COMMENTARY

What Every Pediatrician Should Know in 2016

Hansa Bhargava, MD

Disclosures

February 16, 2016

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2015 was an exciting year with many interesting studies and innovations. This is also true for pediatrics. Here is my take on the top 5 topics that will change practice in 2016.

Vaccinations

First up, vaccinations. Have you ever dismissed a parent who won't vaccinate a child? As a clinician, I have not, but some doctors have had to. Vaccinations and the measles outbreaks last year were topics that everyone was talking about. In a survey[1] of doctors by researchers at the University of Colorado, 83% reported that a small amount of patients refused vaccines. However, only 21% of pediatricians have ever dismissed a family because of this. Interestingly, more physicians from states without philosophical exemptions were likely to dismiss a family over vaccine refusal.

Vaccine refusal seems to be very common with the HPV vaccine. What may add to this is the physician's hesitancy to talk to patients about vaccines. A study published in Cancer Epidemiology, Biomarkers and Prevention found that almost a quarter of the providers did not strongly recommend the HPV vaccine for patients.[2] This was mirrored in a study published in Pediatrics that also showed that a significant number of doctors are not strongly recommending the HPV vaccine.[3] Doctors reported being uncomfortable speaking about it or being concerned that patients did not value the HPV vaccine.

Side effects have been a concern in Europe, but this was investigated thoroughly by the European Medicines Agency (EMA). They concluded that evidence did not support chronic symptom disorders, such as postural orthostatic tachycardia syndrome (POTS), as side effects.[4] Although the Danes are still investigating this, the Centers for Disease Control and Prevention (CDC) maintains that HPV vaccines have an excellent safety record. Considering the impact that the HPV vaccine has on cervical and other cancers, it makes sense to continue to recommend this vaccine to our patients.

Peanut Allergy

Next up: Is peanut exposure a good move for infants? Eating peanut protein early in infancy was certainly a hot topic last year. The Learning Early about Peanut Allergy (LEAP) Study[5] was a groundbreaking study that was published in the New England Journal of Medicine last year. It showed that in high-risk infants, early consumption of peanut products could decrease the incidence of peanut allergy.

Six hundred and forty infants were randomly assigned to exposure or no exposure to peanut protein, and the mean age was 7.8 months. The consumption group was given regular exposure to the protein for up to 60 months of age. There was a 70%-86% decrease in peanut allergy at 60 months of age. Experts immediately called for a change in guidelines, but parents and patients seemed to move even faster. After tremendous media pickup, many parents came in to the office with a question of when—not if—to expose their infants to peanuts.

In August, the American Academy of Pediatrics (AAP) endorsed this. They recommended that providers should advise introducing peanut-containing foods to high-risk infants at age 4-11 months. Together with a working group from the National Institute of Allergy and Infectious Diseases, they will be looking at recommendations for all infants as well as the doses that should be advised. Hopefully, we will hear guidelines about this soon. Right now, we should be advising only high-risk infants to be exposed to peanut products in infancy.

Prescribing Opioids

The third topic is postoperative pain. Are we overdosing our patients? Addiction seems to be increasing, and the number of deaths from overdose of prescription painkillers has quadrupled in the United States. Are we giving too much morphine for postoperative pain in children? In one study, only 56% of 243 children were administered the morphine as prescribed.[6] In fact, of those who were receiving as-needed prescriptions, most received only two doses or less. It seems that we may need to reevaluate how much morphine we are dispensing. As new data develop, let's continue to monitor what makes sense to keep kids pain-free and safe.

Screen Time

How much screen time should kids really get? Because of the explosion of mobile devices over the past 5 years and the changing landscape of media for kids, the AAP convened a symposium called Growing Up Digital, to which experts from academia, healthcare, and private sectors were invited. A statement was made about media guidelines, advising parents to treat media time as another environment with good and bad effects.

Families were advised to parent around media usage, provide good role models, and look at the quality of content the child is consuming. These were intended to be general guidelines while the policy statements were being revised, but it caused a flurry of interest from the media. Unfortunately, many news organizations interpreted this as backpedaling and the AAP giving a nod to more screen time, which is certainly not correct.

With the Common Sense media survey[7] reporting that teens use media for almost 9 hours each day and tweens use it for almost 6 hours each day, screen time is definitely changing parenting and our advice to families. The AAP is expected to come out with definite new guidelines this year in October.

The Microbiome

Will 2016 be another year of the gut? Several groundbreaking studies have linked the microbiome to disease. The microbiome in the intestines encompasses approximately 500-1500 species and roughly 100 trillion bacteria.[8] It seems that these bacteria may be associated with many health issues, including dysbiosis or alterations in the microbiome. These alterations influence a range of processes, including hepatic function and potential development of fatty liver disease. Also, certain bacteria seem to reduce anxiety-like behavior in mice. In a small study, prebiotics influenced stress levels in human volunteers.[9]

But what was really interesting last year was a study on infants.[10] This study found that probiotic exposure in the first month of life was associated with a 60% decrease in the development of pancreatic beta-cell autoimmunity in some infants. Interestingly, a study from earlier in the year showed findings that may be consistent with this. Antibiotics may be associated with a higher risk for type 1 diabetes.[11]

As research continues in these areas and others, it will be exciting to see what's next and how that new information will continue to change our practice as physicians.

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