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|Wednesday, July 27, 2011
|Are Proton-Pump Inhibitors Effective in Children?
|by Pediatric Perspectives at 11:21 AM
Deborah Cloney, MD, Pediatric Gastroenterologist
I've been getting some questions lately about whether we should be prescribing acid-suppressing drugs like Prilosec (omeprazole) and Prevacid (lansoprazole) for infants with troublesome acid reflux or even for older children and teenagers. The concern stems from a review article published in Pediatrics earlier this year that assessed 12 clinical trials evaluating the effectiveness of proton pump inhibitors (PPIs) for gastroesophageal reflux (GERD) in children. The authors concluded that there wasn't enough evidence to show that the medications effectively treated GERD in infants, although they were more effective at resolving symptoms in children.
In addition, an FDA hearing last year found that the number of prescriptions for PPIs dispensed for children from birth through age 17 between 2002 and 2009 had tripled, from 875,000 to 2.6 million, with similar increases in the number of patients prescribed the drug (332,000 in 2002 to 885,000 in 2009).
The committee was particularly struck by the 11-fold increase in PPI prescriptions for infants under age 1 during the same period, from 37,000 to 403,000, with an eight-fold increase in the number of patients prescribed the drug. That's despite the fact that none of the PPIs are approved for use in that age group. Expect to see more on this as the FDA looks deeper into the issue.
My take on the Pediatrics article is not that the drugs shouldn't be prescribed for children, but that there is just not enough data to establish their efficacy in children-which is the case with a lot of the medications we use. Even when it comes to infants, I still have some babies with reflux in whom a PPI seems to help.
The message? Be judicious (as always) in your use of medications; select patients whose symptoms seem to support a diagnosis of reflux; and set parameters on what your patients and their families should expect with treatment. For instance, we know that children with chronic abdominal pain will experience some reduction in symptoms when they start on medication because of a high placebo response. So when the time comes to take them off the drug, they often resist. Because we don't know what the long-term effects of these acid suppressors are on children, it is best to set expectations up front in terms regarding the length of therapy.
Conversely, if the patient's reflux-like symptoms do not respond to a PPI, it is probably time for a referral to a pediatric gastroenterologist for an endoscopy to see if anything else is going on. For instance, an allergic form of esophagitis can mimic the signs of reflux.
How often do you prescribe PPIs for kids with reflux-like symptoms? What kind of response do you see?
|Monday, July 11, 2011
|Gay Teens: A High-Risk Population
|by Pediatric Perspectives at 07:14 AM
Lisa Lowery, MD, MPH, Adolescent Medicine
Spectrum Health Medical Group
Helen DeVos Children's Hospital
The recent vote to allow gay marriage in New York state brought to mind the challenges that we, as healthcare professionals, face when our young patients have questions about or are struggling with issues related to their own sexual identity.
As an adolescent medicine specialist, dealing with these issues is not uncommon. To encourage patients to share their concerns, it's important to create an environment in which your patients feel comfortable having such conversations. In my office, that means pamphlets and posters that demonstrate our support of our patients regardless of their sexual orientation.
Why does this matter? Because as a primary caregiver part of your job is to ensure the safety of your patients. Yet a recent report from the Centers for Disease Control and Prevention found that gay, lesbian, and bisexual high school students were far more likely to engage in risky behavior such as smoking, drinking alcohol, and carrying guns than straight teens. The study of 156,000 high school students should be a "wake up call for families, schools and communities that we need to do a much better job of supporting these young people" said Howell Wechsler, the director of the CDC's Division of Adolescent and School Health. In an article on the study, Laura McGinnis, of the Trevor Project, said the teens are often driven to such risky behavior because they are "rejected by their families and other support groups."
As clinicians bound by our professional ethics to meet our patients wherever they are in order to provide the best possible care for them-regardless of our personal views on homosexuality. The American Academy of Pediatrics (AAP) issued its first statement on homosexuality and adolescents in 1983, revising it in 1993 and, more recently, in 2004. You can read it here.
It notes that "Health care professionals should provide factual, current, nonjudgmental information in a confidential manner . . . The pediatrician should be attentive to various potential psychosocial difficulties, offer counseling or refer for counseling when necessary and ensure that every sexually active youth receives a thorough medical history, physical examination, immunizations, appropriate laboratory tests, and counseling about sexually transmitted infections (including human immunodeficiency virus infection) and appropriate treatment if necessary."
I try to stay away from gender-specific terms like "boyfriend" or "girlfriend." Allowing the teen to self identify provides you with the opportunity to ask more probing questions as needed. I find that asking if they have a special "friend" can help start the conversation. Another good way to start a conversation is to ask about bullying or if the teen is getting picked on. Also be alert to family issues around the teen's sexuality that could become divisive if not downright dangerous. And keep an eye out for signs of depression and other mood disorders, which are also extremely prevalent in this population.
If you're not comfortable talking about homosexuality with your patients, make sure you can refer patients to other community resources or even to another who can provide such support. This is also a recommendation from the AAP: "Any pediatrician who is unable to care for and counsel nonheterosexual youth should refer these patients to an appropriate colleague."
How do you get your patients to discuss concerns related to their sexual orientation?
Lisa Lowery, MD, MPH is an adolescent medicine specialist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.