While I do not prescribe treatments for ADHD, a recent study (LV Moran et al. NEJM 380: 1128-38) was interesting, indicating that amphetamine use was associated with a greater risk of new-onset psychosis than methylphenidate.
- Amphetamine is used for ADHD treatment in the U.S. but rarely in other developed countries. It releases dopamine four times as much as methylphenidate. “The changes in neurotransmission observed in primary psychosis are more consistent with those induced by amphetamine than methylphenidate”
- Using data from two commercial insurance databases, the authors compared 221,846 patients receiving either amphetamine or methylphenidate. There were 343 episodes of new onset psychosis (defined by diagnosis code and prescription for antipsychotic).
- The risk of psychosis was 0.10% (n=106) in the methylphenidate group compared to 0.21% (n=237) in the amphetamine group. Overall, 1 in 660 patients had new onset psychosis with a greater risk in the patients receiving amphetamine.
My take: Only a prospective study can eliminate confounding variables and determine conclusively whether amphetamine is more likely to increase the risk of psychosis; that said, this study indicates a potential for more risk with amphetamine compared to methylphenidate.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition
A recent study (G Xu et al. JAMA Pediatr 2019; 173: 153-9) uses a nationwide, population-based, cross-sectional survey to provided updated estimates of autism spectrum disorder (ASD) prevalence. The authors include more than 43,000 children (3-17 yrs).
- The weighted prevalence of ever-diagnosed and current ASD was 2.79% and 2.50% respectively
- State-level prevalence varied considerably with ever-diagnosed ASD of 1.54% in Texas to 4.88% in Florida.
- 29.5% of those with current ASD did not receive either behavioral or medication treatment.
My take: This study documents the high rates of ASD in the pediatric population and shows that many are not receiving potentially beneficial treatment.
Also, in the same issue, there are three unrelated commentaries regarding vaccine policy (thanks to Ben Gold for these references):
- New York City Childcare Influenza Mandate (YT Yang, J Colgrove. JAMA Pediatr 2019; 173: 119-20)
- Lessons from California’s Discipline of a Popular Physician for Vaccination Exemptions Without Medical Cause (RD Silverman, YT Yang. JAMA Pediatr 2019; 173: 121-2)
- Requiring Human Papillomavirus Vaccination for School Entry (MJ Bayefsky, LO Gastin. JAMA Pediatr 2019; 173: 123-4)
The first of these commentaries discusses the implications of NYC influenza 2013 mandate for infants/children 6 mo-59 months. After implementation, there was an increase in vaccination rates by 11.4% which dropped back after a legal challenge. The second commentary discusses the California State Board’s discipline of a vaccine skeptic, Dr. ‘Bob’ Sears. The final commentary calls for mandating the HPV vaccine. (Related post: HPV Vaccine Eliminating Cervical Cancer)
View from Ryan Mountain, Joshua Tree National Park
The Georgia Chapter of the American Academy of Pediatrics (AAP) had a recent Board of Directors meeting. There is a core group of pediatricians and pediatric specialists who, in conjunction with the AAP staff, work to improve the health of children. This includes arranging conferences, working with legislators, identifying regulatory issues and promoting best practices. The Board of Directors meeting helps guide the chapter’s work. This year’s meeting covered a lot of ground. Two of the presentations provided information from the composite medical board and ABP certification/MOC.
The first presentation discussed the following:
- -How physicians get into trouble: not completing CME credits, drug use, inappropriate contact with patients. A new issue is not registering for PDMP (prescription drug monitoring program). If a physician is not in compliance, they will be fined $3000 and reported to national database.
- -Issue of lack of physician access in rural areas.
- -High debt of physicians completing medical school and loan repayment programs to encourage physicians to locate in underserved areas.
The second presentation by Anna Kuo and Brad Weselman focused on changes in ABP’s MOC process, including the introduction of MOCA-Peds. The goal of the changes is to make MOC process more relevant in improving practice.
A recent retrospective study (TJ Hwang et al. JAMA Pediatr 2019; 173: 68-74) examined the completion rate of FDA-required pediatric studies. Thanks to Ben Gold for this reference.
Background: In 2003, the Pediatric Research Equity Act (PREA) was signed into law and authorized the FDA to require clinical stuides to assess the safety and efficacy of new drugs and drugs with new indications in pediatric subpopulations. However, the FDA cannot withdraw approval for a drug if a manufacturer fails to comply with PREA. In addition, the authors note that “to our knowledge, to date, no financial penalties or enforcement proceedings have been brought against manufacturers fo noncompliance…and only 31 noncompliance letters have been issued.”
- Between 2007-2014, there were 438 new drugs and/or new indications. 114 were subject to PREA. 84 were new drugs and 30 were new indications.
- 222 studies required pediatric postmarketing clinical studies (in these 114 drugs). Only 75 (33.8%) were completed; rates were lower for efficacy studies (38 of 132 –28.8%) compared to pharmacokinetic studies (19 of 34 –55.9%).
- As a result of the PREA-mandated studies, there was an increase in some pediatric information of drug labels in 41.2% after a median follow-up of 6.8 years, compared with 15.8% at time of approval of these 114 drugs.
The authors note that PREA is responsible for “nearly 80% of pediatric drug studies completed for FDA.” Congress also passed the Best Pharmaceuticals for Children Act which provides a financial incentive to companies if they perform certain pediatric studies.
My take: Pharmaceutical companies, for a multitude of reasons, are not completing requied pediatric studies.
I recently downloaded a free Genetics App called Face2Gene. My colleague Jeffery Lewis told me about this app. This App helps identify specific genetic syndromes based on facial appearance. In the first few weeks, a few syndromes that were identified included the following & this was based on very limited usage:
- Williams Syndrome
A recent study (N Engl J Med 2018; 379:1991-2001) showed that
Link to abstract: AR101 Oral Immunotherapy for Peanut Allergy
Methods: Participants with an allergic response were randomly assigned, in a 3:1 ratio, to receive AR101 (a peanut-derived investigational biologic oral immunotherapy drug) or placebo in an escalating-dose program.
Conclusions: In this phase 3 trial of oral immunotherapy in children and adolescents who were highly allergic to peanut, treatment with AR101 resulted in higher doses of peanut protein that could be ingested without dose-limiting symptoms and in lower symptom severity during peanut exposure at the exit food challenge than placebo.
Related blog posts:
An interesting commentary (KP Quinlan. JAMA Pediatrics; 2018; 172: 714-6) points out the need for better surveillance and prevention efforts for sudden unexpected infant deaths (SUIDs).
- Since the late 1990s, there has NOT been significant improvement in SUID. In 1999, there were 3716 SUIDs compared with 3684 in 2015.
- This rate of SUID is 9 times the rate of deaths to motor vehicle crashes for an 18 year-old driver. The author notes the driving-related fatalities have declined by ~50% for persons younger than 20 years since 2000.
- Promotion of safer sleeping habits is important. Bed sharing raises the SUID risk but is commonly practiced by parents from all backgrounds.
- There is very little publicity of this problem and there is not a systematic surveillance system. . How often do we here about a teenager involved in a crash and how often do we here about an infant with SUID? If there was more awareness of this danger, it is likely that there would be more actions taken
Useful website: Charlieskids.org This website has a book called “Sleep Baby Safe and Snug” which incorporates updated recommendations on safe sleep practices.
Children should sleep in the same room but on a separate surface from their parents for at least the first six months of their lives, and ideally the first year. They say that this can halve the risk of SIDS…You can read the AAP’s full guidance here. These are a few more of the pediatricians’ recommendations:
- Infants under a year old should always sleep lying on their backs. Side sleeping “is not safe and is not advised,” the AAP says.
- Infants should always sleep on a firm surface covered by only a flat sheet. That’s because soft mattresses “could create a pocket … and increase the chance of rebreathing or suffocation if the infant is placed in or rolls over to the prone position.”
- Any other bedding or soft objects, like pillows or stuffed animals, could obstruct a child’s airway and increase the risk of SIDS and suffocation, according to the AAP.
- The pediatricians say breastfeeding reduces the risk of SIDS.
- The same goes for pacifiers at nap time and bedtime, although the doctors say the “mechanism is yet unclear.” They add that “the protective effect is observed even if the pacifier falls out of the infant’s mouth.”
- Smoking – both during pregnancy and around the infant after birth – can increase the risk of SIDS. Alcohol and illicit drugs during pregnancy can also contribute to SIDS, and “parental alcohol and/or illicit drug use in combination with bed-sharing places the infant at particularly high risk of SIDS,” the pediatricians say.