OutpatientPediatricPotpourri

3 Things You Need to Know About…

Miranda D. Lu, MDEmily Hersh-Burdick, MD

Lindsey Hay, MDOctober 15, 2013

Case 13:10PM –

3mo F here for WCC

Background

WA had the highest exemption rate in the country in 2011

2011 Immunization Exemption Law dropped rates by ~25%

A lot of misinformation.

Even parents who do vaccinate have concerns about vaccinations.

CASE 13:10pm

3 common concerns re: vaccinations

1. “Overwhelming” the Immune System

2. Thimerosal3. Link to autism

CASE 13:10pm

How would you respond?

1.“Overwhelming” the Immune System No scientific evidence for harm to

the immune system or blunted response.

A child receiving 11 vaccines in 1 day would use up <1% of his or her immune system.

CASE 13:10pm

How would you respond?

2.Thimerosal Ethylmercury preservative Removed in 1999 to eliminate

possibility of risks associated w/ methylmercury

Current use: multi-dose influenza

2004 IOM review: no link between autism & thimerosal

2012: AAP recommends continued use

CASE 13:10pm

How would you respond?

3.Autism controversy 1998- Andrew Wakefield Lancet

review suggests link between MMR & autism

2004- 10 of 13 authors retract paper’s interpretation

2010- Wakefield’s license revoked & Lancet retracts paper

2011- BMJ concludes research was fraudulent

Evidence does NOT support link

CASE 13:10pm

What options & resources can you suggest?

WA DOH Publication: “Plain Talk about Childhood Immunization”

Alternative Schedules: The Vaccine Book, by Robert W. Sears, MD

CASE 13:10pm

References

King County Public Health Childhood Immunization resources: http://www.kingcounty.gov/healthservices/health/communicable/immunization/children.aspx

King County Public Health Immunization resources for health care providers: http://www.kingcounty.gov/healthservices/health/communicable/immunization/providers.aspx

WA DOH Plain Talk about Childhood Immunization: http://here.doh.wa.gov/materials/plain-talk-about-childhood-immunizations/15_PlnTalk_E08L.pdf

VAX Northwest (organization that is trying to address vaccine hesitancy): http://www.vaxnorthwest.org/

Autism studies: http://www.immunize.org/catg.d/p4026.pdf

FDA info on Thimerosal: http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228#t1

CASE 13:10pm

Case 23:25PM –

15mo M w/ fever

CASE 23:25pm

The Tympanic Membrane

CASE 23:25pm

Does this patient meet criteria for Acute Otitis Media (AOM)?

Criteria:

Grade B-

Grade C-

CASE 23:25pm

Mod-severe bulge

or otorrhea (w/o OE)

Mild bulge and

Acute onset otalgia

orTM erythema

Bulging TM

CASE 23:25pm

Should this patient be treated with antibiotics? Why or why

not?

CASE 23:25pm

Age Treat Wait & see

<6mo all

6mo - 2yo

SevereNonsevere bilateral

Nonsevere unilateral

≥2yo Severe Nonsevere

“severe” = moderate or severe otalgia, otalgia >48hrs, T>39C “nonsevere” = mild otalgia <48hrs, T<39C

What is your treatment plan?

Treat otalgiaAcetaminophen, Ibuprofen, Benzocaine gtt

Antibiotics1st line: Amoxicillin (80-90 mg/kg/d, BID dosing)PCN allergy: cefuroxime, cefdinir, cefpodoxime, CTXAmox in last 30d, purulent conjunctivitis, or failed

amoxicillin: Augmentin

Duration: 10d7d if 2-5yo w/ mild or moderate AOM5-7d if >5yo

Side effects of Abx: Diarrhea, diaper dermatitis, allergic reaction, overuse> Abx

resistance

CASE 23:25pm

References

The Diagnosis & management of acute otitis media. Pediatrics, Feb 2013.

Ramakrishnan, K et al. Diagnosis & treatment of acute otitis media, American Family Physician, Dec 2007.

Spiro et al. The concept & practice of a wait-and-see approach to acute otitis media. Current Opinion in Pediatrics, Feb 2008.

Kozyrskyi et al. Short-course antibiotics for acute otitis media. Cochrane Database Systematic Review, Sept 2010.

CASE 23:25pm

Case 33:40PM –

20mo old with pallor

How should we test her for IDA?

CASE 33:40pm

Hemoglobin: poor Se & Sp

10-11 therapeutic trial of Fe

<10Ferritin + CRPorCHr (reticulocyte Hgb concentration)

<7or >2-

3yoWork up other causes

ZPPHAdditional Work-up:Reticulocyte countPBSFOBT+Se Fe, ferritin, TIBC, TF saturationHgb electrophoresisB12, Folate

What is the treatment & follow-up?

CASE 33:40pm

FeSO4: 3mg/kg/d ÷ qd-bid

Treat x1mo, then repeat Hgb

Repeat Hgb q2-3mo til WNL

Cont FeSO4 x3mo after Hgb WNL

1-3yo: <16-20oz milk & 7mg/d Fe

Who should be screened for IDA?

CASE 33:40pm

USPSTF: I

AAP:

Universal @ 12mo

Selective screening anytime if +RF’s

Risk Factors LBW or preterm

Exclusive breastfeeding w/o Fe fortified foods

Poor nutrition

Cow’s milk <12 mo or >16 oz milk/day

References

CASE 33:40pm

Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Baker RD, Greer FR, Committee on Nutrition American Academy of Pediatrics. Pediatrics. 2010;126(5):1040.

Zinc protoporphyrin & iron deficiency screening: trends & therapeutic response in an urban pediatric center. Magge H et al. JAMA Pediatr. 2013 Apr;167(4):361-7.

The use of zinc protoporphyrin in screening young children for iron deficiency. Siegel RM, LaGrone DH. Clin Pediatr (Phila). 1994 Aug;33(8):473-9.

Case 44:10PM –

9mo old for WCC & sleep issues.

Further Questions

Sleep Concern DDx

Trouble initiating or maintaining sleep

BehavioralStress, anxiety, depressionReflux, meds (stimulants, caffeine)

Excessive daytime sleepiness

Insufficient sleep / behavioralOSA, PLMDChronic disease, acute infxn, ICPMeds (anti-histamines, TCA, AEDs)

Snoring OSA

Abnormal movements/behaviors

Noctural seizures, parasomniasPLMD

CASE 44:10pm

Nursing overnight? Response to nighttime awakenings

Family rhythms (dinnertime, other siblings, etc)

Diagnosis

Behavioral Insomnia

Not enough sleep 6-12mo old: 13-14hrs total,

including 2 naps

Bedtime may be too late

Sleep fragmentation

CASE 44:10pm

Interventions

Bedtime routine

Systematic ignoring (aka “sleep training”)

CASE 44:10pm

Sleep Method In a nutshell

FerberSolve Your Child’s Sleep Problems

Sleep ritual, no crutchesIntervals of intervention

WeissbluthHealthy Sleep Habits, Happy Child

Early bedtime, preserve naptimes“cry-it-out”

MindellSleeping Through the Night

Similar to Ferber & Weissbluth with a bit more reality & wiggle room

HoggSecrets of the Baby Whisperer

Find your baby’s “window of opportunity” to fall asleep

PantleyThe No Cry Sleep Solution

Establish sleep routines & associations

SearsThe Baby Book

Attachment parentingFamily bed & night feedings

Consistency is key!

Case 54:25PM –

3 yo with abdominal pain.

What questions do you have for her? Physical Exam?

What are symptoms & risk factors for UTIs?

CASE 54:25pm

Most Common UTI symptoms: Fever and Jaundice in Newborns Suprapubic tenderness and Temp >40 deg Adbominal pain > dysuria/Frequency New-onset urinary incontinence

Risk Factors: Phimosis, Labial adhesions Uncircumcised male infant History of UTI Constipation other bowel/bladder dysfunction

CASE 54:25pm

Empiric Treatment vs. Observation

Empiric Treatment: If acutely ill, after cath (+ BCx, +/- CSF) If at risk and BOTH Nitrate & LE +

Observe for 24-48 hours: if low risk or neg convenient UA testing.

Antibiotics: (7-14 days) >1 month: Ceftriaxone IM or Cefixime PO >13 yo: Bactrim, amoxicillin, or Keflex

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Diagnosis:

AAP Recommendation:

cath specimen > 50K in 2-24 month olds

CCHMC Recommendations:

clean catch >100 K cath specimen >10 K suprapubic aspiration >1K

CASE 54:25pm

Additional Work Up Recommendations:

PCT > 1.3, CRP >10 BCx, CSF if <1 month old or critically ill

AAP: CCHMC:

- ALL get Renal US (2-24 mo)- VCUG if abnormal- VCUG if recurrent UTI

US & VCUG in:- All boys- Girls <36 months- Girls 3-7 yo w/ temp > 38.5

1.) US with every UTI under 24 months2.) More based on age, sex, and severity3.) VCUG if abnormal or recurrent

Optional Testing:CASE 54:25pm

Case 64:40PM –

8yo M with bedwetting

BackgroundCASE 64:40pm

Common issue in childhood

M>F

Enuresis = >2x/wk bedwetting in >5yo

Pathophysiology: Nocturnal polyuria, decreased ADH Small bladder capacity Impaired arousal rarely- GU abnormality or neurologic

5yo 7.5%

8yo 5.5%

11yo 1%

What other conditions do you screen for?

CASE 64:40pm

History Bedwetting pattern, daytime sx’s, fluid/food

intake Constipation Polyuria (DM2) Dysuria (UTI) Urgency (OAB) Snoring (OSA) Screen for: stress, abuse

PEx: Abdomen, GU, Sacral spine

UA

Treatment

CASE 64:40pm

“no one’s fault”; avoid punishing

Behavioral

Treat constipation

If >7yo: Enuresis alarm Desmopressin- 0.2 - 0.6mg PO up to

1hr before bedtime Combo +/- refer if not effective after 6-

8wks 2nd line: oxybutynin, imipramine

References

CASE 64:40pm

American Academy of Pediatrics/European Society for Paediatric Urology/European Society for Paediatric Nephrology/International Children's Continence Society (AAP/ESPU/ESPN/ICCS) practical consensus guideline on management of enuresis. Eur J Pediatr 2012 Jun;171(6):971

Evaluation and treatment of enuresis. Ramakrishnan K. Am Fam Physician. 2008 Aug 15;78(4):489-96.

Clinical practice. Evaluation and management of enuresis. Robson WL. N Engl J Med. 2009 Apr 2;360(14):1429-36.

Take Home Points 3 Things You Need to Know About:

Vaccine Hesitancy

AOM

Anemia

Sleep

UTI

Enuresis

1. Multiple simultaneous vaccinations are not harmful.

2. Thimerosal Used in multi-dose influenza vaccine

only No link to autism

3. No association between MMR & autism.

CASE 13:10pm

3 Things You Need to Know About:Vaccine Hesitancy

3 Things You Need to Know About:AOM

1.Dx = mod-severe bulge OR otorrhea mild bulge AND acute pain or red

2. Treat: <6mo: all 6mo-2yo: bilateral or severe >2yo: severe

3. Acetaminophen + HD Amoxicillin <2yo: 10d 2-5yo: 7d >5yo: 5-7d

CASE 23:25pm

3 Things You Need to Know About:Anemia

1. If Hgb < 11, empiric FeSO4 3mg/kg/d ÷ qd/bid

2. If Hgb <10, confirm or work up other causes

3. AAP: screen kids at 12mo old or anytime if + RF.

CASE 33:40pm

1. Evaluate for medical Dx’s.

2. Behavioral insomnia results from: delayed bedtime sleep fragmentation 2/2 sleep

crutches or parental reinforcement

3. Interventions: Bedtime routine Earlier bedtime Systematic ignoring

CASE 44:10pm

3 Things You Need to Know About:Infant Sleep

1. Diagnose with >50K CFU in febrile 2-24 month old in cath specimen

2. Ceftriaxone IM or Cefixime PO for 7-14 days, narrow when able, treat constipation!

3. Renal US 0-24 month olds with VCUG if US is abnormal or recurrent UTIs.

CASE 54:25pm

3 Things You Need to Know About:UTI (AAP recommendations)

1. Have families fill out a voiding diary capacity vs. polyuria.

2. Ask about & treat co-existing constipation.

3. Treatment: Alarm- small bladder capacity, deep

sleeper Desmopressin- nocturnal polyuria

CASE 64:40pm

3 Things You Need to Know About:Enuresis