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

2. Case 1 3:10PM – 3mo F here for WCC

3. 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 1 3:10pm

4. 3 common concerns re: vaccinations 1. Overwhelming the Immune System 2. Thimerosal 3. Link to autism CASE 1 3:10pm

5. 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 1 3:10pm

6. 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 1 3:10pm

7. How would you respond? 3. Autism controversy 1998- Andrew Wakefield Lancet review suggests link between MMR & autism 2004- 10 of 13 authors retract papers interpretation 2010- Wakefields license revoked & Lancet retracts paper 2011- BMJ concludes research was fraudulent Evidence does NOT support link CASE 1 3:10pm

8. 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 1 3:10pm

9. References King County Public Health Childhood Immunization resources: http://www.kingcounty.gov/healthservices/health/communicable/immuni zation/children.aspx http://www.kingcounty.gov/healthservices/health/communicable/immuni zation/children.aspx King County Public Health Immunization resources for health care providers: http://www.kingcounty.gov/healthservices/health/communicable/immuni zation/providers.aspx http://www.kingcounty.gov/healthservices/health/communicable/immuni zation/providers.aspx WA DOH Plain Talk about Childhood Immunization: http://here.doh.wa.gov/materials/plain-talk-about-childhood- immunizations/15_PlnTalk_E08L.pdf 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/http://www.vaxnorthwest.org/ Autism studies: http://www.immunize.org/catg.d/p4026.pdfhttp://www.immunize.org/catg.d/p4026.pdf FDA info on Thimerosal: http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Vacci neSafety/UCM096228#t1 http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Vacci neSafety/UCM096228#t1 CASE 1 3:10pm

10. Case 2 3:25PM – 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)? Criteria: Grade B- Grade C- CASE 2 3:25pm Mod-severe bulge or otorrhea (w/o OE) Mild bulge and Acute onset otalgia or TM erythema

13. Bulging TM CASE 2 3:25pm

14. Should this patient be treated with antibiotics? Why or why not? CASE 2 3:25pm AgeTreatWait & see <6moall 6mo - 2yoSevere Nonsevere bilateral Nonsevere unilateral 2yoSevereNonsevere severe = moderate or severe otalgia, otalgia >48hrs, T>39C nonsevere = mild otalgia <48hrs, T<39C

15. What is your treatment plan? Treat otalgia Acetaminophen, Ibuprofen, Benzocaine gtt Antibiotics 1 st line: Amoxicillin (80-90 mg/kg/d, BID dosing) PCN allergy: cefuroxime, cefdinir, cefpodoxime, CTX Amox in 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 CASE 2 3:25pm

16. 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 2 3:25pm

17. Case 3 3:40PM – 20mo old with pallor

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

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

20. Who should be screened for IDA? CASE 3 3:40pm USPSTF: I AAP: Universal @ 12mo Selective screening anytime if +RFs Risk Factors LBW or preterm Exclusive breastfeeding w/o Fe fortified foods Poor nutrition Cows milk 16 oz milk/day

21. References CASE 3 3:40pm 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.

22. Case 4 4:10PM – 9mo old for WCC & sleep issues.

23. Further Questions Sleep ConcernDDx Trouble initiating or maintaining sleep Behavioral Stress, anxiety, depression Reflux, meds (stimulants, caffeine) Excessive daytime sleepiness Insufficient sleep / behavioral OSA, PLMD Chronic disease, acute infxn, ICP Meds (anti-histamines, TCA, AEDs) Snoring OSA Abnormal movements/behaviors Noctural seizures, parasomnias PLMD CASE 4 4:10pm Nursing overnight? Response to nighttime awakenings Family rhythms (dinnertime, other siblings, etc)

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

25. Interventions Bedtime routine Systematic ignoring (aka sleep training) CASE 4 4:10pm Sleep MethodIn a nutshell Ferber Solve Your Childs Sleep Problems Sleep ritual, no crutches Intervals of intervention Weissbluth Healthy Sleep Habits, Happy Child Early bedtime, preserve naptimes cry-it-out Mindell Sleeping Through the Night Similar to Ferber & Weissbluth with a bit more reality & wiggle room Hogg Secrets of the Baby Whisperer Find your babys window of opportunity to fall asleep Pantley The No Cry Sleep Solution Establish sleep routines & associations Sears The Baby Book Attachment parenting Family bed & night feedings Consistency is key!

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

27. 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 5 4:25pm

28. 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 CASE 5 4:25pm

29. 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 5 4:25pm

30. 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 months 2.) More based on age, sex, and severity 3.) VCUG if abnormal or recurrent Optional Testing: CASE 5 4:25pm

31. Case 6 4:40PM – 8yo M with bedwetting

32. Background CASE 6 4:40pm 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 5yo7.5% 8yo5.5% 11yo1%

33. What other conditions do you screen for? CASE 6 4:40pm History Bedwetting pattern, daytime sxs, 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 ones 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 2 nd 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):971Eur J Pediatr 2012 Jun;171(6):971 Evaluation and treatment of enuresis. Ramakrishnan K. Am Fam Physician. 2008 Aug 15;78(4):489-96. Evaluation and treatment of enuresis. Clinical practice. Evaluation and management of enuresis. Robson WL. N Engl J Med. 2009 Apr 2;360(14):1429-36. Clinical practice. Evaluation and management of enuresis.

36. Take Home Points 3 Things You Need to Know About: Vaccine Hesitancy AOM Anemia Sleep UTI Enuresis

37. 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 1 3:10pm 3 Things You Need to Know About: Vaccine Hesitancy

38. 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 2 3:25pm

39. 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 3 3:40pm

40. 1. Evaluate for medical Dxs. 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 4 4:10pm 3 Things You Need to Know About: Infant Sleep

41. 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 5 4:25pm 3 Things You Need to Know About: UTI (AAP recommendations)

42. 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 6 4:40pm 3 Things You Need to Know About: Enuresis