2022-23 TOW #1: Well-child care/ health supervision

The beginning of the academic year is a great time to review our central tenets in providing effective well-child care (WCC). We all recognize that providing comprehensive WCC is difficult in a 20-30 minute visit, so we have to prioritize. We also must consider models of care to truly impact social determinants of health and health equity, as one of our own amazing gen peds faculty, Dr. Tumaini Coker, discusses in her research featured below.

Materials for this week:

Take-home points for this week:

  1. Why well-child care? Through WCC visits, we have an opportunity to identify and address important social, developmental, behavioral, and health issues that can have significant effects on children’s lives. Pediatricians provide the vast majority of WCC to children in the US, which differs from other countries’ health systems where general practitioners or nurses provide it. One of our current pediatric challenges is to adapt WCC to better address issues of equity that most affect health across the lifetime including poverty, racism, environmental exposures, and ACEs (Adverse Childhood Experiences). Newer models of care, as Drs. Freeman and Coker describe above, including medical homes with integrated care, group visits, home visitation programs, and health navigators, are all being utilized and studied to improve WCC.
  2. What ages do we recommend WCC visits and why? We have >20 visits recommended with children between ages 0-18. Currently there are 6 visits recommended between birth to age 1 (newborn, 2-4 weeks, and 2, 4, 6 and 9 months). Visits are spaced out over the next 2 years (15, 18, 24, 30 months) and then annually after age 3. The timing for these has been largely influenced by providing vaccines, which is the most evidence-based prevention strategy we use in pediatrics; and by Bright Futures, developed by the maternal and child health bureau in the 1990s to standardize recommendations and care.
  3. How do we prioritize topics for WCC? For each recommended well-child check from newborn to age 21, Bright Futures includes guidelines for screening and a “menu” of 5 possible anticipatory guidance topics. Even with these pared down, there’s a lot to cover, so we often still have to do more focusing. There’s some data that parents can only retain up to 3-4 recommendations from a visit. It’s also not just what we say, but how we say it that matters. We should welcome parents’ concerns and acknowledge their needs and efforts. To support parents feeling engaged and supported, we can use the tools of Promoting First Relationships in primary care. Through specific positive feedback, we can highlight what we see them doing well to engage in responsive parenting, recognize their child’s needs, and to find joy in interacting with their child.
  4. What’s the evidence for effective components of anticipatory guidance? Studies are difficult to do and the data is limited. Because of this, the US Preventive Services Task Force often gives a Category 1 (Insufficient Evidence to Evaluate) rating to pediatric screenings, such as for lead, and cannot say whether outcomes are improved because of the intervention. There are several pediatric preventive health interventions with good supporting evidence including Reach Out and Read, promotion of breastfeeding, the “back to sleep” campaign, and avoidance of physical discipline.
  5. In the limited time we have, what’s most important to cover? Most important is that we address parents’ concerns and set an agenda together. While I don’t love or routinely remember mnemonics, “CHECUP” is a good list for basics to review that more or less maps to the typical flow I use for visits, starting with parent concerns.
  • C – Concerns (or questions)
  • H – History (interval hx, past medical, birth, family, social)
  • E – Environment (home, typical day, nutrition, sleep)
  • C – Child (development, growth, voiding)
  • U – Unanswered questions (inquire about further concerns)
  • P – Prioritized anticipatory guidance

2021-22 TOW #48: Supporting fathers and other parent figures

In honor of Father’s Day next weekend, we’ll how to be intentional about engaging fathers and other parent figures in the care of children. More children are now raised in families in which parents are not married, live in different households, and/or a father is the primary parent. Supporting fathers and/or other parent figures to be actively involved as parents is a great opportunity to help kids have broader support.

Materials for this week:

Take-home points:

  1. How has the definition of “father” expanded? A father can be any adult who is committed to, caring for, and supportive of the child including a stepfather, grandfather, adolescent father, father figure, or a co-parent, regardless of living situation, marital status, or biological relation. Thanks to evolving norms expanding child-raising, dads and other parents have the opportunity to be more actively and equitably involved.
  2. What are common barriers to fathers’ or other parents’ involvement in children’s health care? 4 major barrier categories include employment and structural barriers (lack of flexibility, military service, structural racism related to fathers’ not being in the child’s life, such as incarceration, etc), interpersonal (cultural, primary parent not wanting another parent’s involvement, or not living in the home), personal (lack of knowledge and comfort), and health care system (lack of access to records, appt times, etc).
  3. Why does involvement of fathers or other parents matter? To be clear, children can thrive in single-parent families without an additional parent or father role. For children in which there is a father or other parent present, this can positively impact health, mental health, and educational achievement of children. For those being raised without their biological father, families may consider increasing the involvement of dedicated positive role models of different genders in a child’s life. We can help dads and other parents know what a difference they make and proactively provide them parenting tips and support whenever possible.
  4. Why dads may need coaching and encouragement: Given more traditional gender roles related to caring for children, men are less likely to have babysat or helped care for siblings when growing up. In visits, we should engage dads and other parents by addressing them directly, learning their names, making eye contact, and including them when providing information about parenting and asking questions. We may need to remind moms of the importance of involving dads if more traditional gendered roles are present. We can help foster the mentality of teamwork as the best way to support the child. Doing this at the nursery and newborn visits is especially helpful to set the tone from the start, like handing the baby to the dad or another non-lactating parent to help change the diaper or soothe the baby. Specific ways to encourage dads or non-lactating parents to be part of care for infants include doing bedtime routine, taking walks or playing, reading books, and night-time feedings.
  5. Why we need parent-leave policies: Data from countries with generous parental leave policies for fathers (or other support parents) like Denmark, show impressive outcomes: dads become involved from the beginning in child-raising, and it’s better for the country’s overall productivity. We can all advocate through the AAP and other pediatric organizations to have more family-friendly leave policies in the US for all parents; encouragingly, Washington state and local tech employers have started to improve equity for their parental leave policies.

2021-22 TOW #47: Adverse Childhood Experiences (ACEs)

Neuroscience is catching up with what we have long known about social determinants of health affecting children’s development. The original study on Adverse Child Experiences (ACEs) was published almost 25 years ago in a collaboration between the CDC and Kaiser. Growing understanding of the science behind toxic stress outcomes is generating renewed interest and investment in early childhood programming, such as here in King Co with the Best Starts for Kids program, and nationally in programs like the AAP Resilience Project, among others.

A big thanks to the fantastic advocacy of Drs. Abby Grant, R3 Mike Arenson, and Kari Gillenwater, who helped update this topic, originally written by Drs. Grant and Colleen Gutman (Chief ’17). These materials also build on and relate to the approaches we have discussed in Promoting First Relationships (PFR).

Resources for this week:

Take-home points on ACEs/Trauma-informed care:

  1. What are the “Pair of ACEs”? Adverse Childhood Experiences (ACEs) are early life experiences which can lead to detrimental effects on child development and adult health outcomes. ACE’s include abuse, neglect, exposure to intimate partner violence, mental illness, drug addiction, or being bullied or punished harshly. These ACEs exacerbate historical (i.e., intergenerational) and community level traumas (this makes the “pair of ACEs”), such as poverty, racism, community violence, mass incarceration, and immigration policies at the U.S. border (see illustration below). There is a wide spectrum of adversity, which can oftentimes be expressed as an ACE score, however this score (among other risk factors derived at the population level) are not reliable predictors of individual outcomes.
  2. How do ACEs lead to Toxic Stress? Toxic stress refers to an individual’s physiologic response to these life adversities. Biomarkers of the physiologic response to toxic stress have the potential to be a sensitive and specific measure of experienced adversity at the individual level. Children experiencing adversity and maltreatment have been shown to have elevations in inflammatory cytokines and dysregulation of their HPA axis, which is believed to lead to changes in brain development.
  3. Are ACEs and Social Determinants of Health (SDOHs) different? ACEs and SDOH are conceptually similar, despite developing as separate fields of inquiry, advocacy, policy, and practice. Their definitions vary while including a variety of environmental exposures that threaten children’s health, development, well-being, and safety. One way to distinguish the two is that ACEs tend to affect a young person’s ability to form healthy attachments and relationships. In contrast, CDC defines SDOH as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes.” We now see both are potential causes of toxic stress, and we can prevent, buffer, and repair through relational health building.
  4. Do ACEs always lead to Toxic Stress? Fortunately, adversity in childhood is only half the story, as positive experiences in childhood improve outcomes in life. Positive relational experiences, such as engaged, responsive caregivers, shared children’s book reading, access to quality early childhood education, and opportunities for developmentally appropriate play are all associated with positive impacts on learning, behavior, and health. Other research on positive childhood experiences that provide powerful protection against toxic stress, as described in the HOPE framework (Health Outcomes from Positive Experiences). This research encourages shifting from Trauma-Informed Care framework to a Healing-Centered Engagement (HCE) framework (more on this below).
  5. How does toxic stress affect our biology? The Ecobiodevelopmental (EBD) Framework. Early childhood experiences, both adverse and positive, appear to be biologically embedded and influence both disease and wellness across the life course. The EBD model of disease and wellness explains how the ongoing, cumulative and reciprocal dance between ecology and biology leads to changes at the molecular (e.g., methylation patterns), cellular (e.g., brain connectivity patterns), and behavioral levels (e.g., tobacco, alcohol, or other substance use).
  6. What is the role of the pediatrician in addressing toxic stress? Addressing Toxic Stress within the EBD framework requires a “Public Health Approach” with multiple levels. Prevention entails taking active roles in advocacy to reduce toxic stress in early childhood and promote positive childhood experiences, including addressing racist policies and behavior. Secondary approaches may include screening patients for symptoms or for positive and adverse childhood experiences. While concerns remain about universal screening for ACEs in primary care, Dubowitz et al. (2022) recommends focusing initially on families with children aged <6 years old given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period of time. Primary care professionals and staff must be trained to respond appropriately, including having good referral processes. In all medical environments, we can use the concepts and resources from the trauma-informed care literature. This involves treating everyone with respect and humility, being aware of somatic symptoms that may signal untreated stress/trauma, giving special attention to those affected by trauma, and helping build resilience while avoiding re-traumatization.
  7. Why are we shifting from Trauma-Informed (TIC) to Healing-Centered Engagement (HCE) and relational health building? While TIC offers an important lens to support young people and families, it also has limitations. For example, it runs the risk of focusing on the treatment of pathology (trauma) instead of fostering possibility (well-being). HCE is asset driven and focuses on what we want, rather than symptoms we suppress. HCE builds empathy, encourages young people to dream and imagine, and builds critical reflection. An important ingredient in HCE is the ability to acknowledge the harm and injury, but not be defined by it, and to take loving action. Relational health refers to the capacity to develop and sustain safe, stable, and nurturing relationships (SSNRs), which in turn prevent the extreme and prolonged activation of the body’s stress response system. The focus on relational health is strength based and resilience building.

2021-22 TOW #46: Firearm injury prevention

For us as pediatricians, there seems no more compelling topic to discuss this week given recent events, as hauntingly recounted in the New Yorker by Dr. Rachel Pearson, UW Peds R’19 grad.  This Friday June 3 is national Gun Violence Awareness Day with Wear Orange for Gun Safety events happening locally. We are fortunate that our local general pediatrician hero, Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention, leads visionary research as director of the Firearm Injury and Policy Program (FIPRP) with co-director Dr. Ali Rowhani-Rahbar (Sahar’s husband!) at the Harborview Injury Prevention and Research Center (HIPRC). Materials for this week:

Take-home points for firearm safety:

  1. What are some key statistics on firearms and children? Firearm injuries became the leading cause of death in U.S. children in 2020. 1 in 3 homes in the US with children have firearms. 80% of unintentional firearm deaths of kids under 15 occur in a home. In classic studies, Rivara and his colleagues found in a home with a firearm, the odds ratio of suicide was 4.8; Kellerman found a firearm was 43 times more likely to be used to kill a family member or friend rather than be used in self-defense. Fowler and colleagues found that Black youth aged 15 to 24 years were 19 times as likely to be victims of firearm homicide than White peers. We  must acknowledge the deep inequities in urban firearm injuries disproportionately harming Black youth and seek to eliminate poverty and racism that are key factors in those disparities.
  2. Who should we prioritize for firearm screening? If you are tight for time and cannot screen for firearms in every clinic wellness visit, be sure to include specific counseling in visits with depressed teenagers. In a case-control study done by Grossman et al., storing firearms locked, unloaded, or separate from the ammunition was associated with significantly lower risk of unintentional and self-inflicted firearm injuries and deaths among adolescents and children. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline and the 3 Interventions Toolkit from the FIPRP.
  3. What can we recommend for firearm storage? The safest thing is not to have a firearm in your home. For families that have one, advise that the safest way to store guns is unloaded, locked, and out of reach of young children and teenagers. There are 5 main types of locking devices to improve safe storage: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Generally avoid devices with keys. Visit www.lokitup.org for information about how to store firearms. Consider using a statement like: “Having a loaded or unlocked gun in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store your unloaded guns in a locked drawer or cabinet, out of reach of children.”
  4. How do we advise parents to ask about firearm safety? Research shows that 93% of parents, including parents who choose to own firearms, would be comfortable with being asked about a firearm in their home. Present your concerns with respect. Suggested wording includes:  “Knowing how curious my child can be, I hope you don’t mind me asking if you have a firearm in your home and if it is properly stored…” For family members, this might include: “[Mom, Dad] this is awkward for me and I mean no disrespect. I am concerned Alex will find one of the firearms in your home when we visit, and I want to make sure we keep her safe. Do you keep them locked up with the ammunition stored separately?”
  5. Does counseling work? Several studies have found counseling in office visits to be associated with improved safe storage of firearms. A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Likewise, Barkin et al. found that brief office-based counseling increased the use of safe storage.

2021-22 TOW #45: Travel Preparedness

School is out in just a few weeks and that means many families are preparing for travel this summer. Next week’s topic reflects our increasing globalization that manifests in more children traveling internationally. This is a good time to review some of the key resources and recommendations for travel preparation visits.

Materials for this week:

Take-home points for travel preparedness with children:

  1. How common is international travel among children? The CDC reports 2016, almost 2.81 million international travelers from the United States were children or adults traveling with children. Children are less likely to get travel advice/visits compared to adults. In one review of children with post-travel illnesses evaluated at clinics, only 32% of the children visiting friends and relatives had received pre-travel medical advice, compared with 59% of adults.
  2. What are the most common childhood illnesses encountered while traveling? Most common are diarrheal illnesses, skin conditions (including bites, cutaneous larva migrans, and sunburn), systemic febrile illnesses (especially malaria) and respiratory disorders. Injuries are also common, especially motor vehicle and water-related injuries. Assault and STI are added risks for teenagers who are traveling.
  3. What should pre-travel advice include? Vaccination review is key. Make sure children are up to date on common vaccines and then assess for travel-related vaccines. When indicated, we provide typhoid injection and yellow fever vaccines, and if given enough lead time, we can sometimes get it covered by insurance through a prior authorization. Some pharmacies provide these at reasonable costs-ask your clinic facility. In places where food safety is a concern, a good motto is “Boil it, peel it, cook it, or forget it.” Wear seatbelts and travel with appropriate carseats, whenever possible.
  4. What counseling should be provided for children visiting friends and relatives in developing countries? In many situations, children will have increased risk of exposure to malaria, intestinal parasites, and tuberculosis. Review malaria prevention and provide malaria prophylaxis medications, as appropriate. Zika virus is also a risk for families. Screen for tuberculosis after children return if they have visited an endemic country for a week or more. You can test as early as 10 weeks after they return (or you can wait until their annual well child exam).
  5. What tips can we provide about plane travel with infants/young children? This is a common request for many of us. I was lucky (?crazy) enough to take flights with both of my daughters around 2 months of age. A few suggestions that I have used were compiled in this online article. A few other tips to add: keep plenty of extra clothes, bottles, food, and hand sanitizer when traveling with young children. Traveling with COVID has been extra difficult, and masks are still recommended even though they are now optional on flights. Be sure parents have had all of their vaccines, and give babies theirs as early as possible (2 month vaccines can be given as early as 6 weeks).

2021-22 TOW #44: Hematuria

Until recommendations changed in 2008, pediatricians routinely performed urinalysis screening in otherwise healthy children. This is no longer recommended given lack of benefit; however, we are recommended to annually screen children with higher risks given the possibility of medical complications.

Materials for this week:

Take-home points on hematuria (case also reviews proteinuria part):

  1. How do we define hematuria and how many children have it? Hematuria is presence of 5+ RBCs/HPF in multiple specimens over 4-6 weeks. Microscopic is visible only on testing and macroscopic (gross) hematuria is visible to the eye. Beware of false hematuria from drugs, foods (e.g.,beets, blackberries), toxins (e.g., lead), and urate crystals in newborns. In population samples, 3-6% of school-age children had asymptomatic microscopic hematuria in a single urine sample, declining to 0.5% to 1% on repeat screening.
  2. Who should be screened with annual urinalysis? The AAP recommends urinalysis screening for high-risk populations: prematurity (<32 weeks) [or very low birthweight, other neonatal complications requiring NICU care], congenital heart disease (repaired or unrepaired), recurrent UTIs, known renal disease or urologic malformations, solid organ transplant, malignancy or bone marrow transplant, history of or prolonged treatment with nephrotoxic drugs, history of recurrent episodes of acute kidney injury, or family history of inherited renal disease.
  3. What are important categories of hematuria to know? Diagnostic evaluation depends on the category: gross hematuria, symptomatic microscopic hematuria, asymptomatic microscopic hematuria with proteinuria, or isolated asymptomatic microscopic hematuria (which is usually benign and resolves). Evaluating RBC morphology helps distinguish glomerular and extraglomerular sources. Glomerular bleeding is typically “cola-colored,” with RBC casts and distorted RBC morphology.
  4. How does accompanying proteinuria or other symptoms change things? Hematuria with proteinuria, edema, or hypertension suggests underlying renal disease. Underlying causes of gross hematuria are identified in 56% of cases including UTI, trauma, kidney stones, hypercalciuria, coagulopathy, and kidney disease.
  5. Initial next steps: Repeat the urine test with microscopy, identify other symptoms, and review family history of renal disease. For persistent proteinuria, a morning and evening urine will be needed to identify orthostatic proteinuria, which accounts for 60% of asymptomatic proteinuria cases. If the patient has any markers of serious glomerular pathology, a basic metabolic panel, CBC, C3, C4, albumin, ANA, anti-streptolysin (ASO) and anti-DNAse B titers, and streptozyme would be recommended.

2021-22 TOW #43: Suicide prevention

Huge thanks to the dynamic duo of gen peds faculty at KDM, Drs. Kari Gillenwater and Nicole Johnson, for the fabulous TOW materials for this week! Lots of important info to cover for this topic. Over the past decade we have seen an increase in the rates of suicide in our children in the US. ED visits for suicidal ideation and attempts have increased during the pandemic. Every day as pediatricians, we find ourselves supporting teens and their families through moments of crisis. Understanding how to approach and support families at these times, putting plans in place and having access to crisis prevention resources is essential. We have created this topic of the week to help us respond effectively and help our kids stay safe.

Materials for the week:

Key take-away points on suicide prevention in youth:

  1. How common is suicide among our youth in the US? Suicide is the 2nd leading cause of death in teens 15-19 years old and is now the 8th leading cause of death for 5–11-year-olds. About 16-18% of adolescents report planning for self-harm. The means of completed suicide is > 90% from hanging and firearms, ~7% from overdose, and < 3% from other causes.
  2. What are risk factors for suicide? More than 90% of teens who attempt suicide have an underlying psychiatric illness, typically depression or anxiety. Other major risk factors include having a history of prior suicide attempt, parental psychopathology (including having a family member who has completed suicide), alcohol and drug use, access to lethal methods such as firearms, history of physical or sexual abuse, impulsivity, social isolation, LGBTQ+, male, white, Native American, and exposure to bullying. It has also been shown that self-harm is associated with increased risk of suicide completion. Non-suicidal self-injury is far more common than suicide, with a lifetime prevalence of 21-28%. Additionally, exposure to suicidal behaviors has been identified as a risk factor, commonly known as contagion. One study showed a 5-fold increase for suicide in of 12–13-year-old children after a peer committed suicide.
  3. What are protective factors against suicide? Having strong family connectedness, school engagement, effective coping skills and the absence of lethal means in the home are all protective factors against suicide.
  4. What is the role of the pediatrician in preventing suicide? Primary care visits account for 70% of adolescent visits each year and nearly 75% of adolescents who complete suicide had seen a medical professional within the past 4 months. Pediatricians should be familiar with identifying risk factors for suicide, screening tools to assess risk of suicide, and safety/crisis planning tools, as well as local crisis support resources.
  5. What screening tools are recommended to use in the primary care setting? Based on strong evidence, adolescents ages 12 and should be screened for depression when follow-up can be assured. The PHQ-9 includes a suicide screening question, #9, “Thoughts that you would be better off dead, or thoughts of hurting yourself in some way”. If #9 is positive, following up with a suicide risk screening tool like ASQ (Ask Suicide Screening Questions) is indicated. This tool is available in 12 languages other than English. When suicide concerns arise, the visit should divert to prioritize this issue. If the ASQ indicates, then conduct a brief suicide assessment, which can be used from the ASQ toolkit. Note, although universal screening for suicidality is not supported by current evidence, all adolescents with known risk factors for suicide should be screened proactively.
  6. Does talking about suicide increase the risk of an attempt? No. It is a common misconception, even among physicians, that has been firmly dispelled. It is well established that asking about suicide does not increase the likelihood of an individual thinking about or committing suicide. Studies show that nearly 80% of teens thinking about suicide want others to know about their suffering and stop them from harming themselves.
  7. What are the Washington laws around confidentiality? Washington State allows outpatient mental health treatment if you are 13 years or older without an adult’s consent (RCW 71.34.530). Laws on confidentiality can be reviewed from Washingtonlawhelp.org. Confidentiality is not absolute. It is best practice to discuss the limits of confidentiality at the beginning to let them know if there is risk of harm to self or others or abuse that you will create a plan together to find support from a safe adult.
  8. What management algorithms are recommended for a suicidal patient in outpatient care for suicide prevention? Consider using the Washington Chapter AAP algorithm to help with management, which may be adapted to utilize the supports available in your specific clinical environment. Actively suicidal patients or those at high risk of suicide should be taken to the ED for further evaluation by a mental health professional. Evidence-based treatment includes DBT, CBT and treatment of underlying mental illness. For those who are safe to discharge home, close monitoring is recommended, and a safety plan should be made with the youth and a safe adult. A crisis safety plan: recognizing warning signs, using coping skills, naming support persons, identifying someone who might help resolve a crisis, knowing mental health agencies to contact including lifeline numbers, ensuring a safe environment, identify reasons to live (a positive focus to leverage). Note, this is not a no harm contract, which has not shown to be effective. Connect to crisis resources, consider starting an antidepressant (e.g., SSRI), and provide close follow-up.
  9. What resources can you recommend for youth and their families given the current strain on access to mental health system?  Consider using resources such as your county’s crisis services (CCORS in King County (1-866-4CRISIS) which has 24/7 same day mobile crisis outreach, Pierce County Crisis line (1-800-576-7764)), current mental health providers and their crisis support teams when available, services available within your individual clinics such as social workers and behavioral health integration programs (BHIP) and their providers may provide support during a crisis. National suicide hotlines 800-273-TALK and the 24/7 crisis text line (text “HOME” to 741-741) can be provided.

2021-22 TOW #42: Lymphadenopathy

This week’s topic is a review of lymphadenopathy and how to characterize those lumps and bumps. Fascinating fact to share with kids and families: there are about 600 lymph nodes in the body!

The teaching materials for the week:

Take-home points on lymphadenopathy:

  1. What’s the definition of lymphadenopathy? Lymphadenopathy is abnormality in size, number, or consistency of lymph nodes. Whereas, lymphadenitis is an inflammatory or infectious enlargement of lymph nodes (which I recently saw in a toddler’s pre-auricular lymph node, which had swollen below the ear to about 2cm). Lymph nodes are normally up to 1cm in the axillary and cervical regions and up to 1.5cm in the inguinal region. “Shotty lymphadenopathy” refers to multiple small, mobile lymph nodes resembling birdshot (~2mm) or buckshot (~8mm) under the skin. This is a common, self-limited finding in children under five typically during viral illnesses. Any node >2cm should be considered abnormal. Generalized lymphadenopathy refers to two or more noncontiguous sites of lymph node enlargement.
  2. Why is lymph so important?: An “ultrafiltrate” of blood, lymph carries immune cells in lymph capillaries through the entire body except the brain and heart. The bone marrow and thymus are the primary lymphoid organs because they generate B and T lymphocytes. Secondary lymphoid organs are lymph nodes, spleen, and mucosa-associated lymphoid tissue (MALT), including the tonsils, appendix, and Peyer patches of the ileum. Because young children’s immune systems are actively developing, we commonly feel enlarged lymph nodes.
  3. What’s on the differential diagnosis? The broad categories are infectious, immune disorders, and malignancy. Under age 5, we know enlarged cervical lymph nodes are almost always an infectious cause-don’t forget scalp and dental sources. Supra-clavicular nodes are always abnormal, most commonly caused by lymphoma, mycobacterial infection, or sarcoidosis. Generalized lymph node swelling is more likely to be systemic infection (viruses, including EBV, CMV, HIV, syphilis or toxoplasmosis), but also may be a sign of malignancy or autoimmune disorders.
  4. What are key parts of history and physical exam? Ask about systemic symptoms, including fever, weight loss, night sweats, poor appetite, and fatigue. Ask about the time course, and change in the size or number of lymph nodes. Review exposure to insects, animal contacts, travel, and immunizations. Determine locations of lymph nodes, whether unilateral versus bilateral, soft versus hard, mobile versus fixed, and tender versus non-tender. Focus the rest of the exam on chief complaint/symptoms. More worrisome signs for malignancy include hard/ rubbery, immobile, persistent and non-tender lymph nodes (though malignant ones can also be tender).
  5. When should we do a work-up and what should it include? If nothing suggests malignancy, observe for 2-4 weeks, then follow-up. If not resolved, work-up would include viral serologies and CBC, ESR and CRP. Additional testing is done based on history (e.g., Bartonella henselae PCR for cat scratch, or TB testing for patients at risk). One of the interesting zebras on the differential for lymphadenopathy is Kikuchi disease, a necrotizing lymphadenitis. When there is concern for malignancy, including prolonged duration, location, large or increasing size, abnormal texture, and/or the presence of constitutional symptoms, we should refer for biopsy and obtain CXR to look for mediastinal lymphadenopathy. Lymphadenitis is often empirically treated with antibiotics initially, which is what we did for the toddler noted above (and seemed to be improving per follow-up by my excellent colleague, R3 Dr. Henry Evans).

2021-22 TOW #41: Transition to adult care

R3s will soon be making their own big transitions into jobs and fellowships! Likewise, our adolescent/young adult patients will experience notable transitions as they graduate pediatric care and move on to new life adventures. Transitions for some of our patients with special health care needs require additional support, which we will review in this week’s topic. Big thanks to Dr. Peter Asante for his contributions to this topic!

Materials for this week:

Take Home Points:

  1. Why is transition of care important? Every year, about 500,000 adolescents with special health care needs transition from pediatric to adult care. For children with special healthcare needs, this is the highest risk time for health complications and poor outcomes. Continued care at pediatric medical centers after age 21 has been associated with higher risk of mortality. In a national survey in 2016, only 15% of youth with and without special health care needs received transition planning assistance from their health care providers. We can do better!
  2. When should transition process start? 2018 joint guidelines on transitions of care recommend the following schedule as a general guide:
    • Age 12-14: Start discussing the transition process with teens and parents. Provide a copy of office Transition Policy. (To me this is REALLY early for primary care, so I am more likely to wait to mid- to late teens, depending on the pt)
    • Age 14-18: Jointly develop a Transition Plan with youth and parents and track progress. During this time, providers should create a safe space within clinic visits for teens to start practicing self-management skills.
    • Age 14-18: Review and update Transition Plan, and prepare for adult care.
    • Age 18-21, youth understand and have experienced an adult model of care. The teen and family can visit adult medicine practices, meet new providers, and decide who will be the best fit for their needs. Some may not be ready until closer to age 21.
  3. What are the key elements of transition? Transition involves both assuming self-management of medical care (when appropriate for the patient’s abilities) and transfer of medical summary/ documentation. Six Core Elements of Transition have been described, include establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring, and integrating into an adult practice. Using these elements helps start the conversation with families early and provides a standardized process.
  4. What resources are there to help with this process? GotTransition.org provides customizable forms on their website, which can be used to create many of the important documents needed in transition. For medically complex adolescent patients who see multiple specialist providers for their care, this process will probably be more complicated, so it is encouraged that you start this process early! Locally, the UW Medicine Transitions Clinic can be a valuable resource for 18-24 year old patients who need to transition two or more specialists. The Center for Children with Special Needs maintains its website and online resources (though no longer has a physical home).

2021-22 TOW #40: Seasonal allergies

May is around the corner and is designated National Asthma and Allergy Awareness Month. With Earth Day this Friday, we also acknowledge the effects of climate change that prolong and exacerbate seasonal allergies and what we can do about it.

Materials for this week:

Here are take-home points about evaluating stuffy nose/allergic rhinitis:

  1. How many people are affected by allergic rhinitis? Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR. The National Wildlife Federation had a comprehensive report in 2010 documenting why and how climate changes were affecting allergies – and more recent evidence continues to emerge, so adapting and mitigating risks are key. Reducing fossil fuels is a win-win for slowing climate change and reducing allergy symptoms and asthma attacks.
  2. What is the clinical definition or AR? Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” AR is a hypersensitivity reaction to allergens due to IgE. Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks. It’s often tricky to evaluate relative to viral-induced symptoms, given there is so much frequency of both, but with AR, itching of nose and eyes is more prominent, rhinorrhea is clear.
  3. What do we see on physical exam? Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds around the eyes due to edema. The “allergic salute” is a transverse nasal crease in children who chronically push their palms upward under their noses (to wipe mucus)-(and they really do happen – I was very aware of this one year when my daughter developed one after a very sniffly stretch!)
  4. What’s the appropriate work-up? You may decide to do skin testing to evaluate specific allergens and help with environmental control strategies, such as for dust mites. Skin testing is preferred to blood testing, but is not 100% specific and requires clinical correlation with symptoms/triggers.
  5. How do we manage AR? Treatment options are allergen avoidance (monitoring pollen counts to avoid outdoor time when peaking, using air filtration in homes, wiping/removing shoes, and bathing/showering after outdoor time, etc.), pharmacotherapy, and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids, which is approved for kids >2. Next best are non-sedating antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists. Sometimes people develop tolerance to one group, so switching drugs can help. Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.