1. AFP Journal Review April 15, 2008 Cindi Hurley, MD

2. Wheezing in Children Common Problem at PCP - 25% of infants - 40% of 3-year-olds - 50% of 6-year-olds

3. Etiology of Wheezing Occurs during prolonged expiratory phase Rapid passage of air through narrowed airways

4. Children Wheeze More Often Bronchi are smaller  higher airway resistance Less elastic tissue recoil & fewer collateral airways  easier obstruction & atelectasis Ribs, trachea and bronchi are more compliant Diaphragm inserts horiz vs obliquely

5. Table 1. Causes of Wheezing in Children and Infants Common Allergies Asthma or reactive airway disease Gastroesophageal reflux disease Infections Bronchiolitis Bronchitis Pneumonia Upper respiratory infection Obstructive sleep apnea Uncommon Bronchopulmonary dysplasia Foreign body aspiration Rare Bronchiolitis obliterans Congenital vascular abnormalities Congestive heart failure Cystic fibrosis Immunodeficiency diseases Mediastinal masses Primary ciliary dyskinesia Tracheobronchial anomalies Tumor or malignancy Vocal cord dysfunction

6. Differential Dx Family Hx - recent infectious illness s/a URI, pertussis, TB - ~ of asthma, allergies or eczema increases suspicion for asthma Age at Onset - distinguish between congenital vs non- congenital

7. Pattern/Seasonality Episodic wheezing assoc with season or environmental allergens is more likely asthma persistent wheezing from birth more likely to be a congenital anatomic anomaly if persistent resp illness w/ wheezing  eval for CP, bronchopulm dysplasia, laryngomalacia, primary ciliary dyskinesia

8. Pattern/Seasonality Most RSV is Nov-May with peak in Jan & Feb Croup more common in fall & winter Wheezing assoc with outdoor allergens more common in spring & fall Wheezing in asthma can be triggered by change in seasons

9. Wheezing after feeding  most common is GERD but could be tracheoesophageal fistula & laryngeal clefts (rare) Sudden onset  consider foreign body aspiration Wheezing +/- cough that awakens child at night  consider obstructive sleep apnea

10. Multiple resp illnesses in infants  CF, immunodeficiency or ciliary problems When wheezing occurs with positional changes  tracheomalacia & anomalies of the great vessels

11. Physical Exam Perform skin, cardiac, ear, nose & throat exam Look for retractions, nasal flaring, grunting, allergic shiners, atopic dermatitis, LAD, heart murmur, rhinorrhea, clubbing & nail color changes Ausculation may reveal location of wheezing, stridor or crackles Consider chest X-ray, PFTs, peak flows

12. DDx of Wheezing According to Characteristic Signs & Symptoms

14. Physical Activity Counseling

15. Statistics More than 50% of Americans fail to meet recommended physical activity levels Each year, 84% of Americans consult a physician FPs spend 1.5 – 3 minutes providing health education

16. Barriers to Physical Activity Counseling Limited Time Reimbursement Problems Insufficient Physician Knowledge Decreased Confidence that Pts will Change

17. Recommendations & Key Principles 30 mins of moderate intensity physical activity on at least five days per week The more activity the better Accumulated time is more important than intensity Activity can be accumulated in 10 minute increments

18. Lifestyle changes are more likely to be sustained than structured activities No more than 2 days should elapse between “workouts” Strength and flexibility training help but should not replace aerobic activity

19. The Five A’s Assess - pt’s physical activity, CI to exercise, and readiness for change Advise – review recommendations & key principles Assist – write a prescription, provide printed materials or internet sites, use self- monitoring tools s/a calendars or pedometers

20. Agree –initiate shared decision making; initially setting high goals is more effective than setting a series of incrementally increasing goals Arrange – follow-up visits, support groups, referrals if necessary to PT, dietician, etc

22. Oral Health During Pregnancy Only 22-34% of woman consult a dentist during pregnancy Some prenatal oral conditions may have adverse consequences for child

23. Oral Lesions Oral cavity is more exposed to gastric acid - early  vomiting 2/2 morning sickness - later  pressure from enlarging uterus and a lax esophageal sphincter Mouth should be rinsed with baking soda & water to neutralize acid Avoid brushing teeth immediately after vomiting

24. Caries Pregnant woman are at higher risk for dental caries 2/2 increased acidity in the oral cavity and possible sugary cravings Children of mothers who have high caries are more likely to get caries

25. Pregnancy Oral Tumor Lesions are erythematous, smooth & lobulated, primarily on the gingiva Occurs in approx 5% of pregnancies Caused by increased progesterone More common after 1 st trimester and grows rapidly, typically recedes after pregnancy Mgmt is usually observational

26. Figure 2. Pregnancy oral tumor (pyogenic granuloma).

27. Loose Teeth Teeth can loosen during pregnancy even with no gum disease 2/2 increased progesterone & estrogen Condition is temporary and will not cause tooth loss

28. Gingivitis Most common oral disease in pregnancy – 60-75% 50% of women with pre-existing gingivitis have significant exacerbations If severe, may use mouth rinse s/a chlorhexidine (Peridex)

30. Periodontitis Bacterial infiltration of periodontium Bacterial toxins stimulate chronic inflammatory response Elevated levels of inflammatory markers have been found in amniotic fluid Meta-analysis showed association between periodontitis and preterm birth and low birth wt (although recently disputed)

31. Figure 4. Moderately severe periodontitis.

32. Recommendations If needed, schedule dental procedures during 2 nd trimester after organogenesis is complete Local anesthetics s/a Lidocaine & Prilocaine are category B and are safe when dosed appropriately Screening XR’s should be delayed until after delivery Xylitol & chlorhexidine lower maternal bacterial load and reduce transmission of bacteria to infants when used late in pregnancy