Trends in Prescription Medication Use Among Children and Adolescents—United States, 1999-2014 | Adolescent Medicine | JAMA | JAMA Network
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Table 1.  Prevalence of Prescription Medication Use in Prior 30 Days Among Children and Adolescents Aged 0 to 19 Years: United States, 2011-2014a
Prevalence of Prescription Medication Use in Prior 30 Days Among Children and Adolescents Aged 0 to 19 Years: United States, 2011-2014a
Table 2.  Trends in Prevalence of Use of Any Prescription Medication and 2 or More Prescription Medications in Prior 30 Days, by Sex, Age Group, and Race or Hispanic Origin: Children and Adolescents Aged 0 to 19 Years, United States, 1999-2014a
Trends in Prevalence of Use of Any Prescription Medication and 2 or More Prescription Medications in Prior 30 Days, by Sex, Age Group, and Race or Hispanic Origin: Children and Adolescents Aged 0 to 19 Years, United States, 1999-2014a
Table 3.  Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children and Adolescents Aged 0 to 19 Years, by Therapeutic Class: United States, 1999-2014a
Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children and Adolescents Aged 0 to 19 Years, by Therapeutic Class: United States, 1999-2014a
Table 4.  Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children Aged 0 to 23 Months, by Therapeutic Class: United States, 1999-2014a
Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children Aged 0 to 23 Months, by Therapeutic Class: United States, 1999-2014a
Table 5.  Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children Aged 2 to 5 Years, by Therapeutic Class: United States, 1999-2014a
Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children Aged 2 to 5 Years, by Therapeutic Class: United States, 1999-2014a
Table 6.  Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children Aged 6 to 11 Years, by Therapeutic Class: United States, 1999-2014a
Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Children Aged 6 to 11 Years, by Therapeutic Class: United States, 1999-2014a
Table 7.  Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Adolescents Aged 12 to 19 Years, by Therapeutic Class: United States, 1999-2014a
Trends in Prevalence of Prescription Medication Use in the Prior 30 Days Among Adolescents Aged 12 to 19 Years, by Therapeutic Class: United States, 1999-2014a
1.
Shehab  N, Lovegrove  MC, Geller  AI, Rose  KO, Weidle  NJ, Budnitz  DS.  US emergency department visits for outpatient adverse drug events, 2013-2014.  JAMA. 2016;316(20):2115-2125.PubMedGoogle ScholarCrossref
2.
Johann-Liang  R, Wyeth  J, Chen  M, Cope  JU.  Pediatric drug surveillance and the Food and Drug Administration’s adverse event reporting system: an overview of reports, 2003-2007.  Pharmacoepidemiol Drug Saf. 2009;18(1):24-27.PubMedGoogle ScholarCrossref
3.
Vernacchio  L, Kelly  JP, Kaufman  DW, Mitchell  AA.  Cough and cold medication use by US children, 1999-2006: results from the Slone Survey.  Pediatrics. 2008;122(2):e323-e329.PubMedGoogle ScholarCrossref
4.
Tobias  JD, Green  TP, Coté  CJ; Section on Anesthesiology and Pain Medicine; Committee on Drugs.  Codeine: time to say “no.”  Pediatrics. 2016;138(4):e20162396.PubMedGoogle ScholarCrossref
5.
Youngster  I, Avorn  J, Belleudi  V,  et al.  Antibiotic use in children—a cross-national analysis of 6 countries.  J Pediatr. 2017;182:239-244.PubMedGoogle ScholarCrossref
6.
Vernacchio  L, Kelly  JP, Kaufman  DW, Mitchell  AA.  Medication use among children <12 years of age in the United States: results from the Slone Survey.  Pediatrics. 2009;124(2):446-454.PubMedGoogle ScholarCrossref
7.
Johnson  CL, Dohrmann  SM, Burt  VL, Mohadjer  LK.  National Health and Nutrition Examination Survey: sample design, 2011-2014.  Vital Health Stat 2. 2014;(162):1-33.PubMedGoogle Scholar
8.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). NHANES Response Rates. CDC website. https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx. Accessed July 7, 2017.
9.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). NHANES Data Documentation, Codebook, and Frequencies: Prescription Medications. CDC website. https://wwwn.cdc.gov/Nchs/Nhanes/2013-2014/RXQ_RX_H.htm. Published December 2016. Accessed July 7, 2017.
10.
Tran  AR, Zito  JM, Safer  DJ, Hundley  SD.  National trends in pediatric use of anticonvulsants.  Psychiatr Serv. 2012;63(11):1095-1101.PubMedGoogle ScholarCrossref
11.
Visser  SN, Danielson  ML, Bitsko  RH,  et al.  Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011.  J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.PubMedGoogle ScholarCrossref
12.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). National Health and Nutrition Examination Survey: Questionnaires, Datasets, and Related Documentation. CDC website. https://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Updated October 30, 2015. Accessed July 14, 2017.
13.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). NHANES 1988-2014 Data Documentation: Prescription Medications—Drug Information. CDC website. https://wwwn.cdc.gov/Nchs/Nhanes/1999-2000/RXQ_DRUG.htm. Revised December 2016. Accessed July 7, 2017.
14.
Kit  BK, Simon  AE, Ogden  CL, Akinbami  LJ.  Trends in preventive asthma medication use among children and adolescents, 1988-2008.  Pediatrics. 2012;129(1):62-69.PubMedGoogle ScholarCrossref
15.
Jonas  BS, Gu  Q, Albertorio-Diaz  JR.  Psychotropic medication use among adolescents: United States, 2005-2010.  NCHS Data Brief. 2013;(135):1-8.PubMedGoogle Scholar
16.
Centers for Disease Control and Prevention (CDC). Be Antibiotics Aware: Smart Use, Best Care. CDC website. https://www.cdc.gov/antibiotic-use/. Published 2017. Accessed October 19, 2017.
17.
National Heart, Lung, and Blood Institute (NHLBI). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NHLBI website. https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. Published 2007. Accessed June 27, 2017.
18.
Wolraich  M, Brown  L, Brown  RT,  et al; Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management.  ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.  Pediatrics. 2011;128(5):1007-1022.PubMedGoogle ScholarCrossref
19.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.  Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report.  Pediatrics. 2011;128(suppl 5):S213-S256.PubMedGoogle ScholarCrossref
20.
Centers for Disease Control and Prevention (CDC). CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. CDC website. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Published 2016. Accessed June 27, 2017.
21.
Dowell  D, Haegerich  TM, Chou  R.  CDC guideline for prescribing opioids for chronic pain—United States, 2016.  JAMA. 2016;315(15):1624-1645.PubMedGoogle ScholarCrossref
22.
Korn  EL, Graubard  BI.  Confidence intervals for proportions with small expected number of positive counts estimated from survey data.  Surv Methodol. 1998;24(2):193-201.Google Scholar
23.
R: A Language and Environment for Statistical Computing [computer program]. Vienna, Austria: R Project for Statistical Computing; 2017.
24.
Survey: analysis of complex survey samples. R package version 3.32 [computer program]. Vienna, Austria: R Project for Statistical Computing; 2017.
25.
Frenk  SM, Kit  BK, Lukacs  SL, Hicks  LA, Gu  Q.  Trends in the use of prescription antibiotics: NHANES 1999-2012.  J Antimicrob Chemother. 2016;71(1):251-256.PubMedGoogle ScholarCrossref
26.
Chai  G, Governale  L, McMahon  AW, Trinidad  JP, Staffa  J, Murphy  D.  Trends of outpatient prescription drug utilization in US children, 2002-2010.  Pediatrics. 2012;130(1):23-31.PubMedGoogle ScholarCrossref
27.
Vaz  LE, Kleinman  KP, Raebel  MA,  et al.  Recent trends in outpatient antibiotic use in children.  Pediatrics. 2014;133(3):375-385.PubMedGoogle ScholarCrossref
28.
Centers for Disease Control and Prevention (CDC). Antibiotic use in the United States, 2017: progress and opportunities. CDC website. https://www.cdc.gov/antibiotic-use/stewardship-report/index.html. Published 2017. Accessed April 12, 2018.
29.
Olfson  M, Blanco  C, Liu  SM, Wang  S, Correll  CU.  National trends in the office-based treatment of children, adolescents, and adults with antipsychotics.  Arch Gen Psychiatry. 2012;69(12):1247-1256.PubMedGoogle ScholarCrossref
30.
Olfson  M, King  M, Schoenbaum  M.  Treatment of young people with antipsychotic medications in the United States.  JAMA Psychiatry. 2015;72(9):867-874.PubMedGoogle ScholarCrossref
31.
Akinbami  LJ, Simon  AE, Rossen  LM.  Changing trends in asthma prevalence among children  [published online December 28, 2015].  Pediatrics. doi:10.1542/peds.2015-2354PubMedGoogle Scholar
32.
Sharfstein  JM, North  M, Serwint  JR.  Over the counter but no longer under the radar—pediatric cough and cold medications.  N Engl J Med. 2007;357(23):2321-2324.PubMedGoogle ScholarCrossref
33.
Kantor  ED, Rehm  CD, Haas  JS, Chan  AT, Giovannucci  EL.  Trends in prescription drug use among adults in the United States from 1999-2012.  JAMA. 2015;314(17):1818-1831.PubMedGoogle ScholarCrossref
34.
National Center for Health Statistics.  Health, United States 2016. Hyattsville, MD: National Center for Health Statistics; 2017.
Original Investigation
May 15, 2018

Trends in Prescription Medication Use Among Children and Adolescents—United States, 1999-2014

Author Affiliations
  • 1National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
  • 2Currently with the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
JAMA. 2018;319(19):2009-2020. doi:10.1001/jama.2018.5690
Key Points

Question  What are the trends in use of the most common therapeutic classes of prescription medications among US children and adolescents from 1999 to 2014?

Findings  In this serial cross-sectional study that included 38 277 participants, the overall use of prescription medications in the last 30 days decreased from 24.6% in 1999-2002 to 21.9% in 2011-2014; however, the prevalence of use of asthma medications, attention-deficit/hyperactivity disorder medications, proton pump inhibitors, and contraceptives increased among certain age groups. Use of antibiotics, antihistamines, and upper respiratory combination medications decreased.

Meaning  Between 1999 and 2014 there were divergent patterns in the use of prescription medications among US children and adolescents.

Abstract

Importance  Access to appropriate prescription medications, use of inappropriate or ineffective treatments, and adverse drug events are public health concerns among US children and adolescents.

Objective  To evaluate trends in use of prescription medications among US children and adolescents.

Design, Setting, and Participants  US children and adolescents aged 0 to 19 years in the 1999-2014 National Health and Nutrition Examination Survey (NHANES)—serial cross-sectional, nationally representative surveys of the civilian noninstitutionalized population.

Exposures  Sex, age, race and Hispanic origin, household income and education, insurance status, current health status.

Main Outcomes and Measures  Use of any prescription medications or 2 or more prescription medications taken in the past 30 days; use of medications by therapeutic class; trends in medication use across 4-year periods from 1999-2002 to 2011-2014. Data were collected though in-home interview and direct observation of the prescription container.

Results  Data on prescription medication use were available for 38 277 children and adolescents (mean age, 10 years; 49% girls). Overall, use of any prescription medication in the past 30 days decreased from 24.6% (95% CI, 22.6% to 26.6%) in 1999-2002 to 21.9% (95% CI, 20.3% to 23.6%) in 2011-2014 (β = −0.41 percentage points every 2 years [95% CI, −0.79 to −0.03]; P = .04), but there was no linear trend in the use of 2 or more prescription medications (8.5% [95% CI, 7.6% to 9.4%] in 2011-2014). In 2011-2014, the most commonly used medication classes were asthma medications (6.1% [95% CI, 5.4% to 6.8%]), antibiotics (4.5% [95% CI, 3.7% to 5.5%]), attention-deficit/hyperactivity disorder (ADHD) medications (3.5% [95% CI, 2.9% to 4.2%]), topical agents (eg, dermatologic agents, nasal steroids) (3.5% [95% CI, 3.0% to 4.1%]), and antihistamines (2.0% [95% CI, 1.7% to 2.5%]). There were significant linear trends in 14 of 39 therapeutic classes or subclasses, or in individual medications, with 8 showing increases, including asthma and ADHD medications and contraceptives, and 6 showing decreases, including antibiotics, antihistamines, and upper respiratory combination medications.

Conclusions and Relevance  In this study of US children and adolescents based on a nationally representative survey, estimates of prescription medication use showed an overall decrease in use of any medication from 1999-2014. The prevalence of asthma medication, ADHD medication, and contraceptive use increased among certain age groups, whereas use of antibiotics, antihistamines, and upper respiratory combination medications decreased.

Introduction

Quiz Ref IDMonitoring trends in use of prescription medications among children and adolescents provides insights on several important public health concerns, such as shifting disease burden, changes in access to health care and medicines, increases in the adoption of appropriate therapies, and decreases in use of inappropriate or ineffective treatments. Adverse drug events, particularly involving antibiotics, psychotropics, opioids, and cold and cough medications, are also a concern.1-5 Since the 2009 publication of population-based, age-specific prescription medication trends among US children,6 patterns of use may have changed because of adoption of new clinical practice guidelines, growing concerns about childhood obesity–related health conditions such as diabetes and hypertension, and increased awareness of antibiotic resistance.

This study provides nationally representative estimates and trends in prescription medication use overall and by common therapeutic classes among US children and adolescents from 1999 to 2014.

Methods

The National Health and Nutrition Examination Survey (NHANES) is a nationally representative cross-sectional survey designed to monitor the health and nutritional status of the civilian, noninstitutionalized US population and has been conducted continuously in 2-year cycles since 1999.7 Data from the 2013-2014 cycle are the most recent prescription medication data available. The interview response rate for children and adolescents through age 19 years was 89.2% in 1999-2002 and 80.1% in 2011-2014.8 NHANES participants 18 years or older provided written consent, whereas parental permission was obtained for those younger than 18 years; children and adolescents aged 7 to 17 years also provided documented assent. NHANES was approved by the National Center for Health Statistics research ethics review board.

Quiz Ref IDHome face-to-face interviews were conducted throughout each year. Participants 16 years or older answered questions about prescription medication use themselves; for participants younger than 16 years and those not able to answer questions themselves, a proxy respondent (usually a parent) provided this information. During the interview, survey participants were asked if they had taken any prescription medication in the past 30 days. If “yes,” the interviewer recorded the names of up to 20 prescription medications taken in the last 30 days directly from the medication container (eg, bottle, vial, inhaler, blister pack, paperboard box). If the container was not available, the interviewer recorded the medication name as reported by the participant. In 2013-2014, the interviewer could record the medication name using the participant’s prescription documentation printed at the pharmacy (“printout”) if the medication container was not available. The medication name was matched to the brand or generic name in the Multum Lexicon Plus drug database and converted to the standard drug name.9 Any medications reported that were available only as an over-the-counter product during the 2-year survey cycle were excluded.

The prevalence of use of any prescription medication and 2 or more prescription medications were evaluated for 2011-2012 and 2013-2014 combined, by age group (0-23 months, 2-5 years, 6-11 years, and 12-19 years), sex, race and Hispanic origin, household income to poverty ratio, education level of the household head, insurance status, and current health status, because previous studies have shown different patterns of prescription medication use by these characteristics.6,10,11

Information on race and Hispanic origin were self-reported and categorized as non-Hispanic white, non-Hispanic black, Mexican American, Hispanic (including Mexican American and other Hispanic participants), non-Hispanic Asian, or other (including multiple races). Participants categorized as “other” were included in analyses but were not reported separately. Income to poverty ratio is the ratio of household income to poverty level accounting for inflation and household size and was categorized as less than 1, 1 to less than 2, 2 to less than 3, 3 to less than 4, and 4 or greater (eg, 2 indicates an income 2 times the poverty level). Education level of the household head characterized the socioeconomic status of the household and was categorized as less than a high school degree, high school degree, some college, or college degree or higher. Self-reported insurance status was categorized as insured (including public and private sources) or uninsured.12 Current health status was self-reported12 and categorized as “excellent or very good,” “good,” or “fair or poor.”

Linear trends in use of any prescription medication and 2 or more prescription medications were evaluated from 1999 to 2014 by sex, age group, and race and Hispanic origin. For the trend analysis, race and Hispanic origin was categorized as non-Hispanic white, non-Hispanic black, and Mexican American because surveys from 1999-2006 oversampled Mexican Americans, but not all Hispanics, and non-Hispanic Asians were not oversampled until 2011.

Medications were categorized into therapeutic classes using the Multum Lexicon Plus drug database,13 which provided nested levels of classification. The following additional therapeutic classes were created (eTable in the Supplement): antibiotics (oral only), asthma medications,14 attention-deficit/hyperactivity disorder (ADHD) medications,15 antihypertensive agents, and narcotic-containing analgesics. These classes were added because of their particular relevance to child and adolescent heath, public health priorities, and/or clinical practice guidelines16-21 and were created by either separating certain medications from a broader class (eg, antibiotics were in the same therapeutic class as all other anti-infective agents) or by grouping together medications from different therapeutic classes. Because many medical conditions affect youth at specific ages, use of prescription medication by age group was examined. Individual prescription medications or therapeutic subclasses selected for presentation were reported by at least 10 children or adolescents during at least 2 of the 4-year periods for the age group presented. Prevalence of contraceptive use was estimated in girls only.

Statistical Analysis

Data were aggregated over 4-year periods to provide adequate sample size for estimating small proportions. All analyses used NHANES interview sample weights that adjust for nonresponse, noncoverage, and unequal probabilities of selection; all estimates and 95% CIs were weighted to be nationally representative. Standard errors of prevalences were estimated using Taylor series linearization, and 95% CIs were constructed using the method of Korn and Graubard.22 Trend tests for prevalence of prescription medication use in 2011-2014 across categories of age, education level of the household head, household income, and current health status were performed using linear regression by including these as continuous variables. Differences in prevalence by sex, race and Hispanic origin, and insurance status were evaluated using Pearson χ2 test. Pairwise differences in prevalence by race and Hispanic origin were evaluated using a 2-sided t test. Linear time trends in prevalence were calculated using linear regression models, in which the 2-year NHANES cycle was modeled as a continuous variable. The linear regression estimate for the 2-year cycle (β) can be interpreted as the average percentage point change every 2 years; the 95% CI and P value for this estimate were also calculated. Stated increasing or decreasing linear trends were significant at P < .05 (2-sided).

Trends for a large number of therapeutic classes and individual and prescription medications are presented. No adjustments were made for multiple comparisons, but the magnitude of the trend (β) and 95% CI are presented in addition to the P value to help guide interpretation. Patterns of prescription medication use should be considered in the context of use of related therapeutic classes and among different age groups.

R version 3.4.123 was used for data management, and analyses were performed using the R “survey” package24 to account for the complex sample design.

Results

The sample comprised 38 277 children and adolescents aged 0 to 19 years (mean age, 10 years; 49% girls) over the period 1999-2014, which excluded 21 youths because of missing data on prescription medication use. There were 10 706 study participants in 1999-2002 and 8600 in 2011-2014.

In 2011-2014, 21.9% (95% CI, 20.3% to 23.6%) of children and adolescents took any prescription medication within 30 days before the interview, and 8.5% (95% CI, 7.6% to 9.4%) took 2 or more prescription medications (Table 1). The prevalence of use of both any and 2 or more prescription medications increased with age, from 17.4% (95% CI, 14.9% to 20.1%) and 4.7% (95% CI, 3.6% to 6.0%), respectively, in children aged 0 to 23 months to 25.9% (95% CI, 22.6% to 29.4%) and 10.9% (95% CI, 9.1% to 12.8%), respectively, in adolescents aged 12 to 19 years (Table 1).

Use of any prescription medication was lower among non-Hispanic black (21.1% [95% CI, 18.6% to 23.7%]), Hispanic (16.8% [95% CI, 14.3% to 19.4%]), and non-Hispanic Asian (13.2% [95% CI, 10.5% to 16.2%]) youth compared with non-Hispanic white youth (25.3% [95% CI, 22.6% to 28.2%]) and also was lower among Hispanic and non-Hispanic Asian youth compared with non-Hispanic black youth. Use of 2 or more prescription medications was lower among Hispanic (6.5% [95% CI, 5.2% to 8.1%]) and non-Hispanic Asian (4.7% [95% CI, 3.2% to 6.7%]) youth compared with non-Hispanic white youth (9.5% [95% CI, 8.1% to 11.0%]) and also was lower among non-Hispanic Asian youth compared with non-Hispanic black youth (9.2% [95% CI, 7.6% to 11.0%]).

Insured youth had a higher prevalence of use of any prescription medication (23.1% [95% CI, 21.3% to 24.9%]) and 2 or more prescription medications (9.0% [95% CI, 8.1% to 10.0%]) compared with uninsured youth (9.7% [95% CI, 5.9% to 14.8%] and 2.4% [95% CI, 1.4% to 3.8%], respectively). Prevalence of use of both any prescription medication and 2 or more prescription medications increased with poorer health status, from 18.4% (95% CI, 17.0% to 19.9%) and 5.8% (95% CI, 5.0% to 6.6%), respectively, among youth reporting excellent or very good health to 42.7% (95% CI, 34.4% to 51.3%) and 23.5% (95% CI, 18.3% to 29.5%), respectively, among youth reporting fair or poor health. The prevalence of prescription medication use did not differ by sex, and there were no significant trends by household income or education of the household head.

Overall, use of any prescription medication decreased from 24.6% in 1999-2002 to 21.9% in 2011-2014 (β = −0.41 percentage points every 2 years [95% CI, −0.79 to −0.03]; P = .04), but there was no significant linear trend in the use of 2 or more prescription medications (Table 2). Among children aged 0 to 23 months, use of any prescription medication decreased from 25.5% in 1999-2002 to 17.4% in 2011-2014 (β = −1.14 percentage points every 2 years [95% CI, −1.79 to −0.49]; P < .001) and use of 2 or more prescription medications decreased from 8.3% to 4.7% (β = −0.58 percentage points every 2 years [95% CI, −0.88 to −0.27; P < .001), but there was no significant linear trend for the other age groups. Use of any prescription medication decreased among boys, from 25.7% to 20.6% (β = −0.69 percentage points every 2 years [95% CI, −1.18 to −0.21]; P = .006), and use of 2 or more prescription medication decreased among girls, from 9.3% to 8.1% (β = −0.30 percentage points every 2 years [95% CI, −0.57 to −0.04]; P = .03). Among non-Hispanic black youth, use of any prescription medication increased from 18.1% in 1999-2002 to 21.1% in 2011-2014 (β = 0.52 percentage points every 2 years [95% CI, 0.06 to 0.98]; P = .03) and use of 2 or more prescription medications increased from 6.4% to 9.2% (β = 0.44 percentage points every 2 years [95% CI, 0.12 to 0.76]; P = .009) but showed no significant linear trend for other race and Hispanic origin groups.

From 1999-2000 to 2013-2014, 84% of medication names were recorded from medication containers, and in 2013-2014, 1.2% were recorded from pharmacy printouts. Estimates were calculated for 40 therapeutic classes and subclasses or individual medications (Table 3), or 89.6% of all medications reported. In 1999-2002, the 5 most commonly used prescription medication classes among children and adolescents were antibiotics (8.4%), asthma medications (4.3%), antihistamines (4.3%), topical agents (3.2%), and ADHD medications (2.8%), and in 2011-2014 the 5 most commonly used medication classes were asthma medications (6.1%), antibiotics (4.5%), ADHD medications (3.5%), topical agents (3.5%), and antihistamines (2.0%).

Among children and adolescents aged 0 to 19 years there were significant linear trends from 1999-2002 and 2011-2014 in 14 therapeutic classes or subclasses, or in individual medications, with 6 demonstrating decreases and 8 demonstrating increases (Table 3). Use of ADHD medications increased from 2.8% to 3.5% (β = 0.15 percentage points every 2 years [95% CI, 0.03 to 0.28]; P = .02) with significant increases in use of both centrally acting antiadrenergic agents and amphetamines. Overall antibiotic use decreased from 8.4% to 4.5% (β = −0.62 percentage points every 2 years [95% CI, −0.86 to −0.38]; P < .001) and specifically for cephalosporins, amoxicillin, and amoxicillin/clavulanate. Antihistamine use decreased from 4.3% to 2.0% (β = −0.37 percentage points every 2 years [95% CI, −0.49 to −0.26]; P < .001). Use of asthma medications increased from 4.3% to 6.1% (β = 0.25 percentage points every 2 years [95% CI, 0.11 to 0.40]; P < .001), with significant increases in use of montelukast and inhaled corticosteroids. Contraceptive use among girls increased from 0.9% to 1.8% (β = 0.26 percentage points every 2 years [95% CI, 0.11 to 0.41]; P = .004). Use of proton pump inhibitors increased from 0.2% to 0.7% (β = 0.08 percentage points every 2 years [95% CI, 0.03 to 0.13]; P = .004), and use of upper respiratory combination medications decreased from 2.3% to 0.5% (β = −0.29 percentage points every 2 years [95% CI, −0.40 to −0.19]; P < .001). No statistically significant linear trends were observed among other therapeutic classes, including antidepressants, anticonvulsants, antihypertensive agents, antidiabetic agents, and topical agents.

Among children aged 0 to 23 months, all antibiotic use decreased from 15.5% to 7.6% (β = −1.12 percentage points every 2 years [95% CI, −1.62 to −0.61]; P < .001) and specifically for amoxicillin and amoxicillin/clavulanate (Table 4). Use of upper respiratory combination medications also decreased from 4.3% to 1.1% (β = −0.53 percentage points every 2 years [95% CI, −0.79 to −0.27]; P < .001). However, no statistically significant linear trends were observed among other therapeutic classes, including antihistamines, asthma medications, and topical agents.

Among children aged 2 to 5 years, use of inhaled corticosteroids increased from 1.2% to 2.1% (β = 0.20 percentage points every 2 years [95% CI, 0.02 to 0.39]; P = .03), and use of antihistamines and upper respiratory combination medications decreased 3.1% to 2.3% (β = −0.25 percentage points every 2 years [95% CI, −0.49 to −0.01]; P = .04) and 2.5% to 0.4% (β = −0.39 percentage points every 2 years [95% CI, −0.54 to −0.23]; P < .001), respectively (Table 5). However, no statistically significant linear trends were observed among other therapeutic classes, including antibiotics, glucocorticoids, and topical agents.

Among children aged 6 to 11 years, use of ADHD medications increased from 4.8% to 6.2% (β = 0.32 percentage points every 2 years [95% CI, 0.04 to 0.59]; P = .03) and specifically for amphetamines (Table 6). Significant decreases in all antibiotic use occurred (6.1% to 2.7%, β = −0.52 percentage points every 2 years [95% CI, −0.91 to −0.14]; P = .009) and specifically for amoxicillin. Antihistamine use decreased from 4.8% to 3.0% (β = −0.27 percentage points every 2 years [95% CI, −0.51 to −0.02]; P = .04), and antipsychotic use increased from 0.5% to 1.2% (β = 0.13 percentage points every 2 years [95% CI, 0.04 to 0.22]; P = .006). Asthma medication use increased from 4.6% to 7.6% (β = 0.50 percentage points every 2 years [95% CI, 0.16 to 0.83]; P = .004) and specifically for montelukast and inhaled corticosteroids. Use of proton pump inhibitors and dermatologic agents increased from 0.1% to 0.7% (β = 0.10 percentage points every 2 years [95% CI, 0.02 to 0.19]; P = .02) and 0.5% to 1.2% (β = 0.11 percentage points every 2 years [95% CI, 0.03 to 0.20]; P = .009), respectively, and use of upper respiratory combination medications decreased from 1.8% to 0.6% (β = −0.21 percentage points every 2 years [95% CI, −0.36 to −0.06]; P = .007). However, no statistically significant linear trends were observed among other therapeutic classes, including anticonvulsants; antidepressants; and anxiolytics, sedatives, and hypnotics.

Among adolescents aged 12 to 19 years, use of centrally acting antiadrenergic agents (clonidine and guanfacine) increased from 0.1% to 0.9% (β = 0.13 percentage points every 2 years [95% CI, 0.06 to 0.20]; P < .001), but statistically significant linear trends were not observed in central nervous system stimulants or in ADHD medications overall (Table 7). Significant decreases in all antibiotic use from 8.2% to 4.5% (β = −0.67 percentage points every 2 years [95% CI, −0.97 to −0.38]; P < .001) occurred and specifically for cephalosporins and amoxicillin. Antihypertensive agent use increased from 0.2% to 0.8% (β = 0.10 percentage points every 2 years [95% CI, 0.00 to 0.19]; P = .04), and antihistamine use decreased from 5.1% to 1.5% (β = −0.57 percentage points every 2 years [95% CI, −0.74 to −0.40]; P < .001). Use of asthma medication increased from 4.0% to 6.0% (β = 0.25 percentage points every 2 years [95% CI, 0.04 to 0.47]; P = .02) and specifically for montelukast. Contraceptive use among adolescent girls increased from 4.6% to 8.8% (β = 0.63 percentage points every 2 years [95% CI, 0.27 to 0.99]; P < .001). Use of upper respiratory combination medications decreased from 2.0% to 0.3% (β = −0.26 percentage points every 2 years [95% CI, −0.37 to −0.14]; P < .001). The prevalence of narcotic-containing analgesics was 1.2% in 2011-2014, with no statistically significant linear trend observed (β = −0.10 percentage points every 2 years [95% CI, −0.25 to 0.06]; P = .23).

Discussion

Quiz Ref IDIn 2011-2014, 21.9% of US children and adolescents used any prescription medication in the prior month, and 8.5% used 2 or more prescription medications. The prevalence of using any medication and 2 or more medications varied by age, race and Hispanic origin, insurance status, and current health status; however, medication use did not differ by sex, household income, or education level of the household head. Overall use of any medication decreased from 1999-2002 to 2011-2014, and use of any and 2 or more medications decreased among children aged 0 to 23 months; however, use of any and 2 or more medications increased among non-Hispanic black children and adolescents.

Trends in prevalence of ADHD medication use from 1999-2002 to 2011-2014 in children aged 6 to 11 years and in adolescents aged 12 to 19 years varied. Use of ADHD medications increased among children aged 6 to 11 years and specifically the use of amphetamines. Among adolescents, there were no statistically significant linear trends in overall use of ADHD medications or central nervous system stimulants, but use of centrally acting antiadrenergic agents (clonidine and guanfacine), commonly used to treat ADHD, increased. New ADHD medications, including lisdexamfetamine and the selective norepinephrine reuptake inhibitor atomoxetine, were introduced during the study period, and guanfacine and clonidine were first approved to treat ADHD in 2009 and 2010.

Quiz Ref IDAntibiotic use in children and adolescents decreased by almost half between 1999-2002 and 2011-2014, predominantly in amoxicillin-containing antibiotics and cephalosporins. Decreases were significant in all age groups except children aged 2 to 5 years. Decreases in antibiotic use among children and adolescents have been previously reported using NHANES25 and other data sources.26-28 Children aged 0 to 23 months were the only age group to show decreasing medication use over time, and antibiotics constituted a relatively large proportion of medications used in this age group. This study adds nationally representative age-specific trends for common individual antibiotic classes and provides information for continued monitoring of antibiotic use in children and adolescents to inform programs such as the Centers for Disease Control and Prevention Be Antibiotics Aware: Smart Use, Best Care educational effort,16 which promotes awareness of antibiotic resistance and the importance of appropriate antibiotic prescribing.

Quiz Ref IDThis study also showed an increase in use of antihypertension medications among adolescents. There was no statistically significant linear trend in use of antidiabetic agents. An expert panel has provided recommendations to optimize cardiovascular health of children and adolescents, including recommendations for pharmacologic and nonpharmacologic treatment of hypertension and diabetes.19 While the expert panel also provided recommendations for interventions to reduce dyslipidemia, too few children and adolescents reported taking cholesterol-lowering medications to present prevalence estimates.

Antipsychotic use increased in children aged 6 to 11 years but not in adolescents. A previous study showed increases in the proportion of outpatient visits that included a prescription of antipsychotics from 1993-1998 to 2005-2009 in both children and adolescents.29 Another study of data from 2009 showed that among claims for antipsychotic prescriptions in children aged 7 to 12 years with a psychiatric diagnosis, ADHD was the most common diagnosis, followed by disruptive behavioral disorders and autism and other pervasive developmental disorders.30

Patterns of asthma medication use were consistent with previously reported trends in asthma prevalence, which increased until a plateau in 2009, with subsequent decreases in children but steady increasing prevalence among adolescents.31 The overall increase in use of montelukast may reflect its introduction in 1998 and incorporation into treatment regimens.

The effectiveness and safety of cough and cold medications have been called into question.3,32 NHANES did not collect data on most over-the-counter medications. While certain upper respiratory combination medications (eg, those containing codeine) could be obtained by prescription only, many formulations were available both by prescription and over the counter (eTable in the Supplement). Moreover, certain antihistamines became available over the counter during the study period. This study showed a marked decrease in the use of prescription upper respiratory combination medications and prescription antihistamines overall; decreases also occurred within each age category.

NHANES has several strengths for surveillance of trends in prescription medication use among children and adolescents. NHANES data are nationally representative and included the medication name and linkage to Multum Lexicon Plus therapeutic drug categories. Recording the names of prescription drugs from the medication container by trained personnel strengthened validity and completeness. This study provided more recent estimates over a wider age range then those published using the Slone Survey, a nationally representative telephone survey that included 2857 children younger than 12 years from 1998-2007.6 NHANES data have also been used for surveillance of prescription medication trends among adults 20 years or older,33 and Health, United States periodically publishes estimates of prescription medication use using NHANES data by therapeutic category.34

Limitations

This study has several limitations. First, NHANES did not capture dosages, formulations, or frequency of use, nor did it collect data on most over-the-counter medications. Second, although survey staff worked to capture all prescription medication use, underreporting is possible. Third, because of small sample sizes, estimates could be calculated for only the most common therapeutic classes of prescription medications and individual medications. Interpreting trends in outcomes with low prevalence is difficult in complex surveys, including NHANES, because of uncertainty in the distribution of the outcome and appropriate methods for statistical testing. Large samples are desirable for such analyses, and strategies could include combining NHANES cycles and avoiding analysis of small subgroups. Fourth, because there was no adjustment for multiple comparisons, there is the potential for type I error.

Conclusions

In this study of US children and adolescents based on a nationally representative survey, estimates of prescription medication use showed an overall decrease in use of any medication from 1999-2014. The prevalence of asthma medication, ADHD medication, and contraceptive use increased among certain age groups, whereas use of antibiotics, antihistamines, and upper respiratory combination medications decreased.

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Article Information

Corresponding Author: Craig M. Hales, MD, National Center for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Rd, Hyattsville, MD 20782 (chales@cdc.gov).

Accepted for Publication: April 12, 2018.

Author Contributions: Dr Hales had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Hales.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hales, Kit.

Administrative, technical, or material support: Hales.

Supervision: Hales, Ogden.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Role of the Sponsor: The National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC) had a role in the design and conduct of the National Health and Nutrition Examination Survey, in the collection and management of the data, and in the review and approval of the manuscript; however, the NCHS and the CDC had no role in the analysis and interpretation of the data; preparation of the manuscript; or the decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the NCHS, CDC; National Heart, Lung, and Blood Institute, National Institutes of Health; or the United States Department of Health and Human Services.

References
1.
Shehab  N, Lovegrove  MC, Geller  AI, Rose  KO, Weidle  NJ, Budnitz  DS.  US emergency department visits for outpatient adverse drug events, 2013-2014.  JAMA. 2016;316(20):2115-2125.PubMedGoogle ScholarCrossref
2.
Johann-Liang  R, Wyeth  J, Chen  M, Cope  JU.  Pediatric drug surveillance and the Food and Drug Administration’s adverse event reporting system: an overview of reports, 2003-2007.  Pharmacoepidemiol Drug Saf. 2009;18(1):24-27.PubMedGoogle ScholarCrossref
3.
Vernacchio  L, Kelly  JP, Kaufman  DW, Mitchell  AA.  Cough and cold medication use by US children, 1999-2006: results from the Slone Survey.  Pediatrics. 2008;122(2):e323-e329.PubMedGoogle ScholarCrossref
4.
Tobias  JD, Green  TP, Coté  CJ; Section on Anesthesiology and Pain Medicine; Committee on Drugs.  Codeine: time to say “no.”  Pediatrics. 2016;138(4):e20162396.PubMedGoogle ScholarCrossref
5.
Youngster  I, Avorn  J, Belleudi  V,  et al.  Antibiotic use in children—a cross-national analysis of 6 countries.  J Pediatr. 2017;182:239-244.PubMedGoogle ScholarCrossref
6.
Vernacchio  L, Kelly  JP, Kaufman  DW, Mitchell  AA.  Medication use among children <12 years of age in the United States: results from the Slone Survey.  Pediatrics. 2009;124(2):446-454.PubMedGoogle ScholarCrossref
7.
Johnson  CL, Dohrmann  SM, Burt  VL, Mohadjer  LK.  National Health and Nutrition Examination Survey: sample design, 2011-2014.  Vital Health Stat 2. 2014;(162):1-33.PubMedGoogle Scholar
8.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). NHANES Response Rates. CDC website. https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx. Accessed July 7, 2017.
9.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). NHANES Data Documentation, Codebook, and Frequencies: Prescription Medications. CDC website. https://wwwn.cdc.gov/Nchs/Nhanes/2013-2014/RXQ_RX_H.htm. Published December 2016. Accessed July 7, 2017.
10.
Tran  AR, Zito  JM, Safer  DJ, Hundley  SD.  National trends in pediatric use of anticonvulsants.  Psychiatr Serv. 2012;63(11):1095-1101.PubMedGoogle ScholarCrossref
11.
Visser  SN, Danielson  ML, Bitsko  RH,  et al.  Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011.  J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.PubMedGoogle ScholarCrossref
12.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). National Health and Nutrition Examination Survey: Questionnaires, Datasets, and Related Documentation. CDC website. https://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Updated October 30, 2015. Accessed July 14, 2017.
13.
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). NHANES 1988-2014 Data Documentation: Prescription Medications—Drug Information. CDC website. https://wwwn.cdc.gov/Nchs/Nhanes/1999-2000/RXQ_DRUG.htm. Revised December 2016. Accessed July 7, 2017.
14.
Kit  BK, Simon  AE, Ogden  CL, Akinbami  LJ.  Trends in preventive asthma medication use among children and adolescents, 1988-2008.  Pediatrics. 2012;129(1):62-69.PubMedGoogle ScholarCrossref
15.
Jonas  BS, Gu  Q, Albertorio-Diaz  JR.  Psychotropic medication use among adolescents: United States, 2005-2010.  NCHS Data Brief. 2013;(135):1-8.PubMedGoogle Scholar
16.
Centers for Disease Control and Prevention (CDC). Be Antibiotics Aware: Smart Use, Best Care. CDC website. https://www.cdc.gov/antibiotic-use/. Published 2017. Accessed October 19, 2017.
17.
National Heart, Lung, and Blood Institute (NHLBI). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NHLBI website. https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. Published 2007. Accessed June 27, 2017.
18.
Wolraich  M, Brown  L, Brown  RT,  et al; Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management.  ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.  Pediatrics. 2011;128(5):1007-1022.PubMedGoogle ScholarCrossref
19.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.  Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report.  Pediatrics. 2011;128(suppl 5):S213-S256.PubMedGoogle ScholarCrossref
20.
Centers for Disease Control and Prevention (CDC). CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. CDC website. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Published 2016. Accessed June 27, 2017.
21.
Dowell  D, Haegerich  TM, Chou  R.  CDC guideline for prescribing opioids for chronic pain—United States, 2016.  JAMA. 2016;315(15):1624-1645.PubMedGoogle ScholarCrossref
22.
Korn  EL, Graubard  BI.  Confidence intervals for proportions with small expected number of positive counts estimated from survey data.  Surv Methodol. 1998;24(2):193-201.Google Scholar
23.
R: A Language and Environment for Statistical Computing [computer program]. Vienna, Austria: R Project for Statistical Computing; 2017.
24.
Survey: analysis of complex survey samples. R package version 3.32 [computer program]. Vienna, Austria: R Project for Statistical Computing; 2017.
25.
Frenk  SM, Kit  BK, Lukacs  SL, Hicks  LA, Gu  Q.  Trends in the use of prescription antibiotics: NHANES 1999-2012.  J Antimicrob Chemother. 2016;71(1):251-256.PubMedGoogle ScholarCrossref
26.
Chai  G, Governale  L, McMahon  AW, Trinidad  JP, Staffa  J, Murphy  D.  Trends of outpatient prescription drug utilization in US children, 2002-2010.  Pediatrics. 2012;130(1):23-31.PubMedGoogle ScholarCrossref
27.
Vaz  LE, Kleinman  KP, Raebel  MA,  et al.  Recent trends in outpatient antibiotic use in children.  Pediatrics. 2014;133(3):375-385.PubMedGoogle ScholarCrossref
28.
Centers for Disease Control and Prevention (CDC). Antibiotic use in the United States, 2017: progress and opportunities. CDC website. https://www.cdc.gov/antibiotic-use/stewardship-report/index.html. Published 2017. Accessed April 12, 2018.
29.
Olfson  M, Blanco  C, Liu  SM, Wang  S, Correll  CU.  National trends in the office-based treatment of children, adolescents, and adults with antipsychotics.  Arch Gen Psychiatry. 2012;69(12):1247-1256.PubMedGoogle ScholarCrossref
30.
Olfson  M, King  M, Schoenbaum  M.  Treatment of young people with antipsychotic medications in the United States.  JAMA Psychiatry. 2015;72(9):867-874.PubMedGoogle ScholarCrossref
31.
Akinbami  LJ, Simon  AE, Rossen  LM.  Changing trends in asthma prevalence among children  [published online December 28, 2015].  Pediatrics. doi:10.1542/peds.2015-2354PubMedGoogle Scholar
32.
Sharfstein  JM, North  M, Serwint  JR.  Over the counter but no longer under the radar—pediatric cough and cold medications.  N Engl J Med. 2007;357(23):2321-2324.PubMedGoogle ScholarCrossref
33.
Kantor  ED, Rehm  CD, Haas  JS, Chan  AT, Giovannucci  EL.  Trends in prescription drug use among adults in the United States from 1999-2012.  JAMA. 2015;314(17):1818-1831.PubMedGoogle ScholarCrossref
34.
National Center for Health Statistics.  Health, United States 2016. Hyattsville, MD: National Center for Health Statistics; 2017.
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