Pediatrics

CHICAGO – Rituximab demonstrated a high degree of effectiveness with no safety surprises in the first-ever major clinical trial of the potent B-cell inhibitor conducted in pediatric patients with newly diagnosed or relapsing granulomatosis with polyangiitis or microscopic polyangiitis, Jennifer Cooper, MD, PharmD, said at the annual meeting of the American College of Rheumatology.

Bruce Jancin/MDedge News

“This is exciting news. We know that rituximab is very effective in treating adults with GPA and MPA, both in terms of inducing remission and even for maintenance therapy for this rare and severe disease. A lot of pediatric rheumatologists would like to have access to rituximab. Some are even using it for this condition. But until now there were no data in children. I hope this study improves access to rituximab for pediatric patients with ANCA-associated vasculitis,” said Dr. Cooper, a pediatric rheumatologist at the University of Colorado, Denver.

She presented the results of the PePRS (Pediatric Polyangiitis and Rituximab Study), a phase 2a, single-arm, open-label, long-term study of 25 patients in six countries. She anticipates the results will be practice changing, given that pediatric GPA and MPA are recognized as severe systemic autoimmune disorders with a high unmet need for new therapies.

“I don’t believe there are plans for a randomized, controlled trial. Since we now have the pharmacokinetic and safety data in children, we’ll hopefully be able to use extrapolation and our exploratory efficacy endpoints to gain a pediatric indication, or at least a label update for these patients based on this study,” Dr. Cooper continued.


A total of 19 patients had GPA and 6 had MPA, with a median disease duration of 6 months at study entry. All received three pulsed doses of methylprednisolone during the screening period. Then for induction remission they got four once-weekly intravenous infusions of rituximab (Rituxan) at 375 mg/m² as well as oral corticosteroids, which were tapered from 1 mg/kg per day to 0.2 mg/kg per day over the course of the first 6 months. After that, two-thirds of patients received additional rituximab at their provider’s discretion.

The remission rate by 6 months as defined by Pediatric Vasculitis Activity Score (PVAS) criteria was 56%. At 12 months, the rate was 92%, and at 18 months the rate of remission and sustained disease control was 100%. The mean and median durations of remission were 72 and 56 weeks, respectively.

These results in pediatric patients are comparable to those seen in adults in the landmark RAVE (Rituximab in ANCA-Associated Vasculitis) trial (N Engl J Med. 2013 Aug 1;369[5]:417-27), where 64% of patients reached remission at 6 months, Dr. Cooper noted.

All 25 patients were able to tolerate the four rituximab infusions for remission induction. The main side effect was infusion-related reactions. Overall, 32% of patients experienced such reactions in response to their first infusion, 20% with the second, 12% with the third, and only 8% with the fourth.

Eight patients withdrew from the study after 18 months, mostly because of transfer to adult care. The remaining participants were followed for as long as 4.5 years.

F. Hoffmann-La Roche and Genentech sponsored the PePRS study. Dr. Cooper was a Genentech clinical research fellow at the time.

bjancin@mdedge.com

SOURCE: Brogan P at al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract L04.

CHICAGO – Rituximab demonstrated a high degree of effectiveness with no safety surprises in the first-ever major clinical trial of the potent B-cell inhibitor conducted in pediatric patients with newly diagnosed or relapsing granulomatosis with polyangiitis or microscopic polyangiitis, Jennifer Cooper, MD, PharmD, said at the annual meeting of the American College of Rheumatology.

Bruce Jancin/MDedge News

“This is exciting news. We know that rituximab is very effective in treating adults with GPA and MPA, both in terms of inducing remission and even for maintenance therapy for this rare and severe disease. A lot of pediatric rheumatologists would like to have access to rituximab. Some are even using it for this condition. But until now there were no data in children. I hope this study improves access to rituximab for pediatric patients with ANCA-associated vasculitis,” said Dr. Cooper, a pediatric rheumatologist at the University of Colorado, Denver.

She presented the results of the PePRS (Pediatric Polyangiitis and Rituximab Study), a phase 2a, single-arm, open-label, long-term study of 25 patients in six countries. She anticipates the results will be practice changing, given that pediatric GPA and MPA are recognized as severe systemic autoimmune disorders with a high unmet need for new therapies.

“I don’t believe there are plans for a randomized, controlled trial. Since we now have the pharmacokinetic and safety data in children, we’ll hopefully be able to use extrapolation and our exploratory efficacy endpoints to gain a pediatric indication, or at least a label update for these patients based on this study,” Dr. Cooper continued.


A total of 19 patients had GPA and 6 had MPA, with a median disease duration of 6 months at study entry. All received three pulsed doses of methylprednisolone during the screening period. Then for induction remission they got four once-weekly intravenous infusions of rituximab (Rituxan) at 375 mg/m² as well as oral corticosteroids, which were tapered from 1 mg/kg per day to 0.2 mg/kg per day over the course of the first 6 months. After that, two-thirds of patients received additional rituximab at their provider’s discretion.

The remission rate by 6 months as defined by Pediatric Vasculitis Activity Score (PVAS) criteria was 56%. At 12 months, the rate was 92%, and at 18 months the rate of remission and sustained disease control was 100%. The mean and median durations of remission were 72 and 56 weeks, respectively.

These results in pediatric patients are comparable to those seen in adults in the landmark RAVE (Rituximab in ANCA-Associated Vasculitis) trial (N Engl J Med. 2013 Aug 1;369[5]:417-27), where 64% of patients reached remission at 6 months, Dr. Cooper noted.

All 25 patients were able to tolerate the four rituximab infusions for remission induction. The main side effect was infusion-related reactions. Overall, 32% of patients experienced such reactions in response to their first infusion, 20% with the second, 12% with the third, and only 8% with the fourth.

Eight patients withdrew from the study after 18 months, mostly because of transfer to adult care. The remaining participants were followed for as long as 4.5 years.

F. Hoffmann-La Roche and Genentech sponsored the PePRS study. Dr. Cooper was a Genentech clinical research fellow at the time.

bjancin@mdedge.com

SOURCE: Brogan P at al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract L04.

CHICAGO – Rituximab demonstrated a high degree of effectiveness with no safety surprises in the first-ever major clinical trial of the potent B-cell inhibitor conducted in pediatric patients with newly diagnosed or relapsing granulomatosis with polyangiitis or microscopic polyangiitis, Jennifer Cooper, MD, PharmD, said at the annual meeting of the American College of Rheumatology.

Bruce Jancin/MDedge News

“This is exciting news. We know that rituximab is very effective in treating adults with GPA and MPA, both in terms of inducing remission and even for maintenance therapy for this rare and severe disease. A lot of pediatric rheumatologists would like to have access to rituximab. Some are even using it for this condition. But until now there were no data in children. I hope this study improves access to rituximab for pediatric patients with ANCA-associated vasculitis,” said Dr. Cooper, a pediatric rheumatologist at the University of Colorado, Denver.

She presented the results of the PePRS (Pediatric Polyangiitis and Rituximab Study), a phase 2a, single-arm, open-label, long-term study of 25 patients in six countries. She anticipates the results will be practice changing, given that pediatric GPA and MPA are recognized as severe systemic autoimmune disorders with a high unmet need for new therapies.

“I don’t believe there are plans for a randomized, controlled trial. Since we now have the pharmacokinetic and safety data in children, we’ll hopefully be able to use extrapolation and our exploratory efficacy endpoints to gain a pediatric indication, or at least a label update for these patients based on this study,” Dr. Cooper continued.


A total of 19 patients had GPA and 6 had MPA, with a median disease duration of 6 months at study entry. All received three pulsed doses of methylprednisolone during the screening period. Then for induction remission they got four once-weekly intravenous infusions of rituximab (Rituxan) at 375 mg/m² as well as oral corticosteroids, which were tapered from 1 mg/kg per day to 0.2 mg/kg per day over the course of the first 6 months. After that, two-thirds of patients received additional rituximab at their provider’s discretion.

The remission rate by 6 months as defined by Pediatric Vasculitis Activity Score (PVAS) criteria was 56%. At 12 months, the rate was 92%, and at 18 months the rate of remission and sustained disease control was 100%. The mean and median durations of remission were 72 and 56 weeks, respectively.

These results in pediatric patients are comparable to those seen in adults in the landmark RAVE (Rituximab in ANCA-Associated Vasculitis) trial (N Engl J Med. 2013 Aug 1;369[5]:417-27), where 64% of patients reached remission at 6 months, Dr. Cooper noted.

All 25 patients were able to tolerate the four rituximab infusions for remission induction. The main side effect was infusion-related reactions. Overall, 32% of patients experienced such reactions in response to their first infusion, 20% with the second, 12% with the third, and only 8% with the fourth.

Eight patients withdrew from the study after 18 months, mostly because of transfer to adult care. The remaining participants were followed for as long as 4.5 years.

F. Hoffmann-La Roche and Genentech sponsored the PePRS study. Dr. Cooper was a Genentech clinical research fellow at the time.

bjancin@mdedge.com

SOURCE: Brogan P at al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract L04.

ORLANDO – “Expect the unexpected” when considering the health impacts of climate change on children, Susan Pacheo, MD, advised in her presentation at the annual meeting of the American Academy of Pediatrics.

Jeff Craven/MDedge News

“We don’t know what we’re going to see, and we need to be ready,” said Dr. Pacheo of the University of Texas, Houston.

Climate change is categorized by an increase in droughts, fires, storms, floods, mudslides, and extreme temperatures. According to the Centers for Disease Control and Prevention, the impacts of climate change on human health are multiple, but can include an increased rate of infectious disease, respiratory conditions, injury, cardiovascular-related health issues, malnutrition, and mental health problems.

These problems can especially target children, Dr. Pacheo noted. “Kids are vulnerable. You’ve heard this, you’ve experienced this, you see this every day in your pediatric population.”

Children are more vulnerable because of the increased exposure they have to the environment. They spend more time outdoors, they are closer to the ground, and they are likely to put objects in their mouth. Children also tend to swallow more water when swimming, compared with adults. A 2014 study by de Man et al. found that children exposed to storm sewers and combined sewers swallowed 1.7 mL of water per exposure event and that the risk of infection from pathogens such as noroviruses, enteroviruses, Campylobacter jejuni, Cryptosporidium, and Giardia was 23%-33% per event, compared with 0.016 mL of water per exposure in adults and a mean infection risk of 0.58%-3.90% per event (Water Research. 2014 Jan 1. doi: 10.1016/j.watres.2013.09.022).

In addition, socioeconomic status and built environment as well as a child’s immature lung development and higher respiratory rate can lead to children being impacted by factors such as air pollution. Poverty, access to medical care, and the structure and dynamics of family also can affect children.

“We need to do something because this is a problem of social justice and we, as pediatricians, are advocates of the vulnerable,” Dr. Pacheo said.

Cade Martin, Dawn Arlotta, USCDC

Expect to see an increase in the number of vector-borne, airborne, and pollution-related disease, as well as water- and food-borne diseases, as a result of climate change, in addition to other issues such as hand, foot, and mouth disease and antibiotic resistance, she noted. As historically colder parts of the world continue to have milder winters, disease-carrying insects such as ticks and mosquitoes will expand their habitats and transmission of diseases such as Zika virus, malaria, dengue fever, and chikungunya will increase.

Leptospirosis and Naegleria fowleri, the latter which can cause primary amebic meningoencephalitis, are also becoming more common. Food-borne illnesses like vibriosis are being seen in more northern areas of the world like Alaska, and ciguatera fish poisoning is expected to be more prevalent in the southeastern United States and Gulf of Mexico, Dr. Pacheo said.

Air pollution carries a risk of respiratory diseases, pneumonia, and bronchiolitis, with a 2017 systematic review by Nhung et al. finding increased exposure to ambient air pollution markers such as sulfur dioxide, ozone, nitrogen dioxide, and carbon monoxide was associated with pneumonia in children (Environ Pollut. 2017 Jul 25. doi: 10.1016/j.envpol.2017.07.063). Coccidioidomycosis, or valley fever, is caused by inhaling a fungus in the soil and is associated with dust storms primarily in the southwestern United States. Warmer temperatures also have caused toxic algae blooms that have killed marine life and caused respiratory distress; children should not go near or play in water when algae blooms are growing, she noted.

Recent studies have linked an increase in temperature with incidence of Escherichia coli, with a 2016 study by Philipsborn et al. showing a 1° Celsius increase in mean monthly temperature was associated with an 8% increase in incidence of diarrheagenic E. coli (J Infect Dis. 2016 Feb 29. doi: 10.1093/infdis/jiw081). The incidence of hand, foot, and mouth disease also is linked to temperature and humidity, with a 2018 study by Cheng et al. showing a 1° Celsius increase in temperature and humidity was significantly associated with hand, foot, and mouth disease (Sci Total Environ. 2018 Jan 12. doi: 10.1016/j.scitotenv.2018.01.006). Rates of influenza are controlled by the changing environment as well, and increasing the number of vaccinations will help lower the number of influenza cases.

“We need to be advocates, we need to educate ourselves like we’re doing now so that we can educate our patients and to create a plan for preparedness,” Dr. Pacheo said.

She reported no relevant conflicts of interest.

ORLANDO – “Expect the unexpected” when considering the health impacts of climate change on children, Susan Pacheo, MD, advised in her presentation at the annual meeting of the American Academy of Pediatrics.

Jeff Craven/MDedge News

“We don’t know what we’re going to see, and we need to be ready,” said Dr. Pacheo of the University of Texas, Houston.

Climate change is categorized by an increase in droughts, fires, storms, floods, mudslides, and extreme temperatures. According to the Centers for Disease Control and Prevention, the impacts of climate change on human health are multiple, but can include an increased rate of infectious disease, respiratory conditions, injury, cardiovascular-related health issues, malnutrition, and mental health problems.

These problems can especially target children, Dr. Pacheo noted. “Kids are vulnerable. You’ve heard this, you’ve experienced this, you see this every day in your pediatric population.”

Children are more vulnerable because of the increased exposure they have to the environment. They spend more time outdoors, they are closer to the ground, and they are likely to put objects in their mouth. Children also tend to swallow more water when swimming, compared with adults. A 2014 study by de Man et al. found that children exposed to storm sewers and combined sewers swallowed 1.7 mL of water per exposure event and that the risk of infection from pathogens such as noroviruses, enteroviruses, Campylobacter jejuni, Cryptosporidium, and Giardia was 23%-33% per event, compared with 0.016 mL of water per exposure in adults and a mean infection risk of 0.58%-3.90% per event (Water Research. 2014 Jan 1. doi: 10.1016/j.watres.2013.09.022).

In addition, socioeconomic status and built environment as well as a child’s immature lung development and higher respiratory rate can lead to children being impacted by factors such as air pollution. Poverty, access to medical care, and the structure and dynamics of family also can affect children.

“We need to do something because this is a problem of social justice and we, as pediatricians, are advocates of the vulnerable,” Dr. Pacheo said.

Cade Martin, Dawn Arlotta, USCDC

Expect to see an increase in the number of vector-borne, airborne, and pollution-related disease, as well as water- and food-borne diseases, as a result of climate change, in addition to other issues such as hand, foot, and mouth disease and antibiotic resistance, she noted. As historically colder parts of the world continue to have milder winters, disease-carrying insects such as ticks and mosquitoes will expand their habitats and transmission of diseases such as Zika virus, malaria, dengue fever, and chikungunya will increase.

Leptospirosis and Naegleria fowleri, the latter which can cause primary amebic meningoencephalitis, are also becoming more common. Food-borne illnesses like vibriosis are being seen in more northern areas of the world like Alaska, and ciguatera fish poisoning is expected to be more prevalent in the southeastern United States and Gulf of Mexico, Dr. Pacheo said.

Air pollution carries a risk of respiratory diseases, pneumonia, and bronchiolitis, with a 2017 systematic review by Nhung et al. finding increased exposure to ambient air pollution markers such as sulfur dioxide, ozone, nitrogen dioxide, and carbon monoxide was associated with pneumonia in children (Environ Pollut. 2017 Jul 25. doi: 10.1016/j.envpol.2017.07.063). Coccidioidomycosis, or valley fever, is caused by inhaling a fungus in the soil and is associated with dust storms primarily in the southwestern United States. Warmer temperatures also have caused toxic algae blooms that have killed marine life and caused respiratory distress; children should not go near or play in water when algae blooms are growing, she noted.

Recent studies have linked an increase in temperature with incidence of Escherichia coli, with a 2016 study by Philipsborn et al. showing a 1° Celsius increase in mean monthly temperature was associated with an 8% increase in incidence of diarrheagenic E. coli (J Infect Dis. 2016 Feb 29. doi: 10.1093/infdis/jiw081). The incidence of hand, foot, and mouth disease also is linked to temperature and humidity, with a 2018 study by Cheng et al. showing a 1° Celsius increase in temperature and humidity was significantly associated with hand, foot, and mouth disease (Sci Total Environ. 2018 Jan 12. doi: 10.1016/j.scitotenv.2018.01.006). Rates of influenza are controlled by the changing environment as well, and increasing the number of vaccinations will help lower the number of influenza cases.

“We need to be advocates, we need to educate ourselves like we’re doing now so that we can educate our patients and to create a plan for preparedness,” Dr. Pacheo said.

She reported no relevant conflicts of interest.

ORLANDO – “Expect the unexpected” when considering the health impacts of climate change on children, Susan Pacheo, MD, advised in her presentation at the annual meeting of the American Academy of Pediatrics.

Jeff Craven/MDedge News

“We don’t know what we’re going to see, and we need to be ready,” said Dr. Pacheo of the University of Texas, Houston.

Climate change is categorized by an increase in droughts, fires, storms, floods, mudslides, and extreme temperatures. According to the Centers for Disease Control and Prevention, the impacts of climate change on human health are multiple, but can include an increased rate of infectious disease, respiratory conditions, injury, cardiovascular-related health issues, malnutrition, and mental health problems.

These problems can especially target children, Dr. Pacheo noted. “Kids are vulnerable. You’ve heard this, you’ve experienced this, you see this every day in your pediatric population.”

Children are more vulnerable because of the increased exposure they have to the environment. They spend more time outdoors, they are closer to the ground, and they are likely to put objects in their mouth. Children also tend to swallow more water when swimming, compared with adults. A 2014 study by de Man et al. found that children exposed to storm sewers and combined sewers swallowed 1.7 mL of water per exposure event and that the risk of infection from pathogens such as noroviruses, enteroviruses, Campylobacter jejuni, Cryptosporidium, and Giardia was 23%-33% per event, compared with 0.016 mL of water per exposure in adults and a mean infection risk of 0.58%-3.90% per event (Water Research. 2014 Jan 1. doi: 10.1016/j.watres.2013.09.022).

In addition, socioeconomic status and built environment as well as a child’s immature lung development and higher respiratory rate can lead to children being impacted by factors such as air pollution. Poverty, access to medical care, and the structure and dynamics of family also can affect children.

“We need to do something because this is a problem of social justice and we, as pediatricians, are advocates of the vulnerable,” Dr. Pacheo said.

Cade Martin, Dawn Arlotta, USCDC

Expect to see an increase in the number of vector-borne, airborne, and pollution-related disease, as well as water- and food-borne diseases, as a result of climate change, in addition to other issues such as hand, foot, and mouth disease and antibiotic resistance, she noted. As historically colder parts of the world continue to have milder winters, disease-carrying insects such as ticks and mosquitoes will expand their habitats and transmission of diseases such as Zika virus, malaria, dengue fever, and chikungunya will increase.

Leptospirosis and Naegleria fowleri, the latter which can cause primary amebic meningoencephalitis, are also becoming more common. Food-borne illnesses like vibriosis are being seen in more northern areas of the world like Alaska, and ciguatera fish poisoning is expected to be more prevalent in the southeastern United States and Gulf of Mexico, Dr. Pacheo said.

Air pollution carries a risk of respiratory diseases, pneumonia, and bronchiolitis, with a 2017 systematic review by Nhung et al. finding increased exposure to ambient air pollution markers such as sulfur dioxide, ozone, nitrogen dioxide, and carbon monoxide was associated with pneumonia in children (Environ Pollut. 2017 Jul 25. doi: 10.1016/j.envpol.2017.07.063). Coccidioidomycosis, or valley fever, is caused by inhaling a fungus in the soil and is associated with dust storms primarily in the southwestern United States. Warmer temperatures also have caused toxic algae blooms that have killed marine life and caused respiratory distress; children should not go near or play in water when algae blooms are growing, she noted.

Recent studies have linked an increase in temperature with incidence of Escherichia coli, with a 2016 study by Philipsborn et al. showing a 1° Celsius increase in mean monthly temperature was associated with an 8% increase in incidence of diarrheagenic E. coli (J Infect Dis. 2016 Feb 29. doi: 10.1093/infdis/jiw081). The incidence of hand, foot, and mouth disease also is linked to temperature and humidity, with a 2018 study by Cheng et al. showing a 1° Celsius increase in temperature and humidity was significantly associated with hand, foot, and mouth disease (Sci Total Environ. 2018 Jan 12. doi: 10.1016/j.scitotenv.2018.01.006). Rates of influenza are controlled by the changing environment as well, and increasing the number of vaccinations will help lower the number of influenza cases.

“We need to be advocates, we need to educate ourselves like we’re doing now so that we can educate our patients and to create a plan for preparedness,” Dr. Pacheo said.

She reported no relevant conflicts of interest.

SEATTLE – Children who are suicidal and victims of trauma, especially those with PTSD, pose an especially difficult challenge for psychiatrists. Trauma, suicidality, and self-harm often present together, and they might heighten the risk of treatment.

“It becomes a dilemma to know in what order to treat those symptoms, because sometimes it feels like one will not get better without treating the other,” said Michele Berk, PhD. “But there’s also some question around when it’s safe to do exposure-based treatments – which are the key ingredient to resolving PTSD symptoms,” Dr. Berk said during a session focused on trauma and suicidality in youth at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dialectical behavior therapy, or DBT, is an option. DBT was developed by Marsha M. Linehan, PhD, to treat chronic suicidality comorbid with borderline personality disorder. In addition to PTSD, newer work has shown DBT as efficacious for treating substance use disorders, depression, and eating disorders.

DBT is based on the idea that self-harm occurs, at least in some cases, because the patient is predisposed to experiencing heightened emotional reactions. When the patient is exposed to an invalidating environment, such as when a parent or caregiver tells them to “just get over it; you’re overreacting,” this can lead patients to question their emotions. Most importantly, patients never learn effective strategies to that manage their emotions, according to Dr. Berk, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University.

In addition, Dr. Berk said, traumatized youth sometimes present with the most extreme form of invalidation, in which the patient’s entire being is violated through physical violence.

“So you have people who have these really intense negative emotions but don’t know how to help themselves manage them, and that is where DBT believes suicidal and self-harm behavior comes in,” Dr. Berk said. “We know that self-harm, though not suicidal self-injury, does in fact reduce emotion.”

DBT aims to counter suicidality by assisting the patient to build a life worth living. It encompasses five modes, including skills training, individual psychotherapy, in-the-moment coaching, case management, and a DBT consultation team to support the therapist.

The program prioritizes life-threatening behaviors in stage I and saving any exposure or PTSD therapy for stage II, which might begin up to 12 months later.

Also in stage I, after life-threatening behaviors have been resolved, the therapist addresses symptoms or factors that potentially interfere with further therapy. That’s important, because patients usually have comorbid symptoms and might be acutely distressed. “DBT has developed a clear hierarchy of how to target those things so that the sessions don’t get chaotic or off track,” Dr. Berk said.

Trauma symptoms might be tackled in stage I if they’re directly linked to suicidality or interfere with treatment, through reluctance to share information or because they might lead to dissociation during a session. After that, the program addresses quality of life, since its goal is to help patients create lives they deem worth living.

The skills training component of DBT includes mindfulness to help ground patients in the present moment. It also fosters skills that can be used to address trauma, including distress tolerance. Distress tolerance incorporates actions such as distraction and self-soothing. Emotional regulation seeks to help patients alter their emotions when possible. Interpersonal relationship skills help the patients ask for what they want and how to say “no” effectively.

Exposure therapy does not begin until patients have gone at least 2 months without any self-harming behavior, and it is interrupted if the patients exhibit self-harming behavior after it starts.

DBT remains a subject of continuing research. One avenue would be to more directly integrate exposure therapy with DBT in adolescents, but a protocol has not yet been developed. Prolonged exposure is typically used in adult PTSD patients, but trauma-focused cognitive-behavioral therapy more often is the choice for adolescents.

Whatever the choice, involvement of caring adults would be key. “In adolescents, there’s a need to involve parents and caregivers in whatever the trauma treatment is going to be,” Dr. Berk said.

Dr. Berk disclosed no conflicts of interest.

SEATTLE – Children who are suicidal and victims of trauma, especially those with PTSD, pose an especially difficult challenge for psychiatrists. Trauma, suicidality, and self-harm often present together, and they might heighten the risk of treatment.

“It becomes a dilemma to know in what order to treat those symptoms, because sometimes it feels like one will not get better without treating the other,” said Michele Berk, PhD. “But there’s also some question around when it’s safe to do exposure-based treatments – which are the key ingredient to resolving PTSD symptoms,” Dr. Berk said during a session focused on trauma and suicidality in youth at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dialectical behavior therapy, or DBT, is an option. DBT was developed by Marsha M. Linehan, PhD, to treat chronic suicidality comorbid with borderline personality disorder. In addition to PTSD, newer work has shown DBT as efficacious for treating substance use disorders, depression, and eating disorders.

DBT is based on the idea that self-harm occurs, at least in some cases, because the patient is predisposed to experiencing heightened emotional reactions. When the patient is exposed to an invalidating environment, such as when a parent or caregiver tells them to “just get over it; you’re overreacting,” this can lead patients to question their emotions. Most importantly, patients never learn effective strategies to that manage their emotions, according to Dr. Berk, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University.

In addition, Dr. Berk said, traumatized youth sometimes present with the most extreme form of invalidation, in which the patient’s entire being is violated through physical violence.

“So you have people who have these really intense negative emotions but don’t know how to help themselves manage them, and that is where DBT believes suicidal and self-harm behavior comes in,” Dr. Berk said. “We know that self-harm, though not suicidal self-injury, does in fact reduce emotion.”

DBT aims to counter suicidality by assisting the patient to build a life worth living. It encompasses five modes, including skills training, individual psychotherapy, in-the-moment coaching, case management, and a DBT consultation team to support the therapist.

The program prioritizes life-threatening behaviors in stage I and saving any exposure or PTSD therapy for stage II, which might begin up to 12 months later.

Also in stage I, after life-threatening behaviors have been resolved, the therapist addresses symptoms or factors that potentially interfere with further therapy. That’s important, because patients usually have comorbid symptoms and might be acutely distressed. “DBT has developed a clear hierarchy of how to target those things so that the sessions don’t get chaotic or off track,” Dr. Berk said.

Trauma symptoms might be tackled in stage I if they’re directly linked to suicidality or interfere with treatment, through reluctance to share information or because they might lead to dissociation during a session. After that, the program addresses quality of life, since its goal is to help patients create lives they deem worth living.

The skills training component of DBT includes mindfulness to help ground patients in the present moment. It also fosters skills that can be used to address trauma, including distress tolerance. Distress tolerance incorporates actions such as distraction and self-soothing. Emotional regulation seeks to help patients alter their emotions when possible. Interpersonal relationship skills help the patients ask for what they want and how to say “no” effectively.

Exposure therapy does not begin until patients have gone at least 2 months without any self-harming behavior, and it is interrupted if the patients exhibit self-harming behavior after it starts.

DBT remains a subject of continuing research. One avenue would be to more directly integrate exposure therapy with DBT in adolescents, but a protocol has not yet been developed. Prolonged exposure is typically used in adult PTSD patients, but trauma-focused cognitive-behavioral therapy more often is the choice for adolescents.

Whatever the choice, involvement of caring adults would be key. “In adolescents, there’s a need to involve parents and caregivers in whatever the trauma treatment is going to be,” Dr. Berk said.

Dr. Berk disclosed no conflicts of interest.

SEATTLE – Children who are suicidal and victims of trauma, especially those with PTSD, pose an especially difficult challenge for psychiatrists. Trauma, suicidality, and self-harm often present together, and they might heighten the risk of treatment.

“It becomes a dilemma to know in what order to treat those symptoms, because sometimes it feels like one will not get better without treating the other,” said Michele Berk, PhD. “But there’s also some question around when it’s safe to do exposure-based treatments – which are the key ingredient to resolving PTSD symptoms,” Dr. Berk said during a session focused on trauma and suicidality in youth at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dialectical behavior therapy, or DBT, is an option. DBT was developed by Marsha M. Linehan, PhD, to treat chronic suicidality comorbid with borderline personality disorder. In addition to PTSD, newer work has shown DBT as efficacious for treating substance use disorders, depression, and eating disorders.

DBT is based on the idea that self-harm occurs, at least in some cases, because the patient is predisposed to experiencing heightened emotional reactions. When the patient is exposed to an invalidating environment, such as when a parent or caregiver tells them to “just get over it; you’re overreacting,” this can lead patients to question their emotions. Most importantly, patients never learn effective strategies to that manage their emotions, according to Dr. Berk, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University.

In addition, Dr. Berk said, traumatized youth sometimes present with the most extreme form of invalidation, in which the patient’s entire being is violated through physical violence.

“So you have people who have these really intense negative emotions but don’t know how to help themselves manage them, and that is where DBT believes suicidal and self-harm behavior comes in,” Dr. Berk said. “We know that self-harm, though not suicidal self-injury, does in fact reduce emotion.”

DBT aims to counter suicidality by assisting the patient to build a life worth living. It encompasses five modes, including skills training, individual psychotherapy, in-the-moment coaching, case management, and a DBT consultation team to support the therapist.

The program prioritizes life-threatening behaviors in stage I and saving any exposure or PTSD therapy for stage II, which might begin up to 12 months later.

Also in stage I, after life-threatening behaviors have been resolved, the therapist addresses symptoms or factors that potentially interfere with further therapy. That’s important, because patients usually have comorbid symptoms and might be acutely distressed. “DBT has developed a clear hierarchy of how to target those things so that the sessions don’t get chaotic or off track,” Dr. Berk said.

Trauma symptoms might be tackled in stage I if they’re directly linked to suicidality or interfere with treatment, through reluctance to share information or because they might lead to dissociation during a session. After that, the program addresses quality of life, since its goal is to help patients create lives they deem worth living.

The skills training component of DBT includes mindfulness to help ground patients in the present moment. It also fosters skills that can be used to address trauma, including distress tolerance. Distress tolerance incorporates actions such as distraction and self-soothing. Emotional regulation seeks to help patients alter their emotions when possible. Interpersonal relationship skills help the patients ask for what they want and how to say “no” effectively.

Exposure therapy does not begin until patients have gone at least 2 months without any self-harming behavior, and it is interrupted if the patients exhibit self-harming behavior after it starts.

DBT remains a subject of continuing research. One avenue would be to more directly integrate exposure therapy with DBT in adolescents, but a protocol has not yet been developed. Prolonged exposure is typically used in adult PTSD patients, but trauma-focused cognitive-behavioral therapy more often is the choice for adolescents.

Whatever the choice, involvement of caring adults would be key. “In adolescents, there’s a need to involve parents and caregivers in whatever the trauma treatment is going to be,” Dr. Berk said.

Dr. Berk disclosed no conflicts of interest.

Just over half of infants get 8 hours of uninterrupted sleep at 12 months of age, an analysis of findings from a longitudinal birth cohort study showed.

It also found that whether an infant sleeps through night has no significant associated with any variations in mental or psychomotor development.

However, the rate of breastfeeding was significantly higher among infants who did not sleep through the night, investigators said in their report on the analysis, published in Pediatrics.

Being informed about the normal development of the sleep-wake cycle could be reassuring for parents, according to the authors, who said that new mothers tend to be “greatly surprised” by the sleep disturbance and exhaustion they experience.

“Keeping in mind the wide variability in the age when an infant starts to sleep through the night, expectations for early sleep consolidation could be moderated,” said Marie-Hélène Pennestri, PhD, of the Department of Educational and Counselling Psychology at McGill University, Montreal, and her coauthors.

Dr. Pennestri and colleagues reported on 388 mother-infant dyads in a longitudinal birth cohort study called Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN). Pregnant mothers were recruited from obstetric clinics in Canada. When their infants reached the age of 6 and 12 months, the mothers responded to questionnaires about sleep habits.

At 6 months, 62.4% of infants attained at least 6 hours of uninterrupted sleep, mothers reported, while 43.0% had reached 8 hours, the mothers reported. By 12 months of age, 72.1% of the infants attained 6 hours, and 56.6% attained 8 hours.

There were no associations between sleeping through the night and concurrent mental or psychomotor development, as measured by the Bayley Scales of Infant Development II at both 6 or 12 months of age, with P values greater than 0.05, investigators reported.

A similar lack of association between uninterrupted sleep and development or maternal mood was seen in a follow-up measurement at 36 months of age.

Sleeping through the night was likewise not associated with maternal mood, assessed using a depression scale with items that reflected symptom frequency in the previous week. “This is noteworthy because maternal sleep deprivation is often invoked to support the introduction of early behavioral interventions,” investigators said in a discussion of the results.

By contrast, sleeping through the night was linked to lower rates of breastfeeding as reported by mothers on retrospective questionnaires administered at both 6 and 12 months. At 12 months of age, 22.1% of infants sleeping through the night were breastfed, compared to 47.1% of infants not sleeping through the night (P less than 0.0001), Dr. Pennestri and colleagues reported.

However, that breastfeeding observation needs to be further investigated, according to the authors.

“The results of our study do not allow for the drawing of any causality between not sleeping through the night and breastfeeding,” they wrote.

Dr. Pennestri and coauthors said they had no financial relationships or potential conflicts of interest to disclose relevant to their report. They reported funding from the Ludmer Center for Neuroinformatics and Mental Health, Canadian Institutes of Health Research, and several other research institutions.

SOURCE: Pennestri MH, et al. Pediatrics. 2018;142(6):e20174330.

Just over half of infants get 8 hours of uninterrupted sleep at 12 months of age, an analysis of findings from a longitudinal birth cohort study showed.

It also found that whether an infant sleeps through night has no significant associated with any variations in mental or psychomotor development.

However, the rate of breastfeeding was significantly higher among infants who did not sleep through the night, investigators said in their report on the analysis, published in Pediatrics.

Being informed about the normal development of the sleep-wake cycle could be reassuring for parents, according to the authors, who said that new mothers tend to be “greatly surprised” by the sleep disturbance and exhaustion they experience.

“Keeping in mind the wide variability in the age when an infant starts to sleep through the night, expectations for early sleep consolidation could be moderated,” said Marie-Hélène Pennestri, PhD, of the Department of Educational and Counselling Psychology at McGill University, Montreal, and her coauthors.

Dr. Pennestri and colleagues reported on 388 mother-infant dyads in a longitudinal birth cohort study called Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN). Pregnant mothers were recruited from obstetric clinics in Canada. When their infants reached the age of 6 and 12 months, the mothers responded to questionnaires about sleep habits.

At 6 months, 62.4% of infants attained at least 6 hours of uninterrupted sleep, mothers reported, while 43.0% had reached 8 hours, the mothers reported. By 12 months of age, 72.1% of the infants attained 6 hours, and 56.6% attained 8 hours.

There were no associations between sleeping through the night and concurrent mental or psychomotor development, as measured by the Bayley Scales of Infant Development II at both 6 or 12 months of age, with P values greater than 0.05, investigators reported.

A similar lack of association between uninterrupted sleep and development or maternal mood was seen in a follow-up measurement at 36 months of age.

Sleeping through the night was likewise not associated with maternal mood, assessed using a depression scale with items that reflected symptom frequency in the previous week. “This is noteworthy because maternal sleep deprivation is often invoked to support the introduction of early behavioral interventions,” investigators said in a discussion of the results.

By contrast, sleeping through the night was linked to lower rates of breastfeeding as reported by mothers on retrospective questionnaires administered at both 6 and 12 months. At 12 months of age, 22.1% of infants sleeping through the night were breastfed, compared to 47.1% of infants not sleeping through the night (P less than 0.0001), Dr. Pennestri and colleagues reported.

However, that breastfeeding observation needs to be further investigated, according to the authors.

“The results of our study do not allow for the drawing of any causality between not sleeping through the night and breastfeeding,” they wrote.

Dr. Pennestri and coauthors said they had no financial relationships or potential conflicts of interest to disclose relevant to their report. They reported funding from the Ludmer Center for Neuroinformatics and Mental Health, Canadian Institutes of Health Research, and several other research institutions.

SOURCE: Pennestri MH, et al. Pediatrics. 2018;142(6):e20174330.

Just over half of infants get 8 hours of uninterrupted sleep at 12 months of age, an analysis of findings from a longitudinal birth cohort study showed.

It also found that whether an infant sleeps through night has no significant associated with any variations in mental or psychomotor development.

However, the rate of breastfeeding was significantly higher among infants who did not sleep through the night, investigators said in their report on the analysis, published in Pediatrics.

Being informed about the normal development of the sleep-wake cycle could be reassuring for parents, according to the authors, who said that new mothers tend to be “greatly surprised” by the sleep disturbance and exhaustion they experience.

“Keeping in mind the wide variability in the age when an infant starts to sleep through the night, expectations for early sleep consolidation could be moderated,” said Marie-Hélène Pennestri, PhD, of the Department of Educational and Counselling Psychology at McGill University, Montreal, and her coauthors.

Dr. Pennestri and colleagues reported on 388 mother-infant dyads in a longitudinal birth cohort study called Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN). Pregnant mothers were recruited from obstetric clinics in Canada. When their infants reached the age of 6 and 12 months, the mothers responded to questionnaires about sleep habits.

At 6 months, 62.4% of infants attained at least 6 hours of uninterrupted sleep, mothers reported, while 43.0% had reached 8 hours, the mothers reported. By 12 months of age, 72.1% of the infants attained 6 hours, and 56.6% attained 8 hours.

There were no associations between sleeping through the night and concurrent mental or psychomotor development, as measured by the Bayley Scales of Infant Development II at both 6 or 12 months of age, with P values greater than 0.05, investigators reported.

A similar lack of association between uninterrupted sleep and development or maternal mood was seen in a follow-up measurement at 36 months of age.

Sleeping through the night was likewise not associated with maternal mood, assessed using a depression scale with items that reflected symptom frequency in the previous week. “This is noteworthy because maternal sleep deprivation is often invoked to support the introduction of early behavioral interventions,” investigators said in a discussion of the results.

By contrast, sleeping through the night was linked to lower rates of breastfeeding as reported by mothers on retrospective questionnaires administered at both 6 and 12 months. At 12 months of age, 22.1% of infants sleeping through the night were breastfed, compared to 47.1% of infants not sleeping through the night (P less than 0.0001), Dr. Pennestri and colleagues reported.

However, that breastfeeding observation needs to be further investigated, according to the authors.

“The results of our study do not allow for the drawing of any causality between not sleeping through the night and breastfeeding,” they wrote.

Dr. Pennestri and coauthors said they had no financial relationships or potential conflicts of interest to disclose relevant to their report. They reported funding from the Ludmer Center for Neuroinformatics and Mental Health, Canadian Institutes of Health Research, and several other research institutions.

SOURCE: Pennestri MH, et al. Pediatrics. 2018;142(6):e20174330.

Pediatric headache and migraine are associated with a variety of conditions including respiratory, gastrointestinal, neurologic, and mood disorders, according to findings published in the Journal of Pediatrics.

Marta Ortiz/iStock/Getty Images Plus

In a study of 9,329 pediatric patients from the Philadelphia Neurodevelopmental Cohort, at the University of Pennsylvania, children with any headache type were more likely to have cardiovascular (odds ratio, 1.4; 95% confidence interval, 1.1-1.7) and gastrointestinal (OR, 1.2; 95% CI, 1.1-1.4) problems than did those without headache. In addition, they were more likely to have attention deficit hyperactivity disorder (OR, 1.2; 95% CI, 1.1-1.4), wrote Tarannum M. Lateef, MD, MPH, of the Center for Neuroscience and Behavioral Medicine at Children’s National Medical Center in Washington, and her coauthors.

Study participants were aged 8-21 years and were enrolled in the cohort from November 2009 to November 2011. Physical conditions were identified using EMRs and interviews and were later grouped together by general category.

Patients were asked about lifetime headache and migraine symptoms including sensitivity to light and noise, gastrointestinal symptoms, unilateral pain, throbbing and pulsation, and interference at school or work. Migraine was defined as headache accompanied by any three of these symptoms. Mental disorders were identified using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia, reported Dr. Lateef and her associates.

Lifetime prevalence of any headache was 45.5%, and 22.6% for migraine. Migraine was more common in female patients (25.5%) than in male patients (19.4%).

Compared with nonmigraine headache patients, those with migraine more frequently had neurologic/central nervous system disorders (OR, 1.7; 95% CI, 1.4-2.0), developmental disorders (OR, 1.3; 95% CI, 1.1-1.6), respiratory problems (OR, 1.3; 95% CI, 1.1-1.6), anxiety (OR, 1.6; 95% CI, 1.3-2), mood disorders (OR, 2; 95% CI, 1.6-2.3), and behavioral disorders (OR, 1.3; 95% CI, 1.1-1.6).

The results suggest that “headache, particularly migraine, is associated with respiratory and other neurologic and developmental disorders, as well as with anxiety and mood disorders,” the authors wrote.

“Comorbidity may be an important index of heterogeneity … that can guide clinical management, genetic investigation, and future research on shared pathophysiology” with other disorders, they concluded.

No disclosures were reported.
 

SOURCE: Lateef T et al. J Pediatr. 2018 Oct 29. doi: 10.1016/j.jpeds.2018.09.033.

Pediatric headache and migraine are associated with a variety of conditions including respiratory, gastrointestinal, neurologic, and mood disorders, according to findings published in the Journal of Pediatrics.

Marta Ortiz/iStock/Getty Images Plus

In a study of 9,329 pediatric patients from the Philadelphia Neurodevelopmental Cohort, at the University of Pennsylvania, children with any headache type were more likely to have cardiovascular (odds ratio, 1.4; 95% confidence interval, 1.1-1.7) and gastrointestinal (OR, 1.2; 95% CI, 1.1-1.4) problems than did those without headache. In addition, they were more likely to have attention deficit hyperactivity disorder (OR, 1.2; 95% CI, 1.1-1.4), wrote Tarannum M. Lateef, MD, MPH, of the Center for Neuroscience and Behavioral Medicine at Children’s National Medical Center in Washington, and her coauthors.

Study participants were aged 8-21 years and were enrolled in the cohort from November 2009 to November 2011. Physical conditions were identified using EMRs and interviews and were later grouped together by general category.

Patients were asked about lifetime headache and migraine symptoms including sensitivity to light and noise, gastrointestinal symptoms, unilateral pain, throbbing and pulsation, and interference at school or work. Migraine was defined as headache accompanied by any three of these symptoms. Mental disorders were identified using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia, reported Dr. Lateef and her associates.

Lifetime prevalence of any headache was 45.5%, and 22.6% for migraine. Migraine was more common in female patients (25.5%) than in male patients (19.4%).

Compared with nonmigraine headache patients, those with migraine more frequently had neurologic/central nervous system disorders (OR, 1.7; 95% CI, 1.4-2.0), developmental disorders (OR, 1.3; 95% CI, 1.1-1.6), respiratory problems (OR, 1.3; 95% CI, 1.1-1.6), anxiety (OR, 1.6; 95% CI, 1.3-2), mood disorders (OR, 2; 95% CI, 1.6-2.3), and behavioral disorders (OR, 1.3; 95% CI, 1.1-1.6).

The results suggest that “headache, particularly migraine, is associated with respiratory and other neurologic and developmental disorders, as well as with anxiety and mood disorders,” the authors wrote.

“Comorbidity may be an important index of heterogeneity … that can guide clinical management, genetic investigation, and future research on shared pathophysiology” with other disorders, they concluded.

No disclosures were reported.
 

SOURCE: Lateef T et al. J Pediatr. 2018 Oct 29. doi: 10.1016/j.jpeds.2018.09.033.

Pediatric headache and migraine are associated with a variety of conditions including respiratory, gastrointestinal, neurologic, and mood disorders, according to findings published in the Journal of Pediatrics.

Marta Ortiz/iStock/Getty Images Plus

In a study of 9,329 pediatric patients from the Philadelphia Neurodevelopmental Cohort, at the University of Pennsylvania, children with any headache type were more likely to have cardiovascular (odds ratio, 1.4; 95% confidence interval, 1.1-1.7) and gastrointestinal (OR, 1.2; 95% CI, 1.1-1.4) problems than did those without headache. In addition, they were more likely to have attention deficit hyperactivity disorder (OR, 1.2; 95% CI, 1.1-1.4), wrote Tarannum M. Lateef, MD, MPH, of the Center for Neuroscience and Behavioral Medicine at Children’s National Medical Center in Washington, and her coauthors.

Study participants were aged 8-21 years and were enrolled in the cohort from November 2009 to November 2011. Physical conditions were identified using EMRs and interviews and were later grouped together by general category.

Patients were asked about lifetime headache and migraine symptoms including sensitivity to light and noise, gastrointestinal symptoms, unilateral pain, throbbing and pulsation, and interference at school or work. Migraine was defined as headache accompanied by any three of these symptoms. Mental disorders were identified using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia, reported Dr. Lateef and her associates.

Lifetime prevalence of any headache was 45.5%, and 22.6% for migraine. Migraine was more common in female patients (25.5%) than in male patients (19.4%).

Compared with nonmigraine headache patients, those with migraine more frequently had neurologic/central nervous system disorders (OR, 1.7; 95% CI, 1.4-2.0), developmental disorders (OR, 1.3; 95% CI, 1.1-1.6), respiratory problems (OR, 1.3; 95% CI, 1.1-1.6), anxiety (OR, 1.6; 95% CI, 1.3-2), mood disorders (OR, 2; 95% CI, 1.6-2.3), and behavioral disorders (OR, 1.3; 95% CI, 1.1-1.6).

The results suggest that “headache, particularly migraine, is associated with respiratory and other neurologic and developmental disorders, as well as with anxiety and mood disorders,” the authors wrote.

“Comorbidity may be an important index of heterogeneity … that can guide clinical management, genetic investigation, and future research on shared pathophysiology” with other disorders, they concluded.

No disclosures were reported.
 

SOURCE: Lateef T et al. J Pediatr. 2018 Oct 29. doi: 10.1016/j.jpeds.2018.09.033.

Emergency contraception is perceived as “easy, effective, and discrete,” especially when compared with nonemergent contraception and condoms, according to a qualitative study of contraceptive behaviors and decision making among adolescent females who had previously used emergency contraception (EC) or planned to use it.

“Three main themes emerged from our interviews: There are multiple perceived benefits to using EC, nonemergent contraception (NEC) use is challenging, and the decision to use NEC is multifactorial,” lead author Geetha N. Fink, MD, MPH, and her coauthors wrote in the Journal of Pediatric and Adolescent Gynecology.

The investigators reviewed interview transcripts and questionnaire responses from 28 adolescent females who had all used or were planning to use EC. The participants, who were recruited from school-based health centers (SBHC) in New York, reported having used EC a mean of 3.5 times (range 0-30 times), noted Dr. Fink of the department of obstetrics, gynecology and reproductive sciences at the Icahn School of Medicine at Mount Sinai in New York and her colleagues.

SBHCs in New York can distribute EC for free and – once general consent to care at the SBHC is provided at the start of each school year– without parental notification. This ease of access contributed to EC use, along with its minimal side effects. EC also can “be used discretely without the involvement of the partner,” Dr. Fink and her coauthors noted. Although the majority of participants stated being comfortable discussing their EC use, “they still appreciated that EC does not require partner involvement or awareness, unlike condoms or withdrawal.”

The participants’ decision making often was influenced by misperception; 65% incorrectly stated that EC was 90%-99% effective, and NEC use was ascribed to beliefs that “excess EC decreases efficacy or is detrimental to health and social interactions.” At the same time, Dr. Fink and her colleagues found that NEC use was associated with participants who had more sexual experience or who correctly identified it as more effective than EC.

“Our findings suggest that as adolescents gained more experience with sex and counseling, and also matured, they appeared to be more likely to utilize NEC,” they wrote.

Dr. Fink and her associates shared limitations of their study, including the uniqueness of SBHCs in New York City in providing comprehensive health care options, compared with those in the rest of the United States. However, they also noted the value in interviewing adolescent EC users and therefore better understanding why they’ve made these contraceptive decisions.

“We suspect many more students would benefit from access to EC and the SBHC, but may be unaware of these resources. We recommend increased efforts to promote awareness of these resources in schools, especially incorporated into sexual education. EC should be readily available for all adolescents,” they wrote.

The study was funded through a grant from the Society of Family Planning. No conflicts of interest were reported.

SOURCE: Fink GN et al. J Pediatr Adolesc Gynecol. 2018. doi: 10.1016/j.jpag.2018.10.005.

Emergency contraception is perceived as “easy, effective, and discrete,” especially when compared with nonemergent contraception and condoms, according to a qualitative study of contraceptive behaviors and decision making among adolescent females who had previously used emergency contraception (EC) or planned to use it.

“Three main themes emerged from our interviews: There are multiple perceived benefits to using EC, nonemergent contraception (NEC) use is challenging, and the decision to use NEC is multifactorial,” lead author Geetha N. Fink, MD, MPH, and her coauthors wrote in the Journal of Pediatric and Adolescent Gynecology.

The investigators reviewed interview transcripts and questionnaire responses from 28 adolescent females who had all used or were planning to use EC. The participants, who were recruited from school-based health centers (SBHC) in New York, reported having used EC a mean of 3.5 times (range 0-30 times), noted Dr. Fink of the department of obstetrics, gynecology and reproductive sciences at the Icahn School of Medicine at Mount Sinai in New York and her colleagues.

SBHCs in New York can distribute EC for free and – once general consent to care at the SBHC is provided at the start of each school year– without parental notification. This ease of access contributed to EC use, along with its minimal side effects. EC also can “be used discretely without the involvement of the partner,” Dr. Fink and her coauthors noted. Although the majority of participants stated being comfortable discussing their EC use, “they still appreciated that EC does not require partner involvement or awareness, unlike condoms or withdrawal.”

The participants’ decision making often was influenced by misperception; 65% incorrectly stated that EC was 90%-99% effective, and NEC use was ascribed to beliefs that “excess EC decreases efficacy or is detrimental to health and social interactions.” At the same time, Dr. Fink and her colleagues found that NEC use was associated with participants who had more sexual experience or who correctly identified it as more effective than EC.

“Our findings suggest that as adolescents gained more experience with sex and counseling, and also matured, they appeared to be more likely to utilize NEC,” they wrote.

Dr. Fink and her associates shared limitations of their study, including the uniqueness of SBHCs in New York City in providing comprehensive health care options, compared with those in the rest of the United States. However, they also noted the value in interviewing adolescent EC users and therefore better understanding why they’ve made these contraceptive decisions.

“We suspect many more students would benefit from access to EC and the SBHC, but may be unaware of these resources. We recommend increased efforts to promote awareness of these resources in schools, especially incorporated into sexual education. EC should be readily available for all adolescents,” they wrote.

The study was funded through a grant from the Society of Family Planning. No conflicts of interest were reported.

SOURCE: Fink GN et al. J Pediatr Adolesc Gynecol. 2018. doi: 10.1016/j.jpag.2018.10.005.

Emergency contraception is perceived as “easy, effective, and discrete,” especially when compared with nonemergent contraception and condoms, according to a qualitative study of contraceptive behaviors and decision making among adolescent females who had previously used emergency contraception (EC) or planned to use it.

“Three main themes emerged from our interviews: There are multiple perceived benefits to using EC, nonemergent contraception (NEC) use is challenging, and the decision to use NEC is multifactorial,” lead author Geetha N. Fink, MD, MPH, and her coauthors wrote in the Journal of Pediatric and Adolescent Gynecology.

The investigators reviewed interview transcripts and questionnaire responses from 28 adolescent females who had all used or were planning to use EC. The participants, who were recruited from school-based health centers (SBHC) in New York, reported having used EC a mean of 3.5 times (range 0-30 times), noted Dr. Fink of the department of obstetrics, gynecology and reproductive sciences at the Icahn School of Medicine at Mount Sinai in New York and her colleagues.

SBHCs in New York can distribute EC for free and – once general consent to care at the SBHC is provided at the start of each school year– without parental notification. This ease of access contributed to EC use, along with its minimal side effects. EC also can “be used discretely without the involvement of the partner,” Dr. Fink and her coauthors noted. Although the majority of participants stated being comfortable discussing their EC use, “they still appreciated that EC does not require partner involvement or awareness, unlike condoms or withdrawal.”

The participants’ decision making often was influenced by misperception; 65% incorrectly stated that EC was 90%-99% effective, and NEC use was ascribed to beliefs that “excess EC decreases efficacy or is detrimental to health and social interactions.” At the same time, Dr. Fink and her colleagues found that NEC use was associated with participants who had more sexual experience or who correctly identified it as more effective than EC.

“Our findings suggest that as adolescents gained more experience with sex and counseling, and also matured, they appeared to be more likely to utilize NEC,” they wrote.

Dr. Fink and her associates shared limitations of their study, including the uniqueness of SBHCs in New York City in providing comprehensive health care options, compared with those in the rest of the United States. However, they also noted the value in interviewing adolescent EC users and therefore better understanding why they’ve made these contraceptive decisions.

“We suspect many more students would benefit from access to EC and the SBHC, but may be unaware of these resources. We recommend increased efforts to promote awareness of these resources in schools, especially incorporated into sexual education. EC should be readily available for all adolescents,” they wrote.

The study was funded through a grant from the Society of Family Planning. No conflicts of interest were reported.

SOURCE: Fink GN et al. J Pediatr Adolesc Gynecol. 2018. doi: 10.1016/j.jpag.2018.10.005.

ORLANDO – Consider point-of-care testing and treat potentially infected partners when diagnosing and treating adolescents for STIs, Diane M. Straub, MD, MPH, said at the annual meeting of the American Academy of Pediatrics.

In addition, adolescents are sometimes reluctant to disclose their full sexual history to their health care provider, which can complicate diagnosis and treatment, noted Dr. Straub, professor of pediatrics at the University of South Florida, Tampa. “That sometimes takes a few questions,” but can be achieved by asking the same questions in different ways and emphasizing the clinical importance of testing.

According to the 2017 Youth Risk Behavior Surveillance survey, 40% of adolescents reported ever having sexual intercourse, with 20% of 9th-grade, 36% of 10th-grade, 47% of 11th-grade, and 57% of 12th-grade students reporting they had sexual intercourse. By gender, 41% of adolescent males and 38% of adolescent females reported ever having sexual intercourse; by race, 39% of white, 41% of Hispanic, and 46% of black participants reported any sexual activity. Overall, 10% of adolescents said they had four or more partners, 3% said they had intercourse before age 13 years, 54% used a condom the last time they had intercourse, and 7% said they were raped.

CDC

The rate of STIs in the United States is rising. There has been a sharp increase in the number of combined diagnoses of gonorrhea, syphilis, and chlamydia, with an increase from 1.8 million in 2013 to 2.3 million cases in 2017, according to the Centers for Disease Control and Prevention. During that same time period, gonorrhea increased 67% from 333,004 to 555,608 cases, syphilis (primary and secondary) rose 76% from 17,375 to 30,644 cases, and chlamydia increased 22% to 1.7 million cases.

According to a 2013 CDC infographic shown by Dr. Straub, young people in the United States aged 15-24 years old represent 27% of the total sexually active population but account for 50% of new STI cases each year. Persons in this population account for 70% of gonorrhea cases, 63% of chlamydia cases, 49% of human papillomavirus (HPV) cases, 45% of genital herpes cases, and 20% of syphilis cases.

CDC

All sexually active females aged 25 years or younger should be screened for chlamydia and gonorrhea, as well as “at-risk” young men who have sex with men (YMSM), Dr. Straub said. All adolescent males and females aged over 13 years should be offered HIV screening, and HIV screening should be discussed “at least once.” And depending on how at risk each subpopulation is, health care providers should be have that conversation and offer screening multiple times.

Women who have sex with women (WSW) are a diverse population and should be treated based on their individual sexual identities, behaviors, and practices. “Most self-identified WSWs report having sex with men, so therefore adolescent WSWs and females with both male and female sex partners might be at increased risk for STIs, such as syphillis, chlamydia, and HPV as well as HIV, so you may want to adjust your screening accordingly,” she said.

Pregnant women, if at risk, should be screened for HIV, syphilis, hepatitis B, gonorrhea, and chlamydia.

CDC/Dr. E. Arum; Dr. N. Jacobs

YMSM should have annual screenings for syphilis and HIV, screenings for chlamydia and gonorrhea by infection site; also consider herpes simplex virus serology and anal cytology in these patients, Dr. Straub said. They also should be screened for hepatitis B surface antigen, vaccinated for hepatitis A, hepatitis B and, if using drugs, screened* for hepatitis C virus.

Dr. Straub recommended licensed health care professionals who may treat minor patients review their state’s laws on minors and their legal ability to consent to treatment of STIs without the involvement of their parent or guardian, including disclosure of positive results and in the case of HIV care.

In places where index insured are allowed to find out about any services a beneficiary receives on their insurance, “this is a little problematic, because in some states, this is in direct conflict with the explanation of benefits requirement,” she said. “There are certain ways to get around that, but it’s really important for you to know what the statutes are where you’re practicing and where the breaches of confidentiality [are].”

Expedited partner therapy, or treating one or multiple partners of patients with an STI, is recommended for certain patients and infections, such as male partners of female patients with chlamydia and gonorrhea. While this is recommended less for YMSM because of a higher rate of concurrent infection, “if you have a young person who has partners who are unlikely to have access to care and get treated, it’s recommended you give that treatment to your index patient and to then treat their partners,” Dr. Straub said.

A recent and frequently updated resource on STI treatment can be found at the CDC website.

Dr. Straub reported no relevant conflicts of interest.

*This article was updated 1/11/19.

ORLANDO – Consider point-of-care testing and treat potentially infected partners when diagnosing and treating adolescents for STIs, Diane M. Straub, MD, MPH, said at the annual meeting of the American Academy of Pediatrics.

In addition, adolescents are sometimes reluctant to disclose their full sexual history to their health care provider, which can complicate diagnosis and treatment, noted Dr. Straub, professor of pediatrics at the University of South Florida, Tampa. “That sometimes takes a few questions,” but can be achieved by asking the same questions in different ways and emphasizing the clinical importance of testing.

According to the 2017 Youth Risk Behavior Surveillance survey, 40% of adolescents reported ever having sexual intercourse, with 20% of 9th-grade, 36% of 10th-grade, 47% of 11th-grade, and 57% of 12th-grade students reporting they had sexual intercourse. By gender, 41% of adolescent males and 38% of adolescent females reported ever having sexual intercourse; by race, 39% of white, 41% of Hispanic, and 46% of black participants reported any sexual activity. Overall, 10% of adolescents said they had four or more partners, 3% said they had intercourse before age 13 years, 54% used a condom the last time they had intercourse, and 7% said they were raped.

CDC

The rate of STIs in the United States is rising. There has been a sharp increase in the number of combined diagnoses of gonorrhea, syphilis, and chlamydia, with an increase from 1.8 million in 2013 to 2.3 million cases in 2017, according to the Centers for Disease Control and Prevention. During that same time period, gonorrhea increased 67% from 333,004 to 555,608 cases, syphilis (primary and secondary) rose 76% from 17,375 to 30,644 cases, and chlamydia increased 22% to 1.7 million cases.

According to a 2013 CDC infographic shown by Dr. Straub, young people in the United States aged 15-24 years old represent 27% of the total sexually active population but account for 50% of new STI cases each year. Persons in this population account for 70% of gonorrhea cases, 63% of chlamydia cases, 49% of human papillomavirus (HPV) cases, 45% of genital herpes cases, and 20% of syphilis cases.

CDC

All sexually active females aged 25 years or younger should be screened for chlamydia and gonorrhea, as well as “at-risk” young men who have sex with men (YMSM), Dr. Straub said. All adolescent males and females aged over 13 years should be offered HIV screening, and HIV screening should be discussed “at least once.” And depending on how at risk each subpopulation is, health care providers should be have that conversation and offer screening multiple times.

Women who have sex with women (WSW) are a diverse population and should be treated based on their individual sexual identities, behaviors, and practices. “Most self-identified WSWs report having sex with men, so therefore adolescent WSWs and females with both male and female sex partners might be at increased risk for STIs, such as syphillis, chlamydia, and HPV as well as HIV, so you may want to adjust your screening accordingly,” she said.

Pregnant women, if at risk, should be screened for HIV, syphilis, hepatitis B, gonorrhea, and chlamydia.

CDC/Dr. E. Arum; Dr. N. Jacobs

YMSM should have annual screenings for syphilis and HIV, screenings for chlamydia and gonorrhea by infection site; also consider herpes simplex virus serology and anal cytology in these patients, Dr. Straub said. They also should be screened for hepatitis B surface antigen, vaccinated for hepatitis A, hepatitis B and, if using drugs, screened* for hepatitis C virus.

Dr. Straub recommended licensed health care professionals who may treat minor patients review their state’s laws on minors and their legal ability to consent to treatment of STIs without the involvement of their parent or guardian, including disclosure of positive results and in the case of HIV care.

In places where index insured are allowed to find out about any services a beneficiary receives on their insurance, “this is a little problematic, because in some states, this is in direct conflict with the explanation of benefits requirement,” she said. “There are certain ways to get around that, but it’s really important for you to know what the statutes are where you’re practicing and where the breaches of confidentiality [are].”

Expedited partner therapy, or treating one or multiple partners of patients with an STI, is recommended for certain patients and infections, such as male partners of female patients with chlamydia and gonorrhea. While this is recommended less for YMSM because of a higher rate of concurrent infection, “if you have a young person who has partners who are unlikely to have access to care and get treated, it’s recommended you give that treatment to your index patient and to then treat their partners,” Dr. Straub said.

A recent and frequently updated resource on STI treatment can be found at the CDC website.

Dr. Straub reported no relevant conflicts of interest.

*This article was updated 1/11/19.

ORLANDO – Consider point-of-care testing and treat potentially infected partners when diagnosing and treating adolescents for STIs, Diane M. Straub, MD, MPH, said at the annual meeting of the American Academy of Pediatrics.

In addition, adolescents are sometimes reluctant to disclose their full sexual history to their health care provider, which can complicate diagnosis and treatment, noted Dr. Straub, professor of pediatrics at the University of South Florida, Tampa. “That sometimes takes a few questions,” but can be achieved by asking the same questions in different ways and emphasizing the clinical importance of testing.

According to the 2017 Youth Risk Behavior Surveillance survey, 40% of adolescents reported ever having sexual intercourse, with 20% of 9th-grade, 36% of 10th-grade, 47% of 11th-grade, and 57% of 12th-grade students reporting they had sexual intercourse. By gender, 41% of adolescent males and 38% of adolescent females reported ever having sexual intercourse; by race, 39% of white, 41% of Hispanic, and 46% of black participants reported any sexual activity. Overall, 10% of adolescents said they had four or more partners, 3% said they had intercourse before age 13 years, 54% used a condom the last time they had intercourse, and 7% said they were raped.

CDC

The rate of STIs in the United States is rising. There has been a sharp increase in the number of combined diagnoses of gonorrhea, syphilis, and chlamydia, with an increase from 1.8 million in 2013 to 2.3 million cases in 2017, according to the Centers for Disease Control and Prevention. During that same time period, gonorrhea increased 67% from 333,004 to 555,608 cases, syphilis (primary and secondary) rose 76% from 17,375 to 30,644 cases, and chlamydia increased 22% to 1.7 million cases.

According to a 2013 CDC infographic shown by Dr. Straub, young people in the United States aged 15-24 years old represent 27% of the total sexually active population but account for 50% of new STI cases each year. Persons in this population account for 70% of gonorrhea cases, 63% of chlamydia cases, 49% of human papillomavirus (HPV) cases, 45% of genital herpes cases, and 20% of syphilis cases.

CDC

All sexually active females aged 25 years or younger should be screened for chlamydia and gonorrhea, as well as “at-risk” young men who have sex with men (YMSM), Dr. Straub said. All adolescent males and females aged over 13 years should be offered HIV screening, and HIV screening should be discussed “at least once.” And depending on how at risk each subpopulation is, health care providers should be have that conversation and offer screening multiple times.

Women who have sex with women (WSW) are a diverse population and should be treated based on their individual sexual identities, behaviors, and practices. “Most self-identified WSWs report having sex with men, so therefore adolescent WSWs and females with both male and female sex partners might be at increased risk for STIs, such as syphillis, chlamydia, and HPV as well as HIV, so you may want to adjust your screening accordingly,” she said.

Pregnant women, if at risk, should be screened for HIV, syphilis, hepatitis B, gonorrhea, and chlamydia.

CDC/Dr. E. Arum; Dr. N. Jacobs

YMSM should have annual screenings for syphilis and HIV, screenings for chlamydia and gonorrhea by infection site; also consider herpes simplex virus serology and anal cytology in these patients, Dr. Straub said. They also should be screened for hepatitis B surface antigen, vaccinated for hepatitis A, hepatitis B and, if using drugs, screened* for hepatitis C virus.

Dr. Straub recommended licensed health care professionals who may treat minor patients review their state’s laws on minors and their legal ability to consent to treatment of STIs without the involvement of their parent or guardian, including disclosure of positive results and in the case of HIV care.

In places where index insured are allowed to find out about any services a beneficiary receives on their insurance, “this is a little problematic, because in some states, this is in direct conflict with the explanation of benefits requirement,” she said. “There are certain ways to get around that, but it’s really important for you to know what the statutes are where you’re practicing and where the breaches of confidentiality [are].”

Expedited partner therapy, or treating one or multiple partners of patients with an STI, is recommended for certain patients and infections, such as male partners of female patients with chlamydia and gonorrhea. While this is recommended less for YMSM because of a higher rate of concurrent infection, “if you have a young person who has partners who are unlikely to have access to care and get treated, it’s recommended you give that treatment to your index patient and to then treat their partners,” Dr. Straub said.

A recent and frequently updated resource on STI treatment can be found at the CDC website.

Dr. Straub reported no relevant conflicts of interest.

*This article was updated 1/11/19.

ORLANDO – Putting parents at ease, making vaccination the default option during discussions, appealing to their identity as a good parent, and focusing on positive word choice during discussions are the techniques two pediatricians have recommended using to get vaccine-hesitant parents to immunize their children.

Jeff Craven/MDedge News

“Your goal is to get parents to immunize their kids,” Katrina Saba, MD, of the Permanente Medical Group in Oakland, Calif., said during an interactive group panel at the annual meeting of the American Academy of Pediatrics. “Our goal is not to win a debate. You don’t have to correct every mistaken idea.”

“And really importantly, as we know, belief trumps science,” she added. “Their belief is so much stronger than our proof, and their belief will not be changed by evidence.”

Many parents who are vaccine- hesitant also belong to a social network that forms or reinforces their beliefs, and attacking those beliefs is the same as attacking their identity, Dr. Saba noted. “When you attack someone’s identity, you are immediately seen as not like them, and if you’re not like them, you’ve lost your strength in persuading them.”

Dr. Saba; Kenneth Hempstead, MD; and other pediatricians and educators in the Permanente Medical Group developed a framework for pediatricians and educators to talk with their patients about immunization at their center after California passed a law in 2013 that required health care professionals to discuss vaccines with patients and sign off that they had that discussion.

“We felt that, if we were going to be by law required to have that discussion, maybe we needed some new tools to have [the discussion] more effectively,” Dr. Saba said. “Because clearly, [what we were doing ] wasn’t working or there wouldn’t have been a need for that law.”

Jeff Craven/MDedge News

Dr. Hempstead explained the concerns of three major categories of vaccine-hesitant parents: those patients who are unsure of whether they should vaccinate, parents who wish to delay vaccination, and parents who refuse vaccination of their children.

Each parent requires a different approach for discussing the importance of vaccination based on their level of vaccine hesitancy, he said. For parents who are unsure, they may require general information about the safety and importance of vaccines.

Parents who delay immunization may have less trust in vaccines, have done research in their own social networks, and may present alternatives to a standard immunization schedule or want to omit certain vaccines from their child’s immunization schedule, he noted. Using the analogy of a car seat is one approach to identify the importance of vaccination to these parents: “Waiting to give the shots is like putting your baby in the car seat after you’ve already arrived at the store – the protection isn’t there for the most important part of the journey!”

In cases where parents refuse vaccination, you should not expect to change a parent’s mind in a single visit, but instead focus on building the patient-provider bond. However, presenting information the parent may have already seen, such as vaccination data from the Food and Drug Administration or Centers for Disease Control and Prevention, may alienate parents who identify with groups that share vaccine-hesitant viewpoints and erode your ability to persuade a parent’s intent to vaccinate.

A study by Nyhan et al. randomized parents to receive one of four pieces of interventions about the MMR vaccine: information from the CDC explaining the lack of evidence linking autism and the vaccine, information about the dangers of the diseases prevented by the vaccine, images of children who have had diseases prevented by the vaccine, and a “dramatic narrative” from a CDC fact sheet about a child who nearly died of measles. The researchers found no informational intervention helped in persuading to vaccinate in parents who had the “least favorable” attitudes toward the vaccine. And in the case of the dramatic narrative, there was an increased misperception about the MMR vaccine (Pediatrics. 2014;133[4]:e835-e842).

Dr. Hempstead and Dr. Saba outlined four rhetorical devices to include in conversations with patients about vaccination: cognitive ease, natural assumption, appeal to identity, and using advantageous terms.

Cognitive ease

Cognitive ease means creating an environment in which the patient is relaxed, comfortable, and more likely to be agreeable. Recognize when the tone shifts, and strive to maintain this calm and comfortable environment throughout the discussion. “If your blood pressure is coming up, that means theirs is, too,” Dr. Hempstead said.

Natural assumption

How you are offering the vaccination also matters, he added. Rather than asking whether a patient wants to vaccinate (“Have you thought about your flu vaccine this year?”), instead frame the discussion with vaccination as the default option (“Is your child due for a flu vaccination this year? Yes, he is. Let’s get that taken care of today”). Equating inaction with vaccination prevents the risk fallacy phenomenon from occurring in which, when given multiple options, people give equal weight to each option and may choose not to vaccinate, Dr. Hempstead noted.

Dr. Saba cited research that backed this approach. In a study by Opel et al., using a “presumptive” approach instead of a “participatory” approach when discussing a provider’s recommendation to vaccinate helped: The presumptive conversations had an odds ratio of 17.5, compared with the participatory approach. In cases in which parents resisted the provider’s recommendations, 50% of providers persisted with their original recommendations, and 47% of parents who initially resisted the recommendations agreed to vaccinate (Pediatrics. 2013;132[6]:1037-46).
 

Appeal to identity

Another strategy to use is appealing to the patient’s identity as a good parent and link the concept of vaccination with the good parent identity. Forging a new common identity with the parents through common beliefs – such as recognizing that networks to which parents belong are an important part of his or her identify – and reemphasizing the mutual desire to protect the child is another strategy.
 

Using advantageous terms

Positive terms, such as “protection,” “health,” “safety,” and “what’s best,” are much better words to use in conversation with parents and have more staying power than negative terms, like “autism” and “side effects,” Dr. Hempstead said.

“Stay with positive messaging,” he said. “Immediately coming back to the positive impact of this vaccine, why we care so much, why we’re doing this vaccine, is absolutely critical.”

Dr. Hempstead and Dr. Saba reported no relevant conflicts of interest.

ORLANDO – Putting parents at ease, making vaccination the default option during discussions, appealing to their identity as a good parent, and focusing on positive word choice during discussions are the techniques two pediatricians have recommended using to get vaccine-hesitant parents to immunize their children.

Jeff Craven/MDedge News

“Your goal is to get parents to immunize their kids,” Katrina Saba, MD, of the Permanente Medical Group in Oakland, Calif., said during an interactive group panel at the annual meeting of the American Academy of Pediatrics. “Our goal is not to win a debate. You don’t have to correct every mistaken idea.”

“And really importantly, as we know, belief trumps science,” she added. “Their belief is so much stronger than our proof, and their belief will not be changed by evidence.”

Many parents who are vaccine- hesitant also belong to a social network that forms or reinforces their beliefs, and attacking those beliefs is the same as attacking their identity, Dr. Saba noted. “When you attack someone’s identity, you are immediately seen as not like them, and if you’re not like them, you’ve lost your strength in persuading them.”

Dr. Saba; Kenneth Hempstead, MD; and other pediatricians and educators in the Permanente Medical Group developed a framework for pediatricians and educators to talk with their patients about immunization at their center after California passed a law in 2013 that required health care professionals to discuss vaccines with patients and sign off that they had that discussion.

“We felt that, if we were going to be by law required to have that discussion, maybe we needed some new tools to have [the discussion] more effectively,” Dr. Saba said. “Because clearly, [what we were doing ] wasn’t working or there wouldn’t have been a need for that law.”

Jeff Craven/MDedge News

Dr. Hempstead explained the concerns of three major categories of vaccine-hesitant parents: those patients who are unsure of whether they should vaccinate, parents who wish to delay vaccination, and parents who refuse vaccination of their children.

Each parent requires a different approach for discussing the importance of vaccination based on their level of vaccine hesitancy, he said. For parents who are unsure, they may require general information about the safety and importance of vaccines.

Parents who delay immunization may have less trust in vaccines, have done research in their own social networks, and may present alternatives to a standard immunization schedule or want to omit certain vaccines from their child’s immunization schedule, he noted. Using the analogy of a car seat is one approach to identify the importance of vaccination to these parents: “Waiting to give the shots is like putting your baby in the car seat after you’ve already arrived at the store – the protection isn’t there for the most important part of the journey!”

In cases where parents refuse vaccination, you should not expect to change a parent’s mind in a single visit, but instead focus on building the patient-provider bond. However, presenting information the parent may have already seen, such as vaccination data from the Food and Drug Administration or Centers for Disease Control and Prevention, may alienate parents who identify with groups that share vaccine-hesitant viewpoints and erode your ability to persuade a parent’s intent to vaccinate.

A study by Nyhan et al. randomized parents to receive one of four pieces of interventions about the MMR vaccine: information from the CDC explaining the lack of evidence linking autism and the vaccine, information about the dangers of the diseases prevented by the vaccine, images of children who have had diseases prevented by the vaccine, and a “dramatic narrative” from a CDC fact sheet about a child who nearly died of measles. The researchers found no informational intervention helped in persuading to vaccinate in parents who had the “least favorable” attitudes toward the vaccine. And in the case of the dramatic narrative, there was an increased misperception about the MMR vaccine (Pediatrics. 2014;133[4]:e835-e842).

Dr. Hempstead and Dr. Saba outlined four rhetorical devices to include in conversations with patients about vaccination: cognitive ease, natural assumption, appeal to identity, and using advantageous terms.

Cognitive ease

Cognitive ease means creating an environment in which the patient is relaxed, comfortable, and more likely to be agreeable. Recognize when the tone shifts, and strive to maintain this calm and comfortable environment throughout the discussion. “If your blood pressure is coming up, that means theirs is, too,” Dr. Hempstead said.

Natural assumption

How you are offering the vaccination also matters, he added. Rather than asking whether a patient wants to vaccinate (“Have you thought about your flu vaccine this year?”), instead frame the discussion with vaccination as the default option (“Is your child due for a flu vaccination this year? Yes, he is. Let’s get that taken care of today”). Equating inaction with vaccination prevents the risk fallacy phenomenon from occurring in which, when given multiple options, people give equal weight to each option and may choose not to vaccinate, Dr. Hempstead noted.

Dr. Saba cited research that backed this approach. In a study by Opel et al., using a “presumptive” approach instead of a “participatory” approach when discussing a provider’s recommendation to vaccinate helped: The presumptive conversations had an odds ratio of 17.5, compared with the participatory approach. In cases in which parents resisted the provider’s recommendations, 50% of providers persisted with their original recommendations, and 47% of parents who initially resisted the recommendations agreed to vaccinate (Pediatrics. 2013;132[6]:1037-46).
 

Appeal to identity

Another strategy to use is appealing to the patient’s identity as a good parent and link the concept of vaccination with the good parent identity. Forging a new common identity with the parents through common beliefs – such as recognizing that networks to which parents belong are an important part of his or her identify – and reemphasizing the mutual desire to protect the child is another strategy.
 

Using advantageous terms

Positive terms, such as “protection,” “health,” “safety,” and “what’s best,” are much better words to use in conversation with parents and have more staying power than negative terms, like “autism” and “side effects,” Dr. Hempstead said.

“Stay with positive messaging,” he said. “Immediately coming back to the positive impact of this vaccine, why we care so much, why we’re doing this vaccine, is absolutely critical.”

Dr. Hempstead and Dr. Saba reported no relevant conflicts of interest.

ORLANDO – Putting parents at ease, making vaccination the default option during discussions, appealing to their identity as a good parent, and focusing on positive word choice during discussions are the techniques two pediatricians have recommended using to get vaccine-hesitant parents to immunize their children.

Jeff Craven/MDedge News

“Your goal is to get parents to immunize their kids,” Katrina Saba, MD, of the Permanente Medical Group in Oakland, Calif., said during an interactive group panel at the annual meeting of the American Academy of Pediatrics. “Our goal is not to win a debate. You don’t have to correct every mistaken idea.”

“And really importantly, as we know, belief trumps science,” she added. “Their belief is so much stronger than our proof, and their belief will not be changed by evidence.”

Many parents who are vaccine- hesitant also belong to a social network that forms or reinforces their beliefs, and attacking those beliefs is the same as attacking their identity, Dr. Saba noted. “When you attack someone’s identity, you are immediately seen as not like them, and if you’re not like them, you’ve lost your strength in persuading them.”

Dr. Saba; Kenneth Hempstead, MD; and other pediatricians and educators in the Permanente Medical Group developed a framework for pediatricians and educators to talk with their patients about immunization at their center after California passed a law in 2013 that required health care professionals to discuss vaccines with patients and sign off that they had that discussion.

“We felt that, if we were going to be by law required to have that discussion, maybe we needed some new tools to have [the discussion] more effectively,” Dr. Saba said. “Because clearly, [what we were doing ] wasn’t working or there wouldn’t have been a need for that law.”

Jeff Craven/MDedge News

Dr. Hempstead explained the concerns of three major categories of vaccine-hesitant parents: those patients who are unsure of whether they should vaccinate, parents who wish to delay vaccination, and parents who refuse vaccination of their children.

Each parent requires a different approach for discussing the importance of vaccination based on their level of vaccine hesitancy, he said. For parents who are unsure, they may require general information about the safety and importance of vaccines.

Parents who delay immunization may have less trust in vaccines, have done research in their own social networks, and may present alternatives to a standard immunization schedule or want to omit certain vaccines from their child’s immunization schedule, he noted. Using the analogy of a car seat is one approach to identify the importance of vaccination to these parents: “Waiting to give the shots is like putting your baby in the car seat after you’ve already arrived at the store – the protection isn’t there for the most important part of the journey!”

In cases where parents refuse vaccination, you should not expect to change a parent’s mind in a single visit, but instead focus on building the patient-provider bond. However, presenting information the parent may have already seen, such as vaccination data from the Food and Drug Administration or Centers for Disease Control and Prevention, may alienate parents who identify with groups that share vaccine-hesitant viewpoints and erode your ability to persuade a parent’s intent to vaccinate.

A study by Nyhan et al. randomized parents to receive one of four pieces of interventions about the MMR vaccine: information from the CDC explaining the lack of evidence linking autism and the vaccine, information about the dangers of the diseases prevented by the vaccine, images of children who have had diseases prevented by the vaccine, and a “dramatic narrative” from a CDC fact sheet about a child who nearly died of measles. The researchers found no informational intervention helped in persuading to vaccinate in parents who had the “least favorable” attitudes toward the vaccine. And in the case of the dramatic narrative, there was an increased misperception about the MMR vaccine (Pediatrics. 2014;133[4]:e835-e842).

Dr. Hempstead and Dr. Saba outlined four rhetorical devices to include in conversations with patients about vaccination: cognitive ease, natural assumption, appeal to identity, and using advantageous terms.

Cognitive ease

Cognitive ease means creating an environment in which the patient is relaxed, comfortable, and more likely to be agreeable. Recognize when the tone shifts, and strive to maintain this calm and comfortable environment throughout the discussion. “If your blood pressure is coming up, that means theirs is, too,” Dr. Hempstead said.

Natural assumption

How you are offering the vaccination also matters, he added. Rather than asking whether a patient wants to vaccinate (“Have you thought about your flu vaccine this year?”), instead frame the discussion with vaccination as the default option (“Is your child due for a flu vaccination this year? Yes, he is. Let’s get that taken care of today”). Equating inaction with vaccination prevents the risk fallacy phenomenon from occurring in which, when given multiple options, people give equal weight to each option and may choose not to vaccinate, Dr. Hempstead noted.

Dr. Saba cited research that backed this approach. In a study by Opel et al., using a “presumptive” approach instead of a “participatory” approach when discussing a provider’s recommendation to vaccinate helped: The presumptive conversations had an odds ratio of 17.5, compared with the participatory approach. In cases in which parents resisted the provider’s recommendations, 50% of providers persisted with their original recommendations, and 47% of parents who initially resisted the recommendations agreed to vaccinate (Pediatrics. 2013;132[6]:1037-46).
 

Appeal to identity

Another strategy to use is appealing to the patient’s identity as a good parent and link the concept of vaccination with the good parent identity. Forging a new common identity with the parents through common beliefs – such as recognizing that networks to which parents belong are an important part of his or her identify – and reemphasizing the mutual desire to protect the child is another strategy.
 

Using advantageous terms

Positive terms, such as “protection,” “health,” “safety,” and “what’s best,” are much better words to use in conversation with parents and have more staying power than negative terms, like “autism” and “side effects,” Dr. Hempstead said.

“Stay with positive messaging,” he said. “Immediately coming back to the positive impact of this vaccine, why we care so much, why we’re doing this vaccine, is absolutely critical.”

Dr. Hempstead and Dr. Saba reported no relevant conflicts of interest.

CHICAGO – New draft guidelines for treating juvenile idiopathic arthritis (JIA) written by experts assembled by the American College of Rheumatology “formalize inactive disease as the goal of treatment,” Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology.

Mitchel L. Zoler/MDedge News

“We defined low disease activity as patients with a single active joint, and the goal is to have zero active joints. Low disease activity should not be tolerated” in patients with JIA, said Dr. Beukelman, a pediatric rheumatologist at the University of Alabama at Birmingham and a member of the guideline-writing committee. “Until now, treating these patients to zero active joints has not been recommended. But clinically inactive disease is a realistic target for a majority of JIA patients,” he said in an interview.

Despite this shift in the recommended treatment goal, the writing panel was forced to rely largely on their expertise rather than reported evidence. The recommendation by the committee to escalate therapy in patients with low disease activity was “conditional,” with a level of evidence deemed “very low,” Dr. Beukelman said during a talk in which he cited selected highlights from the committee’s full list of 39 recommendations.

The paucity of evidence reflected the status of many of the recommendations: 31 of the 39 recommendations were conditional, which means that the desirable effects from treatment “probably” outweigh the undesirable effects, and they may not apply to some patients. The writing panel pegged 22 of their recommendations as having a very low evidence backing and another 13 recommendations had low evidence. The JIA committee believed that none of its recommendations had strong evidence to back them up.

Dr. Beukelman defended writing recommendations despite this absence of evidence. “We should continue to write conditional recommendations when we don’t have the evidence. These recommendations had approval from at least 70% of the writing group, a diverse committee of experts. They should not be taken lightly just because they are conditional.”

Dr. Beukelman also stressed that he was presenting draft recommendations that still awaited approval from the ACR and the Arthritis Foundation, which collaborated with the ACR on this project. Once adopted, the new document would revise the existing management recommendations that the ACR approved in 2011 (Arthritis Rheum. 2011 Apr;63[4]:465-82).

The recommendations Dr. Beukelman outlined focused on treatment of polyarthritis, sacroiliitis, and enthesitis, and Dr. Beukelman devoted the most time to detailing some of the statements on polyarthritis. The panel conditionally recommended methotrexate over leflunomide (Arava) or sulfasalazine with moderate or very low evidence and said that subcutaneous methotrexate was conditionally preferred over oral dosing for reasons of both better efficacy and tolerability. Combination of a biologic agent with a nonbiologic received a conditional recommendation over biologic monotherapy, with moderate to very low evidence, but with a strong recommendation for this combined approach when using infliximab (Remicade), based on moderate evidence.

Another strong recommendation was to avoid treating patients with a chronic course of a low-dose, systemic glucocorticoid, based on a very low level of evidence. A brief course, less than 3 months, of an oral glucocorticoid received conditional recommendation for patients with moderate or high disease activity, based on very low evidence, but also received a conditional negative recommendation for patients with low disease activity, also based on very low evidence.

Initial therapy with a disease-modifying antirheumatic drug (DMARD) instead of monotherapy with an NSAID received a strong recommendation, based on a moderate level of evidence, while initial therapy with a DMARD received conditional support over initial therapy with a biologic agent, based on low evidence.

The panel gave a conditional endorsement to the idea of switching from a tumor necrosis factor inhibitor (TNFi) to a different biologic drug class when patients remained with moderate or high disease activity, based on a very low level of evidence.

Regarding sacroiliitis, the panel strongly recommended starting a TNFi in patients with active sacroiliitis despite NSAID treatment, based on low evidence, and the committee strongly recommended against starting methotrexate treatment in these patients, based on very low evidence. For treating active enthesitis despite NSAID treatment, the panel conditionally recommended adding a TNFi over treatment with methotrexate or sulfasalazine, based on a low level of evidence. Dr. Beukelman highlighted that the new recommendations placed increased emphasis on treating sacroiliitis, compared with the 2011 statement, and that the new recommendations dealt with treating enthesitis for the first time.

Dr. Beukelman has been a consultant to Bristol-Myers Squibb, Novartis, Sobi, and UCB.

mzoler@mdedge.com

CHICAGO – New draft guidelines for treating juvenile idiopathic arthritis (JIA) written by experts assembled by the American College of Rheumatology “formalize inactive disease as the goal of treatment,” Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology.

Mitchel L. Zoler/MDedge News

“We defined low disease activity as patients with a single active joint, and the goal is to have zero active joints. Low disease activity should not be tolerated” in patients with JIA, said Dr. Beukelman, a pediatric rheumatologist at the University of Alabama at Birmingham and a member of the guideline-writing committee. “Until now, treating these patients to zero active joints has not been recommended. But clinically inactive disease is a realistic target for a majority of JIA patients,” he said in an interview.

Despite this shift in the recommended treatment goal, the writing panel was forced to rely largely on their expertise rather than reported evidence. The recommendation by the committee to escalate therapy in patients with low disease activity was “conditional,” with a level of evidence deemed “very low,” Dr. Beukelman said during a talk in which he cited selected highlights from the committee’s full list of 39 recommendations.

The paucity of evidence reflected the status of many of the recommendations: 31 of the 39 recommendations were conditional, which means that the desirable effects from treatment “probably” outweigh the undesirable effects, and they may not apply to some patients. The writing panel pegged 22 of their recommendations as having a very low evidence backing and another 13 recommendations had low evidence. The JIA committee believed that none of its recommendations had strong evidence to back them up.

Dr. Beukelman defended writing recommendations despite this absence of evidence. “We should continue to write conditional recommendations when we don’t have the evidence. These recommendations had approval from at least 70% of the writing group, a diverse committee of experts. They should not be taken lightly just because they are conditional.”

Dr. Beukelman also stressed that he was presenting draft recommendations that still awaited approval from the ACR and the Arthritis Foundation, which collaborated with the ACR on this project. Once adopted, the new document would revise the existing management recommendations that the ACR approved in 2011 (Arthritis Rheum. 2011 Apr;63[4]:465-82).

The recommendations Dr. Beukelman outlined focused on treatment of polyarthritis, sacroiliitis, and enthesitis, and Dr. Beukelman devoted the most time to detailing some of the statements on polyarthritis. The panel conditionally recommended methotrexate over leflunomide (Arava) or sulfasalazine with moderate or very low evidence and said that subcutaneous methotrexate was conditionally preferred over oral dosing for reasons of both better efficacy and tolerability. Combination of a biologic agent with a nonbiologic received a conditional recommendation over biologic monotherapy, with moderate to very low evidence, but with a strong recommendation for this combined approach when using infliximab (Remicade), based on moderate evidence.

Another strong recommendation was to avoid treating patients with a chronic course of a low-dose, systemic glucocorticoid, based on a very low level of evidence. A brief course, less than 3 months, of an oral glucocorticoid received conditional recommendation for patients with moderate or high disease activity, based on very low evidence, but also received a conditional negative recommendation for patients with low disease activity, also based on very low evidence.

Initial therapy with a disease-modifying antirheumatic drug (DMARD) instead of monotherapy with an NSAID received a strong recommendation, based on a moderate level of evidence, while initial therapy with a DMARD received conditional support over initial therapy with a biologic agent, based on low evidence.

The panel gave a conditional endorsement to the idea of switching from a tumor necrosis factor inhibitor (TNFi) to a different biologic drug class when patients remained with moderate or high disease activity, based on a very low level of evidence.

Regarding sacroiliitis, the panel strongly recommended starting a TNFi in patients with active sacroiliitis despite NSAID treatment, based on low evidence, and the committee strongly recommended against starting methotrexate treatment in these patients, based on very low evidence. For treating active enthesitis despite NSAID treatment, the panel conditionally recommended adding a TNFi over treatment with methotrexate or sulfasalazine, based on a low level of evidence. Dr. Beukelman highlighted that the new recommendations placed increased emphasis on treating sacroiliitis, compared with the 2011 statement, and that the new recommendations dealt with treating enthesitis for the first time.

Dr. Beukelman has been a consultant to Bristol-Myers Squibb, Novartis, Sobi, and UCB.

mzoler@mdedge.com

CHICAGO – New draft guidelines for treating juvenile idiopathic arthritis (JIA) written by experts assembled by the American College of Rheumatology “formalize inactive disease as the goal of treatment,” Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology.

Mitchel L. Zoler/MDedge News

“We defined low disease activity as patients with a single active joint, and the goal is to have zero active joints. Low disease activity should not be tolerated” in patients with JIA, said Dr. Beukelman, a pediatric rheumatologist at the University of Alabama at Birmingham and a member of the guideline-writing committee. “Until now, treating these patients to zero active joints has not been recommended. But clinically inactive disease is a realistic target for a majority of JIA patients,” he said in an interview.

Despite this shift in the recommended treatment goal, the writing panel was forced to rely largely on their expertise rather than reported evidence. The recommendation by the committee to escalate therapy in patients with low disease activity was “conditional,” with a level of evidence deemed “very low,” Dr. Beukelman said during a talk in which he cited selected highlights from the committee’s full list of 39 recommendations.

The paucity of evidence reflected the status of many of the recommendations: 31 of the 39 recommendations were conditional, which means that the desirable effects from treatment “probably” outweigh the undesirable effects, and they may not apply to some patients. The writing panel pegged 22 of their recommendations as having a very low evidence backing and another 13 recommendations had low evidence. The JIA committee believed that none of its recommendations had strong evidence to back them up.

Dr. Beukelman defended writing recommendations despite this absence of evidence. “We should continue to write conditional recommendations when we don’t have the evidence. These recommendations had approval from at least 70% of the writing group, a diverse committee of experts. They should not be taken lightly just because they are conditional.”

Dr. Beukelman also stressed that he was presenting draft recommendations that still awaited approval from the ACR and the Arthritis Foundation, which collaborated with the ACR on this project. Once adopted, the new document would revise the existing management recommendations that the ACR approved in 2011 (Arthritis Rheum. 2011 Apr;63[4]:465-82).

The recommendations Dr. Beukelman outlined focused on treatment of polyarthritis, sacroiliitis, and enthesitis, and Dr. Beukelman devoted the most time to detailing some of the statements on polyarthritis. The panel conditionally recommended methotrexate over leflunomide (Arava) or sulfasalazine with moderate or very low evidence and said that subcutaneous methotrexate was conditionally preferred over oral dosing for reasons of both better efficacy and tolerability. Combination of a biologic agent with a nonbiologic received a conditional recommendation over biologic monotherapy, with moderate to very low evidence, but with a strong recommendation for this combined approach when using infliximab (Remicade), based on moderate evidence.

Another strong recommendation was to avoid treating patients with a chronic course of a low-dose, systemic glucocorticoid, based on a very low level of evidence. A brief course, less than 3 months, of an oral glucocorticoid received conditional recommendation for patients with moderate or high disease activity, based on very low evidence, but also received a conditional negative recommendation for patients with low disease activity, also based on very low evidence.

Initial therapy with a disease-modifying antirheumatic drug (DMARD) instead of monotherapy with an NSAID received a strong recommendation, based on a moderate level of evidence, while initial therapy with a DMARD received conditional support over initial therapy with a biologic agent, based on low evidence.

The panel gave a conditional endorsement to the idea of switching from a tumor necrosis factor inhibitor (TNFi) to a different biologic drug class when patients remained with moderate or high disease activity, based on a very low level of evidence.

Regarding sacroiliitis, the panel strongly recommended starting a TNFi in patients with active sacroiliitis despite NSAID treatment, based on low evidence, and the committee strongly recommended against starting methotrexate treatment in these patients, based on very low evidence. For treating active enthesitis despite NSAID treatment, the panel conditionally recommended adding a TNFi over treatment with methotrexate or sulfasalazine, based on a low level of evidence. Dr. Beukelman highlighted that the new recommendations placed increased emphasis on treating sacroiliitis, compared with the 2011 statement, and that the new recommendations dealt with treating enthesitis for the first time.

Dr. Beukelman has been a consultant to Bristol-Myers Squibb, Novartis, Sobi, and UCB.

mzoler@mdedge.com

CHICAGO—Use of the CDC case definition for acute flaccid myelitis may lead to misdiagnosis in patients with other conditions, according to research presented at the 47th Annual Meeting of the Child Neurology Society. A review of 45 reported cases of acute flaccid myelitis found that 12 of the patients had other diseases, such as polyradiculoneuropathy, transverse myelitis, spinal cord ischemia, clinically isolated syndrome, meningitis, and myelopathy due to severe Chiari I malformation, said Matthew Elrick, MD, PhD, Clinical Fellow in Neurology at Johns Hopkins Hospital in Baltimore, and colleagues.

Acute flaccid myelitis is a polio-like illness of acute spinal motor neuron injury following viral infection. Recent outbreaks have been reported, but clinical diagnostic criteria are lacking. Clinical characteristics may help differentiate acute flaccid myelitis from other causes of myelopathy, Dr. Elrick said.

Dr. Elrick and colleagues analyzed cases from two patient cohorts. One cohort included patients who were recruited nationwide based on the CDC case definition of acute flaccid myelitis. The other cohort included patients who were referred to the Johns Hopkins Transverse Myelitis Center and received a diagnosis of acute flaccid myelitis. The researchers reviewed patients’ records and imaging data. An independent neurologist reviewed a subset of cases to confirm inter-rater reliability. Characteristics that differed significantly between patients with and without acute flaccid myelitis were used to build a clinical scoring system.

The CDC case definition includes clinical criteria (ie, an illness with onset of acute flaccid limb weakness), confirmatory laboratory evidence (ie, MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more vertebral segments), and supportive laboratory evidence (ie, CSF with pleocytosis). Clinically compatible cases with confirmatory laboratory evidence are considered confirmed, and clinically compatible cases with supportive laboratory evidence are considered probable.

The investigators based their proposed criteria on the physiologic understanding of acute flaccid myelitis as a disease of the motor neuron with features similar to those of poliomyelitis. They refined the criteria based on features commonly seen in apparent cases (eg, weakness involving the limbs, neck, face, or bulbar muscles and prodromal illness with fever, respiratory symptoms, or gastrointestinal symptoms). In addition, they incorporated rule-out criteria to exclude mimics.

Based on the results of their analysis, they developed a clinical scoring system to aid in the bedside diagnosis of acute flaccid myelitis by considering features such as asymmetric onset, decreased tone, and absence of increased tone.

The proposed criteria and clinical scoring system require validation and may be updated in light of data from recent cases of acute flaccid myelitis, Dr. Elrick said.

CHICAGO—Use of the CDC case definition for acute flaccid myelitis may lead to misdiagnosis in patients with other conditions, according to research presented at the 47th Annual Meeting of the Child Neurology Society. A review of 45 reported cases of acute flaccid myelitis found that 12 of the patients had other diseases, such as polyradiculoneuropathy, transverse myelitis, spinal cord ischemia, clinically isolated syndrome, meningitis, and myelopathy due to severe Chiari I malformation, said Matthew Elrick, MD, PhD, Clinical Fellow in Neurology at Johns Hopkins Hospital in Baltimore, and colleagues.

Acute flaccid myelitis is a polio-like illness of acute spinal motor neuron injury following viral infection. Recent outbreaks have been reported, but clinical diagnostic criteria are lacking. Clinical characteristics may help differentiate acute flaccid myelitis from other causes of myelopathy, Dr. Elrick said.

Dr. Elrick and colleagues analyzed cases from two patient cohorts. One cohort included patients who were recruited nationwide based on the CDC case definition of acute flaccid myelitis. The other cohort included patients who were referred to the Johns Hopkins Transverse Myelitis Center and received a diagnosis of acute flaccid myelitis. The researchers reviewed patients’ records and imaging data. An independent neurologist reviewed a subset of cases to confirm inter-rater reliability. Characteristics that differed significantly between patients with and without acute flaccid myelitis were used to build a clinical scoring system.

The CDC case definition includes clinical criteria (ie, an illness with onset of acute flaccid limb weakness), confirmatory laboratory evidence (ie, MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more vertebral segments), and supportive laboratory evidence (ie, CSF with pleocytosis). Clinically compatible cases with confirmatory laboratory evidence are considered confirmed, and clinically compatible cases with supportive laboratory evidence are considered probable.

The investigators based their proposed criteria on the physiologic understanding of acute flaccid myelitis as a disease of the motor neuron with features similar to those of poliomyelitis. They refined the criteria based on features commonly seen in apparent cases (eg, weakness involving the limbs, neck, face, or bulbar muscles and prodromal illness with fever, respiratory symptoms, or gastrointestinal symptoms). In addition, they incorporated rule-out criteria to exclude mimics.

Based on the results of their analysis, they developed a clinical scoring system to aid in the bedside diagnosis of acute flaccid myelitis by considering features such as asymmetric onset, decreased tone, and absence of increased tone.

The proposed criteria and clinical scoring system require validation and may be updated in light of data from recent cases of acute flaccid myelitis, Dr. Elrick said.

CHICAGO—Use of the CDC case definition for acute flaccid myelitis may lead to misdiagnosis in patients with other conditions, according to research presented at the 47th Annual Meeting of the Child Neurology Society. A review of 45 reported cases of acute flaccid myelitis found that 12 of the patients had other diseases, such as polyradiculoneuropathy, transverse myelitis, spinal cord ischemia, clinically isolated syndrome, meningitis, and myelopathy due to severe Chiari I malformation, said Matthew Elrick, MD, PhD, Clinical Fellow in Neurology at Johns Hopkins Hospital in Baltimore, and colleagues.

Acute flaccid myelitis is a polio-like illness of acute spinal motor neuron injury following viral infection. Recent outbreaks have been reported, but clinical diagnostic criteria are lacking. Clinical characteristics may help differentiate acute flaccid myelitis from other causes of myelopathy, Dr. Elrick said.

Dr. Elrick and colleagues analyzed cases from two patient cohorts. One cohort included patients who were recruited nationwide based on the CDC case definition of acute flaccid myelitis. The other cohort included patients who were referred to the Johns Hopkins Transverse Myelitis Center and received a diagnosis of acute flaccid myelitis. The researchers reviewed patients’ records and imaging data. An independent neurologist reviewed a subset of cases to confirm inter-rater reliability. Characteristics that differed significantly between patients with and without acute flaccid myelitis were used to build a clinical scoring system.

The CDC case definition includes clinical criteria (ie, an illness with onset of acute flaccid limb weakness), confirmatory laboratory evidence (ie, MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more vertebral segments), and supportive laboratory evidence (ie, CSF with pleocytosis). Clinically compatible cases with confirmatory laboratory evidence are considered confirmed, and clinically compatible cases with supportive laboratory evidence are considered probable.

The investigators based their proposed criteria on the physiologic understanding of acute flaccid myelitis as a disease of the motor neuron with features similar to those of poliomyelitis. They refined the criteria based on features commonly seen in apparent cases (eg, weakness involving the limbs, neck, face, or bulbar muscles and prodromal illness with fever, respiratory symptoms, or gastrointestinal symptoms). In addition, they incorporated rule-out criteria to exclude mimics.

Based on the results of their analysis, they developed a clinical scoring system to aid in the bedside diagnosis of acute flaccid myelitis by considering features such as asymmetric onset, decreased tone, and absence of increased tone.

The proposed criteria and clinical scoring system require validation and may be updated in light of data from recent cases of acute flaccid myelitis, Dr. Elrick said.