Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

Opioid misuse is a problem of epidemic proportion across the United States. Although significant efforts have been made in recent years to curb opioid prescribing in adult patients, similar efforts have been lacking in the pediatric population. A new report offers guidelines on how to tackle this problem.

, a multidisciplinary team of health care experts on opioid stewardship presented what is believed to be the first-ever set of guidelines on pediatric opioid use for postoperative pain management.

 The goal of the report was to review data on opioid use and risks in pediatric populations, and develop evidence-based opioid prescribing guidelines for children who need surgery.

Lead author of the report, Lorraine Kelley-Quon, MD, pediatric surgeon at Children’s Hospital Los Angeles in California, said pediatricians should encourage families to ask surgical teams about pain management both before and after any surgeries. They need to know what to expect, and how to treat pain effectively and safely.

“If a pediatrician is concerned about managing pain for a child that just had surgery, he or she should communicate both with the child’s surgical team and the family if there are concerns or questions,” Kelly-Quon said.

Historically, there have been previous guidelines for opioid prescribing in adults following surgery but no guidelines targeting the unique needs of children and families, she added.

Clinicians who care for children after surgery should be aware of the risks of using opioids in this population for pain management, and work to maximize non-opioid pain management strategies and educate families about these options. The expert panel that created the guidelines identified frequent opioid misuse in the adolescent population—especially when non-opioid options were found to be as effective.

In drafting the report, the team reviewed data from 1988 to 2019 and drafted 20 guidelines over a course of a 2-day summit. Misuse of opioids in the adolescent years is associated with opioid abuse problems later in life, as well as other high-risk behaviors. Extra opioids exist most often in a teenager’s home after surgery, the report notes, and new and ongoing use of opioids occurs in about 20% of children after surgery.

Many health care institutions have drafted opioid prescribing guidelines for adults in an effort to stem the ongoing opioid epidemic, yet similar guidance has been lacking for children. In developing this first-ever evidence-based opioid guideline for children, the panel sought to answer the following questions:

What are the risks of opioid use and possible long-term use of these medications in pediatric populations?

What are some non-opioid options for pain management?

What education should be provided to patients and families in regard to pain management after surgery?

The recommendations that were made based on these questions generally center on opioid avoidance in favor of non-opioid pain management, and dedicated education on managing pain for patients and families.

The guideline notes that a significant number of teenagers with access to opioids misuse them, and for many, access begins with a valid prescription. This misuse often is associated with a higher rate of heroin abuse and long-term opioid dependence, the report revealed. Teenagers who receive an opioid prescription have high rates of diverting these medications, as well, and are likely to receive additional opioid prescriptions in the years following initial use.

Clinicians have to be aware of these risks, the panel notes, and work to develop postoperative pain management regiments that control pain and also practice good opioid stewardship. In some cases, opioid-free recovery is feasible, according to the panel. Opioid-free recovery is recommended or possible for the following procedures:

If pain management after discharge is needed, non-opioid options should be the first-line choice, the panel recommends.

Ketorolac was one of the most studied opioid alternatives, according to the study, and was shown to be very effective in both perioperative and postoperative pain management. Intravenous acetaminophen is another option offered in the report, as well as dexamethasone. A number of studies cited in the report also suggested that combining some of these alternatives may help as well. Appropriate anesthesia during procedures, including nerve blocks and regional anesthesia, also help to reduce opioid use, the panel suggests.

Two alternatives that weren’t as favored were the use of codeine and tramadol in children aged younger than 18 years. Multiple warnings have been issued about the use of these medications in the pediatric population by the US Food and Drug Administration, particularly in terms of respiratory complications.

In terms of education, the report suggests that frequent education—both perioperatively and post-operatively—about pain and pain management is important for clinicians to offer to both patients and their families. This education should be specific to the situation and diagnosis of the patient, and a consistent message must be repeated throughout the care process from all team members to have the best impact. In this regard, the panel suggests that institutions work to create a consistent message to be shared across locations. When opioids must be prescribed, education should focus on safe storage and disposal of medications, as well as the possibility and seriousness of adverse effects that can occur with opioid use. The panel even recommends that health care centers may want to consider offering opioid disposal resources, as 30% of caregivers admitted to keeping excess opioids in the home because they didn’t get around to disposing of them, and 16% didn’t know where to take them.

“It is our hope that these guidelines will be used by health care providers to highlight the risks inherent in using prescription opioids; advocate for the use of non-opioid alternatives to minimize or eliminate the need for opioids; and that families will be engaged in education about appropriate use, storage, and disposal of opioids,” said Kelly-Quon.

1. Kelley-Quon L, Kirkpatrick M, Ricca R, et al. Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. 

. November 11, 2020. Epub ahead of print. doi:10.1001/jamasurg.2020.5045

Articles

Non-opioid pain management recommended in pediatrics when possible, according to new guideline.

Expert panel warns against post-op opioid use in pediatrics

Multiple studies have examined the relationship between socioeconomic status and diet quality in children, but a new study took a closer look at diet quality and how it relates to obesity risk in children from low-income and racially diverse backgrounds.

 published by the National Institutes of Health earlier this year revealed that although diets of children in the United States have improved somewhat overall, diet quality among kids in general still remains poor. Older children have the worst diets, according to the report, and household income and parental education levels play a big role in diet quality. Consumption of sugar-sweetened beverages declined over the study period, from 1999 to 2016, but sodium increased, significantly exceeding guidelines. This is in large part believed to be due to increased consumption of processed foods and foods not cooked at home.

Journal of Pediatric Gastroenterology and Nutrition

 investigated diet quality in two-year-olds from racially and ethnically diverse backgrounds using the Healthy Eating Index as a benchmark.

The research team assessed diet quality of toddlers aged 2 to 3 years across 4 clinics using a 24-hour recall of the foods they ate according to their caregivers. Most of the participants in the study were hispanic and non-hispanic Black, and from low-income areas. The research team found that hispanic children, and those with parents who were not obese, aged older than 35 years, and born outside the United States had the highest Healthy Eating Scores.

The research team also notes that even in children with higher diet scores, few achieved their best possible scores when it came to certain foods. In fact, only 13% met goals in terms of whole grain consumption, 10% met vegetable goals, and only 7% achieved maximum scores for fatty acid ratio consumption.

The study concluded that even when toddlers in diverse and low-income groups met recommendations for some food categories—like fruit, dairy, and proteins—there is still a lot lacking nutritionally when it comes to overall diet quality in low-income toddlers.

1. Kay M, Silver H, Yin S, et al. Assessing diet quality in a racially and ethnically diverse cohort of low-income toddlers. 

. 2020;71(5):679-685. doi:10.1097/MPG.0000000000002871

The quality of diets in children is improving, but especially in low-income and racially diverse groups, there is still a long way to go in meeting nutritional recommendations.

Toddler diet quality is improving, but has far to go

Product placement in children’s television has been regulated for some time in an attempt to shield children from masked efforts to influence their choices. Social media has proven to be a bit of like the Wild West when it comes to marketing to children, however, especially when it comes to using other children to market to this vulnerable group.

 examines the role of kid influencers in social media marketing through a study and commentary.

In the commentary, Yolanda N Evans, MD, MPH, assistant professor of pediatrics at the University of Washington and Seattle Children’s Hospital, and a member of the American Academy of Pediatrics’ Council on Communications and Media, offers perspective on the scope of the problem kid influencers have created, and what clinicians can do to help.

“As pediatricians, we should ask about social media usage and viewing starting at young ages,” Evans says. “When we have conversations with parents and children, we should use the opportunity to help teach them to be informed consumers of media and learn to recognize advertising and messaging—even when subtle.”

Subtle is the key when it comes to social media marketing. It’s so effective as a tool because it can be difficult to recognize—even for parents.

“Parents should be aware of what children are viewing online,” Evans says. “They can also learn about how advertising online can be subtle and might not be recognized. For example, if a favorite social media influencer is shown eating a food with the logo visible, that could be a paid advertisement and not just the influencer eating a random meal.”

Food and beverage companies spend almost $2 billion per year on marketing efforts targeted to children, and internet-based marketing has drastically increased over the years and regulations on product placement on children’s television programs have become more strict.

Food advertising is believed to be a major contributor to children’s diet choices, and exposure to video streaming content on mobile devices has become a huge issue. Unlike television, one tool that social media has used is influencers, or online celebrities with large fan bases that are paid to endorse certain products in their videos. These “everyday people” are perceived by viewers as more relatable and trustworthy than when mainstream celebrities endorse products, the report notes. For these reasons, the prevalence of kid influencers is on the rise. In 2018 and 2019, an 8-year-old was the highest paid YouTube influencer, earning $26 million from advertisements on video posts.

These types of advertisements shape product preference in several ways, according to the report. One is through “pester power,” where children ask for certain brands or products. “Pester power” is believed to generate $190 billion in sales each year, the study reveals. Additionally, children aren’t easily able to distinguish advertising from content, and the way social media intersperses the 2 exacerbates the effect of these ads. Finally, although parents may be hesitant to allow free viewing of social media, they can be influenced by the popularity and “likes” of some content, and develop their own feelings of trust with the “every day” nature of influencers.

There has been little research on the effect of social media influencers and food purchases. This study sought to examine the frequency of product placement in top social media videos, and the nutritional quality of those items.

“Pediatricians can take many steps. Most are already aligned with the anticipatory guidance we offer routinely,” she says.

 investigated how often kid influencers promote different food and drink brands, and how healthy these brands are. Researchers used social media tracking tools to find the top 5 kid influencers on YouTube for 2019, and then reviewed the 50 most-watched posts by those personalities. What brands were featured, how long and often they were featured, and the nutritional quality of the featured products were all assessed in the study.

Kid influencers generated 48.2 billion views and 38.6 million subscribers across more than 10,000 videos posted to YouTube, according to the study. Each video featured a family with two or three children engaging in fun family activities. Almost half of the videos featured certain foods or drinks that appeared a total of 291 times in 179 videos. These 179 videos generated more than one billion views and almost 3 million likes on YouTube, the report notes. Most of the items featured in these videos were unhealthy, such as fast food or candies, the research team adds. This resulted in millions of children influenced by these social media posts, creating unhealthy impressions for viewers through product placement. Product placement has been regulated in children’s television program since the 1990s, but this report shows that maybe the time has come to extend that regulation to internet content.

The study concludes that kid influencers essentially provide marketers with targeted access to both parents and children. As this marketing channel grows, there is a huge potential to increase children’s exposure to unhealthy products, the study suggests. Even if disclosures are required about product placement, children are unlikely to recognize these in the posts. Enforcement of current regulations aimed at protecting kids from this type of marketing aren’t consistently enforced online. The research team suggests that parents work harder to limit screen time—especially on social media channels—and push for better regulation on product placement and marketing disguised as entertainment on social media.

 on social media marketing to children that was also published in 

, Evans says health care providers have to step up when it comes to warning parents about the allure of marketing to children on social media and advocate for more regulation. Pediatricians can also use their position as experts to generate their own content promoting healthier practices to counter this kind of marketing, she suggests.

Evans says pediatricians should help make parents aware of how important they are in their child’s behavior. Some specific advice she offers for guidance includes:

Encouraging parents to view media content with their children.

Having conversations about what children are seeing online. “Ask yourself and your children open questions about the media influencers and their behavior such as ‘why did they choose that product, brand, or logo? Why do you think they were eating that brand of food instead of something else?’” Evans suggests.

If a product or brand is recommended online or if a product or brand shows up in your media feed, ask why you think that is.

Discuss changes to behavior or choices that have occurred from viewing content online. Are those changes helpful for the health of the family?

Parents and pediatricians can also help advocate for stronger regulations on marketing to children on social media, similar to what was done with children’s television.

“My hope is that pediatricians will continue to help parents advocate for their children,” Evans says. “We have an opportunity to enlighten parents and teach them to be savvy consumers of social media: aware of advertising, algorithms that filter content in an effort to keep us online to view ads, and aware of parents have power to push for stronger regulations and guidelines to prevent marketing of products to very young children.”

1. Alruwaily A, Mangold C, Greene T, et al. Child social media influencers and unhealthy food product placement. Pediatrics. 2020;146(5):e20194057. doi:10.1542/peds.2019-4057

2. Evans Y. One-sided social media relationships and the impact of advertising on children. 

. 2020;146(5):e2020017533. doi:10.1542/peds.2020-017533

Kid influencers are having a field day on social media when it comes to pushing (mostly unhealthy) products on unsuspecting viewers. Here’s how you can help.

Kid influencers have free reign on social media

The American Academy of Allergy, Asthma, and Immunology (AAAAI) has unveiled 

 on preventing allergies and asthma in children.

 The guidance, updated in September, reviews a number of strategies to prevent, or even delay, the development of several types of allergies.

Food allergies are a big deal in children, who aren’t always able to be choosy when it comes to what they eat. Children can have a difficult time discerning the content of some foods, and parents can’t always be with them. This makes prevention key when it comes to food allergies, which can be triggered by a number of foods like peanuts, cow’s milk, eggs, and more.

Infants who have a sibling or at least 1 parent with an allergic condition are particularly at risk of developing food allergies, especially if they already show symptoms of foods allergies like atopic dermatitis, allergic rhinitis, or asthma.

There are a number of methods that help—and others that don’t—that were reviewed in the guidance.

FALSE—Food avoidance. Food avoidance is one method to prevent the development of food allergies. Mothers may restrict their diets during pregnancy or breastfeeding in an attempt to prevent the development of food allergies, but AAAAI says these strategies are not recommended. There are not data to support avoidance of highly allergenic foods during pregnancy or during breastfeeding to prevent allergy development, the guidance notes.

TRUE—Breastfeeding. Breastfeeding is seen as the best way to feed an infant, AAAAI notes, because breast milk is easy to digest and is the least likely to trigger allergic reactions. Studies show breastfeeding in the first 4 to 6 months of life can also help to reduce prevalence of early eczema, wheezing, and cow’s milk allergies, the guidance notes.

TRUE—Careful Introduction. Introducing solid foods gradually to monitor for any allergic reactions is a good strategy, but allergenic foods shouldn’t be avoided, either. The AAAAI supports the gradual introduction of egg, dairy, tree nuts, peanuts, fish, and shellfish in the first 4 to 6 months of solid food introduction, after other less allergenic foods have been attempted.

There are a number of environmental factors that can trigger allergies, too. However, unlike foods, early contact with environmental allergens can make allergies worse. Research is the most robust when it comes to dust mites, according to AAAAI, which suggests working to control dust mites early to prevent allergy problems. Some solutions to control environmental allergens recommended in the guidance include:

using zippered covers on pillows and mattresses that are made to control allergens

remove upholstered furniture and carpeting from infant bedrooms, if possible

avoid exposing children to secondhand tobacco smoke.

Pet are different, though, according to AAAAI, with recent research suggesting that early exposure to pets can actually help protect children from developing allergies.

The AAAAI also offered guidance on when to get help and where. If possible, the organization recommends finding an allergist specifically, as they have received specialized training in allergy and immunology. Allergy testing by a specialist can give detailed information about an allergy, and the best methods for treatment, according to AAAAI. On the other hand, AAAAI recommends against massive allergy screening tests done in retail sites, applied kinesiology, or testing through muscle relaxation, cytotoxicity testing, skit titration, provocative and neutralization testing, or sublingual provocation.

Kari Christine Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics and director of the Sean N. Parker Center for Allergy and Asthma Research at Stanford University in Palo Alto, California says it’s important that advice be given on science and epidemiological studies. In terms of allergy prevention, research studies show that a diversification of diets with a variety of proteins from different food sources introduced all at once—rather than staged as suggested by AAAAI—can decrease the risk of allergy and asthma development.

There are a number of other tips she offers for allergy prevention, including:

Nadeau also makes it clear that vaccination avoidance is not a prevention strategy for allergens, and that allergy prevention can begin at any age.

1. American Academy of Allergy, Asthma & Immunology. Prevention of allergies and asthma in children. Reviewed September 28, 2020. Accessed December 2, 2020. 

https://www.aaaai.org/conditions-and-treatments/library/allergy-library/prevention-of-allergies-and-asthma-in-children

Guidance offers insight on allergy prevention strategies.

Rachael Zimlich, RN, BSN

Articles

Expert panel warns against post-op opioid use in pediatrics

Toddler diet quality is improving, but has far to go

Kid influencers have free reign on social media

Allergy experts weigh in on prevention strategies