Pediatric Annals

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Abstract

Prolonged fatigue in adolescents may reflect more severe mood and anxiety disorders, according to recent study results published in American Journal of Psychiatry.

“Comorbid fatigue states may indicate greater severity of depressive and anxiety disorders in adolescents, and even in the absence of comorbidity, the substantial disability and comorbidity with somatic conditions, particularly pain conditions, among those with fatigue states alone also suggest that prolonged fatigue is a clinically relevant entity,” researchers wrote.

The survey-based study included the data of 10,123 adolescents aged 13 to 18 years from the National Comorbidity Survey Adolescent Supplement. Participants were questioned about prolonged fatigue associated with at least one symptom (pains, dizziness, headache, sleep disturbance, inability to relax, irritability) that is not resolved by resting or relaxing and lasts for at least 3 months.

Researchers found a 3% prevalence of prolonged fatigue, with 1.4% for prolonged fatigue only and 1.6% for fatigue with a depressive or anxiety disorder.

According to researchers, nearly 60% of the participants with prolonged fatigue only had severe or very severe disability.

Researchers also found that participants with prolonged fatigue and mood or anxiety disorders had increased disability, decreased mental health, and utilized health services more often than those with either condition alone.

“The high magnitude of comorbidity with physical disorders also highlights the importance of fatigue states as an index of somatic condition,” researchers wrote. “Although there were relatively high rates of mental health service use among adolescents with comorbid fatigue and mood/anxiety disorders, there was a striking paucity of service use among those with either condition alone, despite high levels of disability.”

Lamers F. Am J Psychiatry. 2013;170:502–510.

Disclosure: See the study for a full list of disclosures.

Primary care pediatricians report skepticism of antibiotic prescribing audit data, according to study results presented at the 2013 Pediatric Academic Societies Annual Meeting in Washington, DC.

To improve antibiotic prescribing for common acute respiratory tract infections, a research team including Julia E. Szymczak, MA, and PhD candidate in the Department of Sociology at the University of Pennsylvania used a cluster-randomized trial to evaluate interviews from 21 physicians at 5 clinics in a large pediatric primary care network. The study included an education session and quarterly feedback reports for 1 year of individual prescribing that were audited to encourage behavior change.

The researchers found that 6 participants reported they ignored or did not remember receiving audit reports. Of the 15 who reported receiving them, 9 said they were skeptical of the data.

Participants who reported skepticism said their reasons included uncertainty of the origin of data, belief that patient encounters could have been improperly documented, and belief that the audit did not capture the complexity of a patient’s case. One participant reported working around the audit by adding bacterial diagnoses to patient cases for acute respiratory infections, despite absence of a bacterial infection, to avoid a feedback report of poor performance.

“This study suggests that interventions intending to change provider prescribing via audit and feedback should include efforts to boost the credibility of the reports,” study researcher Jeffrey S. Gerber, MD, PhD, assistant professor of pediatrics at the University of Pennsylvania School of Medicine, told Pediatric Annals. Doing so, he said, would help to increase the acceptability of the intervention and avert “gaming behavior.”

Szymczak JE. #2913.159. Presented at: Pediatric Academic Societies Annual Meeting; May 4–7, 2013; Washington.

Disclosure: The researchers report no relevant financial disclosures.

Nearly 20% of youth at risk for suicide presenting to the emergency department reported guns in or around the house, according to data presented at the Pediatric Academic Societies Annual Meeting.

“Being at risk for…

Prolonged Fatigue in Teens Tied to Depressive and Anxiety Disorders

Prolonged fatigue in adolescents may reflect more severe mood and anxiety disorders, according to recent study results published in American Journal of Psychiatry.

“Comorbid fatigue states may indicate greater severity of depressive and anxiety disorders in adolescents, and even in the absence of comorbidity, the substantial disability and comorbidity with somatic conditions, particularly pain conditions, among those with fatigue states alone also suggest that prolonged fatigue is a clinically relevant entity,” researchers wrote.

The survey-based study included the data of 10,123 adolescents aged 13 to 18 years from the National Comorbidity Survey Adolescent Supplement. Participants were questioned about prolonged fatigue associated with at least one symptom (pains, dizziness, headache, sleep disturbance, inability to relax, irritability) that is not resolved by resting or relaxing and lasts for at least 3 months.

Researchers found a 3% prevalence of prolonged fatigue, with 1.4% for prolonged fatigue only and 1.6% for fatigue with a depressive or anxiety disorder.

According to researchers, nearly 60% of the participants with prolonged fatigue only had severe or very severe disability.

Researchers also found that participants with prolonged fatigue and mood or anxiety disorders had increased disability, decreased mental health, and utilized health services more often than those with either condition alone.

“The high magnitude of comorbidity with physical disorders also highlights the importance of fatigue states as an index of somatic condition,” researchers wrote. “Although there were relatively high rates of mental health service use among adolescents with comorbid fatigue and mood/anxiety disorders, there was a striking paucity of service use among those with either condition alone, despite high levels of disability.”

Lamers F. Am J Psychiatry. 2013;170:502–510.

Disclosure: See the study for a full list of disclosures.

Pediatricians Question Antibiotic Prescribing Audit Data

Primary care pediatricians report skepticism of antibiotic prescribing audit data, according to study results presented at the 2013 Pediatric Academic Societies Annual Meeting in Washington, DC.

To improve antibiotic prescribing for common acute respiratory tract infections, a research team including Julia E. Szymczak, MA, and PhD candidate in the Department of Sociology at the University of Pennsylvania used a cluster-randomized trial to evaluate interviews from 21 physicians at 5 clinics in a large pediatric primary care network. The study included an education session and quarterly feedback reports for 1 year of individual prescribing that were audited to encourage behavior change.

The researchers found that 6 participants reported they ignored or did not remember receiving audit reports. Of the 15 who reported receiving them, 9 said they were skeptical of the data.

Participants who reported skepticism said their reasons included uncertainty of the origin of data, belief that patient encounters could have been improperly documented, and belief that the audit did not capture the complexity of a patient’s case. One participant reported working around the audit by adding bacterial diagnoses to patient cases for acute respiratory infections, despite absence of a bacterial infection, to avoid a feedback report of poor performance.

“This study suggests that interventions intending to change provider prescribing via audit and feedback should include efforts to boost the credibility of the reports,” study researcher Jeffrey S. Gerber, MD, PhD, assistant professor of pediatrics at the University of Pennsylvania School of Medicine, told Pediatric Annals. Doing so, he said, would help to increase the acceptability of the intervention and avert “gaming behavior.”

Szymczak JE. #2913.159. Presented at: Pediatric Academic Societies Annual Meeting; May 4–7, 2013; Washington.

Disclosure: The researchers report no relevant financial disclosures.

Many Suicidal Adolescents Have Access to Guns at Home

Nearly 20% of youth at risk for suicide presenting to the emergency department reported guns in or around the house, according to data presented at the Pediatric Academic Societies Annual Meeting.

“Being at risk for suicide and having access to firearms is a volatile mix,” study researcher Jeffrey A. Bridge, PhD, of the Research Institute at Nationwide Children’s Hospital and The Ohio State University, told Pediatric Annals. “These conversations need to take place in the ED with families of children at risk for suicide.”

The study included 524 patients aged 10 to 21 years who were screened for suicide risk. The patients also reported on their knowledge of gun storage in their homes, including whether they had access to guns and where ammunition is kept. The study was designed to create a questionnaire used to screen for suicide risk among children and adolescents presenting to emergency departments (EDs) with medical, surgical, or psychiatric complaints. Called the Ask Suicide-Screening Questionnaire, it has been validated against the larger Suicidal Ideation Questionnaire.

According to the researchers, 29% of the youth were determined to be at risk for suicide; 17% of those reported guns in or around the house. Among suicidal youth, 31% knew how to access guns stored at home, and 31% knew how to access the ammunition for those guns. Approximately 15% reported having access to both guns and ammunition.

“For more than 1.5 million adolescents, the ED is their primary point of contact with the health care system, which makes the ED an important place for identifying youth at risk for suicide,” study researcher Stephen J. Teach, MD, MPH, FAAP, associate chief in the division of emergency medicine at Children’s National Medical Center in Washington, DC, said in a press release.

Bridge JA. #3618.8. Presented at: Pediatric Academic Societies Annual Meeting; May 4–7, 2013; Washington.

Disclosure: The researchers report no relevant financial disclosures.

Timing Critical in Exchange Transfusion for Pertussis

Exchange transfusion (ET) should be considered for pertussis treatment based on the early appearance of pneumonia, the presence of pulmonary hypertension, and the rapid increase in white blood count, according to data presented at this year’s Pediatric Academic Societies meeting, held in Washington, DC.

While the efficacy data remain insufficient to indicate routine use of ET for treatment of pertussis, researchers including Delma J. Nieves, MD, Children’s Hospital Orange County, Orange, CA, reported ET may be effective if implemented at the right time.

Because the decision to perform an ET should be based upon the initial white blood cell (WBC) count and how quickly it rises, “WBC counts [should] be performed every 12 to 24 hours; rapidly rising counts 30,000 cells/mm3 or greater should prompt immediate consideration of ET,” Nieves and colleagues concluded.

The study included 10 infants, all of whom were intubated. Five of the children survived, and 5 died. In each group, 3 patients were girls, 2 were boys. Among the 5 fatal cases, the average age at illness onset was 6 weeks, compared with the average age of 7 weeks in survivors.

The mean WBC count among fatal cases was 77,000/mm3, compared with 85,000/mm3 among survivors.

Pulmonary hypertension, shock/hypotension, and pneumonia were present in all 5 fatal cases of pertussis and 4 of the 5 had organ failure noted in their chart before initiation of ET. Three infants received extracorporeal membrane oxygenation. None of these patients had seizures.

In contrast, 2 of the 5 infants who survived had pulmonary hypertension and 4 of the 5 patients had pneumonia, while none had shock/hypotension or organ failure; none received extracorporeal membrane oxygenation (ECMO), and 3 had seizures.

“Our research findings indicated that if we are going to consider ETs as a treatment option in a severe case of pertussis, we need to think about doing it sooner than later. You cannot wait until the patient already has hypotension, shock or evidence of organ failure,” Nieves told Pediatric Annals. “The main point is to immunize infants and their mothers and not get to this point.”

Nieves DJ. #1533.461. Presented at: Pediatric Academic Societies Annual Meeting; May 4–7, 2013; Washington.

Disclosure: Nieves reports no relevant financial disclosures.

AAP Recommends Use of e-Prescriptions

The American Academy of Pediatrics (AAP) recently recommended that pediatric health care providers e-prescribe.

According to a policy statement recently published in Pediatrics, e-prescribing systems for children should include pediatric-specific medication catalogues, decision support, ingredient amount-to-volume conversions for liquid medications, metric-only labeling instructions, and pediatric drug information and formulation options.

The guidelines also state that e-prescribing should include drug interaction and allergy checking; provide patients and parents with instructions based on health literacy and language; pharmacies should enhance their technology to enable efficient processing of e-prescriptions; insurers should offer incentives to providers and pharmacies for using the system; and states should harmonize legislation to the US Drug Enforcement Agency’s interim final rule on e-prescribing of controlled substances.

In a recent systematic review, error rates in pediatric prescribing are between 5% and 27%. Authors of the report said e-prescribing would recognize the inherent challenges of this flaw. Many pharmacologic factors, including age-based variability in absorption, metabolism, and excretion of drugs in children, may cause overdosing in children more often than in adults.

“Prescribing errors are most prevalent with antibiotic agents, but may occur even in medications that do not require weight-based dosing or ingredient-to-volume conversion,” wrote Kevin B. Johnson, MD, MS, and colleagues. “Medication errors in children may lead to more severe complications because of the inability of children to communicate some adverse effects.”

The statement indicated that past studies evaluating e-prescriptions showed consistent reductions in potential adverse events in systems that organize and report medication summaries. E-prescribing systems also can display results of a patient’s previous therapy to help avoid ineffective or harmful medications.

Dosing errors also are common in pediatrics, according to the AAP statement. Dosing error-checking is complicated in children because weights vary from as little as 500 g for premature infants to more than 100 kg for obese adolescents. According to the policy report, e-prescribing systems use the patient’s weight to calculate a dose, convert it to a volume for liquids, and present it in a format that is not likely to be confusing to a prescriber, pharmacist, nurse or parent.

“In pediatrics, there is an additional challenge of modifying a dose for some medication refills as the child grows,” Johnson and colleagues said. “[This] can be facilitated by information technology.”

Johnson KB. Pediatrics. 2013;doi:10.1542/peds.2012–0193.

Disclosure: The researchers report no relevant financial disclosures.

Few Pediatric Neuropsychiatric Drug Trials despite Common Off-Label Uses

Only a small proportion of neuropsychiatric drug trials focus on pediatric populations despite the rising prevalence of neuropsychiatric disorders among children and widespread off-label use of available drugs, according to a study in Pediatrics.

“In our analysis of drug trials for neuropsychiatric conditions, we found that pediatric populations are studied much less frequently than adults, and that the drugs studied tended to lack FDA approval for any indication in children, compared with approval in adults,” study researcher Srinivas Murthy, MD, of the department of critical care medicine at the Hospital for Sick Children in Toronto, told Pediatric Annals. The paucity of drug trials seeking to expand the use of a drug to children was particularly evident in depression and schizophrenia, according to the study.

Murthy and colleagues examined clinical drug trials registered on ClinicalTrials.gov between 2006 and 2011 that focused on five neuropsychiatric conditions that represented the highest burden of disease among children, according to the World Health Organization. These included depression, schizophrenia, bipolar disorder, migraines, and epilepsy. They classified 1,046 of those trials based on the drug’s FDA approval status in children. Murthy and colleagues measured the proportion of drug trials that sought to expand a drug’s use to children and the number of available neuropsychiatric drugs that have been studied in children.

The researchers found that only 10% of the drug trials focused on children. Of the 303 drugs studied in both adults and children, 90% did not have FDA approval for pediatric use, and 97% did not have FDA approval for pediatric use for the neuropsychiatric condition studied. Depression (6%) and schizophrenia (6%) made up the smallest proportion of pediatric trials, compared with the largest proportion of pediatric trials that focused on epilepsy (26%).

The researchers found no drugs studied for the treatment of depression, bipolar disorder or migraine that had FDA approval for use in children.

Results also indicated that 19% (95% CI, 15%–23%) of all neuropsychiatric drugs were studied in pediatric trials vs. 95% (95% CI, 93%–97%) of all neuropsychiatric drugs studied in adult trials. Only 8% of drugs were studied for the treatment of either schizophrenia or depression. Among all pediatric drug trials, 76% studied a drug lacking FDA approval for use in children, and 26% (95% CI, 17%–35%) studied a new use for a drug for an unapproved indication.

“Current strategies need to be strengthened to overcome persistent barriers to research activity in children and to increase evidence-based treatment options for children with neurologic and psychiatric disabilities,” the researchers wrote.

Murthy S. Pediatrics. 2013;doi:10.1542/peds.2012–2694.

Disclosure: Murthy reports no relevant financial disclosures.

Check List ☑

Plan Ahead to Avoid Shaken Baby Syndrome

Even though parents expect their infant to cry, a study recently published in Pediatrics suggests that “Many [parents] may be unprepared for the discomfort and frustration that occur when they are unable to console their child.”

The investigators concluded that by offering some anticipatory guidance about the temporary nature of inconsolable crying, pediatricians “may be able to help [parents] tolerate this common early difficulty in the parent-child relationship, bring about greater parental self-understanding, and provide an opportunity to offer help.”

According to the report, resources such as those published online by the Children’s Hospital of Colorado, can be helpful to parents dealing with an inconsolable infant. Here are three tips from the hospital’s website for helping to calm a crying baby:

  • ☑ Choose a calming technique such as: swaddling the baby, using a pacifier, singing to the child, or turning on some white noise.

  • ☑ Choose another calming technique: take the baby for a car ride, gently rock the child, or hold the baby closely and breathe calmly.

  • ☑ Choose a coping technique: ask someone to give you a break or place the baby safely in its crib, close the door to its room, and check back in a few moments when you feel more calm.

Radesky JS. Pediatrics. 2013;doi:10.1542/peds.2012–3316.

purplecrying.info/sub-pages/soothing/soothing-methods-to-avoid.php

www.calmacryingbaby.org/en/make-a-plan

See study for full list of disclosures.

10.3928/00904481-20130522-02

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