2018-19 TOW #47: Tuberculosis screening

We are fortunate to live in an increasingly diverse city with immigrants from around the world. At this time of year families are often planning summer travel to visit family members abroad, so this is a good time to think about how to screen for TB after travel. Materials for this week:

Key take-home points:

  1. What are the rates of TB in the US, and what are the risk factors among children? TB has been declining in the US and reached an historic low of 3.2 cases per 100,000 in 2012. The biggest risks are being born outside the US, or traveling to another country, especially for >1 week and staying with family. For children, additional risks include living among family members or visitors born in endemic countries, or living with high risk adults (including those affected by homelessness, incarceration, drug use or HIV). Those with chronic diseases, immunodeficiency, and/or those using high-dose steroids are also at higher risk of developing TB.
  2. Who do we need to screen for TB in clinic? It’s recommended to start screening for latent TB infection (LTBI) from the first time we meet patients and annually at well visits, or 10 weeks after return from travel (although considered acceptable to wait for annual check-ups). To assess LTBI risk factors, there are 4 validated questions: 1) Has a family member or contact had TB? 2) Has a family member had a positive TB test? 3) Was the child born in a high-risk country (i.e., outside US, Canada, Australia, New Zealand or Western Europe)? 4) Has the child traveled to a high-risk country for more than 1 week? (and SCH ID team adds: or has child had household visitors from a high-risk country?)
  3. Which screening tests do we use? Screening tests vary by age group: per the CDC, tuberculin skin test (TST or PPD) is still preferred for children less than 5. The preferred test for ages 5 and older is a blood test, the interferon gamma release assay (IGRA, e.g., QuantiFERON -TB Gold). IGRA tests measures interferon gamma response to mycobacterial antigens so are relatively specific to M. tuberculosis. They do not require a return visit, and are not cross-reactive with BCG vaccine. We can use a combination of tests to help establish diagnosis when there are indeterminate results, or concern for false positives or negatives.
  4. What happens if there is a positive TB screen? To establish a diagnosis of latent TB, rule out active disease through a chest x-ray, history and exam. The initial preferred treatment for positive latent TB is with isoniazid (INH) for 9 months (there are alternative schedules to this based on special patient needs).
  5. How common is BCG vaccine? How does BCG vaccine affect interpretation? Bacille Calmette-Guerin (BCG) immunization is widely used in TB endemic countries; the WHO estimates that 83% of the world’s population has received this vaccine. Most countries recommend giving the vaccine at birth, and the majority of children receive it before age 5. Because of the varying effects of BCG on interpreting TB tests, we use a conservative approach, and BCG status is not used in interpreting PPD reactions, and is not a contraindication for receiving PPD. Quantiferon gold testing is not affected by cross-reactivity with BCG, however the test has been less accurate for younger children, and may be more difficult to administer due to phlebotomy requirement.

2018-19 TOW #19: Acute Asthma

It’s the time of year when our clinics and the ED are starting to see more kids with viral-induced asthma exacerbations, so it’s an opportune time to review the guidelines and resources to address these. The REACH pathway residents have provided some helpful materials, which I have included below. Locally we also have the wisdom of the great Dr. Jim Stout, faculty at Odessa Brown, who has been a national leader in asthma quality of care research.

This week’s teaching materials:

Take-home points for acute asthma management:

  1. Epidemiology: the CDC estimates that 8.3% of children have asthma, making it one of the most prevalent diseases of childhood. Rates are higher among blacks, certain Hispanic groups, and those in poverty. Among those with asthma below age 18, 57.9% report having one or more asthma attacks, so the majority of kids with asthma will be treated for exacerbations.
  2. Severity guides treatment: Determining severity is based on many components including level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating respiratory scores used at Seattle Children’s Hospital (SCH), such as in the SCH asthma pathway.
  3. Initial treatment: For moderately severe symptoms, give albuterol MDI 8 puffs (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), start dexamethasone (0.6mg/kg, max of 16mg), and repeat in 24 hours. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity and history.
  4. Education is critical: as we know, education about asthma is so important to families’ understanding and implementation of treatment. It’s important to review and update asthma action plans during exacerbations. Families should receive coaching and should be able to demonstrate use of MDIs with a valved holding chamber (VHCs or “aerochamber”). There are great written resources and videos out there on avoiding triggers through the NW Clear Air Agency. Families in Seattle/King Co are eligible to receive a free home health assessments through the American Lung Association. Most families do not know about this great program, so referral is key.
  5. Provide follow-up: it’s important to have follow-up within a few days (in person for more moderate cases, or maybe by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also important. The Washington Medical-Legal Partnership (MLP) has great sample letter templates we can use to help families notify landlords of needed repairs, such as improving ventilation, removing mold or insects. If you need additional assistance, remember to refer patients via the Washington MLP at Seattle Children’s Hospital (patients are eligible if they are patients at SCH).

TOW #22: Community Acquired Pneumonia

Next week’s topic is community acquired pneumonia (CAP), a relevant topic as we enter the winter months.

Materials for this week

A few take home points to review:

  1. What is the global burden of pneumonia? The WHO reports pneumonia is the single highest cause of death in children worldwide under 5, accounting for 18% of deaths. Fortunately it has become much less of a problem for us in an era of widespread access to vaccines against pneumococcal and HIB. In the US, pneumonia occurs in an estimated ~2.6% of children under age 17.
  2. How do we diagnose pneumonia? Pneumonia is a clinical diagnosis that can be challenging to confirm, and no single definition is used in pediatrics. In diagnosing it, we look for the most common symptoms of cough, fever, and/or tachypnea in the setting of findings of parenchymal disease by either physical exam or chest x-ray. Crackles (rales) are the most common exam finding, but we should also look for decreased breath sounds, egophany, tactile fremitus, and/or dullness to percussion. X-rays are not needed to confirm diagnosis or resolution of pneumonia, but should be obtained when diagnosis is less certain and/or patient symptoms are more severe. Labs such as blood cultures are not routinely indicated for children treated as outpatients.
  3. What is the recommended treatment? Treatment is based on age and severity. Viral pneumonia is much more common in preschool age children, so observation and supportive care is often appropriate. Older children are more likely to have bacterial pneumonia and are treated as appropriate with high-dose amoxicillin as first line therapy for lobar disease. Use azithromycin for suspected atypical pneumonia, or both amox and a macrolide, especially if they are sicker.
  4. Who can be managed as an outpatient? Outpatient management of pneumonia is appropriate for mild-to-moderate disease for children who are not hypoxic or in distress who can tolerate oral antibiotics. The Pediatric Infectious Diseases Society guidelines  recommend hospitalization for children with moderate to severe CAP including respiratory distress and/or hypoxemia (pulse ox <= 90%).

TOW #19: Asthma diagnosis and management

This week our REACH pathway R2s shared some asthma management tips and tricks for morning report and featured R2 Bryan Fate’s new hit song “IHELP You”! As one of our most common childhood conditions, asthma diagnosis and outcomes highlight the effects of social determinants of health and the resulting health disparities that unfortunately exist. Our residents reminded us how we can recognize and address social needs through screening, referral and use of support systems. The IHELP mnemonic is used to screen for Income, Housing, Education, Legal/Literacy and Personal safety needs that affect overall health, including asthma. We want to provide effective care for children of all backgrounds and to recognize and address the powerful influence of social factors on health. Let’s keep this in mind as we discuss asthma.

A BIG thank you to Dr. Cathy Pew our intrepid gen peds team leader at Neighborcare – Meridian who tackled being lead author for our local outpatient asthma management guidelines and to the wise Dr. Jeff Wright, emeritus faculty, who initially designed the algorithms to accompany them.

Materials:

Asthma Diagnosis and Management take-home points:

  1. Epidemiology: Asthma rates are increasing every year in the US. Asthma affects 1-2 out of 10 children in the US and rates are even higher among black and Hispanic children. From 2001 through 2009 asthma rates rose the most among black children, almost a 50% increase.
  2. Asthma diagnosis and management is based on age, severity, and level of control. “Severity” is the intrinsic intensity of the disease process, which is based on impairment and risk. Severity is classified as “intermittent” or as “persistent” with mild, moderate, or severe levels. “Control” refers to the degree to which manifestations of asthma are minimized and the goals of therapy are met. This is classified as “well controlled,” “not well controlled”, or “very poorly controlled.” To help make this diagnostic process easier, please refer to our UW Division of General Pediatrics outpatient clinical guidelines for asthma which are based on the 2007 NHLBI guidelines and include flow diagrams for 0-4 yo, 5-11 yo and 12 and older (as above).
  3. We use a step-wise treatment to help manage asthma. The National Asthma Control Initiative outlines 6 priority messages for clinicians to help control asthma:
  4. To reduce environmental exposures for children, there are a number of resources we can use. Key resources locally include the American Lung Association home health assessment program and the King County asthma program, both of which have home visiting programs that we can refer families to that will help identify environmental exposures. The Medical-Legal Partnership is also helpful to access the legal system to ensure environmental triggers are minimized in rental properties where children live.
  5. Be sure to review your clinic’s management approaches and tools including action plans, EMR tools, screening questionnaires, and spirometry options. For clinics using EPIC, there is a great smartset for asthma that Dr. Sheryl Morelli helped champion based on the outpt guidelines.

Thanks for all you do to care for our community’s children and address their needs at many levels.

TOW #21: Tobacco exposure

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This week's topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up on Thursday November 17th. The American Cancer Society designates the 3rd Thursday of November each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking.

Materials for next week:

Take-homes points:

  1. How many children are exposed to secondhand smoke? More than half of US children have secondhand smoke exposure (based on biological samples of population data).
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with nonrespiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What's the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. "Is your child around anyone who smokes?" is a neutral way to open up the conversation. If the parent is smoking I often follow-up with "How are you feeling about smoking?" as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don't forget about using scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) Using pharmacologic treatment doubles the chance that a smoker will quit.
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes.

TOW #19: Acute asthma

It's the time of year when our clinics and the ED are starting to see more kids with acute asthma exacerbations, so it's an opportune time to review the guidelines and resources to address these. The REACH pathway residents provided super helpful updates to this topic this week for morning report, which I have included below. Locally we also have the wisdom of the great Dr. Jim Stout, faculty at Odessa Brown, who has been a national leader in asthma quality of care research. This week's teaching materials:

Take-home points for acute asthma management:

  1. Epidemiology: the CDC estimates that 8.3% of children have asthma, making it one of the most prevalent diseases of childhood. Rates are higher among blacks, certain Hispanic groups, and those in poverty. Among those with asthma below age 18, 57.9% report having one or more asthma attacks, so the majority of kids with asthma will be treated for exacerbations.
  2. Severity guides treatment: Determining severity is based on many components including level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating respiratory scores used at Seattle Children’s Hospital (SCH), such as in the SCH asthma pathway.
  3. Initial treatment: For moderately severe symptoms, give albuterol MDI 8 puffs (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), start dexamethasone (0.6mg/kg, max of 16mg), and repeat in 24 hours. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity and history.
  4. Education is critical: as we know, education about asthma is so important to families' understanding and implementation of treatment. It's important to review and update asthma action plans during exacerbations. Families should receive coaching and should be able to demonstrate use of MDIs with a valved holding chamber (VHCs or “aerochamber”). There are great written resources and videos out there on avoiding triggers through the NW Clear Air Agency.
  5. Provide follow-up: it's important to have follow-up within a few days (in person for more moderate cases, or maybe by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also critical. Refer to these great resources for home health assessments through the American Lung Association.

TOW #28: Asthma diagnosis and management

Today we had an amazing grand rounds talk sponsored by Odessa Brown Children's Clinic on race and racism in health care by Dr. Steve Nelson from Children's Hospitals of Minnesota. Next week’s topic highlights some of the awful health disparities in one of the most common conditions of childhood, asthma. As Dr. Nelson discussed, the reasons are multifactorial. His message: recognize our biases and do what we can to address racial inequities in systems of care. We as clinicians want to provide appropriate care for ALL children. Let's keep this in mind as we discuss asthma.

A BIG thank you to Dr. Cathy Pew who was the intrepid lead author for our local asthma management guidelines and to Dr. Jeff Wright who designed the beautiful algorithms to accompany them (see link below).

Materials:

Asthma Diagnosis and Management take-home points:

  1. Asthma rates are increasing every year in the US. Asthma affects 1-2 out of 10 children in the US and rates are even higher among black and Hispanic children. From 2001 through 2009 asthma rates rose the most among black children, almost a 50% increase.
  2. The National Asthma Control Initiative outlines 6 priority messages for clinicians to help control asthma:
  1. Refer to our UW Division of General Pediatrics outpatient clinical guidelines for asthma which are based on the 2007 NHLBI guidelines and include flow diagrams for 0-4 yo, 5-11 yo and 12 and older.
  2. Reduce environmental exposures for children. Remember resources available through the American Lung Association home health assessment program and the Medical-Legal Partnership.
  3. Be sure to review your clinic’s management approaches and tools including action plans, EMR tools, screening questionnaires, and spirometry options.

Wishing you all the best-thanks for all you do to care for our community's children and address their needs at all levels.