Recognizing the importance of energy availability in the young athlete

written by Drs Laule, Chung, and Ichesco, provides a wealth of information for pediatric health care providers (HCPs) to better understand the presentation of females and males with subtle or more obvious signs of the diagnosis of female or male athlete triad. The authors stress the importance of early recognition and corrective actions because outcomes of failure to diagnose the female or male who presents with symptoms of the athlete triad at the earliest stages are irreversible. 

Exercise has positive effects on physical and mental well-being

The American Academy of Pediatrics recommends an annual physical examination for adolescents. Included on the periodicity schedule are interpretation of height and weight, body mass index (BMI), blood pressure readings, and known risky behaviors eg, behavioral health assessments including depression screening as well as use of tobacco, alcohol, or drugs.

 Physical activity and sports participation are not included in the table; thus, it is important to ask each child and adolescent about their exercise habits. Responses to history questions should be documented on the electronic health records. Pediatric HCPs often encourage their children and adolescents to plan exercise activities on a daily and weekly basis and participate in sports of their choice. Physical activity has positive effects on both physical and mental well-being.

Awareness of the male athlete triad diagnosis

Exercise and healthy sport participation habits should be a routine part of anticipatory guidance. We often provide anticipatory guidance about wearing and using protective equipment based on the particular sport for prevention of sports-related injuries. The critical question to ask yourself is, how often do I assess adolescents for signs of female or male athlete triad? The 2 cases presented by Drs. Laule, Chung, and Ichesco show that both the female and male had significant weight loss with significant changes in BMI. Both adolescents also presented with bone pain. The female presented with amenorrhea. HCPs may be very aware of the diagnosis of the female athlete triad, but not as aware of the male athlete triad.

Encourage healthy behaviors for all athletes

Healthy behaviors are critically important to stress to young athletes. Healthy eating behaviors, awareness of when the body needs to rest and not ‘play through the pain’ as well as feelings of accomplishments, whether the game outcome is a win or loss. Let’s guide our young athletes to physical and mental health victories while assessing for presenting signs and symptoms that raise the red flag for the athlete triad diagnosis.

1. American Academy of Pediatrics. Recommendations for preventive pediatric health care. Updated March 1, 2021. Accessed April 26, 2021. 

https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

Articles

Knowing the symptoms of athlete triad symptoms can aid with diagnosis before the effects become irreversible.

Diagnosing the female and male who present with athlete triad symptoms

The COVID-19 pandemic has hospitals, health systems, and physician groups still on shaky financial ground as margins and patient volumes remain low and costs remain high.

 from Kaufman Hall found that healthcare organizations are still in a precarious position more than a year into the pandemic even as year-to-date margins increased in March and volumes continued to decline.

“We expect to see additional margin gains in the months ahead, especially in comparison to record-poor performance in the early months of the pandemic,” Jim Blake a managing director at Kaufman Hall and publisher of the National Hospital Flash Report, says in the release. “Over the course of 2021, however, we project hospital margins could be down as much as 80 percent and revenues down as much as $122 billion compared to pre-pandemic levels as hospitals continue to feel the dire repercussions of COVID-19.”

Physician groups saw volatility throughout 2020 leading to productivity, compensation, and revenues for the year fell below where they were in 2019 while the average investment required to supplement physician revenues rose, the release says.

"Healthcare leaders should take a balanced approach with regard to meeting patient demand as they look to grow their physician strategies moving forward," Cynthia Peters Arnold, a senior vice president at Kaufman Hall, says in the release. "This will require rethinking the investment needed to pay physicians, setting clear clinical quality and economic targets, and establishing a physician management system with accountability for both physicians and administrators."

Uncertainty remains in the healthcare sector as the COVID-19 pandemic continues to impact the industry.

Uncertainty remains in health care sector due to pandemic

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

The need for more clinical trials of drugs in pediatrics has been long discussed, as many drugs are given to children that haven’t been formally tested in the population and information on safety and efficacy are not available to clinicians making medication choices. On the other hand, there are clinical trials of drugs in pediatric populations that are never published and result in the loss of potentially helpful information. A 

offers a look at the information that is lost when those trials aren’t published.

The investigators performed an evaluation of pediatric trials that had been registered in ClinicalTrials.gov. Trials were included if they met the following criteria: used a randomized trial design, registered between January 2014 and June 2016, were trialing a drug intervention in children aged younger than 18 years, and were either completed or discontinued by June 30, 2018. A trial’s results were considered published if they were described in a peer-reviewed medical journal, which investigators found by searching PubMed, GoogleScholar, Embase, and company websites. If no publication was found for a drug trial, the investigators searched for reports on the trial in conference abstracts, press releases, thesis documents, trial registries, and preprint servers. The unpublished reports were examined for findings on mortality, adverse events, and efficacy of the drug intervention.

The investigators found 189 pediatric drug trials. One hundred twenty of the trails had an international trial site and 92 of the trials were funded by academic institutions. After a median follow-up period of 3.6 years, 79 were still unpublished. Those unpublished studies accounted for 8395 of 24,338 pediatric participants. Thirty of trials were discontinued and only 6 of those trials were published. Most common reasons for discontinuing trials included scientific reasons, business decisions, and insufficient patient enrollment. Completed trials were more likely to be published, but only 65.4% were published. Reports on unpublished studies were found for 49 of the 79 unpublished trials. In these trials, 2 included reports of deaths; 14 had reports of serious adverse events; and 31 had nonserious adverse events. Safety or efficacy information was available for 44 of the unpublished trials.

The investigators concluded that a sizeable number of pediatric drug trails were unpublished 2 years after the trial ended. Many of the trials included safety and efficacy findings that remain mostly inaccessible to both clinicians and the scientific community. They urged the creation additional efforts and incentives to promote the timely publication of pediatric drug trials.

1. Srivastava A, Bourgeois F. Evaluation of publication of pediatric drug trials. 

. 2021;4(4):e215829. doi:10.1001/jamanetworkopen.2021.5829

With the dearth of pediatric drug trials, it’s crucial that those trials that are implemented get published, but that is not always the case. A research letter looks into what is lost to clinicians when these trials do go unpublished.

What’s lost when pediatric drug trials go unpublished

Using bursts to deliver oral corticosteroids has been seen as a safe way to get necessary medication to children. An investigation examines whether that safety consideration was accurate.

Not every clinical drug trial is published. What’s lost when the findings of those drug trials aren’t made public?

Plus, Dr. Hallas discusses ways to assess for female and male athletic triad.

A look at what to expect from Contemporary Pediatrics this week.

What's new on Contemporary Pediatrics: April 26 to April 30

Using vitamin D to mitigate risk of childhood asthma in offspring of mothers with asthma

Maternal asthma is a major risk factor for a child also developing asthma. A report examines whether vitamin D sufficiency in pregnancy can change that risk.

Addressing maltreatment in children with disabilities

Children with disabilities are at an increased risk of maltreatment and may be unable to communicate this issue effectively. A report offers needed guidance for how to intervene.

Family history linked to depressive disorders

Family health history can serve as a warning for a patient’s current physical health issues. A report indicates that it may also be helpful with mental health issues.

Examining the prevalence of cisplatin-induced hearing loss

A study offers crucial information on the risk factors and prevalence of cisplatin-induced hearing loss in young cancer patients.

It was a very busy week for the Contemporary Pediatrics team.

In case you missed it: April 19 to April 23

Two of the key ways that coronavirus disease 2019 (COVID-19) has been transmitted includes the presymptomatic period as well as asymptomatic cases. Children have been one of the major drivers of those silent forms of transmission. Most children are also not able to get COVID-19 vaccines. A

looks how much identifying silent COVID-19 infections could reduce the disease burden in a way similar to vaccination in adults.

The investigators used an age-structured disease transmission model to simulate the effect of interventions in reducing the attack rates over the course of 1 year. The population in the simulation was representative of US demographics, from the most recent US census, and included 6 age groups: 0 to 4 years, 5 to 10 years, 11 to 18 years, 19 to 49 years, 50 to 64, and 65 years or older.

The simulation found that with a targeted approach that was able to identify 11% of silent infections among children within 2 days of infection and 14% within 3 days of infection would reduce the attack rates to less than 5% with 40% vaccination coverage in adults. However, if the there is no detection of silent infection in children, in order to have the same attack rates, there would need to be a vaccination coverage of ≥81% among children, which can’t be done at this time, in addition to the 40% vaccination coverage in adults.

The investigators concluded that an approach that involved rapid identification of COVID-19 infection in children in conjunction with adult vaccination led to significantly diminished disease burden. Additionally, they concluded that without an interruption in silent infections the vaccination of adults is not likely to contain COVID-19 outbreaks in the near future.

1. Moghadas S, Fitzpatrick M, Shoukat A, Zhang K, Galvani A. Simulated identification of silent COVID-19 infections among children and estimated future infection rates with vaccination. 

. 2021;4(4):e217097. doi:10.1001/jamanetworkopen.2021.7097

With the coronavirus disease 2019 (COVID-19) vaccine still not authorized for use in most of the pediatric population, reducing infection in children is important and identifying asymptomatic and presymptomatic infections could be key.

Identifying “silent” COVID-19 infections reduces disease burden in kids

Today, the US Food & Drug Administration (FDA) announced 2 new tobacco product standards to decrease disease and death due to smoking and hopefully discourage nonsmokers from becoming future smokers.

The first proposed product standard, which will be issued within the next year, will be to ban menthol as a characterizing flavor in cigarettes and cigars. The decision is a result of evidence-based science that shows menthol as both harmful and addictive. "With these actions, the FDA wil help significantly reduce youth initiation, increase the chances of smoking cessation among current smokers, and address health disparities experienced by communities of color, low-income populations, and LGBTQ+ individuals...whom are far more likely to use these tobacco products," said acting FDA Commissioner Janet Woodcock, MD.

Studies show that menthol increases the appeal of tobacco and masks unpleasant flavors and the harsh taste of tobacco, which entices more people to smoke. Furthermore, tobacco products with menthol can be more addictive. 

If implemented, the FDA enforcement of a ban on menthol tobacco products will only address manufacturers, distributors, wholesalers, importers and retailers. It cannot and will not enforce against individual consumer possession.

Secondly, the FDA continues to provide oversight in an attempt to end the selling of illegal e-cigarettes and other electronic nicotine delivery systems (ENDS). To that end, the FDA's Center for Tobacco Products issued warning letters to ENDS product manufacturers and retailers who continue to sell products that are illegally on the market. Finally, the FDA's public education campaign targets nearly 10.7 million young people aged 12 to 17 years who have never used e-cigarettes or might consider trying them, highlighting information about the potential risk of e-cigarette use.

Reference
1. US Food & Drug Administration. FDA commits to evidence-based actions aimed at saving lives and preventing future generations of smokers. April 29, 2021. 


https://www.fda.gov/news-events/press-announcements/fda-commits-evidence-based-actions-aimed-saving-lives-and-preventing-future-generations-smokers?utm_medium=email&utm_source=govdelivery

The FDA announces 2 standards to reduce disease and death from tobacco products.

FDA commits to campaign to prevent future smokers

Childhood obesity remains one of the most important issues in pediatrics and it’s most pressing when a child is overweight by his or her second birthday, due to a greater risk of health problems and long-term obesity. Health literacy programs can help ensure that children and families are following medical guidance and understand why such guidance is important. An 

 examines whether using a health literacy approach can help reduce overweight and obesity in very young children.

The investigators ran a cluster-randomized trial. The sites participating in the trial were randomly assigned to either be a control site or use the Greenlight Intervention. At the sites, infant-caregiver pairs were enrolled at the 2-month well-child visit. The caregiver had to speak either English or Spanish and the child had to have a birth weight of ≥1500 g. The intervention provided each parent a toolkit at every well-child visit and the providers were given training in communicating clearly with patients and family. Primary outcome of the study was the proportion of children overweight (body mass index [BMI] ≥85th percentile) at age 24 months and the secondary outcomes were weight status (BMI z score).

A total of 868 pairs were enrolled with 459 in the intervention arm and 406 in the enrolled arm. Forty-nine percent of the children were overweight at 24 months of age. The adjusted odds for being overweight at 24 months (treatment vs control) was 1.02 (95% CI: 0.63 to 1.64). When looking at the BMI z score, the adjusted average score differences (treatment minus control) were −0.04 (95% CI: −0.07 to −0.01), −0.09 (95% CI: −0.14 to −0.03), −0.19 (−0.33 to −0.05), −0.20 (−0.36 to −0.03), −0.16 (95% CI: −0.34 to 0.01), and 0.00 (95% CI −0.21 to 0.21) at 4, 6, 12, 15, 18, and 24 months, respectively.

Investigators concluded that using the intervention resulted in less weight gain in children through age 18 months, however, that effect was not sustained through 24 months of age. They noted that using greater intervention intensity may be required to keep the early positive effects seen with the clinic-based intervention.

1. Sanders L, Perrin E, Yin H. A health-literacy intervention for early childhood obesity prevention: a cluster-randomized controlled trial. Pediatrics. April 28, 2021. Epub ahead of print. doi:10.1542/peds.2020-049866

Becoming overweight at a young age can lead to long-term obesity and represents an important challenge to tackle in childhood. An investigation looks at the impact of a health literacy intervention on reducing overweight children.

Using a health literacy approach with childhood obesity

Oral corticosteroids are a common treatment for inflammatory bowel disease and asthma. However, long-term use of them has been linked to a number of adverse outcomes such as infections, glaucoma, and hyperglycemia. To avoid those outcomes, some clinicians have started using them in corticosteroid bursts, which is defined as using them for 14 days or fewer. A 

 looks at whether there are other potential harms because of such bursts.

Investigators used data from the National Health Insurance Research Database in Taiwan from January 2013 and December 2017. They included patients aged 18 years and younger. Incidence rates for 4 types of severe adverse events: gastrointestinal bleeding, sepsis, pneumonia, and glaucoma were calculated for both patients who received and did not receive corticosteroid bursts.

A total of 4,542,623 children were included in the study of which 23% had been prescribed a single corticosteroid bursts. The most common reasons for being prescribed a single corticosteroid burst were allergic diseases and acute respiratory tract infections. The incidence rate differences per 1000 person-years between children who received a single corticosteroid burst and those who did not were 9.35 (95% CI, 9.19-9.51) for pneumonia, 0.01 (95% CI, 0.01-0.03), 0.60 (95% CI, 0.55-0.64) for gastrointestinal bleeding, and 0.03 (95% CI, 0.02-0.05) for sepsis. The incidence rate ratios (IRRs) within 5 to 30 days after the burst were 2.19 (95% CI, 2.13-2.25) for pneumonia, 0.98 (95% CI, 0.85-1.13) for glaucoma, 2.02 (95% CI, 1.55-2.64) for sepsis, and 1.41 (95% CI, 1.27-1.57) for gastrointestinal bleeding. In the 31 to 90 days after administration, the IRRs were 1.08 (95% CI, 0.88-1.32) for sepsis, 1.09 (95% CI, 1.07-1.11) for pneumonia, 1.10 (95% CI, 1.02-1.19) for gastrointestinal bleeding, and 0.95 (95% CI, 0.85-1.06) for glaucoma.

The investigators concluded that corticosteroid bursts are linked to a 1.4-to 2.2-fold increased risk of sepsis, pneumonia, and gastrointestinal bleeding in the first month after starting corticosteroid. However, this increased risk is lessened in the subsequent 31 to 90 days. When considering using oral corticosteroid bursts, clinicians should consider the risks.

1. Yao T, Wang J, Chang S, et al. Association of oral corticosteroid bursts with severe adverse events in children. 

. April 19, 2021. Epub ahead of print. doi:10.1001/jamapediatrics.2021.0433

Oral corticosteroids are commonly prescribed, but long-term use can lead to certain adverse outcomes. A new study takes a look at whether using a corticosteroid burst could mitigate those risks.

Are oral corticosteroid bursts linked to adverse events?

With temperatures on the rise and the desire to be outdoors increasing, the question about what’s needed to keep safe remains. To provide some answers the Centers for Disease Control and Prevention has

 for fully vaccinated people, which includes a number of changes for when wearing a mask is advised.

Regardless of vaccination status, masks are no longer needed for walks, runs, and bikes outdoors with members of the household or when attending a small outdoor gathering where all other guests are fully vaccinated. For unvaccinated people, masks are still recommended for small outdoor gatherings with a mix of vaccination statuses, although the events are seen as safe with mask wearing. Other outdoor activities are less safe and still require mask wearing for unvaccinated people. For those who are fully vaccinated, only attending a crowded outdoor event such as sports events or concerts require a mask. Additionally, all indoor activities have been deemed as mostly safe for fully vaccinated people as long as a mask is worn.

In addition to being able to have small indoor gatherings without masks or social distancing with other fully vaccinated individuals, people can also now:

Go back to domestic travel, without needing to test before and after travel as well as self-quarantine after returning

Travel internationally without testing beforehand, unless the destination requires it, and do not need to self-quarantine upon return

1. Center for Disease Control and Prevention. Interim public health recommendations for fully vaccinated people. Updated April 27, 2021. Accessed April 27, 2021.

 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html

The Centers for Disease Control and Prevention (CDC) has updated their interim guidance for fully vaccinated people, which includes a major change in mask requirements for the outdoors.