Lois Levine

Asthma. Allergies. Eczema. Type 2 diabetes. All these disease states can be exacerbated or caused by climate change. “I have pediatricians coming to me saying, ‘I am already seeing children under 2 years old pre-polluted,” began Nathaniel DeNicola, MD, MSHP, from the American College of Obstetricians and Gynecologists, Johns Hopkins Medicine, Washington, DC, at the 2022 American College of Obstetricians and Gynecologists Annual Clinical & Scientific Meeting on a session titled, “Trading spaces: how pediatrics, emergency medicine, and medical society leadership are treating the climate crisis.” DeNicola was joined by Emily Sbiroli, MD, emergency medicine physician, national physician fellow in Climate and Health at the University of Colorado, San Diego, California; Vi Nguyen, MD, AAP California State Government Affairs Expert Committee on Environmental Health and Climate Change, in San Diego; and Colin Nackerman, MD, Associate Director of Policy & Operations, Medical Society Consortium on Climate and Health, San Diego, who all shared their insights as to how climate change affects vulnerable populations such as pregnant women and children. Sbiroli spoke of her experiences treating patients with respiratory exacerbations from heat waves and wildfires, wildfires, that, Nackerman added, “used to be just a few months long and now can be all year long in California.” Nguyen added, “the health effects linked to climate change are profound. I see kids with asthma struggling from air pollution; eczema and allergies from hurricanes and pollen; type 2 diabetes [which can be triggered from temperature changes]; even early puberty. I think nearly every pediatric condition has a link to climate.”

Amidst all the doom and gloom, however, are several silver linings for health care providers. “As doctors, you are the ultimate influencers. It’s about trust equity, and if your patients trust you, they will believe you, so talk to them about this,” urged Nguyen.

But what exactly do you say? DeNicola suggested easy ways to weave how climate conditions affect health into conversations with patients. “Ask them, do you exercise? Do you exercise outdoors? The heat index is very high today, it might not be a good day for that.” 

Additionally, in this "car-centric culture of California," as Nguyen noted, "talk to patients about walking or biking instead of driving somewhere," which is clearly a win-win: protect the environment and keep yourself moving as well.

Other questions: ask patients about their nutrition, and educate them on why, for example, they should avoid eating large fish, because of heavy metals fish have ingested at sea, (a sobering example of how polluted our seas have become). Endocrine disruptors like plastic can also be discussed, with advice, especially during pregnancy, to choose other containers. “I also ask about home environments,” DeNicola added. “Heavy metals are present in dust particles, so frequent cleanings and vacuuming is important.”

What else can health care providers do to address these environmental issues? Suggestions included asking hospitals to decarbonize; getting involved with advocacy groups like Health Care Without Harm; and supporting the Protecting Moms and Babies Against Climate Change Act, a federal bill which establishes grants and directs other activities to address health risks associated with climate change, particularly for members of racial and ethnic minority groups, pregnant or postpartum individuals, and children younger than age 3.

“Climate change is one of the biggest public health crises of our time,” said Nackerman. “We all have the power to amplify and advocate for climate change solutions.”

DeNicola N, Nguyen V, Sbiroli E, Nackerman C. Trading spaces: how pediatrics, emergency medicine, and medical society leadership are treating the climate crisis. 2022 American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting. May 7, 2022. San Diego, California.



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At the 2022 American College of Obstetricians and Gynecologists Annual Clinical & Scientific Meeting, 4 health care professionals spoke of disease states in both women and children caused by climate change, and what HCPs can do to mitigate this crisis.

How climate change is making your patients sick, and what you can do about it.

With existing guidelines from the American Academy of Pediatrics and the Society for Developmental and Behavioral Pediatrics recommending behavioral therapy (BT) as a first-line treatment for preschool-age children with attention-deficit/hyperactivity disorder (ADHD), Shruti Mittal, MD, FAAP, assistant professor and developmental and behavioral pediatrician at Levine Children’s Hospital in Matthews, North Carolina, set out to present the frequency of, and factors associated with, physician-documented receipt of BT in preschool-age children with ADHD. “To our knowledge, no studies have examined this receipt of BT from physicians, prior to medication initiation,” she explained. There is also limited research with provided details about specific types of behavioral therapy received in these children.

The DBPnet (Developmental Behavioral Pediatrics Research Network) study included a review of 497 manual charts of children aged less than 6 years who were seen by a developmental-behavioral pediatrician at 7 different sites, and were started on an alpha 2 agonist or stimulant. Most (82.9%) also had coexisting conditions, such as autism spectrum disorder or disruptive behavioral disorder. Of the group, the number of children documented to have received any BT was low (45% did; the majority of children, 55% did not). Receipt of BT varied across sites, as did coexisting conditions, and although published guidelines do specify the need for evidence-based behavior interventions, the receipt of parent training in behavior management and applied behavioral analysis was low.

“Given the significant variability in receipt of BT…further research is needed to identify factors that improve BT access and delivery,” observed Mittal. Additionally, more research is needed on availability of therapy in each state, as well as insurance reimbursement for specific types of behavioral therapy, which may be a factor in why the majority of preschoolers with ADHD are not getting BT.

Reference
Mittal S, Bax A, Blum NJ, et al. Receipt of behavioral therapy in preschool-age children with ADHD initiated on medications: a DBPNet study. Pediatric Academic Societies 2022; April 24, 2022. Denver, Colorado.

At the 2022 Pediatric Academic Societies meeting, Shruti Mittal, MD, FAAP,  looked at how many children with attention-deficit/hyperactivity disorder get started on behavioral therapy before medication in the preschool years.

Do preschool children with ADHD get the behavioral therapy they need?

Adolescents have been experimenting with marijuana for more than 50 years now, and considered the most used federal illegal drug, with some 18% of Americans using it at least once in 2019. With 37 states having legalized it for medicinal use and 18 states legalizing cannabis for recreational use, no doubt more studies will start to look at what this means in terms of affecting adolescents abuse of the drug.

For now, though, Samuel Akaakole Mensah of Tarkwa Municipal Hospital in Ghana, shared highlights showing that, between 2008 and 2019, 18 states reported an increase in hospitalizations for cannabis use disorder (CUD). “The findings of this study can help policy makers, administrators, and clinicians in the formulation of policies and provision of resources to help identify and provide interventions for CUD in the patient setting,” began Mensah. 

The term cannabis use disorder was introduced in 2013 in the 

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

, and defined as a substance use disorder characterized by a problematic pattern of marijuana use that leads to clinical significant impairment or distress. Mensah’s study took a cross-sectional analysis of pediatric hospitalizations of adolescents and young adults aged 11 to 20 years within the Kids Inpatient Database (KID), pulling data from 2009, 2012, 2016, and 2019.

Out of 5.57 millions pediatric hospitalizations in this age group, 292,816 were associated with CUD from 2009 to 2019. Hospitalizations for CUD steadily increased during this time period: in 2009, there were a little under 40 per 1000 hospitalizations; by 2019, that number was 90 per 1000. The overwhelming majority of these patients were male (almost 85 males per 1000 hospitalizations, as opposed to 37 per 1000 of females). White and Black CUD patients were roughly the same, about 60 per 1000 for both, and, of the 4 hospital regions, most patients with CUD came from the Northeast (62.5 per 1000) and Midwest (68.9) as opposed to the South (40.8) and the West (49.2).

Mensah and the other investigators concluded that there was a significant increase in CUD among pediatric hospitalizations in adolescents and young adults aged 11 to 21 years. Concluded Mensah, “the implications of these findings on the medical and mental health of children and society at large require further investigation.”

Reference
Mensah SA. Trends in cannabis use disorder among pediatric hospitalizations in the United States, 2009-2019. PAS 2022. April 24, 2022. Denver, Colorado.

At the 2022 Pediatric Academic Societies meeting, Samuel Akaakole Mensah shared results of a 10-year study on pediatric hospitalization trends for cannabis use disorder.


Should pediatricians be concerned about increasing rates of cannabis use disorder?

As patient review websites are being increasingly used by patients and caregivers, and have been shown to influence patient selection and providers, Skylar M. Hess, a medical student at the Icahn School of Medicine at Mount Sinai in New York City shared an AI study of a physician review website, which is, “to our knowledge, the first study utilizing machine learning to quantitatively analyze online reviews of pediatricians,” observed Hess.

The researchers used healthgrades.com to search out pediatrician profiles, as that site was one of the first medical reviewer websites, and remains one of most popular. Nearly 5700 pediatrician reviews were selected.

The top 3 most-used words for positively reviewing a caregiver were “care,” “love,” and “kind,” while the top 3 negative words were “rude,” 

 “care,” and “unprofessional.” Other positive words included “comfortable” and “knowledgeable,” and additional negative words were “pain” and “wait.” Because the mechanism of the study did not search for words within context, researchers could only hypothesize on why, for example, the word “care” was used both positively and negatively, such as “lots of care,” or “really care,” vs “doesn’t care” or “indifferent care,” noted Hess. (Other words, such as “pain” also showed up on both positive and negative reviews.)

These results can provide insights to pediatricians for what families and caregivers prioritize when it comes to receiving health care for their children and adolescents. 

Reference
Hess S, Cho S, Kim J. What makes a 5-star pediatrician? A sentiment analysis of online physician reviews. PAS 2022. April 23, 2022. Denver, Colorado.

At the 2022 Pediatric Academic Societies Meeting, Skylar M. Hess shared the key words and phrases that patients used in raving (or ranting) about their pediatricians.

Are you a 5-star pediatrician?

It is certainly no surprise to anyone that virtually all adolescents (97%) in the United States report use of social media. Of that group, over 60% report that they regularly use TikTok, and do so because of 2 significant features; they can easily scroll between the short videos (less than 1 minute); and the platform has a significantly large adolescent presence. Bradley Kerr, MS, a researcher at the University of Wisconsin School of Medicine and Public Health and part of the school’s Social Media and Adolescent Health Research Team (SMAHRT), shared some insights he and his collaborators gleaned, on both mental health benefits and risks for teenagers who use TikTok regularly.

To do so, SMAHRT created a focus group study using Zoom, with data collected in October and November 2021. Questions included:

--How is TikTok different from other social media platforms?

--What are the benefits of TikTok use, compared to other platforms?

--What parts of TikTok may be risky or bad for adolescents’ health?

--Do people your age ever appear to find TikTok “addicting” compared to other platforms?

Kerr then offered up a mélange of responses from the study. For example, one adolescent, in responding to risky trends with the platform, said, “There are a whole lot of…trends going around…that could definitely be like kind of pressuring or influential to somebody’s decision of how to behave and act, so they could potentially put them in risky positions.”

Challenges of self-regulating TikTok use were definitive: “You will get sucked in, so you can’t do it in public;” and “the videos are short, and it’s really convenient to use at…whatever time you need.” “I deleted TikTok…I just could not have that in my life…I wasn’t able to connect with my friends over some of the trends because they’re so…quick…that is the only platform that can move at that pace.”

Comparing yourself to your peers is of monumental importance to adolescents, and , in this case, it seems like TikTok can have a negative emotional impact: “there’s just so much content that can just constantly compare and see what you want, what you hate, and see the differences in people;” “I feel like it’s just another thing where we can see other people’s lives and quickly compare ourselves…for better or worse;” and ”with a lot of people you see on TikTok you get the perception…you’re supposed to act like them or look like them, which could bring about a lot of body image issues or self-confidence issues.”

When it came to being used as a support system for mental health issues, adolescents were mixed in their views. One noted a feeling of competition in who seemed “the worst off” emotionally: “A lot of people…normalize or…glorify struggles people have with mental health issues…I feel people kind of long for those issues, like ‘your issues aren’t as severe as mine.’”

The research team concluded that TikTok is a powerful platform for adolescents to connect with peers and interests, but it can have “addicting” qualities and seems to be associated with peer comparison. Supportiveness of TikTok for teenage mental health discussions, however, remain complex.

The brief study should be a catalyst for future studies, which, noted Kerr, should dig deeper into specific TikTok experiences and mental health outcomes; address the frequency and severity of challenges of self-regulating TikTok; and look at associations between TikTok peer comparison and those mental health outcomes. For pediatric health care providers, making social listening a part of your practice could help enrich your understanding of your adolescent patients.

Reference
Kerr B, Minich M, Moreno MA. Adolescent perspectives on mental health benefits and risks associated with TikTok use. PAS 2022. April 23, 2022. Denver, Colorado.

At the 2022 Pediatric Academic Societies meeting, Bradley Kerr, MS shared research on how adolescents really feel about TikTok when it comes to mental health support and peer comparison.



 Adolescents, mental health, and TikTok use

“By the end of this session, I hope to describe the dynamic landscape of the gluten-free diet in the US, understand medical indications for a gluten-free diet, along with the risks and benefits of dietary intervention, and describe the diagnosis and management,” explained Marisa Stahl, MD,MSCS, assistant professor of pediatrics, the Digestive Health Institute at the Colorado Center for Celiac Disease in Aurora, at her session, “The gluten-free epidemic: myths and facts revealed.”

The gluten-free industry, with some $2 billion worth of products on the market, has been growing worldwide, Stahl noted. Gluten-free diets are no longer just for those with celiac disease (CD), either; 2 in 5 people who eat gluten-free do so because they believe it is better for their overall health. Medical indications for going gluten-free include food intolerances, allergy (wheat), and autoimmune disease (CD). As far as other autoimmune diseases, though, says Stahl, “There is little evidence to support a gluten-free diet for other autoimmune diseases.”

While many believe that a gluten-free diet is healthier, pediatric health care providers should share these facts with their patients: gluten-free diets are frequently higher in fat and sugar content; there is a risk of obesity and insulin resistance; and there are vitamin and nutrient deficiencies as a result of inadequate fiber intake.

For a patient who does have CD, however, the gluten-free diet is currently the only available treatment. Symptoms for this condition can be confusing, as they are wide-ranging and nonspecific, and include fatigue, anemia, headaches, brain fog, oral ulcers diarrhea, abdominal pain, and many more. Screening for diagnosis includes a gene or HLA-based screening (often expensive for patients), and the antibody-based screening (more common and less costly). To add to the murkiness of diagnosis, “Not all antibody positive tests mean your patient has CD,” remarks Stahl. “It could be a transient positivity, perhaps potential CD, infection, or a concurrent autoimmune disease.” Endoscopy can help make a solid determination. Besides strict adherence to a gluten-free diet, health care maintenance includes CBC, thyroid and vitamin D checks; gluten-free multivitamins; and vitamin D and iron supplementation when appropriate.

And while there are no other therapies on the market, there are several on the horizon: drugs currently being studied include latiglutenase, which can break down gluten in the stomach; larazotide a zonulin antagonist; and specific nanoparticles which can retrain the immune system.“The perceived burden [for CD] is high, and we need new treatments,” concluded Stahl.

Reference
Stahl M. The gluten-free epidemic: myths and facts revealed. PAS 2022. April 23, 2022. Denver, Colorado.

At the 2022 Pediatric Academic Societies Meeting, Marisa Stahl, MD, MSCS, discussed how to separate the wheat from the chaff when it comes to the gluten epidemic. 