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Liquid nicotine for e-cigarettes may poison young children
said Preethi Govindarajan of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and his associates.
Since January 2015, pediatric exposures to liquid nicotine have decreased, which may be attributable to legislation requiring child-resistant packaging for liquid nicotine containers and also greater public awareness of the risks associated with e-cigarette products, they noted.
There was a significant increase in the monthly number of liquid nicotine exposures of 2,390% (P less than .001) from November 2012 through January 2015, and a significant decrease of 48% (P less than .001) from January 2015 through April 2017. “From August 2016 (175 exposures), the first month after the federal Child Nicotine Poisoning Prevention Act went into effect, to April 2017 (142 exposures), there was an 18.9% decrease in the number of monthly liquid nicotine exposures,” Mr. Govindarajan and his associates said.
“Child-resistant e-cigarette devices, use of flow restrictors on liquid nicotine containers, and regulations on e-cigarette liquid flavoring, labeling, and concentrations could further reduce the incidence of these exposures and the likelihood of serious medical outcomes when exposures do occur,” they concluded.
SOURCE: Govindarajan P et al. Pediatrics. 2018;141(5):e20173361.
said Preethi Govindarajan of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and his associates.
Since January 2015, pediatric exposures to liquid nicotine have decreased, which may be attributable to legislation requiring child-resistant packaging for liquid nicotine containers and also greater public awareness of the risks associated with e-cigarette products, they noted.
There was a significant increase in the monthly number of liquid nicotine exposures of 2,390% (P less than .001) from November 2012 through January 2015, and a significant decrease of 48% (P less than .001) from January 2015 through April 2017. “From August 2016 (175 exposures), the first month after the federal Child Nicotine Poisoning Prevention Act went into effect, to April 2017 (142 exposures), there was an 18.9% decrease in the number of monthly liquid nicotine exposures,” Mr. Govindarajan and his associates said.
“Child-resistant e-cigarette devices, use of flow restrictors on liquid nicotine containers, and regulations on e-cigarette liquid flavoring, labeling, and concentrations could further reduce the incidence of these exposures and the likelihood of serious medical outcomes when exposures do occur,” they concluded.
SOURCE: Govindarajan P et al. Pediatrics. 2018;141(5):e20173361.
said Preethi Govindarajan of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and his associates.
Since January 2015, pediatric exposures to liquid nicotine have decreased, which may be attributable to legislation requiring child-resistant packaging for liquid nicotine containers and also greater public awareness of the risks associated with e-cigarette products, they noted.
There was a significant increase in the monthly number of liquid nicotine exposures of 2,390% (P less than .001) from November 2012 through January 2015, and a significant decrease of 48% (P less than .001) from January 2015 through April 2017. “From August 2016 (175 exposures), the first month after the federal Child Nicotine Poisoning Prevention Act went into effect, to April 2017 (142 exposures), there was an 18.9% decrease in the number of monthly liquid nicotine exposures,” Mr. Govindarajan and his associates said.
“Child-resistant e-cigarette devices, use of flow restrictors on liquid nicotine containers, and regulations on e-cigarette liquid flavoring, labeling, and concentrations could further reduce the incidence of these exposures and the likelihood of serious medical outcomes when exposures do occur,” they concluded.
SOURCE: Govindarajan P et al. Pediatrics. 2018;141(5):e20173361.
Nickel allergy common in children, significantly higher in girls
said Erin M. Warshaw, MD, MS, of the University of Minnesota, Minneapolis, and her associates.
“Although nickel sensitivity is reported to be problematic in children, the pediatric population is often underrepresented in large-scale epidemiologic studies,” they added.
In this retrospective, cross-sectional study of 1,894 children aged 18 years or younger tested by the North American Contact Dermatitis Group (NACDG) between 1994 and 2014, 23.7% of those patch tested were found to be sensitive to nickel. This included 6.5% who were 5 years or younger, 34.2% who were 6-12 years, and 59.4% who were 13-18 years.
Among all three patient groups, jewelry was the most common source of nickel sensitivity (36.4%), and this sensitivity was found to increase with age (5 years and younger, 20.7%; 6-12 years, 28.3%; and 13-18 years, 42.9%; P = .0006).
More than two-thirds of positive patch test reactions to nickel were found to be extreme or strong, Dr. Warshaw and her colleagues reported in the Journal of the American Academy of Dermatology.
Notably, girls were significantly more likely to exhibit nickel sensitivity than boys, a result the authors credit to “trends and social norms. ”
Citing a separate study conducted recently by NACDG on the correlation between piercing and nickel sensitivity across all ages, researchers found that females were significantly more likely to have piercings than were males, and with age, they speculated, “girls may be more likely to encounter high nickel release through piercing jewelry, bracelets, necklaces, hair clips, etc., resulting in higher proportions of girls than boys with nickel allergy.”
Nickel release, not nickel content, is an important factor in cases of nickel allergic contact dermatitis, the authors added. For nickel release to occur, prolonged skin contact is required. According to the European Chemicals Agency, prolonged exposure is defined as more than 10 minutes over three or more occasions within a 2-week period or more than 30 minutes over one or more occasion within the same 2 weeks.
The research was funded by the Minneapolis Veterans Affairs Medical Center, and in part, by the Nickel Producers Environmental Research Association. Three of the researchers have ties to various pharmaceutical companies and other organizations. Dr. Warshaw and the remaining researchers had no relevant financial disclosures.
SOURCE: Warshaw EM et al. J Am Acad Dermatol. 2018 Apr 14. doi: 10.1016/j.jaad.2018.02.071.
said Erin M. Warshaw, MD, MS, of the University of Minnesota, Minneapolis, and her associates.
“Although nickel sensitivity is reported to be problematic in children, the pediatric population is often underrepresented in large-scale epidemiologic studies,” they added.
In this retrospective, cross-sectional study of 1,894 children aged 18 years or younger tested by the North American Contact Dermatitis Group (NACDG) between 1994 and 2014, 23.7% of those patch tested were found to be sensitive to nickel. This included 6.5% who were 5 years or younger, 34.2% who were 6-12 years, and 59.4% who were 13-18 years.
Among all three patient groups, jewelry was the most common source of nickel sensitivity (36.4%), and this sensitivity was found to increase with age (5 years and younger, 20.7%; 6-12 years, 28.3%; and 13-18 years, 42.9%; P = .0006).
More than two-thirds of positive patch test reactions to nickel were found to be extreme or strong, Dr. Warshaw and her colleagues reported in the Journal of the American Academy of Dermatology.
Notably, girls were significantly more likely to exhibit nickel sensitivity than boys, a result the authors credit to “trends and social norms. ”
Citing a separate study conducted recently by NACDG on the correlation between piercing and nickel sensitivity across all ages, researchers found that females were significantly more likely to have piercings than were males, and with age, they speculated, “girls may be more likely to encounter high nickel release through piercing jewelry, bracelets, necklaces, hair clips, etc., resulting in higher proportions of girls than boys with nickel allergy.”
Nickel release, not nickel content, is an important factor in cases of nickel allergic contact dermatitis, the authors added. For nickel release to occur, prolonged skin contact is required. According to the European Chemicals Agency, prolonged exposure is defined as more than 10 minutes over three or more occasions within a 2-week period or more than 30 minutes over one or more occasion within the same 2 weeks.
The research was funded by the Minneapolis Veterans Affairs Medical Center, and in part, by the Nickel Producers Environmental Research Association. Three of the researchers have ties to various pharmaceutical companies and other organizations. Dr. Warshaw and the remaining researchers had no relevant financial disclosures.
SOURCE: Warshaw EM et al. J Am Acad Dermatol. 2018 Apr 14. doi: 10.1016/j.jaad.2018.02.071.
said Erin M. Warshaw, MD, MS, of the University of Minnesota, Minneapolis, and her associates.
“Although nickel sensitivity is reported to be problematic in children, the pediatric population is often underrepresented in large-scale epidemiologic studies,” they added.
In this retrospective, cross-sectional study of 1,894 children aged 18 years or younger tested by the North American Contact Dermatitis Group (NACDG) between 1994 and 2014, 23.7% of those patch tested were found to be sensitive to nickel. This included 6.5% who were 5 years or younger, 34.2% who were 6-12 years, and 59.4% who were 13-18 years.
Among all three patient groups, jewelry was the most common source of nickel sensitivity (36.4%), and this sensitivity was found to increase with age (5 years and younger, 20.7%; 6-12 years, 28.3%; and 13-18 years, 42.9%; P = .0006).
More than two-thirds of positive patch test reactions to nickel were found to be extreme or strong, Dr. Warshaw and her colleagues reported in the Journal of the American Academy of Dermatology.
Notably, girls were significantly more likely to exhibit nickel sensitivity than boys, a result the authors credit to “trends and social norms. ”
Citing a separate study conducted recently by NACDG on the correlation between piercing and nickel sensitivity across all ages, researchers found that females were significantly more likely to have piercings than were males, and with age, they speculated, “girls may be more likely to encounter high nickel release through piercing jewelry, bracelets, necklaces, hair clips, etc., resulting in higher proportions of girls than boys with nickel allergy.”
Nickel release, not nickel content, is an important factor in cases of nickel allergic contact dermatitis, the authors added. For nickel release to occur, prolonged skin contact is required. According to the European Chemicals Agency, prolonged exposure is defined as more than 10 minutes over three or more occasions within a 2-week period or more than 30 minutes over one or more occasion within the same 2 weeks.
The research was funded by the Minneapolis Veterans Affairs Medical Center, and in part, by the Nickel Producers Environmental Research Association. Three of the researchers have ties to various pharmaceutical companies and other organizations. Dr. Warshaw and the remaining researchers had no relevant financial disclosures.
SOURCE: Warshaw EM et al. J Am Acad Dermatol. 2018 Apr 14. doi: 10.1016/j.jaad.2018.02.071.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Key clinical point: This U.S. study reinforces other recent investigations citing high occurrence of pediatric nickel-associated allergic contact dermatitis.
Major finding: Almost one-quarter (23.7%) of almost 2,000 children patch tested were found to have nickel sensitivity.
Study details: Retrospective, cross-sectional study of 1,894 pediatric patients.
Disclosures: The research was funded by the Minneapolis Veterans Affairs Medical Center, and in part by the Nickel Producers Environmental Research Association. Three of the researchers have ties to various pharmaceutical companies and other organizations. Dr. Warshaw and the remaining researchers had no relevant financial disclosures.
Source: Warshaw EM et al. J Am Acad Dermatol. 2018 Apr 14. doi: 10.1016/j.jaad.2018.02.071.
FDA approves epinephrine autoinjector for infants and toddlers
according to a press release from Kaléo, a privately-held pharmaceutical company.
“Anaphylactic reactions can be frightening and serious, and when experienced by the very young, some of whom can’t communicate about what’s happening, these episodes can be particularly alarming,” Vivian Hernandez-Trujillo, MD, a pediatric allergist and fellow of the American Academy of Allergy, Asthma and Immunology, said in a statement. “Now, caregivers can have the AUVI-Q 0.1 mg in hand to respond to an allergic emergency and safely administer epinephrine to infants and toddlers.”
The approval comes at a time when a higher percentage of children are being admitted to the hospital for food-related anaphylaxis: a 130% increase among children aged 0-4 years and a 196% increase in children aged 5-17 years.
The epinephrine autoinjector will be available for $0 out of pocket for commercially insured patients using the AUVI-Q AffordAbility Program and Direct Delivery Service starting May 1, 2018. More information concerning this EAI can be found here.
according to a press release from Kaléo, a privately-held pharmaceutical company.
“Anaphylactic reactions can be frightening and serious, and when experienced by the very young, some of whom can’t communicate about what’s happening, these episodes can be particularly alarming,” Vivian Hernandez-Trujillo, MD, a pediatric allergist and fellow of the American Academy of Allergy, Asthma and Immunology, said in a statement. “Now, caregivers can have the AUVI-Q 0.1 mg in hand to respond to an allergic emergency and safely administer epinephrine to infants and toddlers.”
The approval comes at a time when a higher percentage of children are being admitted to the hospital for food-related anaphylaxis: a 130% increase among children aged 0-4 years and a 196% increase in children aged 5-17 years.
The epinephrine autoinjector will be available for $0 out of pocket for commercially insured patients using the AUVI-Q AffordAbility Program and Direct Delivery Service starting May 1, 2018. More information concerning this EAI can be found here.
according to a press release from Kaléo, a privately-held pharmaceutical company.
“Anaphylactic reactions can be frightening and serious, and when experienced by the very young, some of whom can’t communicate about what’s happening, these episodes can be particularly alarming,” Vivian Hernandez-Trujillo, MD, a pediatric allergist and fellow of the American Academy of Allergy, Asthma and Immunology, said in a statement. “Now, caregivers can have the AUVI-Q 0.1 mg in hand to respond to an allergic emergency and safely administer epinephrine to infants and toddlers.”
The approval comes at a time when a higher percentage of children are being admitted to the hospital for food-related anaphylaxis: a 130% increase among children aged 0-4 years and a 196% increase in children aged 5-17 years.
The epinephrine autoinjector will be available for $0 out of pocket for commercially insured patients using the AUVI-Q AffordAbility Program and Direct Delivery Service starting May 1, 2018. More information concerning this EAI can be found here.
Why do you need to know about bipolar disorder?
Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?
Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.
While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.
The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.
In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).
You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.
You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?
Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.
While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.
The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.
In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).
You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.
You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?
Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.
While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.
The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.
In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).
You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.
You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Autism spectrum disorder rate calculated at record high in 2014
a new federal report found.
The number suggests the ASD diagnosis rate has continued its steady rise since 2000-2002, when only 0.67 per 1,000 8-year-olds were believed to have the condition.
The report also found that while the gap in diagnosis rates between blacks and whites has dwindled, ASD prevalence “continues to vary among certain racial/ethnic groups and communities.” Indeed, the ASD rate approached 3% in some communities, according to the report published April 28 in Morbidity and Mortality Weekly Report.
The findings are based on statistics gathered by the Autism and Developmental Disabilities Monitoring Network, which uses multiple strategies to track ASD diagnoses among 8-year-olds in Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin.
The network, which started its work in 2000, monitors 8-year-old children because that’s the age when ASD prevalence is thought to be at its highest.
The new report, by Jon Baio of the National Center on Birth Defects and Developmental Disabilities and his associates relied upon ASD definitions from DSM-IV-TR and DSM-5. While the definitions seem to be quite different, the report states, “the prevalence of ASD and characteristics of children identified by each case definition were similar in 2014.” Prevalence estimates in the report are only based on DSM-IV-TR criteria.
In total, the report for 2014 tracked 325,483 children aged 8 years, which accounted for 8% of the entire U.S. population in that age group. Of those, 5,473 were determined to have ASD.
The overall ASD prevalence was 16.8 per 1,000 (1 in 59) children. In 2000, the rate was estimated at 6.7 per 1,000. (The researchers caution that the states included in the monitoring network have changed over time.)
New Jersey had the highest prevalence of ASD (29.3 per 1,000, or 2.93%), and the difference when compared with each of the other 10 states was statistically significant (P less than .01).
The overall ASD rate was 26.6 per 1,000 for boys and 6.6 per 1,000 for girls (P less than .01). For whites, it was 17.2 per 1,000, while blacks (16.0 per 1,000) and Hispanics (14.0 per 1,000) had lower rates.
When intelligence quotient information was available, 44% of those with ASD had IQ greater than 85. Blacks (44%) and Hispanics (35%) with ASD were more likely than whites (22%) to have IQs less than or equal to 70, a sign of intellectual disability, the researcher reported.
Of the children with ASD, 80% had previously been diagnosed with the condition or determined to be eligible for autism services.
In light of the report findings, the authors wrote, “With prevalence of ASD reaching nearly 3% in some communities and representing an increase of 150% since 2000, ASD is an urgent public health concern that could benefit from enhanced strategies to help identify ASD earlier; to determine possible risk factors; and to address the growing behavioral, educational, residential and occupational needs of this population.”
Funding and disclosures were not reported.
SOURCE: Baio J et al. Morb Mortal Wkly Rep. 2018 Apr 27;67(6):1-28.
a new federal report found.
The number suggests the ASD diagnosis rate has continued its steady rise since 2000-2002, when only 0.67 per 1,000 8-year-olds were believed to have the condition.
The report also found that while the gap in diagnosis rates between blacks and whites has dwindled, ASD prevalence “continues to vary among certain racial/ethnic groups and communities.” Indeed, the ASD rate approached 3% in some communities, according to the report published April 28 in Morbidity and Mortality Weekly Report.
The findings are based on statistics gathered by the Autism and Developmental Disabilities Monitoring Network, which uses multiple strategies to track ASD diagnoses among 8-year-olds in Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin.
The network, which started its work in 2000, monitors 8-year-old children because that’s the age when ASD prevalence is thought to be at its highest.
The new report, by Jon Baio of the National Center on Birth Defects and Developmental Disabilities and his associates relied upon ASD definitions from DSM-IV-TR and DSM-5. While the definitions seem to be quite different, the report states, “the prevalence of ASD and characteristics of children identified by each case definition were similar in 2014.” Prevalence estimates in the report are only based on DSM-IV-TR criteria.
In total, the report for 2014 tracked 325,483 children aged 8 years, which accounted for 8% of the entire U.S. population in that age group. Of those, 5,473 were determined to have ASD.
The overall ASD prevalence was 16.8 per 1,000 (1 in 59) children. In 2000, the rate was estimated at 6.7 per 1,000. (The researchers caution that the states included in the monitoring network have changed over time.)
New Jersey had the highest prevalence of ASD (29.3 per 1,000, or 2.93%), and the difference when compared with each of the other 10 states was statistically significant (P less than .01).
The overall ASD rate was 26.6 per 1,000 for boys and 6.6 per 1,000 for girls (P less than .01). For whites, it was 17.2 per 1,000, while blacks (16.0 per 1,000) and Hispanics (14.0 per 1,000) had lower rates.
When intelligence quotient information was available, 44% of those with ASD had IQ greater than 85. Blacks (44%) and Hispanics (35%) with ASD were more likely than whites (22%) to have IQs less than or equal to 70, a sign of intellectual disability, the researcher reported.
Of the children with ASD, 80% had previously been diagnosed with the condition or determined to be eligible for autism services.
In light of the report findings, the authors wrote, “With prevalence of ASD reaching nearly 3% in some communities and representing an increase of 150% since 2000, ASD is an urgent public health concern that could benefit from enhanced strategies to help identify ASD earlier; to determine possible risk factors; and to address the growing behavioral, educational, residential and occupational needs of this population.”
Funding and disclosures were not reported.
SOURCE: Baio J et al. Morb Mortal Wkly Rep. 2018 Apr 27;67(6):1-28.
a new federal report found.
The number suggests the ASD diagnosis rate has continued its steady rise since 2000-2002, when only 0.67 per 1,000 8-year-olds were believed to have the condition.
The report also found that while the gap in diagnosis rates between blacks and whites has dwindled, ASD prevalence “continues to vary among certain racial/ethnic groups and communities.” Indeed, the ASD rate approached 3% in some communities, according to the report published April 28 in Morbidity and Mortality Weekly Report.
The findings are based on statistics gathered by the Autism and Developmental Disabilities Monitoring Network, which uses multiple strategies to track ASD diagnoses among 8-year-olds in Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin.
The network, which started its work in 2000, monitors 8-year-old children because that’s the age when ASD prevalence is thought to be at its highest.
The new report, by Jon Baio of the National Center on Birth Defects and Developmental Disabilities and his associates relied upon ASD definitions from DSM-IV-TR and DSM-5. While the definitions seem to be quite different, the report states, “the prevalence of ASD and characteristics of children identified by each case definition were similar in 2014.” Prevalence estimates in the report are only based on DSM-IV-TR criteria.
In total, the report for 2014 tracked 325,483 children aged 8 years, which accounted for 8% of the entire U.S. population in that age group. Of those, 5,473 were determined to have ASD.
The overall ASD prevalence was 16.8 per 1,000 (1 in 59) children. In 2000, the rate was estimated at 6.7 per 1,000. (The researchers caution that the states included in the monitoring network have changed over time.)
New Jersey had the highest prevalence of ASD (29.3 per 1,000, or 2.93%), and the difference when compared with each of the other 10 states was statistically significant (P less than .01).
The overall ASD rate was 26.6 per 1,000 for boys and 6.6 per 1,000 for girls (P less than .01). For whites, it was 17.2 per 1,000, while blacks (16.0 per 1,000) and Hispanics (14.0 per 1,000) had lower rates.
When intelligence quotient information was available, 44% of those with ASD had IQ greater than 85. Blacks (44%) and Hispanics (35%) with ASD were more likely than whites (22%) to have IQs less than or equal to 70, a sign of intellectual disability, the researcher reported.
Of the children with ASD, 80% had previously been diagnosed with the condition or determined to be eligible for autism services.
In light of the report findings, the authors wrote, “With prevalence of ASD reaching nearly 3% in some communities and representing an increase of 150% since 2000, ASD is an urgent public health concern that could benefit from enhanced strategies to help identify ASD earlier; to determine possible risk factors; and to address the growing behavioral, educational, residential and occupational needs of this population.”
Funding and disclosures were not reported.
SOURCE: Baio J et al. Morb Mortal Wkly Rep. 2018 Apr 27;67(6):1-28.
FROM MMWR
Key clinical point: The ASD rate continues to grow, at least in a sampling of states.
Major finding: An estimated 1.68 per 1,000 (1 in 59) 8-year-old children in 11 states are believed to have ASD.
Study details: The Autism and Developmental Disabilities Monitoring Network uses multiple strategies to track ASD diagnoses among 8-year-olds in 11 states. In 2014, the network tracked 325,483 children.
Disclosures: Funding and disclosures were not reported.
Source: Baio J et al. Morb Mortal Wkly Rep. 2018 Apr 27;67(6):1-28.
Twin study highlights environmental factors that may aggravate acne
A survey conducted at the world’s largest twin celebration provides more evidence that twins share a genetic propensity toward acne, and provides information about several aggravating factors.
The study “further supports that there may be a genetic phenotypic link, though social and environmental factors may also have an influence in the disease process,” the authors wrote.
Previous twin research has linked genetic factors to 80% of acne variance, with environmental factors, such as stress and low intake of produce, believed to account for the rest of the risk (J Invest Dermat. 2002;119[6]:1317-22). For the new study, researchers surveyed twins at the 2016 Twins Day Festival in Twinsburg, Ohio. Thousand of twins – and triplets and quadruplets – from around the world attend the annual event.
After incomplete surveys were discarded, the survey population included 202 identical twins (101 pairs) and 53 fraternal twins or triplets. (A set of triplets was included in addition to 25 pairs of twins.) The majority of participants were female: 23% of identical twins and 17% of the fraternal twins and triplets were male. The mean age was 29 years among the identical twins and 21 years among fraternal twins.
that suggest “acne is largely attributable to genetics,” the authors observed. Among identical twins, those with acne were more likely to have polycystic ovarian syndrome (P = .045), anxiety (P = .014), and asthma (P = .026).
“Identical twin pairs with acne had a higher BMI [body mass index] and exercised less than those without,” the researchers added. These two associations were statistically significant, both for higher BMI (P = .020) and for less exercise (P = .001). “This suggests that a higher BMI and lack of exercise may contribute [along with genetics of course] to acne development. Thus, regular exercise and lower BMI may keep acne at bay,” they noted.
They also analyzed 56 pairs of identical twins with acne, who reported different severities, and found that the twin with more severe acne was more likely to report that sun exposure (P = .048), cosmetic product use (P = .002), and sugar intake (P = .048) aggravated their acne. Refined carbohydrates, as an aggravating factor, approached statistical significance, they said.
A separate analysis of 45 pairs of female identical twins with different degrees of acne severity produced similar findings. There were no significant difference between acne severity groups in terms of menstruation flare frequency or with oral contraceptive use. The twin with more severe acne, however, “was more likely to report aggravation of acne with sun exposure,” cosmetic use, and sugar intake, all associations which reached statistical significance. They were also more likely to report that refined carbohydrates and intake of fried foods aggravated their acne, associations that approached statistical significance.
“This twin study provides further support for reducing intake of sugar and refined carbohydrates to decrease acne severity in susceptible individuals,” the authors wrote. “For females, reducing intake of fried foods may also help,” they added.
There’s a twist to their results: The finding that those with more severe acne reported worsening symptoms with sun exposure “conflicts with prior research, which has found that acne improves with sun,” the authors wrote, adding that “perhaps the data was confounded by comedogenic sunscreen use.”
No specific study funding was reported. The study authors reported no disclosures.
SOURCE: Suggs A et al. J Drugs Dermatol. 2018 Apr;17(4):380-2.
A survey conducted at the world’s largest twin celebration provides more evidence that twins share a genetic propensity toward acne, and provides information about several aggravating factors.
The study “further supports that there may be a genetic phenotypic link, though social and environmental factors may also have an influence in the disease process,” the authors wrote.
Previous twin research has linked genetic factors to 80% of acne variance, with environmental factors, such as stress and low intake of produce, believed to account for the rest of the risk (J Invest Dermat. 2002;119[6]:1317-22). For the new study, researchers surveyed twins at the 2016 Twins Day Festival in Twinsburg, Ohio. Thousand of twins – and triplets and quadruplets – from around the world attend the annual event.
After incomplete surveys were discarded, the survey population included 202 identical twins (101 pairs) and 53 fraternal twins or triplets. (A set of triplets was included in addition to 25 pairs of twins.) The majority of participants were female: 23% of identical twins and 17% of the fraternal twins and triplets were male. The mean age was 29 years among the identical twins and 21 years among fraternal twins.
that suggest “acne is largely attributable to genetics,” the authors observed. Among identical twins, those with acne were more likely to have polycystic ovarian syndrome (P = .045), anxiety (P = .014), and asthma (P = .026).
“Identical twin pairs with acne had a higher BMI [body mass index] and exercised less than those without,” the researchers added. These two associations were statistically significant, both for higher BMI (P = .020) and for less exercise (P = .001). “This suggests that a higher BMI and lack of exercise may contribute [along with genetics of course] to acne development. Thus, regular exercise and lower BMI may keep acne at bay,” they noted.
They also analyzed 56 pairs of identical twins with acne, who reported different severities, and found that the twin with more severe acne was more likely to report that sun exposure (P = .048), cosmetic product use (P = .002), and sugar intake (P = .048) aggravated their acne. Refined carbohydrates, as an aggravating factor, approached statistical significance, they said.
A separate analysis of 45 pairs of female identical twins with different degrees of acne severity produced similar findings. There were no significant difference between acne severity groups in terms of menstruation flare frequency or with oral contraceptive use. The twin with more severe acne, however, “was more likely to report aggravation of acne with sun exposure,” cosmetic use, and sugar intake, all associations which reached statistical significance. They were also more likely to report that refined carbohydrates and intake of fried foods aggravated their acne, associations that approached statistical significance.
“This twin study provides further support for reducing intake of sugar and refined carbohydrates to decrease acne severity in susceptible individuals,” the authors wrote. “For females, reducing intake of fried foods may also help,” they added.
There’s a twist to their results: The finding that those with more severe acne reported worsening symptoms with sun exposure “conflicts with prior research, which has found that acne improves with sun,” the authors wrote, adding that “perhaps the data was confounded by comedogenic sunscreen use.”
No specific study funding was reported. The study authors reported no disclosures.
SOURCE: Suggs A et al. J Drugs Dermatol. 2018 Apr;17(4):380-2.
A survey conducted at the world’s largest twin celebration provides more evidence that twins share a genetic propensity toward acne, and provides information about several aggravating factors.
The study “further supports that there may be a genetic phenotypic link, though social and environmental factors may also have an influence in the disease process,” the authors wrote.
Previous twin research has linked genetic factors to 80% of acne variance, with environmental factors, such as stress and low intake of produce, believed to account for the rest of the risk (J Invest Dermat. 2002;119[6]:1317-22). For the new study, researchers surveyed twins at the 2016 Twins Day Festival in Twinsburg, Ohio. Thousand of twins – and triplets and quadruplets – from around the world attend the annual event.
After incomplete surveys were discarded, the survey population included 202 identical twins (101 pairs) and 53 fraternal twins or triplets. (A set of triplets was included in addition to 25 pairs of twins.) The majority of participants were female: 23% of identical twins and 17% of the fraternal twins and triplets were male. The mean age was 29 years among the identical twins and 21 years among fraternal twins.
that suggest “acne is largely attributable to genetics,” the authors observed. Among identical twins, those with acne were more likely to have polycystic ovarian syndrome (P = .045), anxiety (P = .014), and asthma (P = .026).
“Identical twin pairs with acne had a higher BMI [body mass index] and exercised less than those without,” the researchers added. These two associations were statistically significant, both for higher BMI (P = .020) and for less exercise (P = .001). “This suggests that a higher BMI and lack of exercise may contribute [along with genetics of course] to acne development. Thus, regular exercise and lower BMI may keep acne at bay,” they noted.
They also analyzed 56 pairs of identical twins with acne, who reported different severities, and found that the twin with more severe acne was more likely to report that sun exposure (P = .048), cosmetic product use (P = .002), and sugar intake (P = .048) aggravated their acne. Refined carbohydrates, as an aggravating factor, approached statistical significance, they said.
A separate analysis of 45 pairs of female identical twins with different degrees of acne severity produced similar findings. There were no significant difference between acne severity groups in terms of menstruation flare frequency or with oral contraceptive use. The twin with more severe acne, however, “was more likely to report aggravation of acne with sun exposure,” cosmetic use, and sugar intake, all associations which reached statistical significance. They were also more likely to report that refined carbohydrates and intake of fried foods aggravated their acne, associations that approached statistical significance.
“This twin study provides further support for reducing intake of sugar and refined carbohydrates to decrease acne severity in susceptible individuals,” the authors wrote. “For females, reducing intake of fried foods may also help,” they added.
There’s a twist to their results: The finding that those with more severe acne reported worsening symptoms with sun exposure “conflicts with prior research, which has found that acne improves with sun,” the authors wrote, adding that “perhaps the data was confounded by comedogenic sunscreen use.”
No specific study funding was reported. The study authors reported no disclosures.
SOURCE: Suggs A et al. J Drugs Dermatol. 2018 Apr;17(4):380-2.
FROM THE JOURNAL OF DRUGS IN DERMATOLOGY
Key clinical point: Moderating environmental factors, such as sugar intake and refined carbohydrates, may help reduce the severity of acne.
Major finding: Sun exposure (P = .048), cosmetic product use (P = .002), and sugar intake (P = .048) were among the factors identified that aggravated acne.
Study details: A survey of 202 identical twins (101 pairs) and 53 fraternal twins or triplets conducted at the annual Twins Day Festival in 2016.
Disclosures: No specific study funding was reported. The study authors reported no disclosures.
Source: Suggs A et al. J Drugs Dermatol. 2018 Apr;17(4):380-2.
Walking the walk
In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.
Insurance access continues to be a problem. I wrote a column in June 2017 about obtaining health care insurance for transgender patients. Preauthorization is common for obtaining cross-sex hormones or pubertal blockers even for insurance companies that are willing to pay for them – a process that can take weeks, even months, to complete. This creates delays in obtaining necessary care for transgender patients. This is just one of the many barriers transgender people face in navigating the health care system.
Increasing access to health care services for transgender patients is more about improving health outcomes than patient satisfaction. Even the smallest policy change may have a meaningful impact on the lives of transgender individuals. A study by Russell et al., in the April 2018 issue of Journal of Adolescent Health found that transgender youth allowed to use their chosen name (instead of the name assigned to them by their parents at birth) were more likely to have fewer depressive symptoms and lower rates of suicidal ideation and suicidal behavior.3 These findings highlight that even a small change can have a huge impact on the health and well-being of this patient population.
What can you do to expand access? First, you must educate yourself and teach others. Many providers report never having received education on LGBTQ health during their training,4 and most barriers for transgender patients stem from this lack of training. Second, work with the transgender community – it is very tempting to see your institution’s name on the HEI and think all the work is done, but the lived experiences of transgender patients sometimes are different than what is seen on paper (or online). Team up with local organizations such as PFLAG (formerly known as Parents and Families of Lesbians and Gays) that can create support groups for both transgender youth and their families. Help create a network of referral systems for your transgender patients – the community is often small enough that they know which providers or establishments are safe for transgender individuals. Many transgender patients find this extremely helpful.5 You still wield significant influence in the community, so work with the health care and insurance systems to improve access and coverage for gender-related services. The HRC HEI is becoming coveted by health care institutions. This is a prime opportunity to be involved in committees seeking to improve health care access for transgender individuals. Finally, as there are champions for transgender health in your clinic, there also are champions for transgender health in insurance companies. They often are well known in the community, so find that individual for counseling on how to navigate the insurance system for your transgender patients.
Although an increasing number of health care institutions and clinics are recognizing the health care needs of transgender patients and providing appropriate care, the health care system remains challenging for transgender individuals to navigate. Small policy changes may have a substantial impact on the health and well-being of transgender individuals. Although creating change within an institution may seem like a monumental task, you do have the agency to help create this type change within the system to expand health care access for transgender patients.
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
Resources
- HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
- To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.
References
1. Psychol Bull. 2003 Sep;129(5):674-97.
2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)
3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.
4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.
5. Transgend Health. 2016 Nov 1;1(1):238-49.
In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.
Insurance access continues to be a problem. I wrote a column in June 2017 about obtaining health care insurance for transgender patients. Preauthorization is common for obtaining cross-sex hormones or pubertal blockers even for insurance companies that are willing to pay for them – a process that can take weeks, even months, to complete. This creates delays in obtaining necessary care for transgender patients. This is just one of the many barriers transgender people face in navigating the health care system.
Increasing access to health care services for transgender patients is more about improving health outcomes than patient satisfaction. Even the smallest policy change may have a meaningful impact on the lives of transgender individuals. A study by Russell et al., in the April 2018 issue of Journal of Adolescent Health found that transgender youth allowed to use their chosen name (instead of the name assigned to them by their parents at birth) were more likely to have fewer depressive symptoms and lower rates of suicidal ideation and suicidal behavior.3 These findings highlight that even a small change can have a huge impact on the health and well-being of this patient population.
What can you do to expand access? First, you must educate yourself and teach others. Many providers report never having received education on LGBTQ health during their training,4 and most barriers for transgender patients stem from this lack of training. Second, work with the transgender community – it is very tempting to see your institution’s name on the HEI and think all the work is done, but the lived experiences of transgender patients sometimes are different than what is seen on paper (or online). Team up with local organizations such as PFLAG (formerly known as Parents and Families of Lesbians and Gays) that can create support groups for both transgender youth and their families. Help create a network of referral systems for your transgender patients – the community is often small enough that they know which providers or establishments are safe for transgender individuals. Many transgender patients find this extremely helpful.5 You still wield significant influence in the community, so work with the health care and insurance systems to improve access and coverage for gender-related services. The HRC HEI is becoming coveted by health care institutions. This is a prime opportunity to be involved in committees seeking to improve health care access for transgender individuals. Finally, as there are champions for transgender health in your clinic, there also are champions for transgender health in insurance companies. They often are well known in the community, so find that individual for counseling on how to navigate the insurance system for your transgender patients.
Although an increasing number of health care institutions and clinics are recognizing the health care needs of transgender patients and providing appropriate care, the health care system remains challenging for transgender individuals to navigate. Small policy changes may have a substantial impact on the health and well-being of transgender individuals. Although creating change within an institution may seem like a monumental task, you do have the agency to help create this type change within the system to expand health care access for transgender patients.
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
Resources
- HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
- To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.
References
1. Psychol Bull. 2003 Sep;129(5):674-97.
2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)
3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.
4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.
5. Transgend Health. 2016 Nov 1;1(1):238-49.
In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.
Insurance access continues to be a problem. I wrote a column in June 2017 about obtaining health care insurance for transgender patients. Preauthorization is common for obtaining cross-sex hormones or pubertal blockers even for insurance companies that are willing to pay for them – a process that can take weeks, even months, to complete. This creates delays in obtaining necessary care for transgender patients. This is just one of the many barriers transgender people face in navigating the health care system.
Increasing access to health care services for transgender patients is more about improving health outcomes than patient satisfaction. Even the smallest policy change may have a meaningful impact on the lives of transgender individuals. A study by Russell et al., in the April 2018 issue of Journal of Adolescent Health found that transgender youth allowed to use their chosen name (instead of the name assigned to them by their parents at birth) were more likely to have fewer depressive symptoms and lower rates of suicidal ideation and suicidal behavior.3 These findings highlight that even a small change can have a huge impact on the health and well-being of this patient population.
What can you do to expand access? First, you must educate yourself and teach others. Many providers report never having received education on LGBTQ health during their training,4 and most barriers for transgender patients stem from this lack of training. Second, work with the transgender community – it is very tempting to see your institution’s name on the HEI and think all the work is done, but the lived experiences of transgender patients sometimes are different than what is seen on paper (or online). Team up with local organizations such as PFLAG (formerly known as Parents and Families of Lesbians and Gays) that can create support groups for both transgender youth and their families. Help create a network of referral systems for your transgender patients – the community is often small enough that they know which providers or establishments are safe for transgender individuals. Many transgender patients find this extremely helpful.5 You still wield significant influence in the community, so work with the health care and insurance systems to improve access and coverage for gender-related services. The HRC HEI is becoming coveted by health care institutions. This is a prime opportunity to be involved in committees seeking to improve health care access for transgender individuals. Finally, as there are champions for transgender health in your clinic, there also are champions for transgender health in insurance companies. They often are well known in the community, so find that individual for counseling on how to navigate the insurance system for your transgender patients.
Although an increasing number of health care institutions and clinics are recognizing the health care needs of transgender patients and providing appropriate care, the health care system remains challenging for transgender individuals to navigate. Small policy changes may have a substantial impact on the health and well-being of transgender individuals. Although creating change within an institution may seem like a monumental task, you do have the agency to help create this type change within the system to expand health care access for transgender patients.
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
Resources
- HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
- To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.
References
1. Psychol Bull. 2003 Sep;129(5):674-97.
2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)
3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.
4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.
5. Transgend Health. 2016 Nov 1;1(1):238-49.
Colchicine looks promising for treating prurigo pigmentosa in case report
said Isa An, MD of Dicle University, Diyarbakır, Turkey, and associates.
They described a 16-year-old Turkish girl who presented with an itchy rash on her back of 4 weeks’ duration. Treatment with oral antihistamines, and topical and systemic steroids were ineffective. On physical examination, there were erythematous macules, sporadic excoriated papules, and reticulate hyperpigmentation on her back. Complete blood count and liver function tests were normal.
Histopathologic examination showed “infrequent necrotic keratinocytes with marked acanthosis and spongiosis on the epidermis, increased basal layer pigmentation, and perivascular lymphocytic infiltrate on the upper dermis.” Because of these findings, a diagnosis of prurigo pigmentosa was made, they wrote in Pediatric Dermatology.
Treatment with colchicine 1.5 g/day was started, and while the lesions resolved in the second week of treatment, the reticulate hyperpigmentation remained, Dr. An and her associates reported. The reticulate hyperpigmentation did not regress during the first month of treatment. At 6-month follow-up, there were no more symptoms of itch or recurrence of the original lesions. The reticulate hyperpigmentation was not treated.
A rare inflammatory skin disease seen principally in young Japanese women, prurigo pigmentosa has been reported in both men and women of other ethnicities, they said. Generally, macrolide antibiotics, such as clarithromycin, dapsone, and isotretinoin have been used effectively to treat prurigo pigmentosa. Minocycline and doxycycline are considered to be effective in treating this skin disease because of their anti-inflammatory effects and because they have “been shown to inhibit the synthesis of cytokines and chemokines that regulate leukocyte differentiation and activation.” Leukocyte differentiation and activation “are key pathologic features of prurigo pigmentosa,” the authors added.
Colchicine, a neutral, liposoluble tricyclic alkaloid, “exerts an anti-inflammatory effect by inhibiting neutrophil chemotaxis,” said Dr. An and her associates, which is why it is thought to be a potentially effective drug for treating prurigo pigmentosa, as shown in this case study. “Further studies are required to verify whether colchicine is an effective treatment option,” for prurigo pigmentosa, they added.
SOURCE: An I et al. Pediatr Dermatol. 2018 Apr 11. doi: 10.1111/pde.13480.
said Isa An, MD of Dicle University, Diyarbakır, Turkey, and associates.
They described a 16-year-old Turkish girl who presented with an itchy rash on her back of 4 weeks’ duration. Treatment with oral antihistamines, and topical and systemic steroids were ineffective. On physical examination, there were erythematous macules, sporadic excoriated papules, and reticulate hyperpigmentation on her back. Complete blood count and liver function tests were normal.
Histopathologic examination showed “infrequent necrotic keratinocytes with marked acanthosis and spongiosis on the epidermis, increased basal layer pigmentation, and perivascular lymphocytic infiltrate on the upper dermis.” Because of these findings, a diagnosis of prurigo pigmentosa was made, they wrote in Pediatric Dermatology.
Treatment with colchicine 1.5 g/day was started, and while the lesions resolved in the second week of treatment, the reticulate hyperpigmentation remained, Dr. An and her associates reported. The reticulate hyperpigmentation did not regress during the first month of treatment. At 6-month follow-up, there were no more symptoms of itch or recurrence of the original lesions. The reticulate hyperpigmentation was not treated.
A rare inflammatory skin disease seen principally in young Japanese women, prurigo pigmentosa has been reported in both men and women of other ethnicities, they said. Generally, macrolide antibiotics, such as clarithromycin, dapsone, and isotretinoin have been used effectively to treat prurigo pigmentosa. Minocycline and doxycycline are considered to be effective in treating this skin disease because of their anti-inflammatory effects and because they have “been shown to inhibit the synthesis of cytokines and chemokines that regulate leukocyte differentiation and activation.” Leukocyte differentiation and activation “are key pathologic features of prurigo pigmentosa,” the authors added.
Colchicine, a neutral, liposoluble tricyclic alkaloid, “exerts an anti-inflammatory effect by inhibiting neutrophil chemotaxis,” said Dr. An and her associates, which is why it is thought to be a potentially effective drug for treating prurigo pigmentosa, as shown in this case study. “Further studies are required to verify whether colchicine is an effective treatment option,” for prurigo pigmentosa, they added.
SOURCE: An I et al. Pediatr Dermatol. 2018 Apr 11. doi: 10.1111/pde.13480.
said Isa An, MD of Dicle University, Diyarbakır, Turkey, and associates.
They described a 16-year-old Turkish girl who presented with an itchy rash on her back of 4 weeks’ duration. Treatment with oral antihistamines, and topical and systemic steroids were ineffective. On physical examination, there were erythematous macules, sporadic excoriated papules, and reticulate hyperpigmentation on her back. Complete blood count and liver function tests were normal.
Histopathologic examination showed “infrequent necrotic keratinocytes with marked acanthosis and spongiosis on the epidermis, increased basal layer pigmentation, and perivascular lymphocytic infiltrate on the upper dermis.” Because of these findings, a diagnosis of prurigo pigmentosa was made, they wrote in Pediatric Dermatology.
Treatment with colchicine 1.5 g/day was started, and while the lesions resolved in the second week of treatment, the reticulate hyperpigmentation remained, Dr. An and her associates reported. The reticulate hyperpigmentation did not regress during the first month of treatment. At 6-month follow-up, there were no more symptoms of itch or recurrence of the original lesions. The reticulate hyperpigmentation was not treated.
A rare inflammatory skin disease seen principally in young Japanese women, prurigo pigmentosa has been reported in both men and women of other ethnicities, they said. Generally, macrolide antibiotics, such as clarithromycin, dapsone, and isotretinoin have been used effectively to treat prurigo pigmentosa. Minocycline and doxycycline are considered to be effective in treating this skin disease because of their anti-inflammatory effects and because they have “been shown to inhibit the synthesis of cytokines and chemokines that regulate leukocyte differentiation and activation.” Leukocyte differentiation and activation “are key pathologic features of prurigo pigmentosa,” the authors added.
Colchicine, a neutral, liposoluble tricyclic alkaloid, “exerts an anti-inflammatory effect by inhibiting neutrophil chemotaxis,” said Dr. An and her associates, which is why it is thought to be a potentially effective drug for treating prurigo pigmentosa, as shown in this case study. “Further studies are required to verify whether colchicine is an effective treatment option,” for prurigo pigmentosa, they added.
SOURCE: An I et al. Pediatr Dermatol. 2018 Apr 11. doi: 10.1111/pde.13480.
FROM PEDIATRIC DERMATOLOGY
Ideal sun protection practices by parents low in Toronto
according to Marcus G. Tan, MD, of the University of Toronto, and his associates.
Too much sun exposure as a child is a known risk factor for skin cancer, and “it has been estimated that approximately half of cumulative ultraviolet exposure by age 60 occurs before age 20.” So it is important that children be protected from excessive sun exposure, the investigators wrote, underscoring the reason for their study of parental sun protection by Canadian parents in Toronto, which has a multiracial population.
Parental sun protection efforts were considered ideal if they used sun protection every day; on sunny days all year round; or during the summer, using at least SPF 30, and reapplying sunscreen at least every 2 hours. Parental efforts would be considered nonideal if they did not meet any of these three criteria.
Of 183 parents, 17% used ideal sun protection for their children; 28% were in the lighter-skinned group (Fitzpatrick phototype I-III) and 5% in the darker-skinned group (Fitzpatrick phototype IV-V), The greater likelihood of using ideal sun protection among those in the lighter-skinned group was statistically significant (odds ratio, 7.4; P less than .001). As each child grew 1 year older, parents were 31% less likely to use ideal sun protection (OR, 0.69; P = .007).
Parents whose children were in the lighter-skinned group were “more likely to believe that sun exposure was harmful” for their children (OR, 17.2), and “to perceive value in sun protection,” (OR, 11.4) the researchers said. The parents whose children were in the darker-skinned group were more likely to consider sun protection as having drawbacks (OR, 9.2), and to believe that darker skin tone provides more sun protection (OR, 12.4). Neither of the two groups was more likely to consider that sun exposure provided health benefits or that it improved appearance.
Parents whose children were in the lighter-skinned group reported significantly more frequent use of sunscreen (OR, 3.6), sunglasses (OR, 2.3), and sun suits (OR, 2.7). The parents of the children in this group reported similar or higher rates of use of hats, long-sleeved clothing, and umbrellas; seeking shade; and staying indoors between 12 pm and 2 pm, but these rates were not statistically significantly different from those reported by the parents of children in the darker-skinned group, the investigators said.
“Our study suggests that more targeted education guidelines are necessary to ensure sun safety for all children, especially in a multiracial population,” said Dr. Tan and his colleagues. “Dermatologists and primary care physicians are in ideal positions to initiate personalized efforts to improve overall rates of sun protection.”
Dr. Tan reported no relevant financial disclosures. Dr. Miriam Weinstein has worked as an advisory board member for Johnson & Johnson, which manufactures sunscreen; and Dr. Shudeshna Nag consults for Valeant, which manufactures sunscreen.
SOURCE: Tan MG et al. Pediatr Dermatol. 2018 Feb 13. doi: 10.1111/pde.13433.
according to Marcus G. Tan, MD, of the University of Toronto, and his associates.
Too much sun exposure as a child is a known risk factor for skin cancer, and “it has been estimated that approximately half of cumulative ultraviolet exposure by age 60 occurs before age 20.” So it is important that children be protected from excessive sun exposure, the investigators wrote, underscoring the reason for their study of parental sun protection by Canadian parents in Toronto, which has a multiracial population.
Parental sun protection efforts were considered ideal if they used sun protection every day; on sunny days all year round; or during the summer, using at least SPF 30, and reapplying sunscreen at least every 2 hours. Parental efforts would be considered nonideal if they did not meet any of these three criteria.
Of 183 parents, 17% used ideal sun protection for their children; 28% were in the lighter-skinned group (Fitzpatrick phototype I-III) and 5% in the darker-skinned group (Fitzpatrick phototype IV-V), The greater likelihood of using ideal sun protection among those in the lighter-skinned group was statistically significant (odds ratio, 7.4; P less than .001). As each child grew 1 year older, parents were 31% less likely to use ideal sun protection (OR, 0.69; P = .007).
Parents whose children were in the lighter-skinned group were “more likely to believe that sun exposure was harmful” for their children (OR, 17.2), and “to perceive value in sun protection,” (OR, 11.4) the researchers said. The parents whose children were in the darker-skinned group were more likely to consider sun protection as having drawbacks (OR, 9.2), and to believe that darker skin tone provides more sun protection (OR, 12.4). Neither of the two groups was more likely to consider that sun exposure provided health benefits or that it improved appearance.
Parents whose children were in the lighter-skinned group reported significantly more frequent use of sunscreen (OR, 3.6), sunglasses (OR, 2.3), and sun suits (OR, 2.7). The parents of the children in this group reported similar or higher rates of use of hats, long-sleeved clothing, and umbrellas; seeking shade; and staying indoors between 12 pm and 2 pm, but these rates were not statistically significantly different from those reported by the parents of children in the darker-skinned group, the investigators said.
“Our study suggests that more targeted education guidelines are necessary to ensure sun safety for all children, especially in a multiracial population,” said Dr. Tan and his colleagues. “Dermatologists and primary care physicians are in ideal positions to initiate personalized efforts to improve overall rates of sun protection.”
Dr. Tan reported no relevant financial disclosures. Dr. Miriam Weinstein has worked as an advisory board member for Johnson & Johnson, which manufactures sunscreen; and Dr. Shudeshna Nag consults for Valeant, which manufactures sunscreen.
SOURCE: Tan MG et al. Pediatr Dermatol. 2018 Feb 13. doi: 10.1111/pde.13433.
according to Marcus G. Tan, MD, of the University of Toronto, and his associates.
Too much sun exposure as a child is a known risk factor for skin cancer, and “it has been estimated that approximately half of cumulative ultraviolet exposure by age 60 occurs before age 20.” So it is important that children be protected from excessive sun exposure, the investigators wrote, underscoring the reason for their study of parental sun protection by Canadian parents in Toronto, which has a multiracial population.
Parental sun protection efforts were considered ideal if they used sun protection every day; on sunny days all year round; or during the summer, using at least SPF 30, and reapplying sunscreen at least every 2 hours. Parental efforts would be considered nonideal if they did not meet any of these three criteria.
Of 183 parents, 17% used ideal sun protection for their children; 28% were in the lighter-skinned group (Fitzpatrick phototype I-III) and 5% in the darker-skinned group (Fitzpatrick phototype IV-V), The greater likelihood of using ideal sun protection among those in the lighter-skinned group was statistically significant (odds ratio, 7.4; P less than .001). As each child grew 1 year older, parents were 31% less likely to use ideal sun protection (OR, 0.69; P = .007).
Parents whose children were in the lighter-skinned group were “more likely to believe that sun exposure was harmful” for their children (OR, 17.2), and “to perceive value in sun protection,” (OR, 11.4) the researchers said. The parents whose children were in the darker-skinned group were more likely to consider sun protection as having drawbacks (OR, 9.2), and to believe that darker skin tone provides more sun protection (OR, 12.4). Neither of the two groups was more likely to consider that sun exposure provided health benefits or that it improved appearance.
Parents whose children were in the lighter-skinned group reported significantly more frequent use of sunscreen (OR, 3.6), sunglasses (OR, 2.3), and sun suits (OR, 2.7). The parents of the children in this group reported similar or higher rates of use of hats, long-sleeved clothing, and umbrellas; seeking shade; and staying indoors between 12 pm and 2 pm, but these rates were not statistically significantly different from those reported by the parents of children in the darker-skinned group, the investigators said.
“Our study suggests that more targeted education guidelines are necessary to ensure sun safety for all children, especially in a multiracial population,” said Dr. Tan and his colleagues. “Dermatologists and primary care physicians are in ideal positions to initiate personalized efforts to improve overall rates of sun protection.”
Dr. Tan reported no relevant financial disclosures. Dr. Miriam Weinstein has worked as an advisory board member for Johnson & Johnson, which manufactures sunscreen; and Dr. Shudeshna Nag consults for Valeant, which manufactures sunscreen.
SOURCE: Tan MG et al. Pediatr Dermatol. 2018 Feb 13. doi: 10.1111/pde.13433.
FROM PEDIATRIC DERMATOLOGY
Key clinical point: More targeted education of parents regarding sun protection practices may be needed.
Major finding: Of 183 parents, 17% used ideal sun protection; 28% were in the lighter-skinned group and 5% in the darker-skinned group (odds ratio, 7.4; P less than .001).
Study details: The parents of 183 children aged from 6 months to 6 years in Toronto completed a questionnaire about their sun protection practices.
Disclosures: Dr. Marcus G. Tan reported no relevant financial disclosures. Dr.Miriam Weinstein has worked as an advisory board member for Johnson & Johnson, which manufactures sunscreen; and Dr. Shudeshna Nag consults for Valeant, which manufactures sunscreen.
Source: Tan MG et al. Pediatr Dermatol. 2018 Feb 13. doi: 10.1111/pde.13433.
Intraventricular enzyme replacement slows CLN2 disease progression
LOS ANGELES – Intraventricular administration of cerliponase alfa seemed to slow the rate of motor and language decline in an open-label trial of 23 children with neuronal ceroid lipofuscinosis type 2 disease.
Neuronal ceroid lipofuscinosis type 2 disease (CLN2), a form of Batten’s disease, is a rare lysosomal storage disorder that causes progressive dementia in children. Patients have pathogenic variants in the gene encoding lysosomal enzyme tripeptidyl peptidase 1 (TPP1). Without functioning enzyme, lysosomal storage material accumulates in neurons throughout the CNS and retina.
Symptoms start at 2-4 years with seizures and language delays, followed by rapid motor, language, and cognitive declines, and blindness. Children die in early adolescence. Treatment is symptomatic; there are no approved therapies.
The idea of the study was to replace the enzyme in the CNS with cerliponase alfa, a recombinant form of TPP1. Twenty-four children aged 3-16 years received 30 mg, 100 mg, or 300 mg intraventricular infusions every 2 weeks during the dose-finding phase of the open-label trial; they were then switched to 300 mg infused over 4 hours every 14 days for at least 96 weeks. One child dropped out after the first dose in the study, but the others continued.
The investigators used Ommaya or Rickham ventricular reservoirs to deliver the enzyme, which were more convenient than intrathecal administration, said investigator Emily de Los Reyes, MD, a pediatric neurologist at Nationwide Children’s Hospital, Columbus, Ohio.
The primary outcome was the time until a 2-point decline on the motor and language scores of the CLN2 Clinical Rating Scale, with 0 representing no function and 6 representing normal function in both domains. The mean unadjusted rate of decline in the motor-language score per 48-week period was 0.27 points in treated patients, versus 2.12 points in 42 historical controls (P less than .001). The treatment difference at 96 weeks was about 3.3 points. There was also a decrease in seizure severity and frequency.
All but one child experienced convulsions, over two-thirds pyrexia, and almost two-thirds vomiting and hypersensitivity. About half developed upper respiratory tract infections, and about half had increased CSF white-cell counts. There were also cases of device leakage, and two children developed infections detected by CSF monitoring, without symptoms of meningitis. Both continued treatment after removal of the intraventricular device, followed by antibiotics, and device replacement.
Fourteen patients (58%) had at least one grade 3 adverse event, and there was one grade 4 event: status epilepticus deemed unrelated to the study. Side effects resolved on their own or responded to medical management. There were no deaths, study discontinuations, or dose reductions.
The mean age in the study was 60 months, about two-thirds of the patients were girls, and CLN2 diagnosis was confirmed by genotyping. Almost all the children had seizure histories. The majority were moderately advanced at baseline, with motor-language scores of 3 out of 6 in 11 patients.
An audience member asked Dr. de Los Reyes if there would be even more benefit by starting treatment before children became symptomatic. “I think all the neurologists in this group, we know that the earlier the treatment for rare diseases, the better the response,” she said.
The results were published simultaneously in the New England Journal of Medicine.
BioMarin Pharmaceutical funded the work, along with grants from the German Federal Ministry of Education and Research, the European Union’s Horizon 2020 Research and Innovation Program, and the National Institute for Health Research. Several authors were BioMarin employees. Dr. de Los Reyes is a consultant and reported a grant from the company.
SOURCE: Schulz A et al. N Engl J Med. 2018 Apr 24. doi: 10.1056/NEJMoa1712649.
LOS ANGELES – Intraventricular administration of cerliponase alfa seemed to slow the rate of motor and language decline in an open-label trial of 23 children with neuronal ceroid lipofuscinosis type 2 disease.
Neuronal ceroid lipofuscinosis type 2 disease (CLN2), a form of Batten’s disease, is a rare lysosomal storage disorder that causes progressive dementia in children. Patients have pathogenic variants in the gene encoding lysosomal enzyme tripeptidyl peptidase 1 (TPP1). Without functioning enzyme, lysosomal storage material accumulates in neurons throughout the CNS and retina.
Symptoms start at 2-4 years with seizures and language delays, followed by rapid motor, language, and cognitive declines, and blindness. Children die in early adolescence. Treatment is symptomatic; there are no approved therapies.
The idea of the study was to replace the enzyme in the CNS with cerliponase alfa, a recombinant form of TPP1. Twenty-four children aged 3-16 years received 30 mg, 100 mg, or 300 mg intraventricular infusions every 2 weeks during the dose-finding phase of the open-label trial; they were then switched to 300 mg infused over 4 hours every 14 days for at least 96 weeks. One child dropped out after the first dose in the study, but the others continued.
The investigators used Ommaya or Rickham ventricular reservoirs to deliver the enzyme, which were more convenient than intrathecal administration, said investigator Emily de Los Reyes, MD, a pediatric neurologist at Nationwide Children’s Hospital, Columbus, Ohio.
The primary outcome was the time until a 2-point decline on the motor and language scores of the CLN2 Clinical Rating Scale, with 0 representing no function and 6 representing normal function in both domains. The mean unadjusted rate of decline in the motor-language score per 48-week period was 0.27 points in treated patients, versus 2.12 points in 42 historical controls (P less than .001). The treatment difference at 96 weeks was about 3.3 points. There was also a decrease in seizure severity and frequency.
All but one child experienced convulsions, over two-thirds pyrexia, and almost two-thirds vomiting and hypersensitivity. About half developed upper respiratory tract infections, and about half had increased CSF white-cell counts. There were also cases of device leakage, and two children developed infections detected by CSF monitoring, without symptoms of meningitis. Both continued treatment after removal of the intraventricular device, followed by antibiotics, and device replacement.
Fourteen patients (58%) had at least one grade 3 adverse event, and there was one grade 4 event: status epilepticus deemed unrelated to the study. Side effects resolved on their own or responded to medical management. There were no deaths, study discontinuations, or dose reductions.
The mean age in the study was 60 months, about two-thirds of the patients were girls, and CLN2 diagnosis was confirmed by genotyping. Almost all the children had seizure histories. The majority were moderately advanced at baseline, with motor-language scores of 3 out of 6 in 11 patients.
An audience member asked Dr. de Los Reyes if there would be even more benefit by starting treatment before children became symptomatic. “I think all the neurologists in this group, we know that the earlier the treatment for rare diseases, the better the response,” she said.
The results were published simultaneously in the New England Journal of Medicine.
BioMarin Pharmaceutical funded the work, along with grants from the German Federal Ministry of Education and Research, the European Union’s Horizon 2020 Research and Innovation Program, and the National Institute for Health Research. Several authors were BioMarin employees. Dr. de Los Reyes is a consultant and reported a grant from the company.
SOURCE: Schulz A et al. N Engl J Med. 2018 Apr 24. doi: 10.1056/NEJMoa1712649.
LOS ANGELES – Intraventricular administration of cerliponase alfa seemed to slow the rate of motor and language decline in an open-label trial of 23 children with neuronal ceroid lipofuscinosis type 2 disease.
Neuronal ceroid lipofuscinosis type 2 disease (CLN2), a form of Batten’s disease, is a rare lysosomal storage disorder that causes progressive dementia in children. Patients have pathogenic variants in the gene encoding lysosomal enzyme tripeptidyl peptidase 1 (TPP1). Without functioning enzyme, lysosomal storage material accumulates in neurons throughout the CNS and retina.
Symptoms start at 2-4 years with seizures and language delays, followed by rapid motor, language, and cognitive declines, and blindness. Children die in early adolescence. Treatment is symptomatic; there are no approved therapies.
The idea of the study was to replace the enzyme in the CNS with cerliponase alfa, a recombinant form of TPP1. Twenty-four children aged 3-16 years received 30 mg, 100 mg, or 300 mg intraventricular infusions every 2 weeks during the dose-finding phase of the open-label trial; they were then switched to 300 mg infused over 4 hours every 14 days for at least 96 weeks. One child dropped out after the first dose in the study, but the others continued.
The investigators used Ommaya or Rickham ventricular reservoirs to deliver the enzyme, which were more convenient than intrathecal administration, said investigator Emily de Los Reyes, MD, a pediatric neurologist at Nationwide Children’s Hospital, Columbus, Ohio.
The primary outcome was the time until a 2-point decline on the motor and language scores of the CLN2 Clinical Rating Scale, with 0 representing no function and 6 representing normal function in both domains. The mean unadjusted rate of decline in the motor-language score per 48-week period was 0.27 points in treated patients, versus 2.12 points in 42 historical controls (P less than .001). The treatment difference at 96 weeks was about 3.3 points. There was also a decrease in seizure severity and frequency.
All but one child experienced convulsions, over two-thirds pyrexia, and almost two-thirds vomiting and hypersensitivity. About half developed upper respiratory tract infections, and about half had increased CSF white-cell counts. There were also cases of device leakage, and two children developed infections detected by CSF monitoring, without symptoms of meningitis. Both continued treatment after removal of the intraventricular device, followed by antibiotics, and device replacement.
Fourteen patients (58%) had at least one grade 3 adverse event, and there was one grade 4 event: status epilepticus deemed unrelated to the study. Side effects resolved on their own or responded to medical management. There were no deaths, study discontinuations, or dose reductions.
The mean age in the study was 60 months, about two-thirds of the patients were girls, and CLN2 diagnosis was confirmed by genotyping. Almost all the children had seizure histories. The majority were moderately advanced at baseline, with motor-language scores of 3 out of 6 in 11 patients.
An audience member asked Dr. de Los Reyes if there would be even more benefit by starting treatment before children became symptomatic. “I think all the neurologists in this group, we know that the earlier the treatment for rare diseases, the better the response,” she said.
The results were published simultaneously in the New England Journal of Medicine.
BioMarin Pharmaceutical funded the work, along with grants from the German Federal Ministry of Education and Research, the European Union’s Horizon 2020 Research and Innovation Program, and the National Institute for Health Research. Several authors were BioMarin employees. Dr. de Los Reyes is a consultant and reported a grant from the company.
SOURCE: Schulz A et al. N Engl J Med. 2018 Apr 24. doi: 10.1056/NEJMoa1712649.
REPORTING FROM AAN 2018
Key clinical point: Intraventricular administration of cerliponase alfa seemed to slow the rate of motor and language decline in 23 children with neuronal ceroid lipofuscinosis type 2 disease.
Major finding: The mean unadjusted rate of decline in the motor-language score per 48-week period was 0.27 points in treated patients, versus 2.12 points in 42 historical controls (P less than .001).
Study details: Open-label trial of 23 children.
Disclosures: BioMarin Pharmaceutical funded the work, along with grants from the German Federal Ministry of Education and Research, the European Union’s Horizon 2020 Research and Innovation Program, and the National Institute for Health Research. Several authors were BioMarin employees. The presenter is a consultant to BioMarin and reported a grant from the company.
Source: Schulz A et al. N Engl J Med. 2018 Apr 24. doi: 10.1056/NEJMoa1712649.
