Tara Haelle

Estimated prevalence of autism spectrum disorder among 4-year-olds falls short of the estimated prevalence among 8-year-olds in a recent study comparing nationally representative age cohorts.

“Because previous reports indicate that many children with ASD are not evaluated until after age 4, ASD prevalence in this 4-year-old age cohort will likely rise when measured at a later age,” Deborah L. Christensen, Ph.D., of the Centers for Disease Control and Prevention, and her associates reported. “Lowering the age at first evaluation may be more relevant than lowering the age at diagnosis given the challenges of diagnosing young children with ASD,” they wrote (J Dev Behav Pediatr. 2016 Jan;37[1]:1-8).

©Devonyu/thinkstockphotos.com

The investigators screened health and education records for all 4-year-old and 8-year-old children participating in 5 of the 11 sites involved in the 2010 Autism and Developmental Disabilities Monitoring Network, an active surveillance system for identifying 4-year-olds with ASD. The authors looked for an ICD billing code and/or special education data that included an ASD diagnosis or a description of “behavior consistent with ASD.”

They then compared autism prevalence, cognitive test scores, demographics, and ages of evaluation and ASD diagnosis among the 58,467 4-year-olds and 56,727 8-year-olds assessed, each cohort representing approximately 1.4% of those age groups in the 2010 U.S. population.

Prevalence of ASD among 4-year-olds was 13/1,000 children overall, approximately 30% lower than prevalence estimates for 8-year-olds and ranging from a low of 9/1,000 in Missouri to a high of 20/1,000 in New Jersey. Other states involved in the analysis included Arizona, Utah, and Wisconsin. Prevalence was significantly higher in states with both education and health records available than in those states with only health records available.

At all five sites, boys significantly proportionally outnumbered girls in ASD diagnosis. Overall, three boys had ASD for every one girl with ASD, but the ratio varied from 2.6 in Arizona, Missouri and Wisconsin to 4.4 in New Jersey. Despite no overall difference in ASD prevalence by race/ethnicity among 4-year-olds, white 8-year-olds had 1.4 times greater prevalence than that among black children and 1.2 greater prevalence than that among Hispanic children the same age.

Among the 70% of children in Arizona, New Jersey, and Utah who had data on cognitive assessments, 46% of 4-year-olds and 28% of 8-year-olds had cognitive impairment, defined as a score of 70 or lower. Prevalence of both ASD and cognitive impairment among 4-year-olds was 6/1,000 children, compared with 5/1,000 children among 8-year-olds. Prevalence of ASD without cognitive impairment was 7/1,000 among 4-year-olds and 12/1,000 among 8-year-olds.

A history of developmental concerns before 3 years old existed for 93% of the 4-year-olds and 87% of the 8-year-olds with ASD. In addition, 71% of the 4-year-olds and 43% of the 8-year-olds had received their first comprehensive evaluation by 36 months.

The research was funded by the Centers for Disease Control and Prevention. Dr. Christensen and her associates reported no disclosures.

Estimated prevalence of autism spectrum disorder among 4-year-olds falls short of the estimated prevalence among 8-year-olds in a recent study comparing nationally representative age cohorts.

“Because previous reports indicate that many children with ASD are not evaluated until after age 4, ASD prevalence in this 4-year-old age cohort will likely rise when measured at a later age,” Deborah L. Christensen, Ph.D., of the Centers for Disease Control and Prevention, and her associates reported. “Lowering the age at first evaluation may be more relevant than lowering the age at diagnosis given the challenges of diagnosing young children with ASD,” they wrote (J Dev Behav Pediatr. 2016 Jan;37[1]:1-8).

©Devonyu/thinkstockphotos.com

The investigators screened health and education records for all 4-year-old and 8-year-old children participating in 5 of the 11 sites involved in the 2010 Autism and Developmental Disabilities Monitoring Network, an active surveillance system for identifying 4-year-olds with ASD. The authors looked for an ICD billing code and/or special education data that included an ASD diagnosis or a description of “behavior consistent with ASD.”

They then compared autism prevalence, cognitive test scores, demographics, and ages of evaluation and ASD diagnosis among the 58,467 4-year-olds and 56,727 8-year-olds assessed, each cohort representing approximately 1.4% of those age groups in the 2010 U.S. population.

Prevalence of ASD among 4-year-olds was 13/1,000 children overall, approximately 30% lower than prevalence estimates for 8-year-olds and ranging from a low of 9/1,000 in Missouri to a high of 20/1,000 in New Jersey. Other states involved in the analysis included Arizona, Utah, and Wisconsin. Prevalence was significantly higher in states with both education and health records available than in those states with only health records available.

At all five sites, boys significantly proportionally outnumbered girls in ASD diagnosis. Overall, three boys had ASD for every one girl with ASD, but the ratio varied from 2.6 in Arizona, Missouri and Wisconsin to 4.4 in New Jersey. Despite no overall difference in ASD prevalence by race/ethnicity among 4-year-olds, white 8-year-olds had 1.4 times greater prevalence than that among black children and 1.2 greater prevalence than that among Hispanic children the same age.

Among the 70% of children in Arizona, New Jersey, and Utah who had data on cognitive assessments, 46% of 4-year-olds and 28% of 8-year-olds had cognitive impairment, defined as a score of 70 or lower. Prevalence of both ASD and cognitive impairment among 4-year-olds was 6/1,000 children, compared with 5/1,000 children among 8-year-olds. Prevalence of ASD without cognitive impairment was 7/1,000 among 4-year-olds and 12/1,000 among 8-year-olds.

A history of developmental concerns before 3 years old existed for 93% of the 4-year-olds and 87% of the 8-year-olds with ASD. In addition, 71% of the 4-year-olds and 43% of the 8-year-olds had received their first comprehensive evaluation by 36 months.

The research was funded by the Centers for Disease Control and Prevention. Dr. Christensen and her associates reported no disclosures.

Estimated prevalence of autism spectrum disorder among 4-year-olds falls short of the estimated prevalence among 8-year-olds in a recent study comparing nationally representative age cohorts.

“Because previous reports indicate that many children with ASD are not evaluated until after age 4, ASD prevalence in this 4-year-old age cohort will likely rise when measured at a later age,” Deborah L. Christensen, Ph.D., of the Centers for Disease Control and Prevention, and her associates reported. “Lowering the age at first evaluation may be more relevant than lowering the age at diagnosis given the challenges of diagnosing young children with ASD,” they wrote (J Dev Behav Pediatr. 2016 Jan;37[1]:1-8).

©Devonyu/thinkstockphotos.com

The investigators screened health and education records for all 4-year-old and 8-year-old children participating in 5 of the 11 sites involved in the 2010 Autism and Developmental Disabilities Monitoring Network, an active surveillance system for identifying 4-year-olds with ASD. The authors looked for an ICD billing code and/or special education data that included an ASD diagnosis or a description of “behavior consistent with ASD.”

They then compared autism prevalence, cognitive test scores, demographics, and ages of evaluation and ASD diagnosis among the 58,467 4-year-olds and 56,727 8-year-olds assessed, each cohort representing approximately 1.4% of those age groups in the 2010 U.S. population.

Prevalence of ASD among 4-year-olds was 13/1,000 children overall, approximately 30% lower than prevalence estimates for 8-year-olds and ranging from a low of 9/1,000 in Missouri to a high of 20/1,000 in New Jersey. Other states involved in the analysis included Arizona, Utah, and Wisconsin. Prevalence was significantly higher in states with both education and health records available than in those states with only health records available.

At all five sites, boys significantly proportionally outnumbered girls in ASD diagnosis. Overall, three boys had ASD for every one girl with ASD, but the ratio varied from 2.6 in Arizona, Missouri and Wisconsin to 4.4 in New Jersey. Despite no overall difference in ASD prevalence by race/ethnicity among 4-year-olds, white 8-year-olds had 1.4 times greater prevalence than that among black children and 1.2 greater prevalence than that among Hispanic children the same age.

Among the 70% of children in Arizona, New Jersey, and Utah who had data on cognitive assessments, 46% of 4-year-olds and 28% of 8-year-olds had cognitive impairment, defined as a score of 70 or lower. Prevalence of both ASD and cognitive impairment among 4-year-olds was 6/1,000 children, compared with 5/1,000 children among 8-year-olds. Prevalence of ASD without cognitive impairment was 7/1,000 among 4-year-olds and 12/1,000 among 8-year-olds.

A history of developmental concerns before 3 years old existed for 93% of the 4-year-olds and 87% of the 8-year-olds with ASD. In addition, 71% of the 4-year-olds and 43% of the 8-year-olds had received their first comprehensive evaluation by 36 months.

The research was funded by the Centers for Disease Control and Prevention. Dr. Christensen and her associates reported no disclosures.

Middle schoolers who socialize with friends engaged in risky or deviant behaviors are more likely to use alcohol, tobacco, or drugs early, but increased parental monitoring mediates this effect, according to a recent study.

“The peer selection pathway describes how children who use or intend to use alcohol, tobacco, or drugs select peers who will facilitate alcohol, tobacco, or drug use,” reported Thomas J. Schofield, Ph.D., of Iowa State University, Ames, and his associates. “In contrast, the peer socialization pathway describes how children with deviant peers become more likely to use alcohol, tobacco, or drugs because of peer influence. In the current investigation, we found support for both of these pathways over time among a sample of Mexican-origin children,” they wrote (Drug Alcohol Depend. 2015 Dec 1;157:129-35).

©rez-art/thinkstockphotos.com

The researchers tracked 674 California fifth graders, all of Mexican origin, for 2 years, collecting data during fifth and seventh grades on the kids’ social relationships, their intent to use alcohol, tobacco, or other drugs, and their use of those substances in the previous year. Families were also video-recorded during a 20-minute structured interaction task between the mother and child and, if possible, father and child, at the fifth grade assessment so trained observers could rate parents’ interactions with their children.

“The monitoring variable was operationalized as the degree to which parents accurately track the behaviors, activities, and social involvements of the child, as well as parents’ specific knowledge about the child’s life and activities,” the researchers wrote.

Questions about social relationships specifically asked the children how many of their friends engaged in various risky or deviant behaviors, such as using alcohol to get drunk, hanging out with a gang, and using substances to get high.

In fifth grade, less than 1% of the kids had tried cigarettes, and 92% had no intention of doing so; 3.4% had tried beer while 89.6% had no plans to use alcohol. No children reported trying street drugs in fifth grade, and 93.2% reported no intention of doing so. Similarly high numbers of kids had no intentions of smoking or using drugs or alcohol in seventh grade.

No data emerged to suggest children’s gender or generational status influenced their substance use, and the proportion of children interacting with deviant peers, intending to use substances or already using substances remained stable from fifth to seventh grades. However, interaction with deviant peers increased kids’ likelihood of using substances or intending to.

“Despite almost no use or intent to use alcohol, tobacco, and other drugs in fifth grade, adolescents who did entertain the idea of using alcohol, tobacco, and other drugs over the next year were already more likely to be associating with deviant peers in fifth grade,” the authors wrote. But analyses of parent interactions revealed that “parental monitoring significantly moderated the pathway from deviant peers in fifth grade to later alcohol, tobacco, and other drug use as well as the pathway from alcohol, tobacco, and other drug use in fifth grade to later associations with deviant peers.”

The only personality feature that reduced children’s likelihood of socializing with deviant peers was being shy. Parents’ use of alcohol predicted an increase in children’s alcohol, tobacco, and other drug use.

Parental monitoring may reduce kids’ likelihood of using substances because a close relationship may help the child identify with the parent values more or children may have fewer opportunities to use with closer monitoring, the authors propose.

The research was funded by the National Institute on Drug Abuse. The authors reported no disclosures.

Middle schoolers who socialize with friends engaged in risky or deviant behaviors are more likely to use alcohol, tobacco, or drugs early, but increased parental monitoring mediates this effect, according to a recent study.

“The peer selection pathway describes how children who use or intend to use alcohol, tobacco, or drugs select peers who will facilitate alcohol, tobacco, or drug use,” reported Thomas J. Schofield, Ph.D., of Iowa State University, Ames, and his associates. “In contrast, the peer socialization pathway describes how children with deviant peers become more likely to use alcohol, tobacco, or drugs because of peer influence. In the current investigation, we found support for both of these pathways over time among a sample of Mexican-origin children,” they wrote (Drug Alcohol Depend. 2015 Dec 1;157:129-35).

©rez-art/thinkstockphotos.com

The researchers tracked 674 California fifth graders, all of Mexican origin, for 2 years, collecting data during fifth and seventh grades on the kids’ social relationships, their intent to use alcohol, tobacco, or other drugs, and their use of those substances in the previous year. Families were also video-recorded during a 20-minute structured interaction task between the mother and child and, if possible, father and child, at the fifth grade assessment so trained observers could rate parents’ interactions with their children.

“The monitoring variable was operationalized as the degree to which parents accurately track the behaviors, activities, and social involvements of the child, as well as parents’ specific knowledge about the child’s life and activities,” the researchers wrote.

Questions about social relationships specifically asked the children how many of their friends engaged in various risky or deviant behaviors, such as using alcohol to get drunk, hanging out with a gang, and using substances to get high.

In fifth grade, less than 1% of the kids had tried cigarettes, and 92% had no intention of doing so; 3.4% had tried beer while 89.6% had no plans to use alcohol. No children reported trying street drugs in fifth grade, and 93.2% reported no intention of doing so. Similarly high numbers of kids had no intentions of smoking or using drugs or alcohol in seventh grade.

No data emerged to suggest children’s gender or generational status influenced their substance use, and the proportion of children interacting with deviant peers, intending to use substances or already using substances remained stable from fifth to seventh grades. However, interaction with deviant peers increased kids’ likelihood of using substances or intending to.

“Despite almost no use or intent to use alcohol, tobacco, and other drugs in fifth grade, adolescents who did entertain the idea of using alcohol, tobacco, and other drugs over the next year were already more likely to be associating with deviant peers in fifth grade,” the authors wrote. But analyses of parent interactions revealed that “parental monitoring significantly moderated the pathway from deviant peers in fifth grade to later alcohol, tobacco, and other drug use as well as the pathway from alcohol, tobacco, and other drug use in fifth grade to later associations with deviant peers.”

The only personality feature that reduced children’s likelihood of socializing with deviant peers was being shy. Parents’ use of alcohol predicted an increase in children’s alcohol, tobacco, and other drug use.

Parental monitoring may reduce kids’ likelihood of using substances because a close relationship may help the child identify with the parent values more or children may have fewer opportunities to use with closer monitoring, the authors propose.

The research was funded by the National Institute on Drug Abuse. The authors reported no disclosures.

Middle schoolers who socialize with friends engaged in risky or deviant behaviors are more likely to use alcohol, tobacco, or drugs early, but increased parental monitoring mediates this effect, according to a recent study.

“The peer selection pathway describes how children who use or intend to use alcohol, tobacco, or drugs select peers who will facilitate alcohol, tobacco, or drug use,” reported Thomas J. Schofield, Ph.D., of Iowa State University, Ames, and his associates. “In contrast, the peer socialization pathway describes how children with deviant peers become more likely to use alcohol, tobacco, or drugs because of peer influence. In the current investigation, we found support for both of these pathways over time among a sample of Mexican-origin children,” they wrote (Drug Alcohol Depend. 2015 Dec 1;157:129-35).

©rez-art/thinkstockphotos.com

The researchers tracked 674 California fifth graders, all of Mexican origin, for 2 years, collecting data during fifth and seventh grades on the kids’ social relationships, their intent to use alcohol, tobacco, or other drugs, and their use of those substances in the previous year. Families were also video-recorded during a 20-minute structured interaction task between the mother and child and, if possible, father and child, at the fifth grade assessment so trained observers could rate parents’ interactions with their children.

“The monitoring variable was operationalized as the degree to which parents accurately track the behaviors, activities, and social involvements of the child, as well as parents’ specific knowledge about the child’s life and activities,” the researchers wrote.

Questions about social relationships specifically asked the children how many of their friends engaged in various risky or deviant behaviors, such as using alcohol to get drunk, hanging out with a gang, and using substances to get high.

In fifth grade, less than 1% of the kids had tried cigarettes, and 92% had no intention of doing so; 3.4% had tried beer while 89.6% had no plans to use alcohol. No children reported trying street drugs in fifth grade, and 93.2% reported no intention of doing so. Similarly high numbers of kids had no intentions of smoking or using drugs or alcohol in seventh grade.

No data emerged to suggest children’s gender or generational status influenced their substance use, and the proportion of children interacting with deviant peers, intending to use substances or already using substances remained stable from fifth to seventh grades. However, interaction with deviant peers increased kids’ likelihood of using substances or intending to.

“Despite almost no use or intent to use alcohol, tobacco, and other drugs in fifth grade, adolescents who did entertain the idea of using alcohol, tobacco, and other drugs over the next year were already more likely to be associating with deviant peers in fifth grade,” the authors wrote. But analyses of parent interactions revealed that “parental monitoring significantly moderated the pathway from deviant peers in fifth grade to later alcohol, tobacco, and other drug use as well as the pathway from alcohol, tobacco, and other drug use in fifth grade to later associations with deviant peers.”

The only personality feature that reduced children’s likelihood of socializing with deviant peers was being shy. Parents’ use of alcohol predicted an increase in children’s alcohol, tobacco, and other drug use.

Parental monitoring may reduce kids’ likelihood of using substances because a close relationship may help the child identify with the parent values more or children may have fewer opportunities to use with closer monitoring, the authors propose.

The research was funded by the National Institute on Drug Abuse. The authors reported no disclosures.

Signs of early puberty can be deceiving and recognition of true early onset of puberty can help primary care providers make appropriate referrals to pediatric endocrinologists, according to a new guide to evaluation of children with these symptoms.

Most children with symptoms that appear to indicate early puberty simply show benign variations in typical growth and development that do not require testing or interventions, wrote Dr. Paul Kaplowitz and his colleagues with the American Academy of Pediatrics Section on Endocrinology.

“The most common of these signs of early puberty are premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (nonprogressive breast development, usually occurring before 2 years of age), and lipomastia, in which girls have apparent breast development which, on careful palpation, is determined to be adipose tissue,” wrote the investigators (Pediatrics 2015 Dec 14. doi:10.1542/peds.2015-3732).

Although there has been a decrease in the age of puberty onset, this trend stabilized in the 1950s, and currently, precocious puberty refers to onset before 8 years old in girls and before 9 years old in boys, though ethnicity and body weight can play a significant role in variation. Black girls appear to enter puberty earlier than white girls on average, for example. “Thus, the evaluation of girls with signs of early puberty has to take into account increased [body mass index] as well as race/ethnicity,” the authors wrote. Penile or testicular enlargement before age 9 in boys is concerning enough to warrant a referral, they suggested.

Early pubic hair growth and/or body odor without clitoromegaly, penile growth, or testicular enlargement may occur with increased levels of dehydroepiandrosterone sulfate (DHEA-S), typically 30-150 mcg/dL, but usually does not require referral or additional testing. A radiograph with cautious interpretation of bone age may help rule out early puberty.

Similarly, genital hair in infancy without genital enlargement or crossing of growth percentiles generally does not require any labs and has become somewhat less rare in recent years. It’s less clear with premature thelarche – palpable glandular tissue in girls under 2 year old – how much testing and follow-up is needed, but “it seems reasonable to hold off on hormonal testing and pelvic ultrasonography in most girls” when it does not increase and no crossing of growth percentiles occurs, the authors wrote.

Prepubertal vaginal bleeding – once potential trauma or tumors have been ruled out – is generally benign unless it becomes recurrent or continuous. In overweight and obese girls with apparent early breast development, a clinical exam can rule out progressive precocious puberty if no firm glandular tissue is found under the areolae and no estrogenic stimulation around the nipples and areolae exists.

A central precocious puberty (CPP) diagnosis may be considered in girls with “progressive breast development and who cross percentiles upward on the linear growth chart,” the authors wrote. Rarer in boys, the diagnosis may be considered with testicular and penile enlargement before age 9.

“The typical evaluation includes obtaining a family history, because CPP is occasionally inherited from the parents; menarche in the mother at 10 years or younger or a growth spurt in the father before 12 years of age are suggestive of autosomal-dominant inheritance,” the researchers noted. Questions to the family should include the child’s possible exposure to birth control pills, transdermal estrogen creams or testosterone gels, certain essential oils such as lavender and tea tree oil, and other potential exogenous sources of sex steroids.

“The family should also be asked about any [central nervous system] symptoms, including severe frequent headaches or recent visual deficits, and a history of disorders associated with CPP, including brain tumor, meningitis, CNS trauma, cranial irradiation, hypoxic-ischemic injury, histiocytosis, and neurofibromatosis,” the investigators wrote.

Diagnostic evaluation of central precocious puberty generally includes a bone age determination, baseline lab testing of follicle-stimulating hormone, luteinizing hormone, and estradiol or testosterone levels, and possibly pelvic ultrasonography, though most of this would be done by a pediatric endocrinologist.

No external funding or disclosures were reported.

Signs of early puberty can be deceiving and recognition of true early onset of puberty can help primary care providers make appropriate referrals to pediatric endocrinologists, according to a new guide to evaluation of children with these symptoms.

Most children with symptoms that appear to indicate early puberty simply show benign variations in typical growth and development that do not require testing or interventions, wrote Dr. Paul Kaplowitz and his colleagues with the American Academy of Pediatrics Section on Endocrinology.

“The most common of these signs of early puberty are premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (nonprogressive breast development, usually occurring before 2 years of age), and lipomastia, in which girls have apparent breast development which, on careful palpation, is determined to be adipose tissue,” wrote the investigators (Pediatrics 2015 Dec 14. doi:10.1542/peds.2015-3732).

Although there has been a decrease in the age of puberty onset, this trend stabilized in the 1950s, and currently, precocious puberty refers to onset before 8 years old in girls and before 9 years old in boys, though ethnicity and body weight can play a significant role in variation. Black girls appear to enter puberty earlier than white girls on average, for example. “Thus, the evaluation of girls with signs of early puberty has to take into account increased [body mass index] as well as race/ethnicity,” the authors wrote. Penile or testicular enlargement before age 9 in boys is concerning enough to warrant a referral, they suggested.

Early pubic hair growth and/or body odor without clitoromegaly, penile growth, or testicular enlargement may occur with increased levels of dehydroepiandrosterone sulfate (DHEA-S), typically 30-150 mcg/dL, but usually does not require referral or additional testing. A radiograph with cautious interpretation of bone age may help rule out early puberty.

Similarly, genital hair in infancy without genital enlargement or crossing of growth percentiles generally does not require any labs and has become somewhat less rare in recent years. It’s less clear with premature thelarche – palpable glandular tissue in girls under 2 year old – how much testing and follow-up is needed, but “it seems reasonable to hold off on hormonal testing and pelvic ultrasonography in most girls” when it does not increase and no crossing of growth percentiles occurs, the authors wrote.

Prepubertal vaginal bleeding – once potential trauma or tumors have been ruled out – is generally benign unless it becomes recurrent or continuous. In overweight and obese girls with apparent early breast development, a clinical exam can rule out progressive precocious puberty if no firm glandular tissue is found under the areolae and no estrogenic stimulation around the nipples and areolae exists.

A central precocious puberty (CPP) diagnosis may be considered in girls with “progressive breast development and who cross percentiles upward on the linear growth chart,” the authors wrote. Rarer in boys, the diagnosis may be considered with testicular and penile enlargement before age 9.

“The typical evaluation includes obtaining a family history, because CPP is occasionally inherited from the parents; menarche in the mother at 10 years or younger or a growth spurt in the father before 12 years of age are suggestive of autosomal-dominant inheritance,” the researchers noted. Questions to the family should include the child’s possible exposure to birth control pills, transdermal estrogen creams or testosterone gels, certain essential oils such as lavender and tea tree oil, and other potential exogenous sources of sex steroids.

“The family should also be asked about any [central nervous system] symptoms, including severe frequent headaches or recent visual deficits, and a history of disorders associated with CPP, including brain tumor, meningitis, CNS trauma, cranial irradiation, hypoxic-ischemic injury, histiocytosis, and neurofibromatosis,” the investigators wrote.

Diagnostic evaluation of central precocious puberty generally includes a bone age determination, baseline lab testing of follicle-stimulating hormone, luteinizing hormone, and estradiol or testosterone levels, and possibly pelvic ultrasonography, though most of this would be done by a pediatric endocrinologist.

No external funding or disclosures were reported.

Signs of early puberty can be deceiving and recognition of true early onset of puberty can help primary care providers make appropriate referrals to pediatric endocrinologists, according to a new guide to evaluation of children with these symptoms.

Most children with symptoms that appear to indicate early puberty simply show benign variations in typical growth and development that do not require testing or interventions, wrote Dr. Paul Kaplowitz and his colleagues with the American Academy of Pediatrics Section on Endocrinology.

“The most common of these signs of early puberty are premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (nonprogressive breast development, usually occurring before 2 years of age), and lipomastia, in which girls have apparent breast development which, on careful palpation, is determined to be adipose tissue,” wrote the investigators (Pediatrics 2015 Dec 14. doi:10.1542/peds.2015-3732).

Although there has been a decrease in the age of puberty onset, this trend stabilized in the 1950s, and currently, precocious puberty refers to onset before 8 years old in girls and before 9 years old in boys, though ethnicity and body weight can play a significant role in variation. Black girls appear to enter puberty earlier than white girls on average, for example. “Thus, the evaluation of girls with signs of early puberty has to take into account increased [body mass index] as well as race/ethnicity,” the authors wrote. Penile or testicular enlargement before age 9 in boys is concerning enough to warrant a referral, they suggested.

Early pubic hair growth and/or body odor without clitoromegaly, penile growth, or testicular enlargement may occur with increased levels of dehydroepiandrosterone sulfate (DHEA-S), typically 30-150 mcg/dL, but usually does not require referral or additional testing. A radiograph with cautious interpretation of bone age may help rule out early puberty.

Similarly, genital hair in infancy without genital enlargement or crossing of growth percentiles generally does not require any labs and has become somewhat less rare in recent years. It’s less clear with premature thelarche – palpable glandular tissue in girls under 2 year old – how much testing and follow-up is needed, but “it seems reasonable to hold off on hormonal testing and pelvic ultrasonography in most girls” when it does not increase and no crossing of growth percentiles occurs, the authors wrote.

Prepubertal vaginal bleeding – once potential trauma or tumors have been ruled out – is generally benign unless it becomes recurrent or continuous. In overweight and obese girls with apparent early breast development, a clinical exam can rule out progressive precocious puberty if no firm glandular tissue is found under the areolae and no estrogenic stimulation around the nipples and areolae exists.

A central precocious puberty (CPP) diagnosis may be considered in girls with “progressive breast development and who cross percentiles upward on the linear growth chart,” the authors wrote. Rarer in boys, the diagnosis may be considered with testicular and penile enlargement before age 9.

“The typical evaluation includes obtaining a family history, because CPP is occasionally inherited from the parents; menarche in the mother at 10 years or younger or a growth spurt in the father before 12 years of age are suggestive of autosomal-dominant inheritance,” the researchers noted. Questions to the family should include the child’s possible exposure to birth control pills, transdermal estrogen creams or testosterone gels, certain essential oils such as lavender and tea tree oil, and other potential exogenous sources of sex steroids.

“The family should also be asked about any [central nervous system] symptoms, including severe frequent headaches or recent visual deficits, and a history of disorders associated with CPP, including brain tumor, meningitis, CNS trauma, cranial irradiation, hypoxic-ischemic injury, histiocytosis, and neurofibromatosis,” the investigators wrote.

Diagnostic evaluation of central precocious puberty generally includes a bone age determination, baseline lab testing of follicle-stimulating hormone, luteinizing hormone, and estradiol or testosterone levels, and possibly pelvic ultrasonography, though most of this would be done by a pediatric endocrinologist.

No external funding or disclosures were reported.

WASHINGTON – Understanding a child’s fever history and other symptoms is essential to accurately determining what is causing a fever and what kind of management, if any, it requires, Dr. Kathryn M. Edwards explained at the American Academy of Pediatrics annual meeting.

Dr. Edwards aimed largely to help clinicians distinguish between familial recurrent fever syndromes and the syndrome PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Cervical Adenitis). Although familial cases of PFAPA have been reported, the syndrome’s etiology isn’t fully understood.

©IPGGutenbergUKLtd/Thinkstock

She began with a review of fever definition and pathogenesis, and used a series of case studies to introduce various fever syndromes. Although the simplest definition is an above-normal body temperature, fever is best thought of not as “a single value, but rather a range depending on time, place, individual, and measurement site,” Dr. Edwards explained. An inflammatory response, fever may result from an infection or occur secondarily to other conditions. The inflammatory response begins after both monocytes and macrophages release cytokines that stimulate the brain’s thermoregulatory center, inducing prostaglandin production.

Recurrent and periodic fever overview

Unlike a fever of unknown origin, recurrent and periodic fevers occur regularly in repeated cycles or intermittently over a period of time. The most important step in identifying what’s going on with a child’s recurrent/periodic fever is taking a complete fever history, including not only exposures and travel, but also family history and ethnicity. Clinicians can provide parents with a fever diary that tracks fever date and time, the temperature, other symptoms, medication administered, and other relevant information because “knowing the fever pattern is critical,” Dr. Edwards emphasized. A good fever history also requires clinicians to conduct a comprehensive physical exam, be aware of temperature norms for a child’s age and sex, and diligently evaluate a child’s growth parameters.

Using a flowchart adapted from Long’s article in “Pediatric Clinics of North America,” Dr. Edwards pointed out that recurrent fever may result from identified infections or may be stereotypical and episodic without an infection. The source of multiple viral infections is generally environmental, such as day care or cigarette smoke exposure. Multiple bacterial infections involving different organ systems may indicate an immunodeficiency, whereas recurrent infections in the same organ system require assessment specific to that system. Among stereotypical recurrent fevers, irregular episodes likely indicate a monogenic fever syndrome, while more predictable episodes could be cyclic neutropenia or PFAPA.

“There are a couple remarkable differences between PFAPA patients and patients with repeated viral infections,” said Dr. Edwards , professor of pediatrics at Vanderbilt University, Nashville, Tenn. “One is the frequency of the fevers, how often they come,” which underscores the need for a meticulous fever history, she explained. A parent might perceive that the fevers come once a month, but it’s essential to know whether they truly come like clockwork or whether they are more sporadic. “In addition, between the episodes, the children get nothing else,” she said, “and certainly they’re not infectious. Nobody else gets sick.”

Recognizing PFAPA

Children with PFAPA show normal growth and development, and no symptoms between very regular intervals of fever (above 38.3º C) with sore throat, mouth sores, and/or glandular swelling in the absence of an infection. About two-thirds of patients report headache, sore throat and/or mouth ulcers, and more than three quarters report swelling of the lymph nodes. About half experience abdominal pain or nausea.

PFAPA typically has an early age of onset and is diagnosed after exclusion of cyclic neutropenia and other fever syndromes. Episodes last an average of 3-4 days with intervals gradually becoming less frequent as the child ages. In one study, intervals at onset lasted an average of 28 days, but gradually extended to a mean 159 days during long-term follow-up in which average syndrome duration ranged from 5 to 7 years. Studies show a family history of recurrent fever in 10%-60% of patients, and recurrent tonsillitis in one parent is twice as likely among children with PFAPA.

Primary treatments for PFAPA include corticosteroids, cimetidine, and tonsillectomy, with anakinra, colchicine, and montelukast comprising additional options. Although the fever should subside within 4-12 hours after a corticosteroid dose of 1-2 mg/kg, a quarter of children may require a second dose within the next 12-24 hours, and corticosteroids treatment may increase episode frequency in up to half of children. By contrast, cimetidine is used prophylactically – twice daily over 6 months – and has led to remission in approximately a quarter of patients, although some experience recurrence after stopping treatment. The most successful intervention for curing PFAPA is tonsillectomy: Episodes completely stopped in 70%-97% of children in European and U.S. studies. But Dr. Edwards said the surgery should not be a first-line intervention.

“The role of the tonsils in all of the fever syndromes is quite fascinating, and I also think it’s interesting the parents have similar pharyngeal or oropharyngeal symptoms when they were children,” she said, noting that some research has been investigating tonsil cells for a better understanding of these syndromes.

“I think the decision to do a tonsillectomy is very dependent upon families,” she said. “I certainly don’t recommend it first thing, but there are some patients who have had these episodes for 2 or 3 years, the family is falling apart, and [the parents] are unable to go to work. In those situations, I will say this looks like something we should do.”

Familial fever syndromes

Dr. Edwards covered several familial fever syndromes during the remainder of the presentation using case studies to introduce each one. The first, familial Mediterranean fever (FMF), also known as Armenian disease, results from a mutation in the MEFV gene and occurs among those of Sephardic and Ashkenazi Jewish, Middle Eastern Arab, Armenian, Italian, North African or Turkish ethnicities.

Episodes last 12-72 hours, and clinical features include an erysipeloid rash and inflammation of various membranes, causing abdominal, chest or joint pain (serositis of the peritoneum, pleura or synovia, respectively). Treatment with colchicine can prevent FMF’s most significant complication, amyloidosis, which can otherwise lead to renal failure. About 95% of patients experience improvement, and 75% have remission with colchicine, and anakinra is an additional treatment option.

The second familial syndrome, hyperimmunoglobulinemia D with periodic fever syndrome, or hyper IgD (HIDS), has an early age of onset, typically before 12 months and with more than half before 6 months. Resulting from mutations in the MVK gene (and hence also called mevalonate kinase deficiency), HIDS primarily afflicts those with European ancestry, and about half of patients are of Dutch ancestry. Despite the syndrome’s name, about 22% of patients have normal IgD levels, and high IgD levels may indicate other conditions, so high IgD labs are not diagnostic. Diagnosis is based on genetic testing and elevated mevalonic acid levels in urine.

Stress, vaccination, or an upper respiratory infection may trigger a HIDS episode that lasts 3-7 days with clinical features that include a widespread red rash – frequently on the lower legs – as well as oral or vaginal ulcers. More than 80% of patients report swollen lymph nodes, abdominal pain, and joint pain, particularly in the knees, ankles, wrists, and elbows. More than half of patients report diarrhea, vomiting, skin lesions, headache, cold chills, or arthritis.

The final fever syndrome Dr. Edwards covered was tumor necrosis factor receptor–associated periodic syndrome (TRAPS), also called Hibernian fever. Resulting from mutations in TNFRSF1A gene, this condition first appeared in Scottish and Irish populations but can occur among any ethnicity. Episodes can last from a few days to 1-2 weeks, and can include migratory nonspecific pain, a rash, abdominal pain, joint pain, chest pain, mouth sores, puffy eyes, and various inflammatory eye symptoms, such as uveitis, iritis, and conjunctivitis.

Although PFAPA is the most common pediatric periodic fever syndrome, a thorough fever history and family history can help clinicians identify whether a familial syndrome is involved.

WASHINGTON – Understanding a child’s fever history and other symptoms is essential to accurately determining what is causing a fever and what kind of management, if any, it requires, Dr. Kathryn M. Edwards explained at the American Academy of Pediatrics annual meeting.

Dr. Edwards aimed largely to help clinicians distinguish between familial recurrent fever syndromes and the syndrome PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Cervical Adenitis). Although familial cases of PFAPA have been reported, the syndrome’s etiology isn’t fully understood.

©IPGGutenbergUKLtd/Thinkstock

She began with a review of fever definition and pathogenesis, and used a series of case studies to introduce various fever syndromes. Although the simplest definition is an above-normal body temperature, fever is best thought of not as “a single value, but rather a range depending on time, place, individual, and measurement site,” Dr. Edwards explained. An inflammatory response, fever may result from an infection or occur secondarily to other conditions. The inflammatory response begins after both monocytes and macrophages release cytokines that stimulate the brain’s thermoregulatory center, inducing prostaglandin production.

Recurrent and periodic fever overview

Unlike a fever of unknown origin, recurrent and periodic fevers occur regularly in repeated cycles or intermittently over a period of time. The most important step in identifying what’s going on with a child’s recurrent/periodic fever is taking a complete fever history, including not only exposures and travel, but also family history and ethnicity. Clinicians can provide parents with a fever diary that tracks fever date and time, the temperature, other symptoms, medication administered, and other relevant information because “knowing the fever pattern is critical,” Dr. Edwards emphasized. A good fever history also requires clinicians to conduct a comprehensive physical exam, be aware of temperature norms for a child’s age and sex, and diligently evaluate a child’s growth parameters.

Using a flowchart adapted from Long’s article in “Pediatric Clinics of North America,” Dr. Edwards pointed out that recurrent fever may result from identified infections or may be stereotypical and episodic without an infection. The source of multiple viral infections is generally environmental, such as day care or cigarette smoke exposure. Multiple bacterial infections involving different organ systems may indicate an immunodeficiency, whereas recurrent infections in the same organ system require assessment specific to that system. Among stereotypical recurrent fevers, irregular episodes likely indicate a monogenic fever syndrome, while more predictable episodes could be cyclic neutropenia or PFAPA.

“There are a couple remarkable differences between PFAPA patients and patients with repeated viral infections,” said Dr. Edwards , professor of pediatrics at Vanderbilt University, Nashville, Tenn. “One is the frequency of the fevers, how often they come,” which underscores the need for a meticulous fever history, she explained. A parent might perceive that the fevers come once a month, but it’s essential to know whether they truly come like clockwork or whether they are more sporadic. “In addition, between the episodes, the children get nothing else,” she said, “and certainly they’re not infectious. Nobody else gets sick.”

Recognizing PFAPA

Children with PFAPA show normal growth and development, and no symptoms between very regular intervals of fever (above 38.3º C) with sore throat, mouth sores, and/or glandular swelling in the absence of an infection. About two-thirds of patients report headache, sore throat and/or mouth ulcers, and more than three quarters report swelling of the lymph nodes. About half experience abdominal pain or nausea.

PFAPA typically has an early age of onset and is diagnosed after exclusion of cyclic neutropenia and other fever syndromes. Episodes last an average of 3-4 days with intervals gradually becoming less frequent as the child ages. In one study, intervals at onset lasted an average of 28 days, but gradually extended to a mean 159 days during long-term follow-up in which average syndrome duration ranged from 5 to 7 years. Studies show a family history of recurrent fever in 10%-60% of patients, and recurrent tonsillitis in one parent is twice as likely among children with PFAPA.

Primary treatments for PFAPA include corticosteroids, cimetidine, and tonsillectomy, with anakinra, colchicine, and montelukast comprising additional options. Although the fever should subside within 4-12 hours after a corticosteroid dose of 1-2 mg/kg, a quarter of children may require a second dose within the next 12-24 hours, and corticosteroids treatment may increase episode frequency in up to half of children. By contrast, cimetidine is used prophylactically – twice daily over 6 months – and has led to remission in approximately a quarter of patients, although some experience recurrence after stopping treatment. The most successful intervention for curing PFAPA is tonsillectomy: Episodes completely stopped in 70%-97% of children in European and U.S. studies. But Dr. Edwards said the surgery should not be a first-line intervention.

“The role of the tonsils in all of the fever syndromes is quite fascinating, and I also think it’s interesting the parents have similar pharyngeal or oropharyngeal symptoms when they were children,” she said, noting that some research has been investigating tonsil cells for a better understanding of these syndromes.

“I think the decision to do a tonsillectomy is very dependent upon families,” she said. “I certainly don’t recommend it first thing, but there are some patients who have had these episodes for 2 or 3 years, the family is falling apart, and [the parents] are unable to go to work. In those situations, I will say this looks like something we should do.”

Familial fever syndromes

Dr. Edwards covered several familial fever syndromes during the remainder of the presentation using case studies to introduce each one. The first, familial Mediterranean fever (FMF), also known as Armenian disease, results from a mutation in the MEFV gene and occurs among those of Sephardic and Ashkenazi Jewish, Middle Eastern Arab, Armenian, Italian, North African or Turkish ethnicities.

Episodes last 12-72 hours, and clinical features include an erysipeloid rash and inflammation of various membranes, causing abdominal, chest or joint pain (serositis of the peritoneum, pleura or synovia, respectively). Treatment with colchicine can prevent FMF’s most significant complication, amyloidosis, which can otherwise lead to renal failure. About 95% of patients experience improvement, and 75% have remission with colchicine, and anakinra is an additional treatment option.

The second familial syndrome, hyperimmunoglobulinemia D with periodic fever syndrome, or hyper IgD (HIDS), has an early age of onset, typically before 12 months and with more than half before 6 months. Resulting from mutations in the MVK gene (and hence also called mevalonate kinase deficiency), HIDS primarily afflicts those with European ancestry, and about half of patients are of Dutch ancestry. Despite the syndrome’s name, about 22% of patients have normal IgD levels, and high IgD levels may indicate other conditions, so high IgD labs are not diagnostic. Diagnosis is based on genetic testing and elevated mevalonic acid levels in urine.

Stress, vaccination, or an upper respiratory infection may trigger a HIDS episode that lasts 3-7 days with clinical features that include a widespread red rash – frequently on the lower legs – as well as oral or vaginal ulcers. More than 80% of patients report swollen lymph nodes, abdominal pain, and joint pain, particularly in the knees, ankles, wrists, and elbows. More than half of patients report diarrhea, vomiting, skin lesions, headache, cold chills, or arthritis.

The final fever syndrome Dr. Edwards covered was tumor necrosis factor receptor–associated periodic syndrome (TRAPS), also called Hibernian fever. Resulting from mutations in TNFRSF1A gene, this condition first appeared in Scottish and Irish populations but can occur among any ethnicity. Episodes can last from a few days to 1-2 weeks, and can include migratory nonspecific pain, a rash, abdominal pain, joint pain, chest pain, mouth sores, puffy eyes, and various inflammatory eye symptoms, such as uveitis, iritis, and conjunctivitis.

Although PFAPA is the most common pediatric periodic fever syndrome, a thorough fever history and family history can help clinicians identify whether a familial syndrome is involved.

WASHINGTON – Understanding a child’s fever history and other symptoms is essential to accurately determining what is causing a fever and what kind of management, if any, it requires, Dr. Kathryn M. Edwards explained at the American Academy of Pediatrics annual meeting.

Dr. Edwards aimed largely to help clinicians distinguish between familial recurrent fever syndromes and the syndrome PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Cervical Adenitis). Although familial cases of PFAPA have been reported, the syndrome’s etiology isn’t fully understood.

©IPGGutenbergUKLtd/Thinkstock

She began with a review of fever definition and pathogenesis, and used a series of case studies to introduce various fever syndromes. Although the simplest definition is an above-normal body temperature, fever is best thought of not as “a single value, but rather a range depending on time, place, individual, and measurement site,” Dr. Edwards explained. An inflammatory response, fever may result from an infection or occur secondarily to other conditions. The inflammatory response begins after both monocytes and macrophages release cytokines that stimulate the brain’s thermoregulatory center, inducing prostaglandin production.

Recurrent and periodic fever overview

Unlike a fever of unknown origin, recurrent and periodic fevers occur regularly in repeated cycles or intermittently over a period of time. The most important step in identifying what’s going on with a child’s recurrent/periodic fever is taking a complete fever history, including not only exposures and travel, but also family history and ethnicity. Clinicians can provide parents with a fever diary that tracks fever date and time, the temperature, other symptoms, medication administered, and other relevant information because “knowing the fever pattern is critical,” Dr. Edwards emphasized. A good fever history also requires clinicians to conduct a comprehensive physical exam, be aware of temperature norms for a child’s age and sex, and diligently evaluate a child’s growth parameters.

Using a flowchart adapted from Long’s article in “Pediatric Clinics of North America,” Dr. Edwards pointed out that recurrent fever may result from identified infections or may be stereotypical and episodic without an infection. The source of multiple viral infections is generally environmental, such as day care or cigarette smoke exposure. Multiple bacterial infections involving different organ systems may indicate an immunodeficiency, whereas recurrent infections in the same organ system require assessment specific to that system. Among stereotypical recurrent fevers, irregular episodes likely indicate a monogenic fever syndrome, while more predictable episodes could be cyclic neutropenia or PFAPA.

“There are a couple remarkable differences between PFAPA patients and patients with repeated viral infections,” said Dr. Edwards , professor of pediatrics at Vanderbilt University, Nashville, Tenn. “One is the frequency of the fevers, how often they come,” which underscores the need for a meticulous fever history, she explained. A parent might perceive that the fevers come once a month, but it’s essential to know whether they truly come like clockwork or whether they are more sporadic. “In addition, between the episodes, the children get nothing else,” she said, “and certainly they’re not infectious. Nobody else gets sick.”

Recognizing PFAPA

Children with PFAPA show normal growth and development, and no symptoms between very regular intervals of fever (above 38.3º C) with sore throat, mouth sores, and/or glandular swelling in the absence of an infection. About two-thirds of patients report headache, sore throat and/or mouth ulcers, and more than three quarters report swelling of the lymph nodes. About half experience abdominal pain or nausea.

PFAPA typically has an early age of onset and is diagnosed after exclusion of cyclic neutropenia and other fever syndromes. Episodes last an average of 3-4 days with intervals gradually becoming less frequent as the child ages. In one study, intervals at onset lasted an average of 28 days, but gradually extended to a mean 159 days during long-term follow-up in which average syndrome duration ranged from 5 to 7 years. Studies show a family history of recurrent fever in 10%-60% of patients, and recurrent tonsillitis in one parent is twice as likely among children with PFAPA.

Primary treatments for PFAPA include corticosteroids, cimetidine, and tonsillectomy, with anakinra, colchicine, and montelukast comprising additional options. Although the fever should subside within 4-12 hours after a corticosteroid dose of 1-2 mg/kg, a quarter of children may require a second dose within the next 12-24 hours, and corticosteroids treatment may increase episode frequency in up to half of children. By contrast, cimetidine is used prophylactically – twice daily over 6 months – and has led to remission in approximately a quarter of patients, although some experience recurrence after stopping treatment. The most successful intervention for curing PFAPA is tonsillectomy: Episodes completely stopped in 70%-97% of children in European and U.S. studies. But Dr. Edwards said the surgery should not be a first-line intervention.

“The role of the tonsils in all of the fever syndromes is quite fascinating, and I also think it’s interesting the parents have similar pharyngeal or oropharyngeal symptoms when they were children,” she said, noting that some research has been investigating tonsil cells for a better understanding of these syndromes.

“I think the decision to do a tonsillectomy is very dependent upon families,” she said. “I certainly don’t recommend it first thing, but there are some patients who have had these episodes for 2 or 3 years, the family is falling apart, and [the parents] are unable to go to work. In those situations, I will say this looks like something we should do.”

Familial fever syndromes

Dr. Edwards covered several familial fever syndromes during the remainder of the presentation using case studies to introduce each one. The first, familial Mediterranean fever (FMF), also known as Armenian disease, results from a mutation in the MEFV gene and occurs among those of Sephardic and Ashkenazi Jewish, Middle Eastern Arab, Armenian, Italian, North African or Turkish ethnicities.

Episodes last 12-72 hours, and clinical features include an erysipeloid rash and inflammation of various membranes, causing abdominal, chest or joint pain (serositis of the peritoneum, pleura or synovia, respectively). Treatment with colchicine can prevent FMF’s most significant complication, amyloidosis, which can otherwise lead to renal failure. About 95% of patients experience improvement, and 75% have remission with colchicine, and anakinra is an additional treatment option.

The second familial syndrome, hyperimmunoglobulinemia D with periodic fever syndrome, or hyper IgD (HIDS), has an early age of onset, typically before 12 months and with more than half before 6 months. Resulting from mutations in the MVK gene (and hence also called mevalonate kinase deficiency), HIDS primarily afflicts those with European ancestry, and about half of patients are of Dutch ancestry. Despite the syndrome’s name, about 22% of patients have normal IgD levels, and high IgD levels may indicate other conditions, so high IgD labs are not diagnostic. Diagnosis is based on genetic testing and elevated mevalonic acid levels in urine.

Stress, vaccination, or an upper respiratory infection may trigger a HIDS episode that lasts 3-7 days with clinical features that include a widespread red rash – frequently on the lower legs – as well as oral or vaginal ulcers. More than 80% of patients report swollen lymph nodes, abdominal pain, and joint pain, particularly in the knees, ankles, wrists, and elbows. More than half of patients report diarrhea, vomiting, skin lesions, headache, cold chills, or arthritis.

The final fever syndrome Dr. Edwards covered was tumor necrosis factor receptor–associated periodic syndrome (TRAPS), also called Hibernian fever. Resulting from mutations in TNFRSF1A gene, this condition first appeared in Scottish and Irish populations but can occur among any ethnicity. Episodes can last from a few days to 1-2 weeks, and can include migratory nonspecific pain, a rash, abdominal pain, joint pain, chest pain, mouth sores, puffy eyes, and various inflammatory eye symptoms, such as uveitis, iritis, and conjunctivitis.

Although PFAPA is the most common pediatric periodic fever syndrome, a thorough fever history and family history can help clinicians identify whether a familial syndrome is involved.

Children with bladder and bowel dysfunction (BBD) and vesicoureteral reflux (VUR) have greater risk of developing recurrent urinary tract infections (UTIs) compared with children who have only one or neither of these disorders, according to a recent study.

“Data presented in this article provide a unique window into the poorly understood relationship between VUR, BBD, antimicrobial prophylaxis, and recurrent UTIs,” reported Nader Shaikh of the University of Pittsburgh, and his colleagues.

“Our results also underscore that, among toilet-trained children, prophylaxis was significantly more effective in children with both VUR and BBD than in any other subgroup of children,” they wrote (Pediatrics. 2015 Dec. 8. doi: 10.1542/peds.2015-2982). “This pattern suggests that children with both BBD and VUR have a substantial risk of recurrent UTIs and could potentially benefit the most from antimicrobial prophylaxis.”

The researchers analyzed data for 181 toilet-trained children aged younger than 6 years from two longitudinal studies. One study tracked children who had been diagnosed with VUR after a first or second UTI and were randomized to receive an antibiotic or placebo prophylactically. The other, parallel study, had enrolled children without VUR who did not receive antibiotic prophylaxis.

At enrollment and at the 1-year and 2-year follow-up visits, parents filled out the Dysfunctional Voiding Scoring System questionnaire used for providers to assess whether the child had BBD. The cut-off for having BBD was a score of at least 9 in boys and at least 6 in girls. The researchers assessed the children for constipation at baseline, 1 year, and 2 years based on the Paris Consensus on Childhood Constipation Terminology questionnaire.

At the study’s start, BBD was diagnosed in 54% of the children, all of whom were girls and 94% of whom reported daytime wetting, constipation, or withholding maneuvers, such as crossing legs, squatting, or “dancing” around. In addition, 39% reported frequent painful defecation, 22% met criteria for constipation, and 8% had fewer than three bowel movements per week over the previous 8 weeks.

Among the toilet-trained children with VUR, 57% had BBD, compared with 46% of the children without VUR (P = .15). Presence of BBD did not predict grades of VUR, and no specific symptoms of BBD or constipation correlated with VUR.

Just over half (51%) of the children with BBD and VUR had recurrent UTIs if not taking prophylaxic antibiotics. Yet only 20% of children with only VUR, 35% of children with BBD alone, and 32% of children without VUR or BBD developed recurrent UTIs when not taking antimicrobial prophylaxis.

Among children with VUR and taking antibiotics, BBD did not predict recurrent UTIs, which occurred for 18% of those with BBD and for 25% of those without.

Children with both VUR and BBD but without antimicrobial prophylaxis were more than three times more likely to have recurrent UTIs than were children with only VUR (hazard ratio, 3.49), and nearly six times more likely (HR, 5.71) after adjustment for age, sex, race, and clinic site.

No evidence of causation between BBD and VUR appeared, and the former was not significantly associated with renal scarring.

Screening for at least one of these conditions (BBD or VUR) seems justifiable on the basis of these data, but VUR screening is more invasive and VUR treatment has greater risk of harm than treatment of BBD, the authors pointed out.

“Thus, one approach would be to routinely screen all toilet-trained children with UTI for BBD and to treat BBD in those who screen positive,” they wrote. Only additional research can determine if this is the most effective strategy.

The National Institute of Diabetes and Digestive and Kidney Diseases funded the research. The authors reported no disclosures.

Children with bladder and bowel dysfunction (BBD) and vesicoureteral reflux (VUR) have greater risk of developing recurrent urinary tract infections (UTIs) compared with children who have only one or neither of these disorders, according to a recent study.

“Data presented in this article provide a unique window into the poorly understood relationship between VUR, BBD, antimicrobial prophylaxis, and recurrent UTIs,” reported Nader Shaikh of the University of Pittsburgh, and his colleagues.

“Our results also underscore that, among toilet-trained children, prophylaxis was significantly more effective in children with both VUR and BBD than in any other subgroup of children,” they wrote (Pediatrics. 2015 Dec. 8. doi: 10.1542/peds.2015-2982). “This pattern suggests that children with both BBD and VUR have a substantial risk of recurrent UTIs and could potentially benefit the most from antimicrobial prophylaxis.”

The researchers analyzed data for 181 toilet-trained children aged younger than 6 years from two longitudinal studies. One study tracked children who had been diagnosed with VUR after a first or second UTI and were randomized to receive an antibiotic or placebo prophylactically. The other, parallel study, had enrolled children without VUR who did not receive antibiotic prophylaxis.

At enrollment and at the 1-year and 2-year follow-up visits, parents filled out the Dysfunctional Voiding Scoring System questionnaire used for providers to assess whether the child had BBD. The cut-off for having BBD was a score of at least 9 in boys and at least 6 in girls. The researchers assessed the children for constipation at baseline, 1 year, and 2 years based on the Paris Consensus on Childhood Constipation Terminology questionnaire.

At the study’s start, BBD was diagnosed in 54% of the children, all of whom were girls and 94% of whom reported daytime wetting, constipation, or withholding maneuvers, such as crossing legs, squatting, or “dancing” around. In addition, 39% reported frequent painful defecation, 22% met criteria for constipation, and 8% had fewer than three bowel movements per week over the previous 8 weeks.

Among the toilet-trained children with VUR, 57% had BBD, compared with 46% of the children without VUR (P = .15). Presence of BBD did not predict grades of VUR, and no specific symptoms of BBD or constipation correlated with VUR.

Just over half (51%) of the children with BBD and VUR had recurrent UTIs if not taking prophylaxic antibiotics. Yet only 20% of children with only VUR, 35% of children with BBD alone, and 32% of children without VUR or BBD developed recurrent UTIs when not taking antimicrobial prophylaxis.

Among children with VUR and taking antibiotics, BBD did not predict recurrent UTIs, which occurred for 18% of those with BBD and for 25% of those without.

Children with both VUR and BBD but without antimicrobial prophylaxis were more than three times more likely to have recurrent UTIs than were children with only VUR (hazard ratio, 3.49), and nearly six times more likely (HR, 5.71) after adjustment for age, sex, race, and clinic site.

No evidence of causation between BBD and VUR appeared, and the former was not significantly associated with renal scarring.

Screening for at least one of these conditions (BBD or VUR) seems justifiable on the basis of these data, but VUR screening is more invasive and VUR treatment has greater risk of harm than treatment of BBD, the authors pointed out.

“Thus, one approach would be to routinely screen all toilet-trained children with UTI for BBD and to treat BBD in those who screen positive,” they wrote. Only additional research can determine if this is the most effective strategy.

The National Institute of Diabetes and Digestive and Kidney Diseases funded the research. The authors reported no disclosures.

Children with bladder and bowel dysfunction (BBD) and vesicoureteral reflux (VUR) have greater risk of developing recurrent urinary tract infections (UTIs) compared with children who have only one or neither of these disorders, according to a recent study.

“Data presented in this article provide a unique window into the poorly understood relationship between VUR, BBD, antimicrobial prophylaxis, and recurrent UTIs,” reported Nader Shaikh of the University of Pittsburgh, and his colleagues.

“Our results also underscore that, among toilet-trained children, prophylaxis was significantly more effective in children with both VUR and BBD than in any other subgroup of children,” they wrote (Pediatrics. 2015 Dec. 8. doi: 10.1542/peds.2015-2982). “This pattern suggests that children with both BBD and VUR have a substantial risk of recurrent UTIs and could potentially benefit the most from antimicrobial prophylaxis.”

The researchers analyzed data for 181 toilet-trained children aged younger than 6 years from two longitudinal studies. One study tracked children who had been diagnosed with VUR after a first or second UTI and were randomized to receive an antibiotic or placebo prophylactically. The other, parallel study, had enrolled children without VUR who did not receive antibiotic prophylaxis.

At enrollment and at the 1-year and 2-year follow-up visits, parents filled out the Dysfunctional Voiding Scoring System questionnaire used for providers to assess whether the child had BBD. The cut-off for having BBD was a score of at least 9 in boys and at least 6 in girls. The researchers assessed the children for constipation at baseline, 1 year, and 2 years based on the Paris Consensus on Childhood Constipation Terminology questionnaire.

At the study’s start, BBD was diagnosed in 54% of the children, all of whom were girls and 94% of whom reported daytime wetting, constipation, or withholding maneuvers, such as crossing legs, squatting, or “dancing” around. In addition, 39% reported frequent painful defecation, 22% met criteria for constipation, and 8% had fewer than three bowel movements per week over the previous 8 weeks.

Among the toilet-trained children with VUR, 57% had BBD, compared with 46% of the children without VUR (P = .15). Presence of BBD did not predict grades of VUR, and no specific symptoms of BBD or constipation correlated with VUR.

Just over half (51%) of the children with BBD and VUR had recurrent UTIs if not taking prophylaxic antibiotics. Yet only 20% of children with only VUR, 35% of children with BBD alone, and 32% of children without VUR or BBD developed recurrent UTIs when not taking antimicrobial prophylaxis.

Among children with VUR and taking antibiotics, BBD did not predict recurrent UTIs, which occurred for 18% of those with BBD and for 25% of those without.

Children with both VUR and BBD but without antimicrobial prophylaxis were more than three times more likely to have recurrent UTIs than were children with only VUR (hazard ratio, 3.49), and nearly six times more likely (HR, 5.71) after adjustment for age, sex, race, and clinic site.

No evidence of causation between BBD and VUR appeared, and the former was not significantly associated with renal scarring.

Screening for at least one of these conditions (BBD or VUR) seems justifiable on the basis of these data, but VUR screening is more invasive and VUR treatment has greater risk of harm than treatment of BBD, the authors pointed out.

“Thus, one approach would be to routinely screen all toilet-trained children with UTI for BBD and to treat BBD in those who screen positive,” they wrote. Only additional research can determine if this is the most effective strategy.

The National Institute of Diabetes and Digestive and Kidney Diseases funded the research. The authors reported no disclosures.

Screening for early identification and management of vision abnormalities should begin from birth and continue throughout childhood and adolescence, according to a new policy statement released by the American Academy of Pediatrics.

“Through careful evaluation of the visual system, retinal abnormalities, cataracts, glaucoma, retinoblastoma, strabismus, and neurologic disorders, including amblyopia, can be identified,” Dr. Sean P. Donahue and Dr. Cynthia N. Baker wrote on behalf of five committees and organizations involved in the statement. “Timely treatment of these conditions is critical, as is the education of parents with respect to the importance of timely follow-up and documentation in the medical record that the education occurred” (Pediatrics 2015 Dec. 7. doi: 10.1542/peds.2015-3596 and doi:10.1542/peds.2015-3597).

JPC-PROD/Thinkstock.com

The most common conditions in children that can result in visual impairment include amblyopia, high refractive error, and strabismus. Instrument-based screening devices can detect all of these at any age, but particularly after 18 months of age. The policy recommends annual screenings through 5 years or until clinicians can use optotypes to assess visual acuity, recommended from age 4 years on.

“Eye examinations and vision assessments are critical for the detection of conditions that often result in visual impairment, signify serious systemic disease, lead to problems with school performance, and, in some cases, threaten the child’s life,” the statement noted.

In the clinical report, the authors recommend that clinicians take relevant family history regarding parent or sibling cataracts, strabismus, amblyopia, refractive error, other eye disorders, eye surgery, or use of glasses during childhood. Doctors also should ask parents about the child’s eyes and vision, such as whether the child’s eyes appear normal and functional or whether any eye injuries have occurred or the parents have noticed anything unusual.

An ocular examination in newborns and children up to 6 months old should include a general vision assessment using the fixation and follow response, use of the red reflex to test ocular media clarity, and direct observation for any other apparent abnormalities. Children with inconsistent or lack of response to the fixation and follow response by 3 months of age should be referred, as should children with any concerning abnormalities or with a white pupil, dark spots in the iris, or an absent or asymmetric (strabismus) red reflex. After 6 months of age, these tests should continue, along with pupil examination with a flashlight.

Starting at age 1 and through age 3 years, clinicians should add autorefraction tests, such as photoscreening, to annual exams, which can “estimate refractive error, media clarity, ocular alignment, and eyelid position,” the statement noted. “Abnormalities in these characteristics constitute risk factors for the presence or development of amblyopia.” They can also add HOTV or LEA SYMBOLS tests to assess distance visual acuity at these ages.

Guidelines for ages 4-5 years include distance visual acuity assessment with HOTV or LEA SYMBOLS, assessing ocular alignment with a cross cover test, and testing red reflex. Clinicians can begin using Sloan letters or Snellen letters at age 6 years, to be continued annually, and should continue to test red reflex.

The groups contributing to the statement include the AAP Committee on Practice and Ambulatory Medicine, the AAP Section on Ophthalmology Executive Committee, the American Association of Certified Orthoptists, the American Association of Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. The statement updates and replaces three previous policy statements: “Eye Examination in Infants, Children, and Young Adults by Pediatricians” in 2003, “Red Reflex Examination in Neonates, Infants, and Children” in 2008, and “Instrument-Based Pediatric Vision Screening” in 2012.

The statement did not require external funding. The authors did not report disclosures.

Screening for early identification and management of vision abnormalities should begin from birth and continue throughout childhood and adolescence, according to a new policy statement released by the American Academy of Pediatrics.

“Through careful evaluation of the visual system, retinal abnormalities, cataracts, glaucoma, retinoblastoma, strabismus, and neurologic disorders, including amblyopia, can be identified,” Dr. Sean P. Donahue and Dr. Cynthia N. Baker wrote on behalf of five committees and organizations involved in the statement. “Timely treatment of these conditions is critical, as is the education of parents with respect to the importance of timely follow-up and documentation in the medical record that the education occurred” (Pediatrics 2015 Dec. 7. doi: 10.1542/peds.2015-3596 and doi:10.1542/peds.2015-3597).

JPC-PROD/Thinkstock.com

The most common conditions in children that can result in visual impairment include amblyopia, high refractive error, and strabismus. Instrument-based screening devices can detect all of these at any age, but particularly after 18 months of age. The policy recommends annual screenings through 5 years or until clinicians can use optotypes to assess visual acuity, recommended from age 4 years on.

“Eye examinations and vision assessments are critical for the detection of conditions that often result in visual impairment, signify serious systemic disease, lead to problems with school performance, and, in some cases, threaten the child’s life,” the statement noted.

In the clinical report, the authors recommend that clinicians take relevant family history regarding parent or sibling cataracts, strabismus, amblyopia, refractive error, other eye disorders, eye surgery, or use of glasses during childhood. Doctors also should ask parents about the child’s eyes and vision, such as whether the child’s eyes appear normal and functional or whether any eye injuries have occurred or the parents have noticed anything unusual.

An ocular examination in newborns and children up to 6 months old should include a general vision assessment using the fixation and follow response, use of the red reflex to test ocular media clarity, and direct observation for any other apparent abnormalities. Children with inconsistent or lack of response to the fixation and follow response by 3 months of age should be referred, as should children with any concerning abnormalities or with a white pupil, dark spots in the iris, or an absent or asymmetric (strabismus) red reflex. After 6 months of age, these tests should continue, along with pupil examination with a flashlight.

Starting at age 1 and through age 3 years, clinicians should add autorefraction tests, such as photoscreening, to annual exams, which can “estimate refractive error, media clarity, ocular alignment, and eyelid position,” the statement noted. “Abnormalities in these characteristics constitute risk factors for the presence or development of amblyopia.” They can also add HOTV or LEA SYMBOLS tests to assess distance visual acuity at these ages.

Guidelines for ages 4-5 years include distance visual acuity assessment with HOTV or LEA SYMBOLS, assessing ocular alignment with a cross cover test, and testing red reflex. Clinicians can begin using Sloan letters or Snellen letters at age 6 years, to be continued annually, and should continue to test red reflex.

The groups contributing to the statement include the AAP Committee on Practice and Ambulatory Medicine, the AAP Section on Ophthalmology Executive Committee, the American Association of Certified Orthoptists, the American Association of Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. The statement updates and replaces three previous policy statements: “Eye Examination in Infants, Children, and Young Adults by Pediatricians” in 2003, “Red Reflex Examination in Neonates, Infants, and Children” in 2008, and “Instrument-Based Pediatric Vision Screening” in 2012.

The statement did not require external funding. The authors did not report disclosures.

Screening for early identification and management of vision abnormalities should begin from birth and continue throughout childhood and adolescence, according to a new policy statement released by the American Academy of Pediatrics.

“Through careful evaluation of the visual system, retinal abnormalities, cataracts, glaucoma, retinoblastoma, strabismus, and neurologic disorders, including amblyopia, can be identified,” Dr. Sean P. Donahue and Dr. Cynthia N. Baker wrote on behalf of five committees and organizations involved in the statement. “Timely treatment of these conditions is critical, as is the education of parents with respect to the importance of timely follow-up and documentation in the medical record that the education occurred” (Pediatrics 2015 Dec. 7. doi: 10.1542/peds.2015-3596 and doi:10.1542/peds.2015-3597).

JPC-PROD/Thinkstock.com

The most common conditions in children that can result in visual impairment include amblyopia, high refractive error, and strabismus. Instrument-based screening devices can detect all of these at any age, but particularly after 18 months of age. The policy recommends annual screenings through 5 years or until clinicians can use optotypes to assess visual acuity, recommended from age 4 years on.

“Eye examinations and vision assessments are critical for the detection of conditions that often result in visual impairment, signify serious systemic disease, lead to problems with school performance, and, in some cases, threaten the child’s life,” the statement noted.

In the clinical report, the authors recommend that clinicians take relevant family history regarding parent or sibling cataracts, strabismus, amblyopia, refractive error, other eye disorders, eye surgery, or use of glasses during childhood. Doctors also should ask parents about the child’s eyes and vision, such as whether the child’s eyes appear normal and functional or whether any eye injuries have occurred or the parents have noticed anything unusual.

An ocular examination in newborns and children up to 6 months old should include a general vision assessment using the fixation and follow response, use of the red reflex to test ocular media clarity, and direct observation for any other apparent abnormalities. Children with inconsistent or lack of response to the fixation and follow response by 3 months of age should be referred, as should children with any concerning abnormalities or with a white pupil, dark spots in the iris, or an absent or asymmetric (strabismus) red reflex. After 6 months of age, these tests should continue, along with pupil examination with a flashlight.

Starting at age 1 and through age 3 years, clinicians should add autorefraction tests, such as photoscreening, to annual exams, which can “estimate refractive error, media clarity, ocular alignment, and eyelid position,” the statement noted. “Abnormalities in these characteristics constitute risk factors for the presence or development of amblyopia.” They can also add HOTV or LEA SYMBOLS tests to assess distance visual acuity at these ages.

Guidelines for ages 4-5 years include distance visual acuity assessment with HOTV or LEA SYMBOLS, assessing ocular alignment with a cross cover test, and testing red reflex. Clinicians can begin using Sloan letters or Snellen letters at age 6 years, to be continued annually, and should continue to test red reflex.

The groups contributing to the statement include the AAP Committee on Practice and Ambulatory Medicine, the AAP Section on Ophthalmology Executive Committee, the American Association of Certified Orthoptists, the American Association of Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. The statement updates and replaces three previous policy statements: “Eye Examination in Infants, Children, and Young Adults by Pediatricians” in 2003, “Red Reflex Examination in Neonates, Infants, and Children” in 2008, and “Instrument-Based Pediatric Vision Screening” in 2012.

The statement did not require external funding. The authors did not report disclosures.

Women with gestational diabetes reduced their risk of progressing to type 2 diabetes by more than half if they exclusively breastfed their infants, compared with women who fed their babies exclusively with formula, according to a new study.

Researchers also found that breastfeeding for more than 2 months was associated with a lower incidence of progression to type 2 diabetes.

“In our study, both higher lactation intensity and duration showed strong, graded protective associations with type 2 diabetes mellitus incidence, independent of risk factors (sociodemographic characteristics, prenatal metabolic status and course, perinatal outcomes, and lifestyle behaviors) that were not explained by weight loss,” Erica P. Gunderson, Ph.D., of Kaiser Permanente Northern California, and her associates wrote.

©lokisurina/thinkstockphotos.com

The researchers initially evaluated 1,035 women who had been diagnosed with gestational diabetes mellitus (GDM) and had a singleton delivery at 35 weeks’ gestation or later, but followed only the 1,010 women without type 2 diabetes at 6-9 weeks postpartum. Of the 959 women evaluated at the end of the 2-year follow-up, 11.8% had progressed to type 2 diabetes (Ann Intern Med. 2015 Nov 24. doi:10.7326/M15-0807).

Data on breastfeeding intensity and duration were collected through feeding diaries, phone calls, in-person exams, and monthly mailed questionnaires. The four categories of intensity included exclusive lactation, mostly lactation (about 1-6 ounces of formula per 24 hours), mostly formula (more than 17 ounces per 24 hours), and mixed feeding (7-17 ounces of formula per 24 hours). These categories were compared to exclusive formula feeding.

Compared with mothers who exclusively fed their infants formula, mothers who exclusively breastfed had a 54% lower risk of developing type 2 diabetes (hazard ratio, 0.46). The risk of developing type 2 diabetes was 46% lower for women who mostly breastfed, and women who mostly used formula or who mixed formula and breastfeeding had a 36% reduced risk (HR, 0.54 and 0.64, respectively; P trend = 0.016).

Similarly, duration of breastfeeding correlated with the reduced risk of developing diabetes. Compared with mothers who breastfed their infants from 0 to 2 months, those who breastfed for longer than 10 months had a 57% lower risk of developing type 2 diabetes. Women who breastfed their infants for 5-10 months had a 50% lower risk, and those who breastfed from 2 to 5 months had a 45% lower risk, compared with those breastfeeding up to 2 months.

“Potential mechanisms to explain the lower incidence of [diabetes mellitus] with higher intensity and duration of lactation include preservation of pancreatic beta cells, less inflammation, and improved endothelial function; however, biochemical evidence is sparse,” the researchers wrote, noting the effect prolactin has during pregnancy on increasing pancreatic beta-cell mass and function.

In analyzing the relationship between development of type 2 diabetes and lactation duration and intensity, the researchers controlled for a range of confounders. These included maternal body mass index, gestational diabetes treatment, prepregnancy weight, maternal delivery weight, delivery method, and newborn outcomes (birth weight, length, gestational age, Apgar score, hospital stay duration, medical diagnoses, and NICU admission). Researchers also accounted for lifestyle behaviors, depression, medication use, maternal education, parity, age, race/ethnicity, and health history.

The research was funded by the National Institutes of Health, Kaiser Permanente Northern California, and the W.K. Kellogg Foundation. Dr. Gunderson has received grant funding from the American Diabetes Association. Other authors reported receiving industry grants outside of this study.

Women with gestational diabetes reduced their risk of progressing to type 2 diabetes by more than half if they exclusively breastfed their infants, compared with women who fed their babies exclusively with formula, according to a new study.

Researchers also found that breastfeeding for more than 2 months was associated with a lower incidence of progression to type 2 diabetes.

“In our study, both higher lactation intensity and duration showed strong, graded protective associations with type 2 diabetes mellitus incidence, independent of risk factors (sociodemographic characteristics, prenatal metabolic status and course, perinatal outcomes, and lifestyle behaviors) that were not explained by weight loss,” Erica P. Gunderson, Ph.D., of Kaiser Permanente Northern California, and her associates wrote.

©lokisurina/thinkstockphotos.com

The researchers initially evaluated 1,035 women who had been diagnosed with gestational diabetes mellitus (GDM) and had a singleton delivery at 35 weeks’ gestation or later, but followed only the 1,010 women without type 2 diabetes at 6-9 weeks postpartum. Of the 959 women evaluated at the end of the 2-year follow-up, 11.8% had progressed to type 2 diabetes (Ann Intern Med. 2015 Nov 24. doi:10.7326/M15-0807).

Data on breastfeeding intensity and duration were collected through feeding diaries, phone calls, in-person exams, and monthly mailed questionnaires. The four categories of intensity included exclusive lactation, mostly lactation (about 1-6 ounces of formula per 24 hours), mostly formula (more than 17 ounces per 24 hours), and mixed feeding (7-17 ounces of formula per 24 hours). These categories were compared to exclusive formula feeding.

Compared with mothers who exclusively fed their infants formula, mothers who exclusively breastfed had a 54% lower risk of developing type 2 diabetes (hazard ratio, 0.46). The risk of developing type 2 diabetes was 46% lower for women who mostly breastfed, and women who mostly used formula or who mixed formula and breastfeeding had a 36% reduced risk (HR, 0.54 and 0.64, respectively; P trend = 0.016).

Similarly, duration of breastfeeding correlated with the reduced risk of developing diabetes. Compared with mothers who breastfed their infants from 0 to 2 months, those who breastfed for longer than 10 months had a 57% lower risk of developing type 2 diabetes. Women who breastfed their infants for 5-10 months had a 50% lower risk, and those who breastfed from 2 to 5 months had a 45% lower risk, compared with those breastfeeding up to 2 months.

“Potential mechanisms to explain the lower incidence of [diabetes mellitus] with higher intensity and duration of lactation include preservation of pancreatic beta cells, less inflammation, and improved endothelial function; however, biochemical evidence is sparse,” the researchers wrote, noting the effect prolactin has during pregnancy on increasing pancreatic beta-cell mass and function.

In analyzing the relationship between development of type 2 diabetes and lactation duration and intensity, the researchers controlled for a range of confounders. These included maternal body mass index, gestational diabetes treatment, prepregnancy weight, maternal delivery weight, delivery method, and newborn outcomes (birth weight, length, gestational age, Apgar score, hospital stay duration, medical diagnoses, and NICU admission). Researchers also accounted for lifestyle behaviors, depression, medication use, maternal education, parity, age, race/ethnicity, and health history.

The research was funded by the National Institutes of Health, Kaiser Permanente Northern California, and the W.K. Kellogg Foundation. Dr. Gunderson has received grant funding from the American Diabetes Association. Other authors reported receiving industry grants outside of this study.

Women with gestational diabetes reduced their risk of progressing to type 2 diabetes by more than half if they exclusively breastfed their infants, compared with women who fed their babies exclusively with formula, according to a new study.

Researchers also found that breastfeeding for more than 2 months was associated with a lower incidence of progression to type 2 diabetes.

“In our study, both higher lactation intensity and duration showed strong, graded protective associations with type 2 diabetes mellitus incidence, independent of risk factors (sociodemographic characteristics, prenatal metabolic status and course, perinatal outcomes, and lifestyle behaviors) that were not explained by weight loss,” Erica P. Gunderson, Ph.D., of Kaiser Permanente Northern California, and her associates wrote.

©lokisurina/thinkstockphotos.com

The researchers initially evaluated 1,035 women who had been diagnosed with gestational diabetes mellitus (GDM) and had a singleton delivery at 35 weeks’ gestation or later, but followed only the 1,010 women without type 2 diabetes at 6-9 weeks postpartum. Of the 959 women evaluated at the end of the 2-year follow-up, 11.8% had progressed to type 2 diabetes (Ann Intern Med. 2015 Nov 24. doi:10.7326/M15-0807).

Data on breastfeeding intensity and duration were collected through feeding diaries, phone calls, in-person exams, and monthly mailed questionnaires. The four categories of intensity included exclusive lactation, mostly lactation (about 1-6 ounces of formula per 24 hours), mostly formula (more than 17 ounces per 24 hours), and mixed feeding (7-17 ounces of formula per 24 hours). These categories were compared to exclusive formula feeding.

Compared with mothers who exclusively fed their infants formula, mothers who exclusively breastfed had a 54% lower risk of developing type 2 diabetes (hazard ratio, 0.46). The risk of developing type 2 diabetes was 46% lower for women who mostly breastfed, and women who mostly used formula or who mixed formula and breastfeeding had a 36% reduced risk (HR, 0.54 and 0.64, respectively; P trend = 0.016).

Similarly, duration of breastfeeding correlated with the reduced risk of developing diabetes. Compared with mothers who breastfed their infants from 0 to 2 months, those who breastfed for longer than 10 months had a 57% lower risk of developing type 2 diabetes. Women who breastfed their infants for 5-10 months had a 50% lower risk, and those who breastfed from 2 to 5 months had a 45% lower risk, compared with those breastfeeding up to 2 months.

“Potential mechanisms to explain the lower incidence of [diabetes mellitus] with higher intensity and duration of lactation include preservation of pancreatic beta cells, less inflammation, and improved endothelial function; however, biochemical evidence is sparse,” the researchers wrote, noting the effect prolactin has during pregnancy on increasing pancreatic beta-cell mass and function.

In analyzing the relationship between development of type 2 diabetes and lactation duration and intensity, the researchers controlled for a range of confounders. These included maternal body mass index, gestational diabetes treatment, prepregnancy weight, maternal delivery weight, delivery method, and newborn outcomes (birth weight, length, gestational age, Apgar score, hospital stay duration, medical diagnoses, and NICU admission). Researchers also accounted for lifestyle behaviors, depression, medication use, maternal education, parity, age, race/ethnicity, and health history.

The research was funded by the National Institutes of Health, Kaiser Permanente Northern California, and the W.K. Kellogg Foundation. Dr. Gunderson has received grant funding from the American Diabetes Association. Other authors reported receiving industry grants outside of this study.

Children with attention-deficit hyperactivity disorder (ADHD) take longer to fall asleep and sleep less efficiently when they are taking stimulant medications, according to a recent meta-analysis.

“In [randomized controlled trials] using objective measurements of sleep, stimulant medications led to longer sleep latency, worse sleep efficiency, and shorter sleep duration,” Katherine M. Kidwell and her associates in the department of psychology at the University of Nebraska–Lincoln reported Nov. 23 in Pediatrics. “Overall, children and adolescents had worse sleep when they took stimulant medications.”

©deyangeorgiev/ thinkstockphotos.com

The researchers searched CINAHL (EBSCO), PsycINFO and PubMed databases for articles through March 2015 that examined the effect on sleep of stimulants prescribed to youth for ADHD or ADD. The inclusion criteria included patients diagnosed with ADHD, randomization of stimulant drugs, sleep measured by actigraphy or polysomnography and adequate statistical information to calculate effect sizes of key sleep variables (Pediatrics 2015 Nov. 23 [doi:10.1542/peds.2015-1708]).

Nine articles met the inclusion criteria; they included a total of 246 patients with mean ages of 8-11 years old.

Seven articles, involving 171 participants, looked at the effect of stimulants on sleep latency and had a combined effect size of 0.78, indicating a longer sleep latency associated with stimulant medications. After adjustment for publication bias, the adjusted effect size was a significant 0.54 (P < .001).

Frequency of dosage per day moderated the sleep latency effect, with each additional dose per day increasing the effect size by 0.42.

“The effect of stimulant medication on sleep latency became greater when the stimulant was taken more frequently throughout the day,” Ms. Kidwell and her associates wrote.

Seven studies involving 155 participants investigated sleep efficiency in children taking stimulant medications and had a significant overall effect size of –0.39 before adjustment and –0.32 after adjustment (P < .001), indicating poorer sleep efficiency associated with stimulants.

Both study design and sample characteristics moderated the effect. Each extra day that youth took medication, the effect size became less negative by 0.05. “This finding is mostly consistent with a frequently proposed, but rarely tested, argument that youth adjust to medication over time and may have initial sleep problems that will resolve,” according to the investigators.

Polysomnography revealed poorer sleep efficiency than actigraphy did, and the effect of poorer sleep efficiency was greater for boys than for girls.

Seven studies involving 223 participants examined total sleep time. The significant effect size of –0.59 indicated an association between the stimulants and shorter total sleep time with no moderators or need for adjustment (P < .001).

“Stimulant medications impair the sleep of children and adolescents, as evidenced by findings using rigorous methods,” Ms. Kidwell and associates concluded. “It is recommended that pediatricians carefully assess for sleep problems in children with ADHD and monitor medication type and dosage schedules to promote optimal sleep and minimize medication-induced sleep impairments.”

The research did not receive external funding. The authors reported no relevant conflicts of interest.

Children with attention-deficit hyperactivity disorder (ADHD) take longer to fall asleep and sleep less efficiently when they are taking stimulant medications, according to a recent meta-analysis.

“In [randomized controlled trials] using objective measurements of sleep, stimulant medications led to longer sleep latency, worse sleep efficiency, and shorter sleep duration,” Katherine M. Kidwell and her associates in the department of psychology at the University of Nebraska–Lincoln reported Nov. 23 in Pediatrics. “Overall, children and adolescents had worse sleep when they took stimulant medications.”

©deyangeorgiev/ thinkstockphotos.com

The researchers searched CINAHL (EBSCO), PsycINFO and PubMed databases for articles through March 2015 that examined the effect on sleep of stimulants prescribed to youth for ADHD or ADD. The inclusion criteria included patients diagnosed with ADHD, randomization of stimulant drugs, sleep measured by actigraphy or polysomnography and adequate statistical information to calculate effect sizes of key sleep variables (Pediatrics 2015 Nov. 23 [doi:10.1542/peds.2015-1708]).

Nine articles met the inclusion criteria; they included a total of 246 patients with mean ages of 8-11 years old.

Seven articles, involving 171 participants, looked at the effect of stimulants on sleep latency and had a combined effect size of 0.78, indicating a longer sleep latency associated with stimulant medications. After adjustment for publication bias, the adjusted effect size was a significant 0.54 (P < .001).

Frequency of dosage per day moderated the sleep latency effect, with each additional dose per day increasing the effect size by 0.42.

“The effect of stimulant medication on sleep latency became greater when the stimulant was taken more frequently throughout the day,” Ms. Kidwell and her associates wrote.

Seven studies involving 155 participants investigated sleep efficiency in children taking stimulant medications and had a significant overall effect size of –0.39 before adjustment and –0.32 after adjustment (P < .001), indicating poorer sleep efficiency associated with stimulants.

Both study design and sample characteristics moderated the effect. Each extra day that youth took medication, the effect size became less negative by 0.05. “This finding is mostly consistent with a frequently proposed, but rarely tested, argument that youth adjust to medication over time and may have initial sleep problems that will resolve,” according to the investigators.

Polysomnography revealed poorer sleep efficiency than actigraphy did, and the effect of poorer sleep efficiency was greater for boys than for girls.

Seven studies involving 223 participants examined total sleep time. The significant effect size of –0.59 indicated an association between the stimulants and shorter total sleep time with no moderators or need for adjustment (P < .001).

“Stimulant medications impair the sleep of children and adolescents, as evidenced by findings using rigorous methods,” Ms. Kidwell and associates concluded. “It is recommended that pediatricians carefully assess for sleep problems in children with ADHD and monitor medication type and dosage schedules to promote optimal sleep and minimize medication-induced sleep impairments.”

The research did not receive external funding. The authors reported no relevant conflicts of interest.

Children with attention-deficit hyperactivity disorder (ADHD) take longer to fall asleep and sleep less efficiently when they are taking stimulant medications, according to a recent meta-analysis.

“In [randomized controlled trials] using objective measurements of sleep, stimulant medications led to longer sleep latency, worse sleep efficiency, and shorter sleep duration,” Katherine M. Kidwell and her associates in the department of psychology at the University of Nebraska–Lincoln reported Nov. 23 in Pediatrics. “Overall, children and adolescents had worse sleep when they took stimulant medications.”

©deyangeorgiev/ thinkstockphotos.com

The researchers searched CINAHL (EBSCO), PsycINFO and PubMed databases for articles through March 2015 that examined the effect on sleep of stimulants prescribed to youth for ADHD or ADD. The inclusion criteria included patients diagnosed with ADHD, randomization of stimulant drugs, sleep measured by actigraphy or polysomnography and adequate statistical information to calculate effect sizes of key sleep variables (Pediatrics 2015 Nov. 23 [doi:10.1542/peds.2015-1708]).

Nine articles met the inclusion criteria; they included a total of 246 patients with mean ages of 8-11 years old.

Seven articles, involving 171 participants, looked at the effect of stimulants on sleep latency and had a combined effect size of 0.78, indicating a longer sleep latency associated with stimulant medications. After adjustment for publication bias, the adjusted effect size was a significant 0.54 (P < .001).

Frequency of dosage per day moderated the sleep latency effect, with each additional dose per day increasing the effect size by 0.42.

“The effect of stimulant medication on sleep latency became greater when the stimulant was taken more frequently throughout the day,” Ms. Kidwell and her associates wrote.

Seven studies involving 155 participants investigated sleep efficiency in children taking stimulant medications and had a significant overall effect size of –0.39 before adjustment and –0.32 after adjustment (P < .001), indicating poorer sleep efficiency associated with stimulants.

Both study design and sample characteristics moderated the effect. Each extra day that youth took medication, the effect size became less negative by 0.05. “This finding is mostly consistent with a frequently proposed, but rarely tested, argument that youth adjust to medication over time and may have initial sleep problems that will resolve,” according to the investigators.

Polysomnography revealed poorer sleep efficiency than actigraphy did, and the effect of poorer sleep efficiency was greater for boys than for girls.

Seven studies involving 223 participants examined total sleep time. The significant effect size of –0.59 indicated an association between the stimulants and shorter total sleep time with no moderators or need for adjustment (P < .001).

“Stimulant medications impair the sleep of children and adolescents, as evidenced by findings using rigorous methods,” Ms. Kidwell and associates concluded. “It is recommended that pediatricians carefully assess for sleep problems in children with ADHD and monitor medication type and dosage schedules to promote optimal sleep and minimize medication-induced sleep impairments.”

The research did not receive external funding. The authors reported no relevant conflicts of interest.

One of the biggest barriers to mental health services for victims of bullying is the fact that too few medical providers are screening adolescents for bullying, according to a recent study.

“Efforts are needed to encourage medical providers to screen for bullying and to refer to mental health services when necessary,” said Dr. Amira El Sherif of KidzCare Pediatrics in Fayetteville, N.C. The study by Dr. El Sherif and her colleagues was presented at the annual meeting of the American Academy of Pediatrics.

©monkeybusinessimages/Thinkstock.com

“There is also a continuous need for school training programs to ensure staff respond appropriately to bullying incidents, and that investigation procedures are followed,” Dr. El Sherif said in an interview, echoing her research team’s conclusions. “Finally, it is critical to streamline a process of communication between medical providers, school officials, and parents to allow for a team approach to bullying,” she said.

Almost 30% of U.S. adolescents are involved in bullying, which is linked to various mental health conditions, such as attention-deficit/hyperactivity disorder, anxiety, self-harming behaviors, suicidal thoughts, and suicide attempts, the researchers noted. Yet only one in five children who need mental health evaluations actually receive services.

To learn what factors are contributing to poor access to services, Dr. El Sherif and her associates conducted focus groups with bullying victims and their parents as well as interviews with teachers and community mental health providers. Based on the findings from these interviews and focus groups, the team developed a survey they administered to 440 middle school and high school students in Cumberland County, N.C. Among these students, 29% said they had been victims of bullying in the past.

All the students rated answers to questions on a Likert scale which assigned 5 points to the greatest potential barrier to receiving mental health services. Of the 28 barriers reported, students who had previously been bullied reported 11 more often.

“Our study showed that the biggest barriers to mental health care were the lack of screening and counseling about bullying by medical providers,” Dr. El Sherif said in the interview. “There were also school system challenges, including inaction by school personnel and poor enforcement of investigation procedures. Inadequate school follow-up and communication with parents were other major obstacles.”

Among barriers with the highest scores from adolescents who had been bullied were not having the school investigate the bullying incident, and the teen’s doctor not talking to the school or counseling the student.

Because the study was limited to one North Carolina county, it is not clear how generalizable the findings are, Dr. El Sherif said, indicating the need for larger, more nationally representative studies.

“We noted that girls were more likely to be bullied than boys,” Dr. El Sherif said. “Larger studies may be necessary to ascertain differences between racial/ethnic groups.”

In this study, 55% of respondents were male, but 44% of those who reported being bullied were male. Although girls made up 45% of the sample, they represented 56% of those who said they had been bullied. Among all the respondents, 18% were white, 65% were black, 5% were Latino, 1% were Asian, and 11% were of another race/ethnic group.

The implications of the study, however, still apply to children across the United States, Dr. El Sherif suggested.

“In general, all children should be screened for mental health concerns during their annual physicals, particularly children with risk factors for mental health sequelae such as bullying,” she said.

Parents also have an important role to play in helping their children if they have been bullied, Dr. El Sherif said.

“Parents are a child’s primary advocate both at home and out in the world,” she said. “They should provide support and advice to their child at home on how to handle bullying, report the incident to the school, and seek help from their pediatrician if they feel that bullying is affecting their child’s everyday life.”

No disclosures or external funding were reported.

One of the biggest barriers to mental health services for victims of bullying is the fact that too few medical providers are screening adolescents for bullying, according to a recent study.

“Efforts are needed to encourage medical providers to screen for bullying and to refer to mental health services when necessary,” said Dr. Amira El Sherif of KidzCare Pediatrics in Fayetteville, N.C. The study by Dr. El Sherif and her colleagues was presented at the annual meeting of the American Academy of Pediatrics.

©monkeybusinessimages/Thinkstock.com

“There is also a continuous need for school training programs to ensure staff respond appropriately to bullying incidents, and that investigation procedures are followed,” Dr. El Sherif said in an interview, echoing her research team’s conclusions. “Finally, it is critical to streamline a process of communication between medical providers, school officials, and parents to allow for a team approach to bullying,” she said.

Almost 30% of U.S. adolescents are involved in bullying, which is linked to various mental health conditions, such as attention-deficit/hyperactivity disorder, anxiety, self-harming behaviors, suicidal thoughts, and suicide attempts, the researchers noted. Yet only one in five children who need mental health evaluations actually receive services.

To learn what factors are contributing to poor access to services, Dr. El Sherif and her associates conducted focus groups with bullying victims and their parents as well as interviews with teachers and community mental health providers. Based on the findings from these interviews and focus groups, the team developed a survey they administered to 440 middle school and high school students in Cumberland County, N.C. Among these students, 29% said they had been victims of bullying in the past.

All the students rated answers to questions on a Likert scale which assigned 5 points to the greatest potential barrier to receiving mental health services. Of the 28 barriers reported, students who had previously been bullied reported 11 more often.

“Our study showed that the biggest barriers to mental health care were the lack of screening and counseling about bullying by medical providers,” Dr. El Sherif said in the interview. “There were also school system challenges, including inaction by school personnel and poor enforcement of investigation procedures. Inadequate school follow-up and communication with parents were other major obstacles.”

Among barriers with the highest scores from adolescents who had been bullied were not having the school investigate the bullying incident, and the teen’s doctor not talking to the school or counseling the student.

Because the study was limited to one North Carolina county, it is not clear how generalizable the findings are, Dr. El Sherif said, indicating the need for larger, more nationally representative studies.

“We noted that girls were more likely to be bullied than boys,” Dr. El Sherif said. “Larger studies may be necessary to ascertain differences between racial/ethnic groups.”

In this study, 55% of respondents were male, but 44% of those who reported being bullied were male. Although girls made up 45% of the sample, they represented 56% of those who said they had been bullied. Among all the respondents, 18% were white, 65% were black, 5% were Latino, 1% were Asian, and 11% were of another race/ethnic group.

The implications of the study, however, still apply to children across the United States, Dr. El Sherif suggested.

“In general, all children should be screened for mental health concerns during their annual physicals, particularly children with risk factors for mental health sequelae such as bullying,” she said.

Parents also have an important role to play in helping their children if they have been bullied, Dr. El Sherif said.

“Parents are a child’s primary advocate both at home and out in the world,” she said. “They should provide support and advice to their child at home on how to handle bullying, report the incident to the school, and seek help from their pediatrician if they feel that bullying is affecting their child’s everyday life.”

No disclosures or external funding were reported.

One of the biggest barriers to mental health services for victims of bullying is the fact that too few medical providers are screening adolescents for bullying, according to a recent study.

“Efforts are needed to encourage medical providers to screen for bullying and to refer to mental health services when necessary,” said Dr. Amira El Sherif of KidzCare Pediatrics in Fayetteville, N.C. The study by Dr. El Sherif and her colleagues was presented at the annual meeting of the American Academy of Pediatrics.

©monkeybusinessimages/Thinkstock.com

“There is also a continuous need for school training programs to ensure staff respond appropriately to bullying incidents, and that investigation procedures are followed,” Dr. El Sherif said in an interview, echoing her research team’s conclusions. “Finally, it is critical to streamline a process of communication between medical providers, school officials, and parents to allow for a team approach to bullying,” she said.

Almost 30% of U.S. adolescents are involved in bullying, which is linked to various mental health conditions, such as attention-deficit/hyperactivity disorder, anxiety, self-harming behaviors, suicidal thoughts, and suicide attempts, the researchers noted. Yet only one in five children who need mental health evaluations actually receive services.

To learn what factors are contributing to poor access to services, Dr. El Sherif and her associates conducted focus groups with bullying victims and their parents as well as interviews with teachers and community mental health providers. Based on the findings from these interviews and focus groups, the team developed a survey they administered to 440 middle school and high school students in Cumberland County, N.C. Among these students, 29% said they had been victims of bullying in the past.

All the students rated answers to questions on a Likert scale which assigned 5 points to the greatest potential barrier to receiving mental health services. Of the 28 barriers reported, students who had previously been bullied reported 11 more often.

“Our study showed that the biggest barriers to mental health care were the lack of screening and counseling about bullying by medical providers,” Dr. El Sherif said in the interview. “There were also school system challenges, including inaction by school personnel and poor enforcement of investigation procedures. Inadequate school follow-up and communication with parents were other major obstacles.”

Among barriers with the highest scores from adolescents who had been bullied were not having the school investigate the bullying incident, and the teen’s doctor not talking to the school or counseling the student.

Because the study was limited to one North Carolina county, it is not clear how generalizable the findings are, Dr. El Sherif said, indicating the need for larger, more nationally representative studies.

“We noted that girls were more likely to be bullied than boys,” Dr. El Sherif said. “Larger studies may be necessary to ascertain differences between racial/ethnic groups.”

In this study, 55% of respondents were male, but 44% of those who reported being bullied were male. Although girls made up 45% of the sample, they represented 56% of those who said they had been bullied. Among all the respondents, 18% were white, 65% were black, 5% were Latino, 1% were Asian, and 11% were of another race/ethnic group.

The implications of the study, however, still apply to children across the United States, Dr. El Sherif suggested.

“In general, all children should be screened for mental health concerns during their annual physicals, particularly children with risk factors for mental health sequelae such as bullying,” she said.

Parents also have an important role to play in helping their children if they have been bullied, Dr. El Sherif said.

“Parents are a child’s primary advocate both at home and out in the world,” she said. “They should provide support and advice to their child at home on how to handle bullying, report the incident to the school, and seek help from their pediatrician if they feel that bullying is affecting their child’s everyday life.”

No disclosures or external funding were reported.

Marijuana is dangerous, and you need to know how dangerous to adequately counsel adolescent patients and their families.

The growing number of states legalizing marijuana, whether exclusively for medical use or for recreational use, is changing the landscape for physicians, addiction specialists, and others working in public health, explained Dr. Miriam Schizer of the adolescent substance abuse program at Boston Children’s Hospital.

Currently, 23 states plus Washington have legalized medical marijuana, and 4 states plus Washington have legalized recreational use, Dr. Schizer said at the annual meeting of the American Academy of Pediatrics. Cannabis products are expanding rapidly, with many becoming more potent, but misconceptions about marijuana use also are potent and growing.

©iStock/ThinkStockPhotos.com

The proportion of high school seniors who believe marijuana carries a “great risk of harm” is nearly at an all-time low, based on findings from the Monitoring the Future survey. With annual samples of approximately 50,000 8th, 10th and 12th grade students each year, the survey provides a glimpse into long-term trends in adolescents’ attitudes and behaviors regarding substance use. Just over a third of high school seniors (36%) perceived marijuana to have a great risk of harm in 2014, one of the lowest recorded numbers since the survey began in 1975. And 14% of seniors surveyed reported having used marijuana in the past month.

Understanding the mechanisms of THC

The primary psychoactive ingredient in marijuana is delta-9 tetrahydrocannabinol, or THC, one of more than 100 cannabinoids in marijuana. This fat-soluble molecule crosses both the blood-brain barrier and the placenta and accumulates in adipose tissue, where its half-life ranges from several days to a week. Its concentration in cannabis products also has increased from an average of less than 4% in 1994 to an average of 9% in cannabis products in 2008.

The way THC makes its way into adolescents’ systems varies: Smoking buds and leaves is the most common, but people also eat edible products, inhale cannabis through hookahs or e-cigarette–like “vaping” systems, or use hash oil “dabbing” for an exceptionally potent dose.

While the positive effects of cannabis use are what keep users coming back, the negative effects are just as common and can carry over until the day after, like a hangover. Those include paranoia, anxiety, irritability, impaired short-term memory, poor attention or judgment, poor coordination, distorted spatial perception, and an altered sense of the passage of time. The positive effects that users report include reduced anxiety, increased sociability, the perception that time slows down, an increased appetite, decreased pain, and overall euphoria.

Physiologic effects – peaking 30 minutes after inhalation or 2-4 hours after ingestion – can include tachycardia up to 20-50 beats per minute above baseline, increased blood pressure, bronchial relaxation, red eyes, and dry mouth and throat. These effects increase with the concentration of THC, also increasing the likelihood of paranoia, panic, hallucinations, vomiting, erratic mood swings, and aggressive behavior.

Following the discovery of cannabinoid receptors in the brain in 1988, scientists learned that the brain contains its own cannabinoid known as anandamide, giving rise to an endocannabinoid system in the brain. This system shapes brain development, supports myelin growth on neurons, and controls neuron activity. Both THC and anandamide play a role in regulating neurotransmitters such as dopamine, glutamate, endorphins, and serotonin, but THC has much stronger, longer-lasting effects and consequently interferes with cell function and growth.

Misconceptions about marijuana use

Dr. Schizer addressed the most common myths about marijuana use, pointing out that it is harmful to human health, it is addictive, and it does impair driving. Short-term harms include impaired short-term memory and motor coordination, altered judgment, and, in higher doses, paranoia and psychosis.

“There is a link to worsening depression and anxiety over time,” Dr. Schizer said. “Something is emerging very clearly: Among individuals with a genetic disposition to psychotic disorder, there’s an increased risk of developing the psychotic disorder.”

Long-term use can alter brain development, particularly among those using it in early adolescence, and lead to higher dropout rates, a lower IQ, and a poorer sense of life satisfaction. In one study of 1,037 individuals tracked from age 13 to 38 years, the average IQ of those who never used marijuana ranged from 99.8 to 100.6, compared with 99.7 to 93.9 among those dependent on marijuana for at least 3 years (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64).

Marijuana use also has adverse effects on the lungs, on male and female sexual function, and on the cardiovascular system. In pregnant women using marijuana, the fetus is exposed to THC through the placenta and umbilical cord, receives less oxygen, and has a higher risk of birth defects.

Approximately 9% of users develop an addiction to marijuana, but that nearly doubles to 17% among users who start in adolescence, according to the National Institute on Drug Abuse.

“The earlier they are when they start, the more likely they are to develop an addiction,” Dr. Schizer said, pointing out that 88% of all substance abuse treatment admissions among adolescents aged 12-17 years involved marijuana, according to 2012 Substance Abuse and Mental Health Services Administration data. By age 21 years, approximately 4% of users are addicted, but about a quarter to half of daily users develop an addiction. Further evidence of marijuana’s addictiveness are “bona fide withdrawal symptoms,” which typically peak about 10 days after last use, and can include restlessness, anxiety, increased irritability or aggression, difficulty falling and staying asleep, nightmares or strange dreams, decreased appetite, and weight loss.

Driving impairment under the influence of marijuana results from poorer attention, worse working memory, lack of coordination, poorer reaction time, and lack of visual perception caused by THC. In a graphic Dr. Schizer presented comparing Colorado to 34 states without medical marijuana, the proportion of drivers testing positive for marijuana in fatal crashes began sharply increasing in 2009, the year widespread medical marijuana was implemented in Colorado.

“In particular, we are thinking about relatively inexperienced drivers, so the effects are even more important,” Dr. Schizer said.

Medical marijuana

What began as an Institute of Medicine recommendation for “compassionate use” to relieve suffering in terminally ill patients has become a movement to medicalize marijuana despite limited evidence of its therapeutic benefits, Dr. Schizer explained. Since California legalized medical marijuana in 1996, many other states have followed suit. Yet the only condition for which modest evidence supports its use is treating adults’ nausea and vomiting resulting from chemotherapy. For chronic pain, anorexia associated with HIV/AIDS, and neurologic problems such as multiple sclerosis, the evidence is not sufficient to show therapeutic efficacy, and no studies have looked at medical marijuana use in children.

“Marijuana is not a medication,” Dr. Schizer said. “There is therapeutic potential in these cannabinoids, but that’s not the same as directing patients to using medical marijuana. We know that penicillin was originally derived from mold, but you would give patients penicillin, not a slice of moldy bread” to treat a bacterial infection.

Actual medical cannabinoids approved for treatments include Marinol and Sativex. The Food and Drug Administration has approved Marinol, a slow-acting oral formulation, to treat weight loss in patients with anorexia or AIDS and to treat nausea and vomiting from chemotherapy. Ongoing phase III clinical studies are testing Sativex for the treatment of advanced cancer pain. To suggest that a patient use commercially available marijuana therapeutically would be akin to sending patients to an opium den instead of prescribing a precise opioid for pain, Dr. Schizer suggested. “I think it’s unconscionable for doctors to prescribe something that is smoked.”

Data from Colorado and Oregon suggest few individuals with medical marijuana cards may be using it for serious illnesses, Dr. Schizer pointed out. Less than 2% of medical marijuana cardholders report cancer, HIV/AIDS, glaucoma,i or multiple sclerosis as their reasons for using marijuana. The typical profile of a cardholder is a 32-year-old white man with a history of alcohol and cocaine abuse and no history of life-threatening illnesses, she said. According to the Colorado Department of Public Health and Environment, 12% of medical marijuana users report using it for severe nausea, 17% for muscle spasms, and 94% for “severe pain.”

Meanwhile, Colorado’s legalization of recreational marijuana imparts several lessons, Dr. Schizer said. The highest rate of teen marijuana use in the United States occurs in Denver, and 11% of teens report using marijuana in the past month, compared with a national average of 8%. Drug-related school suspensions have increased, and the rate of car crashes in which the driver tested positive for marijuana tripled between January 2014, when stores opened, and April 2014.

Dr. Schizer reported no relevant financial disclosures.

Marijuana is dangerous, and you need to know how dangerous to adequately counsel adolescent patients and their families.

The growing number of states legalizing marijuana, whether exclusively for medical use or for recreational use, is changing the landscape for physicians, addiction specialists, and others working in public health, explained Dr. Miriam Schizer of the adolescent substance abuse program at Boston Children’s Hospital.

Currently, 23 states plus Washington have legalized medical marijuana, and 4 states plus Washington have legalized recreational use, Dr. Schizer said at the annual meeting of the American Academy of Pediatrics. Cannabis products are expanding rapidly, with many becoming more potent, but misconceptions about marijuana use also are potent and growing.

©iStock/ThinkStockPhotos.com

The proportion of high school seniors who believe marijuana carries a “great risk of harm” is nearly at an all-time low, based on findings from the Monitoring the Future survey. With annual samples of approximately 50,000 8th, 10th and 12th grade students each year, the survey provides a glimpse into long-term trends in adolescents’ attitudes and behaviors regarding substance use. Just over a third of high school seniors (36%) perceived marijuana to have a great risk of harm in 2014, one of the lowest recorded numbers since the survey began in 1975. And 14% of seniors surveyed reported having used marijuana in the past month.

Understanding the mechanisms of THC

The primary psychoactive ingredient in marijuana is delta-9 tetrahydrocannabinol, or THC, one of more than 100 cannabinoids in marijuana. This fat-soluble molecule crosses both the blood-brain barrier and the placenta and accumulates in adipose tissue, where its half-life ranges from several days to a week. Its concentration in cannabis products also has increased from an average of less than 4% in 1994 to an average of 9% in cannabis products in 2008.

The way THC makes its way into adolescents’ systems varies: Smoking buds and leaves is the most common, but people also eat edible products, inhale cannabis through hookahs or e-cigarette–like “vaping” systems, or use hash oil “dabbing” for an exceptionally potent dose.

While the positive effects of cannabis use are what keep users coming back, the negative effects are just as common and can carry over until the day after, like a hangover. Those include paranoia, anxiety, irritability, impaired short-term memory, poor attention or judgment, poor coordination, distorted spatial perception, and an altered sense of the passage of time. The positive effects that users report include reduced anxiety, increased sociability, the perception that time slows down, an increased appetite, decreased pain, and overall euphoria.

Physiologic effects – peaking 30 minutes after inhalation or 2-4 hours after ingestion – can include tachycardia up to 20-50 beats per minute above baseline, increased blood pressure, bronchial relaxation, red eyes, and dry mouth and throat. These effects increase with the concentration of THC, also increasing the likelihood of paranoia, panic, hallucinations, vomiting, erratic mood swings, and aggressive behavior.

Following the discovery of cannabinoid receptors in the brain in 1988, scientists learned that the brain contains its own cannabinoid known as anandamide, giving rise to an endocannabinoid system in the brain. This system shapes brain development, supports myelin growth on neurons, and controls neuron activity. Both THC and anandamide play a role in regulating neurotransmitters such as dopamine, glutamate, endorphins, and serotonin, but THC has much stronger, longer-lasting effects and consequently interferes with cell function and growth.

Misconceptions about marijuana use

Dr. Schizer addressed the most common myths about marijuana use, pointing out that it is harmful to human health, it is addictive, and it does impair driving. Short-term harms include impaired short-term memory and motor coordination, altered judgment, and, in higher doses, paranoia and psychosis.

“There is a link to worsening depression and anxiety over time,” Dr. Schizer said. “Something is emerging very clearly: Among individuals with a genetic disposition to psychotic disorder, there’s an increased risk of developing the psychotic disorder.”

Long-term use can alter brain development, particularly among those using it in early adolescence, and lead to higher dropout rates, a lower IQ, and a poorer sense of life satisfaction. In one study of 1,037 individuals tracked from age 13 to 38 years, the average IQ of those who never used marijuana ranged from 99.8 to 100.6, compared with 99.7 to 93.9 among those dependent on marijuana for at least 3 years (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64).

Marijuana use also has adverse effects on the lungs, on male and female sexual function, and on the cardiovascular system. In pregnant women using marijuana, the fetus is exposed to THC through the placenta and umbilical cord, receives less oxygen, and has a higher risk of birth defects.

Approximately 9% of users develop an addiction to marijuana, but that nearly doubles to 17% among users who start in adolescence, according to the National Institute on Drug Abuse.

“The earlier they are when they start, the more likely they are to develop an addiction,” Dr. Schizer said, pointing out that 88% of all substance abuse treatment admissions among adolescents aged 12-17 years involved marijuana, according to 2012 Substance Abuse and Mental Health Services Administration data. By age 21 years, approximately 4% of users are addicted, but about a quarter to half of daily users develop an addiction. Further evidence of marijuana’s addictiveness are “bona fide withdrawal symptoms,” which typically peak about 10 days after last use, and can include restlessness, anxiety, increased irritability or aggression, difficulty falling and staying asleep, nightmares or strange dreams, decreased appetite, and weight loss.

Driving impairment under the influence of marijuana results from poorer attention, worse working memory, lack of coordination, poorer reaction time, and lack of visual perception caused by THC. In a graphic Dr. Schizer presented comparing Colorado to 34 states without medical marijuana, the proportion of drivers testing positive for marijuana in fatal crashes began sharply increasing in 2009, the year widespread medical marijuana was implemented in Colorado.

“In particular, we are thinking about relatively inexperienced drivers, so the effects are even more important,” Dr. Schizer said.

Medical marijuana

What began as an Institute of Medicine recommendation for “compassionate use” to relieve suffering in terminally ill patients has become a movement to medicalize marijuana despite limited evidence of its therapeutic benefits, Dr. Schizer explained. Since California legalized medical marijuana in 1996, many other states have followed suit. Yet the only condition for which modest evidence supports its use is treating adults’ nausea and vomiting resulting from chemotherapy. For chronic pain, anorexia associated with HIV/AIDS, and neurologic problems such as multiple sclerosis, the evidence is not sufficient to show therapeutic efficacy, and no studies have looked at medical marijuana use in children.

“Marijuana is not a medication,” Dr. Schizer said. “There is therapeutic potential in these cannabinoids, but that’s not the same as directing patients to using medical marijuana. We know that penicillin was originally derived from mold, but you would give patients penicillin, not a slice of moldy bread” to treat a bacterial infection.

Actual medical cannabinoids approved for treatments include Marinol and Sativex. The Food and Drug Administration has approved Marinol, a slow-acting oral formulation, to treat weight loss in patients with anorexia or AIDS and to treat nausea and vomiting from chemotherapy. Ongoing phase III clinical studies are testing Sativex for the treatment of advanced cancer pain. To suggest that a patient use commercially available marijuana therapeutically would be akin to sending patients to an opium den instead of prescribing a precise opioid for pain, Dr. Schizer suggested. “I think it’s unconscionable for doctors to prescribe something that is smoked.”

Data from Colorado and Oregon suggest few individuals with medical marijuana cards may be using it for serious illnesses, Dr. Schizer pointed out. Less than 2% of medical marijuana cardholders report cancer, HIV/AIDS, glaucoma,i or multiple sclerosis as their reasons for using marijuana. The typical profile of a cardholder is a 32-year-old white man with a history of alcohol and cocaine abuse and no history of life-threatening illnesses, she said. According to the Colorado Department of Public Health and Environment, 12% of medical marijuana users report using it for severe nausea, 17% for muscle spasms, and 94% for “severe pain.”

Meanwhile, Colorado’s legalization of recreational marijuana imparts several lessons, Dr. Schizer said. The highest rate of teen marijuana use in the United States occurs in Denver, and 11% of teens report using marijuana in the past month, compared with a national average of 8%. Drug-related school suspensions have increased, and the rate of car crashes in which the driver tested positive for marijuana tripled between January 2014, when stores opened, and April 2014.

Dr. Schizer reported no relevant financial disclosures.

Marijuana is dangerous, and you need to know how dangerous to adequately counsel adolescent patients and their families.

The growing number of states legalizing marijuana, whether exclusively for medical use or for recreational use, is changing the landscape for physicians, addiction specialists, and others working in public health, explained Dr. Miriam Schizer of the adolescent substance abuse program at Boston Children’s Hospital.

Currently, 23 states plus Washington have legalized medical marijuana, and 4 states plus Washington have legalized recreational use, Dr. Schizer said at the annual meeting of the American Academy of Pediatrics. Cannabis products are expanding rapidly, with many becoming more potent, but misconceptions about marijuana use also are potent and growing.

©iStock/ThinkStockPhotos.com

The proportion of high school seniors who believe marijuana carries a “great risk of harm” is nearly at an all-time low, based on findings from the Monitoring the Future survey. With annual samples of approximately 50,000 8th, 10th and 12th grade students each year, the survey provides a glimpse into long-term trends in adolescents’ attitudes and behaviors regarding substance use. Just over a third of high school seniors (36%) perceived marijuana to have a great risk of harm in 2014, one of the lowest recorded numbers since the survey began in 1975. And 14% of seniors surveyed reported having used marijuana in the past month.

Understanding the mechanisms of THC

The primary psychoactive ingredient in marijuana is delta-9 tetrahydrocannabinol, or THC, one of more than 100 cannabinoids in marijuana. This fat-soluble molecule crosses both the blood-brain barrier and the placenta and accumulates in adipose tissue, where its half-life ranges from several days to a week. Its concentration in cannabis products also has increased from an average of less than 4% in 1994 to an average of 9% in cannabis products in 2008.

The way THC makes its way into adolescents’ systems varies: Smoking buds and leaves is the most common, but people also eat edible products, inhale cannabis through hookahs or e-cigarette–like “vaping” systems, or use hash oil “dabbing” for an exceptionally potent dose.

While the positive effects of cannabis use are what keep users coming back, the negative effects are just as common and can carry over until the day after, like a hangover. Those include paranoia, anxiety, irritability, impaired short-term memory, poor attention or judgment, poor coordination, distorted spatial perception, and an altered sense of the passage of time. The positive effects that users report include reduced anxiety, increased sociability, the perception that time slows down, an increased appetite, decreased pain, and overall euphoria.

Physiologic effects – peaking 30 minutes after inhalation or 2-4 hours after ingestion – can include tachycardia up to 20-50 beats per minute above baseline, increased blood pressure, bronchial relaxation, red eyes, and dry mouth and throat. These effects increase with the concentration of THC, also increasing the likelihood of paranoia, panic, hallucinations, vomiting, erratic mood swings, and aggressive behavior.

Following the discovery of cannabinoid receptors in the brain in 1988, scientists learned that the brain contains its own cannabinoid known as anandamide, giving rise to an endocannabinoid system in the brain. This system shapes brain development, supports myelin growth on neurons, and controls neuron activity. Both THC and anandamide play a role in regulating neurotransmitters such as dopamine, glutamate, endorphins, and serotonin, but THC has much stronger, longer-lasting effects and consequently interferes with cell function and growth.

Misconceptions about marijuana use

Dr. Schizer addressed the most common myths about marijuana use, pointing out that it is harmful to human health, it is addictive, and it does impair driving. Short-term harms include impaired short-term memory and motor coordination, altered judgment, and, in higher doses, paranoia and psychosis.

“There is a link to worsening depression and anxiety over time,” Dr. Schizer said. “Something is emerging very clearly: Among individuals with a genetic disposition to psychotic disorder, there’s an increased risk of developing the psychotic disorder.”

Long-term use can alter brain development, particularly among those using it in early adolescence, and lead to higher dropout rates, a lower IQ, and a poorer sense of life satisfaction. In one study of 1,037 individuals tracked from age 13 to 38 years, the average IQ of those who never used marijuana ranged from 99.8 to 100.6, compared with 99.7 to 93.9 among those dependent on marijuana for at least 3 years (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64).

Marijuana use also has adverse effects on the lungs, on male and female sexual function, and on the cardiovascular system. In pregnant women using marijuana, the fetus is exposed to THC through the placenta and umbilical cord, receives less oxygen, and has a higher risk of birth defects.

Approximately 9% of users develop an addiction to marijuana, but that nearly doubles to 17% among users who start in adolescence, according to the National Institute on Drug Abuse.

“The earlier they are when they start, the more likely they are to develop an addiction,” Dr. Schizer said, pointing out that 88% of all substance abuse treatment admissions among adolescents aged 12-17 years involved marijuana, according to 2012 Substance Abuse and Mental Health Services Administration data. By age 21 years, approximately 4% of users are addicted, but about a quarter to half of daily users develop an addiction. Further evidence of marijuana’s addictiveness are “bona fide withdrawal symptoms,” which typically peak about 10 days after last use, and can include restlessness, anxiety, increased irritability or aggression, difficulty falling and staying asleep, nightmares or strange dreams, decreased appetite, and weight loss.

Driving impairment under the influence of marijuana results from poorer attention, worse working memory, lack of coordination, poorer reaction time, and lack of visual perception caused by THC. In a graphic Dr. Schizer presented comparing Colorado to 34 states without medical marijuana, the proportion of drivers testing positive for marijuana in fatal crashes began sharply increasing in 2009, the year widespread medical marijuana was implemented in Colorado.

“In particular, we are thinking about relatively inexperienced drivers, so the effects are even more important,” Dr. Schizer said.

Medical marijuana

What began as an Institute of Medicine recommendation for “compassionate use” to relieve suffering in terminally ill patients has become a movement to medicalize marijuana despite limited evidence of its therapeutic benefits, Dr. Schizer explained. Since California legalized medical marijuana in 1996, many other states have followed suit. Yet the only condition for which modest evidence supports its use is treating adults’ nausea and vomiting resulting from chemotherapy. For chronic pain, anorexia associated with HIV/AIDS, and neurologic problems such as multiple sclerosis, the evidence is not sufficient to show therapeutic efficacy, and no studies have looked at medical marijuana use in children.

“Marijuana is not a medication,” Dr. Schizer said. “There is therapeutic potential in these cannabinoids, but that’s not the same as directing patients to using medical marijuana. We know that penicillin was originally derived from mold, but you would give patients penicillin, not a slice of moldy bread” to treat a bacterial infection.

Actual medical cannabinoids approved for treatments include Marinol and Sativex. The Food and Drug Administration has approved Marinol, a slow-acting oral formulation, to treat weight loss in patients with anorexia or AIDS and to treat nausea and vomiting from chemotherapy. Ongoing phase III clinical studies are testing Sativex for the treatment of advanced cancer pain. To suggest that a patient use commercially available marijuana therapeutically would be akin to sending patients to an opium den instead of prescribing a precise opioid for pain, Dr. Schizer suggested. “I think it’s unconscionable for doctors to prescribe something that is smoked.”

Data from Colorado and Oregon suggest few individuals with medical marijuana cards may be using it for serious illnesses, Dr. Schizer pointed out. Less than 2% of medical marijuana cardholders report cancer, HIV/AIDS, glaucoma,i or multiple sclerosis as their reasons for using marijuana. The typical profile of a cardholder is a 32-year-old white man with a history of alcohol and cocaine abuse and no history of life-threatening illnesses, she said. According to the Colorado Department of Public Health and Environment, 12% of medical marijuana users report using it for severe nausea, 17% for muscle spasms, and 94% for “severe pain.”

Meanwhile, Colorado’s legalization of recreational marijuana imparts several lessons, Dr. Schizer said. The highest rate of teen marijuana use in the United States occurs in Denver, and 11% of teens report using marijuana in the past month, compared with a national average of 8%. Drug-related school suspensions have increased, and the rate of car crashes in which the driver tested positive for marijuana tripled between January 2014, when stores opened, and April 2014.

Dr. Schizer reported no relevant financial disclosures.