Feb. doi. 10.1542/peds.2018-1872.
Homelessness among LGBT youth in the United States
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
Confidential, parent-free discussion should occur by age 13
Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.
“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.
According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.
You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.
Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.
The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).
On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.
Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).
Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).
Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.
Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.
Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.
“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”
You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.
Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.
It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.
Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.
The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.
SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.
Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”
Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.
Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.
The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.
Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.
The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.
What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.
Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.
Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”
Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.
Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.
The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.
Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.
The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.
What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.
Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.
Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”
Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.
Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.
The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.
Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.
The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.
What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.
Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.
Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.
“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.
According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.
You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.
Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.
The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).
On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.
Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).
Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).
Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.
Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.
Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.
“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”
You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.
Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.
It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.
Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.
The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.
SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.
Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.
“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.
According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.
You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.
Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.
The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).
On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.
Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).
Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).
Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.
Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.
Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.
“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”
You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.
Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.
It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.
Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.
The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.
SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.
FROM PEDIATRICS
Key clinical point:
Major finding: The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%).
Study details: Self-report survey.
Disclosures: The authors had no financial relationships relevant to this article to disclose. The study was funded by an unrestricted research grant from the Merck Foundation.
Source: Santelli J. et. al. Pediatrics. 2019;143(2):e20181403.
Medicaid youth suicides include more females, younger kids, hanging deaths
Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.
Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.
“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.
Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.
Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.
Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.
Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.
Nevertheless, , Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.
This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.
The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.
SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.
Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.
“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.
Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.
Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.
Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.
Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.
Nevertheless, , Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.
This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.
The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.
SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
Young people enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth, results of a large, observational, population-based study suggest.
Nearly 40% of young people in the study who died by suicide were covered by Medicaid, according to study lead author Cynthia A. Fontanella, PhD, of the department of psychiatry and behavioral health at the Ohio State University, Columbus. Those findings, in addition to those of other studies indicating that youth enrolled in Medicaid endure more maltreatment and poverty-related adversity, suggest a need for health care delivery systems to develop “trauma-informed approaches” and implement them, Dr. Fontanella and her coauthors reported in the American Journal of Preventive Medicine.
“Effective suicide screening of enrollees could substantially decrease suicide mortality in the United States,” they wrote.
Dr. Fontanella and her coauthors reviewed death certificate data from the 16 most populous states to identify all youth aged 10-18 who committed suicide during 2009-2013. They identified 4,045 deaths from suicide based on state death certificate data in California, Florida, Georgia, Illinois, Indiana, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Texas, Virginia, Washington, and Wisconsin. To identify the subset of youth who were enrolled in Medicaid, they used Social Security numbers to link the death certificate data to data from a Medicaid database.
Out of 4,045 youth suicide deaths that occurred during that time period, 39% were among youth enrolled in Medicaid, the investigators found.
Although the overall suicide rate did not differ significantly between the Medicaid and non-Medicaid groups, investigators said they did identify significant differences in age and sex subgroups. Specifically, those in the Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, and a 14% increased risk of suicide among females, the findings showed. Moreover, the risk of death by hanging was 26% greater among the Medicare youth.
Dr. Fontanella and her coauthors reported several limitations. One is that the findings might not be generalizable to all 50 states. Also, they said, because suicide is underreported as a cause of death, the prevalence of suicide found in the study might have been underreported.
Nevertheless, , Dr. Fontanella and her associates wrote. Boundaried populations are those defined by a service setting or organizational function. In other words, they wrote, findings based on an analysis of service use patterns captured in Medicaid claims “could prove helpful in identifying periods known to be associated with heightened suicide risk, such as that immediately following discharge from inpatient psychiatric care.”
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force has recommended that those populations be targeted for research on interventions designed to reduce suicide deaths, Dr. Fontanella and her coauthors wrote.
This is the first-ever study to evaluate suicide-related mortality among Medicaid-covered youth, the investigators said. Previous studies of suicide in Medicaid have focused on adults – specifically those in the Veterans Health Administration, specific state Medicaid programs, or health maintenance organization networks.
The American Foundation for Suicide Prevention and the National Institutes of Health funded the study. Dr. Fontanella and her coauthors reported no other financial conflicts of interest.
SOURCE: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point: Youth enrolled in Medicaid who commit suicide are disproportionately female, younger, and more likely to die by hanging, compared with non-Medicaid youth.
Major finding: The Medicaid group had a 28% increased risk of suicide among the 10- to 14-year age subgroup, a 14% increased risk of suicide among females, and a 26% greater risk of death by hanging.
Study details: An observational study from the 16 most populous states that includes 4,045 youth who committed suicide during 2009-2013.
Disclosures: The authors reported no financial conflicts. The study was funded by the American Foundation for Suicide Prevention and the National Institutes of Health.
Source: Fontanella CA et al. Am J Prev Med. 2019 Jan 17. doi: 10.1016/j.amepre.2018.10.008.
Carbs vs. fats for CVD
Also today, from MDedge Pediatrics, a consult on influenza and pneumonia, brodalumab beats ustekinumab to PASI 100, and a novel agent cuts LDL in patients who are intolerant to statins.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, from MDedge Pediatrics, a consult on influenza and pneumonia, brodalumab beats ustekinumab to PASI 100, and a novel agent cuts LDL in patients who are intolerant to statins.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, from MDedge Pediatrics, a consult on influenza and pneumonia, brodalumab beats ustekinumab to PASI 100, and a novel agent cuts LDL in patients who are intolerant to statins.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Intrapartum molecular GBS screening reduced newborn early-onset disease, antibiotic use
Point-of-care intrapartum molecular screening of group B Streptococcus reduced the incidence of early-onset disease cases and antibiotic use, according to research published in Obstetrics & Gynecology.
Najoua El Helali, PharmD, from the Service de Microbiologie Clinique at Groupe Hospitalier Paris Saint-Joseph, and her colleagues measured the rate of early-onset disease group B Streptococcus (GBS) in a single-center study analyzing antenatal culture screening for 4 years prior to implementation (2006-2009) of polymerase chain reaction (PCR) screening (2010-2015). There were 11,226 deliveries (11,818 live births) during the antenatal screening period and 18,835 deliveries (18,980 live births) during the PCR screening period. Overall, 4% of deliveries during the antenatal period and 0.1% of deliveries during the intrapartum period were not screened for GBS (P less than .001).
During 2006-2015, the rate of early-onset disease of GBS decreased to 0.21/1,000 cases from 1.01/1,000 cases (risk ratio, 0.25; 95% confidence interval, 0.14-0.43; P = .026), while the rate of probable early-onset disease GBS decreased to 0.73/1,000 cases from 2.8/1,000 cases (RR, 0.25; (95% CI, 0.14-0.43; P less than .001).
For patients with early-onset GBS, length of stay in hospital decreased by 64%, and antibiotic therapy decreased by 60%, but there was no significant difference in average length of stay or duration of antibiotic therapy during the study period. There was a reduction in annual delivery- and treatment-associated costs of early-onset disease GBS from $41,875 to $11,945, while the estimated extra cost of PCR screening to avoid one additional case of early-onset disease GBS was $5,819 and a cost increase of $49 per newborn.
“The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs,” the investigators said.
“A randomized, controlled multicenter study is probably needed to evaluate the cost-effectiveness of this prevention strategy and demonstrate a better efficacy in populations where poorly followed women are of unknown GBS status at presentation for delivery,” the researchers said. “In term newborns, however, using infection rate as an endpoint is problematic given the sample size needed.”
The researchers said their study was potentially limited by lack of a control group and population selection, and described mothers in their center as “mostly well-informed and well-monitored during their pregnancy.”
The authors reported no relevant conflicts of interest.
SOURCE: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
Point-of-care intrapartum molecular screening of group B Streptococcus reduced the incidence of early-onset disease cases and antibiotic use, according to research published in Obstetrics & Gynecology.
Najoua El Helali, PharmD, from the Service de Microbiologie Clinique at Groupe Hospitalier Paris Saint-Joseph, and her colleagues measured the rate of early-onset disease group B Streptococcus (GBS) in a single-center study analyzing antenatal culture screening for 4 years prior to implementation (2006-2009) of polymerase chain reaction (PCR) screening (2010-2015). There were 11,226 deliveries (11,818 live births) during the antenatal screening period and 18,835 deliveries (18,980 live births) during the PCR screening period. Overall, 4% of deliveries during the antenatal period and 0.1% of deliveries during the intrapartum period were not screened for GBS (P less than .001).
During 2006-2015, the rate of early-onset disease of GBS decreased to 0.21/1,000 cases from 1.01/1,000 cases (risk ratio, 0.25; 95% confidence interval, 0.14-0.43; P = .026), while the rate of probable early-onset disease GBS decreased to 0.73/1,000 cases from 2.8/1,000 cases (RR, 0.25; (95% CI, 0.14-0.43; P less than .001).
For patients with early-onset GBS, length of stay in hospital decreased by 64%, and antibiotic therapy decreased by 60%, but there was no significant difference in average length of stay or duration of antibiotic therapy during the study period. There was a reduction in annual delivery- and treatment-associated costs of early-onset disease GBS from $41,875 to $11,945, while the estimated extra cost of PCR screening to avoid one additional case of early-onset disease GBS was $5,819 and a cost increase of $49 per newborn.
“The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs,” the investigators said.
“A randomized, controlled multicenter study is probably needed to evaluate the cost-effectiveness of this prevention strategy and demonstrate a better efficacy in populations where poorly followed women are of unknown GBS status at presentation for delivery,” the researchers said. “In term newborns, however, using infection rate as an endpoint is problematic given the sample size needed.”
The researchers said their study was potentially limited by lack of a control group and population selection, and described mothers in their center as “mostly well-informed and well-monitored during their pregnancy.”
The authors reported no relevant conflicts of interest.
SOURCE: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
Point-of-care intrapartum molecular screening of group B Streptococcus reduced the incidence of early-onset disease cases and antibiotic use, according to research published in Obstetrics & Gynecology.
Najoua El Helali, PharmD, from the Service de Microbiologie Clinique at Groupe Hospitalier Paris Saint-Joseph, and her colleagues measured the rate of early-onset disease group B Streptococcus (GBS) in a single-center study analyzing antenatal culture screening for 4 years prior to implementation (2006-2009) of polymerase chain reaction (PCR) screening (2010-2015). There were 11,226 deliveries (11,818 live births) during the antenatal screening period and 18,835 deliveries (18,980 live births) during the PCR screening period. Overall, 4% of deliveries during the antenatal period and 0.1% of deliveries during the intrapartum period were not screened for GBS (P less than .001).
During 2006-2015, the rate of early-onset disease of GBS decreased to 0.21/1,000 cases from 1.01/1,000 cases (risk ratio, 0.25; 95% confidence interval, 0.14-0.43; P = .026), while the rate of probable early-onset disease GBS decreased to 0.73/1,000 cases from 2.8/1,000 cases (RR, 0.25; (95% CI, 0.14-0.43; P less than .001).
For patients with early-onset GBS, length of stay in hospital decreased by 64%, and antibiotic therapy decreased by 60%, but there was no significant difference in average length of stay or duration of antibiotic therapy during the study period. There was a reduction in annual delivery- and treatment-associated costs of early-onset disease GBS from $41,875 to $11,945, while the estimated extra cost of PCR screening to avoid one additional case of early-onset disease GBS was $5,819 and a cost increase of $49 per newborn.
“The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs,” the investigators said.
“A randomized, controlled multicenter study is probably needed to evaluate the cost-effectiveness of this prevention strategy and demonstrate a better efficacy in populations where poorly followed women are of unknown GBS status at presentation for delivery,” the researchers said. “In term newborns, however, using infection rate as an endpoint is problematic given the sample size needed.”
The researchers said their study was potentially limited by lack of a control group and population selection, and described mothers in their center as “mostly well-informed and well-monitored during their pregnancy.”
The authors reported no relevant conflicts of interest.
SOURCE: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point:
Major finding: The rate of early-onset disease group B Streptococcus decreased from 1.01/1,000 cases to 0.21/1,000 cases across the antenatal and intrapartum periods.
Study details: A single-center study of antenatal culture screening for 11,226 deliveries during 2006-2009 and intrapartum PCR screening for 18,835 deliveries during 2010-2015.
Disclosures: The authors reported no relevant conflicts of interest.
Source: El Helali N et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003057.
Warmth and moisture help keep preterm neonates’ skin healthy
The skin of premature infants is very fragile and can take up to 4 weeks to become cornified. Until then, it’s apt to rapidly lose water and heat, putting babies at risk of hypothermia, dehydration, and electrolyte imbalances, Ayan Kusari and his colleagues wrote in Pediatric Dermatology.
The team examined evidence-based skin care in these tiny patients, extracting recommendations from a meta-analysis of 68 studies.
“There are a number of unifying features that distinguish preterm skin from term skin,” wrote Mr. Kusari, a clinical research associate at the Rady Children’s Hospital–San Diego, and his associates. “Preterm skin is thinner, making preterm neonates more susceptible to skin infections and caustic agents. The vernix caseosa is typically thicker in preterm neonates [though thinner in extremely preterm neonates]. Accordingly, there are a number of general principles that can guide skin care for most preterm neonates.”
Bathing
The team identified eight studies of bathing preterm neonates and concluded that a daily bath isn’t necessary.
“Colonization by pathogenic bacterial strains, size of the total bacterial population, and incidence of skin infection do not vary between preterm infants bathed every 2 days and preterm infants bathed every 4 days in all studies,” the authors wrote.
These less frequent baths appear to decrease the risk of temperature variability, and tub baths are preferable to sponge baths. “In sponge bathing, wet skin is more exposed to ambient air, which is typically colder than body temperature. Physiological and behavioral parameters in preterm infants are often disrupted during sponge bathing. In contrast, tub bathing results in less variability in body temperature and warmer temperatures after bathing,” Mr. Kusari and his associates found.
However, premoistened baby wipes appeared beneficial, lowering skin pH, which might help “facilitate acid mantle development, infection control, and barrier repair,” they wrote.
Emollients
Seven studies and one meta-analysis examined the use of emollients in preterm infants; there was agreement that emollients do improve skin condition. Plant-based emollients appeared superior to petrolatum-based products.
“In developing countries where oil massage of infants and children is traditional, there appears to be a clear benefit to massage with some oils. In developed countries, research has emphasized petrolatum-based creams and ointments, whose benefits are tempered by the increased risk of serious infections with some products,” Mr. Kusari and his colleagues wrote.
Sunflower seed oil was particularly beneficial in studies carried out in developing countries. A mixture of 70% lanolin and 30% olive oil proved better than olive oil alone. Coconut oil also displayed positive impact on skin condition.
“In contrast, multiple studies show an increased risk of sepsis with the application of petrolatum ointment to preterm neonates,” they noted.
In one study, following the adoption of a new skin care protocol involving regular application of petrolatum‐based ointments for extremely low-birth-weight neonates, researchers in Texas observed a significant, 200% increase in the incidence of systemic candidiasis. A study in Saudi Arabia replicated this finding. The largest study of a petrolatum-based ointment on premature babies was conducted in Vermont and found a statistically significant increase in infection with coagulase-negative staphylococcus (CoNS). “This ... study appears to be the driving force in a Cochrane Database meta-analysis, which concludes that topical emollients are associated with increased CoNS infection in preterm neonates,” the authors wrote.
Temperature regulation
It’s notoriously tough to maintain core temperature in preterm newborns. Six studies in the meta-analysis tackled this issue using impermeable plastic wraps or garments after birth and semipermeable barriers in the weeks after.
“Plastic wraps or bags can help neonates to retain their body heat, and greater skin coverage with plastic devices appears to be associated with a better outcome. In infants less than 28 weeks’ gestational age, the use of polyethylene occlusive wraps prevents heat loss after delivery and results in higher NICU admission temperatures and a lower incidence of hypothermia,” Mr Kusari and his associates wrote.
Semipermeable wraps can be used for an extended period after birth to reduce transepidermal water loss. Seven studies examined this technique, using both adhesive and nonadhesive polyurethane dressings.
“These studies show that semipermeable adhesive membranes decrease water loss, reduce skin breakdown, and decrease erythema while applied, but may strip superficial skin layers when they are removed, leading to a transient post-removal increase in transepidermal water loss. Furthermore, due to their semipermeable design, application of these adhesive membranes does not appear to decrease fluid requirement or affect electrolyte status in preterm neonates; however, skin barrier function is disrupted following removal of plastic tape, with increased transepidermal water loss at sites of tape removal,” the investigators wrote.
Pectin-based dressings and those containing hydrocolloid or acrylate can damage preterm neonatal skin by inflicting medical adhesive-related skin injury, the team wrote; this can involve epidermal stripping, tension injury, shearing, maceration, folliculitis, or contact dermatitis.
Skin sterilization
There’s little consensus when it comes to sterilization choices for preterm neonatal skin about to undergo a venipuncture or other procedure. Popular methods are povidone-iodine and chlorhexidine, with gestational age affecting choice. Iodine-based antiseptics have been associated with thyroid disruption and chlorhexidine with chemical burns.
“Some studies suggest 0.2% chlorhexidine gluconate may be an attractive alternative to povidone-iodine for the very and extremely preterm,” the authors wrote. One study they examined compared chlorhexidine gluconate 0.2% and 0.5% in extremely preterm infants, showing a significant decrease in skin irritation in the lower-concentration group.
But a randomized trial following this finding, which compared 0.2% chlorhexidine gluconate with 10% aqueous povidone-iodine, found no differences in any infection outcome or skin irritation, but there was more thyroid suppression in the povidone-iodine group.
More research is needed, the team concluded.
Cord care
Tincture of time may be the best alternative here.
The investigators examined a meta-analysis of 21 umbilical cord care studies and found that cleaning the cord with antiseptic prolonged the time to cord separation, compared with simple air drying.
“Interestingly, one study does suggest that one-time cleansing with chlorhexidine reduces neonatal mortality when compared to dry cord care; however, most of the existing evidence suggests that antiseptic treatment does not offer a benefit over dry cord care,” they wrote.
“Further studies, particularly in the very preterm and extremely preterm neonates, with an emphasis placed on subclassifying the preterm patient population based on gestational age, are needed to further examine and validate the real‐world utility of these interventions,” Mr. Kusari and his associates concluded. “In the meantime, it may be useful to establish practice guidelines based on the evidence we have presented here.”
The authors reported no relevant financial disclosures.
SOURCE: Kusari A et al. Pediatr Dermatol. 2018 Dec 12. doi: 10.1111/pde.13725.
The skin of premature infants is very fragile and can take up to 4 weeks to become cornified. Until then, it’s apt to rapidly lose water and heat, putting babies at risk of hypothermia, dehydration, and electrolyte imbalances, Ayan Kusari and his colleagues wrote in Pediatric Dermatology.
The team examined evidence-based skin care in these tiny patients, extracting recommendations from a meta-analysis of 68 studies.
“There are a number of unifying features that distinguish preterm skin from term skin,” wrote Mr. Kusari, a clinical research associate at the Rady Children’s Hospital–San Diego, and his associates. “Preterm skin is thinner, making preterm neonates more susceptible to skin infections and caustic agents. The vernix caseosa is typically thicker in preterm neonates [though thinner in extremely preterm neonates]. Accordingly, there are a number of general principles that can guide skin care for most preterm neonates.”
Bathing
The team identified eight studies of bathing preterm neonates and concluded that a daily bath isn’t necessary.
“Colonization by pathogenic bacterial strains, size of the total bacterial population, and incidence of skin infection do not vary between preterm infants bathed every 2 days and preterm infants bathed every 4 days in all studies,” the authors wrote.
These less frequent baths appear to decrease the risk of temperature variability, and tub baths are preferable to sponge baths. “In sponge bathing, wet skin is more exposed to ambient air, which is typically colder than body temperature. Physiological and behavioral parameters in preterm infants are often disrupted during sponge bathing. In contrast, tub bathing results in less variability in body temperature and warmer temperatures after bathing,” Mr. Kusari and his associates found.
However, premoistened baby wipes appeared beneficial, lowering skin pH, which might help “facilitate acid mantle development, infection control, and barrier repair,” they wrote.
Emollients
Seven studies and one meta-analysis examined the use of emollients in preterm infants; there was agreement that emollients do improve skin condition. Plant-based emollients appeared superior to petrolatum-based products.
“In developing countries where oil massage of infants and children is traditional, there appears to be a clear benefit to massage with some oils. In developed countries, research has emphasized petrolatum-based creams and ointments, whose benefits are tempered by the increased risk of serious infections with some products,” Mr. Kusari and his colleagues wrote.
Sunflower seed oil was particularly beneficial in studies carried out in developing countries. A mixture of 70% lanolin and 30% olive oil proved better than olive oil alone. Coconut oil also displayed positive impact on skin condition.
“In contrast, multiple studies show an increased risk of sepsis with the application of petrolatum ointment to preterm neonates,” they noted.
In one study, following the adoption of a new skin care protocol involving regular application of petrolatum‐based ointments for extremely low-birth-weight neonates, researchers in Texas observed a significant, 200% increase in the incidence of systemic candidiasis. A study in Saudi Arabia replicated this finding. The largest study of a petrolatum-based ointment on premature babies was conducted in Vermont and found a statistically significant increase in infection with coagulase-negative staphylococcus (CoNS). “This ... study appears to be the driving force in a Cochrane Database meta-analysis, which concludes that topical emollients are associated with increased CoNS infection in preterm neonates,” the authors wrote.
Temperature regulation
It’s notoriously tough to maintain core temperature in preterm newborns. Six studies in the meta-analysis tackled this issue using impermeable plastic wraps or garments after birth and semipermeable barriers in the weeks after.
“Plastic wraps or bags can help neonates to retain their body heat, and greater skin coverage with plastic devices appears to be associated with a better outcome. In infants less than 28 weeks’ gestational age, the use of polyethylene occlusive wraps prevents heat loss after delivery and results in higher NICU admission temperatures and a lower incidence of hypothermia,” Mr Kusari and his associates wrote.
Semipermeable wraps can be used for an extended period after birth to reduce transepidermal water loss. Seven studies examined this technique, using both adhesive and nonadhesive polyurethane dressings.
“These studies show that semipermeable adhesive membranes decrease water loss, reduce skin breakdown, and decrease erythema while applied, but may strip superficial skin layers when they are removed, leading to a transient post-removal increase in transepidermal water loss. Furthermore, due to their semipermeable design, application of these adhesive membranes does not appear to decrease fluid requirement or affect electrolyte status in preterm neonates; however, skin barrier function is disrupted following removal of plastic tape, with increased transepidermal water loss at sites of tape removal,” the investigators wrote.
Pectin-based dressings and those containing hydrocolloid or acrylate can damage preterm neonatal skin by inflicting medical adhesive-related skin injury, the team wrote; this can involve epidermal stripping, tension injury, shearing, maceration, folliculitis, or contact dermatitis.
Skin sterilization
There’s little consensus when it comes to sterilization choices for preterm neonatal skin about to undergo a venipuncture or other procedure. Popular methods are povidone-iodine and chlorhexidine, with gestational age affecting choice. Iodine-based antiseptics have been associated with thyroid disruption and chlorhexidine with chemical burns.
“Some studies suggest 0.2% chlorhexidine gluconate may be an attractive alternative to povidone-iodine for the very and extremely preterm,” the authors wrote. One study they examined compared chlorhexidine gluconate 0.2% and 0.5% in extremely preterm infants, showing a significant decrease in skin irritation in the lower-concentration group.
But a randomized trial following this finding, which compared 0.2% chlorhexidine gluconate with 10% aqueous povidone-iodine, found no differences in any infection outcome or skin irritation, but there was more thyroid suppression in the povidone-iodine group.
More research is needed, the team concluded.
Cord care
Tincture of time may be the best alternative here.
The investigators examined a meta-analysis of 21 umbilical cord care studies and found that cleaning the cord with antiseptic prolonged the time to cord separation, compared with simple air drying.
“Interestingly, one study does suggest that one-time cleansing with chlorhexidine reduces neonatal mortality when compared to dry cord care; however, most of the existing evidence suggests that antiseptic treatment does not offer a benefit over dry cord care,” they wrote.
“Further studies, particularly in the very preterm and extremely preterm neonates, with an emphasis placed on subclassifying the preterm patient population based on gestational age, are needed to further examine and validate the real‐world utility of these interventions,” Mr. Kusari and his associates concluded. “In the meantime, it may be useful to establish practice guidelines based on the evidence we have presented here.”
The authors reported no relevant financial disclosures.
SOURCE: Kusari A et al. Pediatr Dermatol. 2018 Dec 12. doi: 10.1111/pde.13725.
The skin of premature infants is very fragile and can take up to 4 weeks to become cornified. Until then, it’s apt to rapidly lose water and heat, putting babies at risk of hypothermia, dehydration, and electrolyte imbalances, Ayan Kusari and his colleagues wrote in Pediatric Dermatology.
The team examined evidence-based skin care in these tiny patients, extracting recommendations from a meta-analysis of 68 studies.
“There are a number of unifying features that distinguish preterm skin from term skin,” wrote Mr. Kusari, a clinical research associate at the Rady Children’s Hospital–San Diego, and his associates. “Preterm skin is thinner, making preterm neonates more susceptible to skin infections and caustic agents. The vernix caseosa is typically thicker in preterm neonates [though thinner in extremely preterm neonates]. Accordingly, there are a number of general principles that can guide skin care for most preterm neonates.”
Bathing
The team identified eight studies of bathing preterm neonates and concluded that a daily bath isn’t necessary.
“Colonization by pathogenic bacterial strains, size of the total bacterial population, and incidence of skin infection do not vary between preterm infants bathed every 2 days and preterm infants bathed every 4 days in all studies,” the authors wrote.
These less frequent baths appear to decrease the risk of temperature variability, and tub baths are preferable to sponge baths. “In sponge bathing, wet skin is more exposed to ambient air, which is typically colder than body temperature. Physiological and behavioral parameters in preterm infants are often disrupted during sponge bathing. In contrast, tub bathing results in less variability in body temperature and warmer temperatures after bathing,” Mr. Kusari and his associates found.
However, premoistened baby wipes appeared beneficial, lowering skin pH, which might help “facilitate acid mantle development, infection control, and barrier repair,” they wrote.
Emollients
Seven studies and one meta-analysis examined the use of emollients in preterm infants; there was agreement that emollients do improve skin condition. Plant-based emollients appeared superior to petrolatum-based products.
“In developing countries where oil massage of infants and children is traditional, there appears to be a clear benefit to massage with some oils. In developed countries, research has emphasized petrolatum-based creams and ointments, whose benefits are tempered by the increased risk of serious infections with some products,” Mr. Kusari and his colleagues wrote.
Sunflower seed oil was particularly beneficial in studies carried out in developing countries. A mixture of 70% lanolin and 30% olive oil proved better than olive oil alone. Coconut oil also displayed positive impact on skin condition.
“In contrast, multiple studies show an increased risk of sepsis with the application of petrolatum ointment to preterm neonates,” they noted.
In one study, following the adoption of a new skin care protocol involving regular application of petrolatum‐based ointments for extremely low-birth-weight neonates, researchers in Texas observed a significant, 200% increase in the incidence of systemic candidiasis. A study in Saudi Arabia replicated this finding. The largest study of a petrolatum-based ointment on premature babies was conducted in Vermont and found a statistically significant increase in infection with coagulase-negative staphylococcus (CoNS). “This ... study appears to be the driving force in a Cochrane Database meta-analysis, which concludes that topical emollients are associated with increased CoNS infection in preterm neonates,” the authors wrote.
Temperature regulation
It’s notoriously tough to maintain core temperature in preterm newborns. Six studies in the meta-analysis tackled this issue using impermeable plastic wraps or garments after birth and semipermeable barriers in the weeks after.
“Plastic wraps or bags can help neonates to retain their body heat, and greater skin coverage with plastic devices appears to be associated with a better outcome. In infants less than 28 weeks’ gestational age, the use of polyethylene occlusive wraps prevents heat loss after delivery and results in higher NICU admission temperatures and a lower incidence of hypothermia,” Mr Kusari and his associates wrote.
Semipermeable wraps can be used for an extended period after birth to reduce transepidermal water loss. Seven studies examined this technique, using both adhesive and nonadhesive polyurethane dressings.
“These studies show that semipermeable adhesive membranes decrease water loss, reduce skin breakdown, and decrease erythema while applied, but may strip superficial skin layers when they are removed, leading to a transient post-removal increase in transepidermal water loss. Furthermore, due to their semipermeable design, application of these adhesive membranes does not appear to decrease fluid requirement or affect electrolyte status in preterm neonates; however, skin barrier function is disrupted following removal of plastic tape, with increased transepidermal water loss at sites of tape removal,” the investigators wrote.
Pectin-based dressings and those containing hydrocolloid or acrylate can damage preterm neonatal skin by inflicting medical adhesive-related skin injury, the team wrote; this can involve epidermal stripping, tension injury, shearing, maceration, folliculitis, or contact dermatitis.
Skin sterilization
There’s little consensus when it comes to sterilization choices for preterm neonatal skin about to undergo a venipuncture or other procedure. Popular methods are povidone-iodine and chlorhexidine, with gestational age affecting choice. Iodine-based antiseptics have been associated with thyroid disruption and chlorhexidine with chemical burns.
“Some studies suggest 0.2% chlorhexidine gluconate may be an attractive alternative to povidone-iodine for the very and extremely preterm,” the authors wrote. One study they examined compared chlorhexidine gluconate 0.2% and 0.5% in extremely preterm infants, showing a significant decrease in skin irritation in the lower-concentration group.
But a randomized trial following this finding, which compared 0.2% chlorhexidine gluconate with 10% aqueous povidone-iodine, found no differences in any infection outcome or skin irritation, but there was more thyroid suppression in the povidone-iodine group.
More research is needed, the team concluded.
Cord care
Tincture of time may be the best alternative here.
The investigators examined a meta-analysis of 21 umbilical cord care studies and found that cleaning the cord with antiseptic prolonged the time to cord separation, compared with simple air drying.
“Interestingly, one study does suggest that one-time cleansing with chlorhexidine reduces neonatal mortality when compared to dry cord care; however, most of the existing evidence suggests that antiseptic treatment does not offer a benefit over dry cord care,” they wrote.
“Further studies, particularly in the very preterm and extremely preterm neonates, with an emphasis placed on subclassifying the preterm patient population based on gestational age, are needed to further examine and validate the real‐world utility of these interventions,” Mr. Kusari and his associates concluded. “In the meantime, it may be useful to establish practice guidelines based on the evidence we have presented here.”
The authors reported no relevant financial disclosures.
SOURCE: Kusari A et al. Pediatr Dermatol. 2018 Dec 12. doi: 10.1111/pde.13725.
FROM PEDIATRIC DERMATOLOGY
Key clinical point: Limiting baths, using plant-based emollients, and using plastic wraps benefit preterm neonates’ skin early in life.
Major finding: The team identified eight studies of bathing preterm neonates and concluded that a daily bath isn’t necessary.
Study details: A meta-analysis of 68 studies.
Disclosures: The authors reported no relevant financial disclosures.
Source: Kusari A et al. Pediatr Dermatol. 2018 Dec 12. doi: 10.1111/pde.13725.
AAP infantile hemangioma guideline should empower primary care clinicians
given the dramatic increase in information available over the past decade. 
The aim in providing an evidence-based approach to evaluating, triaging, and managing IH cases is to arm primary care providers with the confidence needed to successfully treat high-risk cases, reported Daniel P. Krowchuk, MD, of the department of pediatrics and dermatology, Wake Forest University, Winston-Salem, N.C., and his associates who are members of the AAP subcommittee on the management of IHs.
With an occurrence rate of 4%-5%, IHs are the most common benign tumor presenting in childhood, especially occurring in girls, twins, preterm or low-birth-weight infants, and white neonates.
The AAP’s guideline “provides a framework for clinical decision-making” – it should not be considered a sole source of guidance. It also should not be used to replace clinical judgment or as a protocol for managing all patients with IHs, explained Dr. Krowchuk and his associates.
Clinicians, especially, are encouraged to consult promptly with a hemangioma specialist if they are not experienced in managing IHs.
According to one study cited by the authors, the mean age of examination by a dermatologist is 5 months, when most growth has already been completed. Lesions are first noticed, on average, at 2 weeks; 4 weeks has been recommended as the ideal time for professional consultation. It is important for clinicians to recognize the difficulty families are likely to face in obtaining an appointment, which makes caregiver and clinician advocacy on behalf of infants affected critical, urged Dr. Krowchuk and his colleagues. In cases or locations where hemangioma specialists are in short supply, telemedicine triage or photographic consultation is especially helpful.
Dr. Krowchuk and his associates noted several possible challenges in implementing this clinical practice guideline (CPG) published in Pediatrics. The growth of individual IHs is difficult to predict, especially in young infants, and there are no markers or imaging studies to correct this challenge. For this reason, they advised: “Prompt evaluation, either in-person or via photographs, is warranted for any infant reported by parents to have a changing birthmark during the first 2 months of life.”
Wide heterogeneity in terms of size, location, patterns, of distribution, and depth, when coupled with unpredictable growth, makes management of IHs unpredictable. Thus, there can be no one-size-fits-all treatment approach.
Further complicating implementation of the CPG is the long-held myth that IHs are benign and resolve spontaneously. While this may accurately describe the vast majority of outcomes, “ample evidence” demonstrates what can happen when family and/or caregivers yield to such “false reassurance.” According to Dr. Krowchuk and his associates, hemangioma specialists have seen their share of “examples of lost opportunities to intervene and prevent poor outcomes because of lack of or delayed referral.”
The paucity of data on high-risk cases in primary care and referral care settings should be the subject of future research, the authors noted. Scorings systems, such as the Hemangioma Severity Score, are growing in popularity as a triage tool, but more research is needed to demonstrate that primary care physicians are accurately interpreting findings and that high-risk cases are accurately identified to avoid over-referral to specialists.
Dr. Krowchuk and his colleagues did call attention to important evidence gaps that may be answered by research currently underway, or that may require further research in the future by asking the following questions: How safe is treatment with topical timolol in early infancy, and what proportion of patients can be observed without referral? For healthy infants 5 weeks or older, to what extent, if any, is cardiovascular monitoring for propranolol necessary? How should pediatricians be involved in beta-blocker management of infants and when should specialty reevaluation be made? What is the accuracy of primary care identification of high-risk IH cases using many of the parameters offered within this CPG? Are pediatric trainees being sufficiently trained in stratifying and managing IH risk?
One noteworthy barrier to improved management and outcomes noted by the authors is the “imprecision of current diagnostic codes.” At present, the existing coding in the International Classification of Diseases, 10th Revision does not include specific reference to IH but rather describes “hemangioma of the skin and subcutaneous tissues” and can include congenital as well as verrucous hemangioma. The codes also do not address the details characteristic of IHs or the higher risk aspects of IH, such as location or multifocality. Advocacy, in this instance, would be appropriate, advised Dr. Krowchuk and his associates.
In an interview, Dr. Krowchuk provided additional insight into what sets the AAP’s CPG apart from consensus statements published previously by European and Australasian expert groups. Although these might appear to be similar documents with analogous content at first glance, there are important differences, he said.
The consensus statements were based on expert opinion, while “the academy’s CPG was founded on an extensive review of the medical literature (1982-2017) regarding the potential benefits and harms of diagnostic modalities and pharmacologic and surgical treatments,” Dr. Krowchuk explained. The information that came out of this extensive review is what members of the subcommittee used to develop key action statements that pediatricians can use to evaluate and manage infants with IHs.
“The scope of the consensus statements was more limited, focusing primarily on the treatment of IH with propranolol. While the benefits of propranolol, its use and dosing, and potential adverse effects were addressed in depth in the academy’s CPG, the document went well beyond this,” he clarified.
The AAP also previously published a clinical report that provides a comprehensive evaluation of the pathogenesis, clinical features, and treatment of IH (Pediatrics. 2015 Oct. doi: 10.1542/peds.2015-2485).
There was no external funding for the CPG, and the authors said there were no potential conflicts of interest. Ilona J. Frieden, MD, is a member of the data monitoring safety board for Pfizer and the scientific advisory board for Venthera/Bridge Bio; Anthony J. Mancini, MD, said he has advisory board relationships with Verrica, Valeant, and Pfizer.
SOURCE: Krowchuk, DP et al. Pediatrics 2019;143(1):e20183475.
given the dramatic increase in information available over the past decade.
The aim in providing an evidence-based approach to evaluating, triaging, and managing IH cases is to arm primary care providers with the confidence needed to successfully treat high-risk cases, reported Daniel P. Krowchuk, MD, of the department of pediatrics and dermatology, Wake Forest University, Winston-Salem, N.C., and his associates who are members of the AAP subcommittee on the management of IHs.
With an occurrence rate of 4%-5%, IHs are the most common benign tumor presenting in childhood, especially occurring in girls, twins, preterm or low-birth-weight infants, and white neonates.
The AAP’s guideline “provides a framework for clinical decision-making” – it should not be considered a sole source of guidance. It also should not be used to replace clinical judgment or as a protocol for managing all patients with IHs, explained Dr. Krowchuk and his associates.
Clinicians, especially, are encouraged to consult promptly with a hemangioma specialist if they are not experienced in managing IHs.
According to one study cited by the authors, the mean age of examination by a dermatologist is 5 months, when most growth has already been completed. Lesions are first noticed, on average, at 2 weeks; 4 weeks has been recommended as the ideal time for professional consultation. It is important for clinicians to recognize the difficulty families are likely to face in obtaining an appointment, which makes caregiver and clinician advocacy on behalf of infants affected critical, urged Dr. Krowchuk and his colleagues. In cases or locations where hemangioma specialists are in short supply, telemedicine triage or photographic consultation is especially helpful.
Dr. Krowchuk and his associates noted several possible challenges in implementing this clinical practice guideline (CPG) published in Pediatrics. The growth of individual IHs is difficult to predict, especially in young infants, and there are no markers or imaging studies to correct this challenge. For this reason, they advised: “Prompt evaluation, either in-person or via photographs, is warranted for any infant reported by parents to have a changing birthmark during the first 2 months of life.”
Wide heterogeneity in terms of size, location, patterns, of distribution, and depth, when coupled with unpredictable growth, makes management of IHs unpredictable. Thus, there can be no one-size-fits-all treatment approach.
Further complicating implementation of the CPG is the long-held myth that IHs are benign and resolve spontaneously. While this may accurately describe the vast majority of outcomes, “ample evidence” demonstrates what can happen when family and/or caregivers yield to such “false reassurance.” According to Dr. Krowchuk and his associates, hemangioma specialists have seen their share of “examples of lost opportunities to intervene and prevent poor outcomes because of lack of or delayed referral.”
The paucity of data on high-risk cases in primary care and referral care settings should be the subject of future research, the authors noted. Scorings systems, such as the Hemangioma Severity Score, are growing in popularity as a triage tool, but more research is needed to demonstrate that primary care physicians are accurately interpreting findings and that high-risk cases are accurately identified to avoid over-referral to specialists.
Dr. Krowchuk and his colleagues did call attention to important evidence gaps that may be answered by research currently underway, or that may require further research in the future by asking the following questions: How safe is treatment with topical timolol in early infancy, and what proportion of patients can be observed without referral? For healthy infants 5 weeks or older, to what extent, if any, is cardiovascular monitoring for propranolol necessary? How should pediatricians be involved in beta-blocker management of infants and when should specialty reevaluation be made? What is the accuracy of primary care identification of high-risk IH cases using many of the parameters offered within this CPG? Are pediatric trainees being sufficiently trained in stratifying and managing IH risk?
One noteworthy barrier to improved management and outcomes noted by the authors is the “imprecision of current diagnostic codes.” At present, the existing coding in the International Classification of Diseases, 10th Revision does not include specific reference to IH but rather describes “hemangioma of the skin and subcutaneous tissues” and can include congenital as well as verrucous hemangioma. The codes also do not address the details characteristic of IHs or the higher risk aspects of IH, such as location or multifocality. Advocacy, in this instance, would be appropriate, advised Dr. Krowchuk and his associates.
In an interview, Dr. Krowchuk provided additional insight into what sets the AAP’s CPG apart from consensus statements published previously by European and Australasian expert groups. Although these might appear to be similar documents with analogous content at first glance, there are important differences, he said.
The consensus statements were based on expert opinion, while “the academy’s CPG was founded on an extensive review of the medical literature (1982-2017) regarding the potential benefits and harms of diagnostic modalities and pharmacologic and surgical treatments,” Dr. Krowchuk explained. The information that came out of this extensive review is what members of the subcommittee used to develop key action statements that pediatricians can use to evaluate and manage infants with IHs.
“The scope of the consensus statements was more limited, focusing primarily on the treatment of IH with propranolol. While the benefits of propranolol, its use and dosing, and potential adverse effects were addressed in depth in the academy’s CPG, the document went well beyond this,” he clarified.
The AAP also previously published a clinical report that provides a comprehensive evaluation of the pathogenesis, clinical features, and treatment of IH (Pediatrics. 2015 Oct. doi: 10.1542/peds.2015-2485).
There was no external funding for the CPG, and the authors said there were no potential conflicts of interest. Ilona J. Frieden, MD, is a member of the data monitoring safety board for Pfizer and the scientific advisory board for Venthera/Bridge Bio; Anthony J. Mancini, MD, said he has advisory board relationships with Verrica, Valeant, and Pfizer.
SOURCE: Krowchuk, DP et al. Pediatrics 2019;143(1):e20183475.
given the dramatic increase in information available over the past decade.
The aim in providing an evidence-based approach to evaluating, triaging, and managing IH cases is to arm primary care providers with the confidence needed to successfully treat high-risk cases, reported Daniel P. Krowchuk, MD, of the department of pediatrics and dermatology, Wake Forest University, Winston-Salem, N.C., and his associates who are members of the AAP subcommittee on the management of IHs.
With an occurrence rate of 4%-5%, IHs are the most common benign tumor presenting in childhood, especially occurring in girls, twins, preterm or low-birth-weight infants, and white neonates.
The AAP’s guideline “provides a framework for clinical decision-making” – it should not be considered a sole source of guidance. It also should not be used to replace clinical judgment or as a protocol for managing all patients with IHs, explained Dr. Krowchuk and his associates.
Clinicians, especially, are encouraged to consult promptly with a hemangioma specialist if they are not experienced in managing IHs.
According to one study cited by the authors, the mean age of examination by a dermatologist is 5 months, when most growth has already been completed. Lesions are first noticed, on average, at 2 weeks; 4 weeks has been recommended as the ideal time for professional consultation. It is important for clinicians to recognize the difficulty families are likely to face in obtaining an appointment, which makes caregiver and clinician advocacy on behalf of infants affected critical, urged Dr. Krowchuk and his colleagues. In cases or locations where hemangioma specialists are in short supply, telemedicine triage or photographic consultation is especially helpful.
Dr. Krowchuk and his associates noted several possible challenges in implementing this clinical practice guideline (CPG) published in Pediatrics. The growth of individual IHs is difficult to predict, especially in young infants, and there are no markers or imaging studies to correct this challenge. For this reason, they advised: “Prompt evaluation, either in-person or via photographs, is warranted for any infant reported by parents to have a changing birthmark during the first 2 months of life.”
Wide heterogeneity in terms of size, location, patterns, of distribution, and depth, when coupled with unpredictable growth, makes management of IHs unpredictable. Thus, there can be no one-size-fits-all treatment approach.
Further complicating implementation of the CPG is the long-held myth that IHs are benign and resolve spontaneously. While this may accurately describe the vast majority of outcomes, “ample evidence” demonstrates what can happen when family and/or caregivers yield to such “false reassurance.” According to Dr. Krowchuk and his associates, hemangioma specialists have seen their share of “examples of lost opportunities to intervene and prevent poor outcomes because of lack of or delayed referral.”
The paucity of data on high-risk cases in primary care and referral care settings should be the subject of future research, the authors noted. Scorings systems, such as the Hemangioma Severity Score, are growing in popularity as a triage tool, but more research is needed to demonstrate that primary care physicians are accurately interpreting findings and that high-risk cases are accurately identified to avoid over-referral to specialists.
Dr. Krowchuk and his colleagues did call attention to important evidence gaps that may be answered by research currently underway, or that may require further research in the future by asking the following questions: How safe is treatment with topical timolol in early infancy, and what proportion of patients can be observed without referral? For healthy infants 5 weeks or older, to what extent, if any, is cardiovascular monitoring for propranolol necessary? How should pediatricians be involved in beta-blocker management of infants and when should specialty reevaluation be made? What is the accuracy of primary care identification of high-risk IH cases using many of the parameters offered within this CPG? Are pediatric trainees being sufficiently trained in stratifying and managing IH risk?
One noteworthy barrier to improved management and outcomes noted by the authors is the “imprecision of current diagnostic codes.” At present, the existing coding in the International Classification of Diseases, 10th Revision does not include specific reference to IH but rather describes “hemangioma of the skin and subcutaneous tissues” and can include congenital as well as verrucous hemangioma. The codes also do not address the details characteristic of IHs or the higher risk aspects of IH, such as location or multifocality. Advocacy, in this instance, would be appropriate, advised Dr. Krowchuk and his associates.
In an interview, Dr. Krowchuk provided additional insight into what sets the AAP’s CPG apart from consensus statements published previously by European and Australasian expert groups. Although these might appear to be similar documents with analogous content at first glance, there are important differences, he said.
The consensus statements were based on expert opinion, while “the academy’s CPG was founded on an extensive review of the medical literature (1982-2017) regarding the potential benefits and harms of diagnostic modalities and pharmacologic and surgical treatments,” Dr. Krowchuk explained. The information that came out of this extensive review is what members of the subcommittee used to develop key action statements that pediatricians can use to evaluate and manage infants with IHs.
“The scope of the consensus statements was more limited, focusing primarily on the treatment of IH with propranolol. While the benefits of propranolol, its use and dosing, and potential adverse effects were addressed in depth in the academy’s CPG, the document went well beyond this,” he clarified.
The AAP also previously published a clinical report that provides a comprehensive evaluation of the pathogenesis, clinical features, and treatment of IH (Pediatrics. 2015 Oct. doi: 10.1542/peds.2015-2485).
There was no external funding for the CPG, and the authors said there were no potential conflicts of interest. Ilona J. Frieden, MD, is a member of the data monitoring safety board for Pfizer and the scientific advisory board for Venthera/Bridge Bio; Anthony J. Mancini, MD, said he has advisory board relationships with Verrica, Valeant, and Pfizer.
SOURCE: Krowchuk, DP et al. Pediatrics 2019;143(1):e20183475.
FROM PEDIATRICS
Dissuading parents from using corporal punishment
The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.
One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.
Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.
We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.
Corporal punishment effects
“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.
We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.
Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4
Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.
Specific strategies
We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.
Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).
Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!
The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.
References
1. Pediatrics. 2018 Dec 1;142[6]: e20183112.
2. J Youth Adolesc. 2015 Mar;44(3):658-69.
3. Child Abuse Negl. 2017 Sep;71:24-31.
4. Neuroimage. 2009 Aug;47 Suppl 2:T66-71.
The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.
One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.
Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.
We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.
Corporal punishment effects
“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.
We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.
Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4
Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.
Specific strategies
We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.
Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).
Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!
The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.
References
1. Pediatrics. 2018 Dec 1;142[6]: e20183112.
2. J Youth Adolesc. 2015 Mar;44(3):658-69.
3. Child Abuse Negl. 2017 Sep;71:24-31.
4. Neuroimage. 2009 Aug;47 Suppl 2:T66-71.
The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.
One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.
Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.
We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.
Corporal punishment effects
“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.
We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.
Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4
Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.
Specific strategies
We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.
Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).
Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!
The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.
References
1. Pediatrics. 2018 Dec 1;142[6]: e20183112.
2. J Youth Adolesc. 2015 Mar;44(3):658-69.
3. Child Abuse Negl. 2017 Sep;71:24-31.
4. Neuroimage. 2009 Aug;47 Suppl 2:T66-71.