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Outpatient Pediatric Potpourri

Outpatient Pediatric Potpourri. 3 Things You Need to Know About…. Miranda D. Lu, MD Emily Hersh -Burdick, MD Lindsey Hay, MD October 15, 2013. Case 1 3:10PM – 3mo F here for WCC. CASE 1 3:10pm. Background. WA had the highest exemption rate in the country in 2011

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Outpatient Pediatric Potpourri

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  1. OutpatientPediatricPotpourri 3 Things You Need to Know About… Miranda D. Lu, MD Emily Hersh-Burdick, MD Lindsey Hay, MD October 15, 2013

  2. Case 13:10PM – 3mo F here for WCC

  3. CASE 1 3:10pm 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.

  4. CASE 1 3:10pm 3 common concerns re: vaccinations • “Overwhelming” the Immune System • Thimerosal • Link to autism

  5. CASE 1 3:10pm How would you respond? • “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.

  6. CASE 1 3:10pm How would you respond? • 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

  7. CASE 1 3:10pm How would you respond? • 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

  8. CASE 1 3:10pm What options & resources can you suggest? • WA DOH Publication: “Plain Talk about Childhood Immunization” • Alternative Schedules: The Vaccine Book, by Robert W. Sears, MD

  9. CASE 1 3:10pm 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

  10. Case 23:25PM – 15mo M w/ fever CASE 2 3:25pm

  11. The Tympanic Membrane CASE 2 3:25pm

  12. Does this patient meet criteria for Acute Otitis Media (AOM)? CASE 2 3:25pm Mod-severe bulge otorrhea(w/o OE) or Acute onset otalgia or TM erythema Mild bulge and • Criteria: • Grade B- • Grade C-

  13. CASE 2 3:25pm Bulging TM

  14. CASE 2 3:25pm Should this patient be treated with antibiotics? Why or why not? • “severe” = moderate or severe otalgia, otalgia >48hrs, T>39C • “nonsevere” = mild otalgia <48hrs, T<39C

  15. CASE 2 3:25pm What is your treatment plan? • Treat otalgia Acetaminophen, Ibuprofen, Benzocainegtt • Antibiotics 1st line: Amoxicillin (80-90 mg/kg/d, BID dosing) PCN allergy:cefuroxime,cefdinir, cefpodoxime, CTX Amoxin last 30d, purulent conjunctivitis, or failed amoxicillin: Augmentin • Duration: 10d 7d if 2-5yo w/mild or moderate AOM 5-7d if >5yo • Side effects of Abx: Diarrhea, diaper dermatitis, allergic reaction, overuse> Abx resistance

  16. CASE 2 3:25pm 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.

  17. Case 33:40PM – 20mo old with pallor

  18. CASE 3 3:40pm How should we test her for IDA? • Hemoglobin: poor Se & Sp 10-11 therapeutictrial of Fe Ferritin + CRP or CHr(reticulocyteHgb concentration) <10 <7 or >2-3yo Work up other causes Additional Work-up: Reticulocyte count PBS FOBT + Se Fe, ferritin, TIBC, TF saturation Hgb electrophoresis B12, Folate • ZPPH

  19. CASE 3 3:40pm What is the treatment & follow-up? • 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

  20. CASE 3 3:40pm Who should be screened for IDA? • 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

  21. CASE 3 3:40pm References • 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. ClinPediatr (Phila). 1994 Aug;33(8):473-9.

  22. Case 44:10PM – 9mo old for WCC & sleep issues.

  23. CASE 4 4:10pm Further Questions • Nursing overnight? Response to nighttime awakenings • Family rhythms (dinnertime, other siblings, etc)

  24. CASE 4 4:10pm Diagnosis • Behavioral Insomnia • Not enough sleep • 6-12mo old: 13-14hrs total, including 2 naps • Bedtime may be too late • Sleep fragmentation

  25. CASE 4 4:10pm Interventions Consistency is key! Bedtime routine Systematic ignoring (aka “sleep training”)

  26. Case 54:25PM –3 yo with abdominal pain. CASE 5 4:25pm What questions do you have for her? Physical Exam? Whatare symptoms & risk factors for UTIs?

  27. CASE 5 4:25pm 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

  28. CASE 5 4:25pm 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

  29. CASE 5 4:25pm Diagnosis: • AAP Recommendation: • cath specimen> 50K in 2-24 month olds • CCHMC Recommendations: • clean catch >100 K • cath specimen >10 K • suprapubic aspiration >1K

  30. Optional Testing: CASE 5 4:25pm • PCT > 1.3, CRP >10 • BCx, CSF if <1 month old or critically ill Additional Work Up Recommendations: 1.) US with every UTI under 24 months 2.) More based on age, sex, and severity 3.) VCUG if abnormal or recurrent AAP: CCHMC: • US & VCUG in: • All boys • Girls <36 months • Girls 3-7 yo w/ temp > 38.5 - ALL get Renal US (2-24 mo) - VCUG if abnormal - VCUG if recurrent UTI

  31. Case 64:40PM –8yo M with bedwetting

  32. CASE 6 4:40pm Background • 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

  33. What other conditions do you screen for? CASE 6 4:40pm • 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

  34. Treatment CASE 6 4:40pm • “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

  35. References CASE 6 4:40pm 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.

  36. Take Home Points3 Things You Need to Know About: • Vaccine Hesitancy • AOM • Anemia • Sleep • UTI • Enuresis

  37. CASE 1 3:10pm 3 Things You Need to Know About:Vaccine Hesitancy • Multiple simultaneous vaccinations are not harmful. • Thimerosal • Used in multi-dose influenza vaccine only • No link to autism • No association between MMR & autism.

  38. CASE 2 3:25pm 3 Things You Need to Know About:AOM • Dx = mod-severe bulge ORotorrhea mild bulge AND acute pain or red • Treat: • <6mo: all • 6mo-2yo: bilateral or severe • >2yo: severe • Acetaminophen + HD Amoxicillin • <2yo: 10d • 2-5yo: 7d • >5yo: 5-7d

  39. 3 Things You Need to Know About:Anemia CASE 3 3:40pm If Hgb < 11, empiric FeSO4 3mg/kg/d ÷ qd/bid If Hgb <10, confirm or work up other causes AAP: screen kids at 12mo old or anytime if + RF.

  40. CASE 4 4:10pm 3 Things You Need to Know About:Infant Sleep • Evaluate for medical Dx’s. • Behavioral insomnia results from: • delayed bedtime • sleep fragmentation 2/2 sleep crutches or parental reinforcement • Interventions: • Bedtime routine • Earlier bedtime • Systematic ignoring

  41. 3 Things You Need to Know About:UTI (AAP recommendations) CASE 5 4:25pm Diagnose with >50K CFU in febrile 2-24 month old in cath specimen Ceftriaxone IM or Cefixime PO for 7-14 days, narrow when able, treat constipation! Renal US 0-24 month olds with VCUG if US is abnormal or recurrent UTIs.

  42. 3 Things You Need to Know About:Enuresis CASE 6 4:40pm • Have families fill out a voiding diary capacity vs. polyuria. • Ask about & treat co-existing constipation. • Treatment: • Alarm- small bladder capacity, deep sleeper • Desmopressin- nocturnal polyuria

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