2018-19 TOW #44: Circumcision

Newborn male circumcision is a topic that remains controversial in pediatrics, and overall the AAP has maintained a neutral stance on it. The most recent AAP report, issued in 2012, stated that overall, male circumcision has adequate benefits compared to risks to “justify access to the procedure for families who choose it.” In Washington State, families who choose circumcision must pay for the procedure out of pocket. At the UW Northgate Clinic, one of the available local sites, it costs about $300.

Materials for this week:

Key take-home points:

  1. What are the main benefits and risks of circumcision? Benefits include decreased risk of UTI before age 2, and decreased risk of heterosexual transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in female partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, and buried penis.
  2. What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
  3. What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw appearance from lysing foreskin adhesions, which can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
  4. When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, phimosis or paraphimosis, or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves).
  5. What advice do we give about care for the uncircumcised penis? The only care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractible foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 3 in about 90% of boys, and by teenage years in almost all boys.

2018-19 TOW #35: Menstrual disorders

As we help with the process of puberty, addressing the challenges that arise with menarche and menstrual disorders in adolescents is a common issue we see in primary care. This is a great topic for seniors who have done their adolescent rotation to facilitate.

Materials for this week:

Take-home points for this week:

  1. How is the menstrual cycle different for adolescents than fully mature females? In adolescents the hypothalamic-pituitary-ovarian (HPO) axis feedback loops are not yet mature. For the first 1-2 years after menarche, steroid hormones do not yet regularly have coordinated negative and positive feedback loops to cause ovulation, so menstrual cycles may be anovulatory or infrequent /irregular (oligoovulation). In the first year after menstruation, ~50% of cycles are anovulatory. One of the most difficult aspects of these cycles for teens is that they can cause prolonged and/or unpredictable bleeding.
  2. What’s considered a “normal” cycle for a teen? AAP and ACOG define normal menstrual cycles for adolescents as having an interval of 21–45 days with the duration of flow lasting <=7 days, and average product use of 3-6 pads/tampons per day. We should be concerned when there’s heavier bleeding (soaking through products after 1-2 hours), cycles >90 days apart for even one cycle, or a change from regular to very irregular.
  3. What defines “abnormal uterine bleeding (AUB)”? Bleeding that’s heavy or prolonged or occurs outside normal menstrual cycles. Ovulatory AUB, or heavy menstrual bleeding, occuring as part of the usual cycle, is most commonly caused by uterine problems (i.e., endometrial polyps, leiomyomas, malignancy) or bleeding disorders. Ovulatory dysfunction is AUB that presents as irregular, heavy, or frequent episodes of bleeding without a clear pattern. While this is usually from anovulatory cycles, it’s considered a diagnosis of exclusion; other causes to consider would be endocrine disorders, pregnancy and infection.
  4. When working up AUB, what are key parts of the history and physical? In addition to regular elements of H&P, we should obtain 1) Menstrual history: timing of menarche, usual frequency, duration, and volume of bleeding, presence of menstrual cramps, when/how did menstrual bleeding change, and any medical problems or lifestyle changes or other events that coincided with the change; 2) confidential HEADSSS review of substance use, sexuality, sexual activity, exposure to STIs, contraception, and any history of sexual abuse; 3) related ROS including symptoms of PCOS, thyroid disease, bleeding disorders, pelvic infection, anemia, psychosocial disorders like eating disorders/female athlete triad; and 4) physical exam including external genitalia; consider a full pelvic exam in sexually active females.
  5. What tests would you obtain? Depending on the presentation, appropriate lab testing could include a urine pregnancy test or quantitative hCG level, CBC, TSH, and iron studies. If there’s heavy bleeding, check coagulation studies including von Willebrand panel and possibly platelet function. An androgen panel would be useful if a patient is hirsute or has significant acne. An ultrasound would be done to help evaluate pelvic anatomy, uterine abnormalities and endometrial thickness – usually it could be done transabdominally, but transvaginal can provide better anatomy if patient is sexually active and more detail is needed.

TOW #40: Toilet training

With the April showers bringing spring flowers, we can talk about a topic of toddler “blooming,” so to speak… toilet training! I’m grateful those days are long behind us at our house… in the process of going through it with our daughters, I learned how different approaches work for different children, as described below. Attached are the case and discussion, thanks to our own fabulous Dr. Heather McPhillips, and several summary articles.

Materials for this week:

Take home points on toilet training:

  1. Age of toilet training changing: Toilet training in the US has moved later in toddler years (combination of factors including availability of better disposable diaper options and children in child care settings). Average age at which toilet training begins has increased from earlier than 18 months to between 21 and 36 months. Some believe there is little benefit of intensive training before 27 months of age. Only 40 to 60 percent of children now complete toilet training by 36 months of age; the average age is 37 months.
  2. Earlier start is associated with longer time to potty train, but earlier completion: Generally the earlier that children start, the longer it may take to fully potty train. Earlier start has also been associated with earlier completion of toilet training. Girls usually begin and complete toilet training about 2-3 months before boys.
  3. Child-centered toilet-training approach: this is the most commonly used approach now in the US. As described by Dr. Barry Brazelton and recommended by the AAP, this approach suggests that children are more likely to be developmentally ready after 24 months. This approach follows the child’s lead, looks for developmental readiness cues and provides positive encouragement for attempts at toilet training but avoids forcing / coercing or any negative comments.
  4. “Train in a day” type approach: as described by Azrin and Foxx, this potty training “bootcamp” is often done in a dedicated day/weekend using an operant conditioning model with positive reinforcement and negative reinforcement for accidents. One element we found helpful at our house was to set a “potty timer” to remind when to go make an attempt-about every 30-60 minutes to avoid accidents (can start with more frequent then gradually spread them out).
  5. Different approaches work: both of the most common approaches have been shown to work in practice to effectively teach typically developing children how to potty train. Different approaches are used around the world and can all be effective in context. In countries with more limited resources, there is much more use of elimination communication (EC), in which parents potty train children as early as 6 months based on parent use of watching infant cues and minimal to no use of diapers. Pediatricians who have experience with EC are now advocating for more broad discussion and adoption of this approach as well. We can help explore with families what they are comfortable with trying in their home.

TOW #35: Urinary incontinence / enuresis

Next week we cover another bread and butter topic in gen peds – urinary incontinence, especially during sleep, which is termed “enuresis.” Below I try to digest some of the notably esoteric-sounding definitions from the International Children’s Continence Society (ICCS), which is the main organization that deals with related diagnoses in children. Understanding differences in degree and type of enuresis helps with determining appropriate treatment. Big take-aways are the importance of treating underlying constipation, being aware of other lower urinary tract symptoms, and associated behavioral diagnoses like ADHD.

Materials for this week:

Take-home points on enuresis:

  1. What are the definitions of incontinence and enuresis? Urinary incontinence is the involuntary leakage of urine, which can be continuous or intermittent and can occur during the day or at night. Generally, urinary incontinence is not considered pathologic until a child reaches age 5 years, according to the DSM-5. Enuresis refers to intermittent incontinence that happens while the child is asleep (mostly at night but can also happen with daytime naps). Lower urinary tract (LUT) symptoms should be assessed (frequency, urgency, hesitancy, dysuria, etc). Primary monosymptomatic nocturnal enuresis (PMNE) is defined as “lifelong continuous enuresis without any other history of lower urinary tract symptoms and without a history of bladder dysfunction.” Children with enuresis and any LUT symptoms have nonmonosymptomatic enuresis (NMSE) (This was formerly called diurnal enuresis). Recent stressors, UTI, and constipation can all lead to secondary enuresis, which is enuresis occuring after a period of regular bladder control.
  2. How many children are affected by bedwetting? What are other associated conditions? 15% of children will have primary monosymptomatic nocturnal enuresis (PMNE) at age 6 years, but only 1% to 2% of adolescents will continue to have wetting by the late teen years. About 1/3 of children who have bedwetting 2 or more nights per week also have daytime urinary symptoms (thus classified as NMSE). Children with enuresis have a ~20% to 30% incidence of comorbid behavioral conditions, such as ADHD, oppositional defiant disorder, and conduct disorder.
  3. What screening questions can distinguish type of enuresis? Ask about whether patients have 1) been previously dry for 6 months, 2) have daytime urine control issues, 3) constipation or fecal soiling, and/or 4) severe recent stress.
  4. How do we treat primary nocturnal enuresis (PMNE)? We are seeking to treat 3 primary physiologic disturbances involving the kidney, brain, and bladder: nocturnal polyuria, diminished sleep arousal, and reduced nocturnal bladder capacity or bladder overactivity. As far as fluid intake, a good guideline is to drink two thirds of daily fluid during school, and then one-third of the fluid in the afternoon/ evening, with no fluid an hour before bed. Children should go to the bathroom before bed and anytime they wake up. The bedwetting alarm is 1 of 2 first-line treatments recommended by the ICCS, and has the best long-term outcomes. It helps by improving arousal from sleep. Effective bed alarms use vibratory or auditory stimuli or both. Some experts believe the auditory alarms may be more effective because they alert parents as well. The alarm should be used consistently, and the child should be motivated to participate. Oral desmopressin (DDAVP) is the other first-line treatment, with caution used because of hyponatremia (intranasal is no longer recommended due to more severe hyponatremia). If used, limit fluid consumption in evening (ICCS suggests 200mL) starting 1 hour before the medication is given and until the child wakes the next morning. Long-term use does not seem to be harmful, but many of the guidelines suggest trial off the medication every 3 months to see if the child still needs it.
  5. How do we treat NMSE? Treatment includes addressing 1) Underlying constipation or fecal incontinence, 2) LUT dysfunction and daytime voiding symptoms, 3) Behavioral conditions. Urotherapy is recommended for LUT symptoms, which involves parent and patient education on normal elimination habits and a structured behavioral program to improve bladder and bowel function. A 48-hour daytime frequency and volume chart over a weekend period is recommended to provide more details to evaluate LUT dysfunction.

TOW #31: Sick child

Many young children present with fever this time of year (indeed, it’s been record census at Children’s throughout recent weeks). We need to decide the degree of illness and appropriate disposition. This week’s topic is an opportunity to delve into this process and literature behind how we decide if a child is “sick or not sick.”

This week’s teaching materials:

Take-home points for identifying the sick child:

  1. What’s the frequency of febrile illnesses in young children?: Young children under 5 typically experience 3-6 febrile illnesses per year, and the likelihood of serious disease for these children is about 1-3%. The epidemiology of these illnesses has evolved over time with our immunization available and new viral testing available, as highlighted in this review in JAMA Peds.
  2. How do we make a diagnosis of serious illness?: Unfortunately, there is no identified set of signs and symptoms that definitively rule in or out a serious illness in all patients. In one review of 30 studies, high fever, cyanosis, rapid breathing, poor peripheral perfusion, and petechial rash were confirmed as warning signs for serious infection in children. The presence of cyanosis or poor peripheral perfusion raised the probability of severe illness from 1% to between 25% and 30%. Fever over 40 degrees C had a post-test probabillity of 5% for a serious illness. Parental concern was also identified as a strong red flag.
  3. How important is our “instinct” in these situations? Clinician instinct (“gut instinct”) is among the best performing assessments among clinicians when trying to determine whether a child has a serious illness. This skill develops over time. We can use active observation from the moment we walk in the room and throughout the visit. Experienced providers have been found to rely heavily on stimulus response information while assessing children with acute illness. Children with serious illness typically do not respond normally to age-appropriate activities or stimuli.
  4. Clinical Prediction Rules: In the study linked above comparing clinical prediction rules (CPRs), the best performing in a primary care setting was the Five Stage Decision Tree (FSDT), which uses the physician’s gut feeling, the patient’s age and temperature, and presence of dyspnea and diarrhea. The UK’s National Institute for Health and Care Excellence (NICE) Guideline on Feverish illness in children also did fairly well in ruling out serious illness.
  5. Finally, don’t forget to “phone a friend” in these situations – without doubt, I have found the insight of colleagues invaluable in assessing children I am concerned about, and helping make a plan.

TOW #48: Menstrual disorders

As we help with the process of puberty, addressing the challenges that arise with menarche and menstrual disorders in adolescents is a common issue we see in primary care. For those of you who have had your adolescent rotation, this is a great topic for you to facilitate.

Materials for this week:

Take-home points for this week:

  1. How is the menstrual cycle different for adolescents than fully mature females? In adolescents the hypothalamic-pituitary-ovarian (HPO) axis feedback loops are not yet mature. For the first 1-2 years after menarche, steroid hormones do not yet regularly have coordinated negative and positive feedback loops to cause ovulation, so menstrual cycles may be anovulatory or infrequent /irregular (oligoovulation). In the first year after menstruation, ~50% of cycles are anovulatory. One of the most difficult aspects of these cycles for teens is that they can cause prolonged and/or unpredictable bleeding.
  2. What's considered a "normal" cycle for a teen? AAP and ACOG define normal menstrual cycles for adolescents as having an interval of 21–45 days with the duration of flow lasting <=7 days, and average product use of 3-6 pads/tampons per day. We should be concerned when there's heavier bleeding (soaking through products after 1-2 hours), cycles >90 days apart for even one cycle, or a change from regular to very irregular.
  3. What defines "abnormal uterine bleeding (AUB)"? Bleeding that's heavy or prolonged or occurs outside normal menstrual cycles. Ovulatory AUB, or heavy menstrual bleeding, occuring as part of the usual cycle, is most commonly caused by uterine problems (i.e., endometrial polyps, leiomyomas, malignancy) or bleeding disorders. Ovulatory dysfunction is AUB that presents as irregular, heavy, or frequent episodes of bleeding without a clear pattern. While this is usually from anovulatory cycles, it's considered a diagnosis of exclusion; other causes to consider would be endocrine disorders, pregnancy and infection.
  4. When working up AUB, what are key parts of the history and physical? In addition to regular elements of H&P, we should obtain 1) Menstrual history: timing of menarche, usual frequency, duration, and volume of bleeding, presence of menstrual cramps, when/how did menstrual bleeding change, and any medical problems or lifestyle changes or other events that coincided with the change; 2) confidential HEADSSS review of substance use, sexuality, sexual activity, exposure to STIs, contraception, and any history of sexual abuse; 3) related ROS including symptoms of PCOS, thyroid disease, bleeding disorders, pelvic infection, anemia, psychosocial dz like eating disorders/female athlete triad; and 4) physical exam including external genitalia; consider a full pelvic exam in sexually active females.
  5. What tests would you obtain? Depending on the presentation, appropriate lab testing could include a urine pregnancy test or quantitative hCG level, CBC, TSH, and iron studies. If there's heavy bleeding, check coagulation studies including von Willebrand panel and possibly platelet function. An androgen panel would be useful if a patient is hirsute or has significant acne. An ultrasound would be done to help evaluate pelvic anatomy, uterine abnormalities and endometrial thickness – usually it could be done transabdominally, but transvaginal can provide better anatomy if patient is sexually active and more detail is needed.

TOW #45: Newborn circumcision

Newborn male circumcision is a topic that remains controversial in pediatrics, and overall the AAP has maintained a neutral stance on it. The most recent reports from the AAP were issued in 2012 with our own Dr. Doug Diekema as one of the authors on the policy statement. In reviewing the evidence, they declared that, overall, male circumcision has adequate benefits compared to risks to "justify access to the procedure for families who choose it." In Washington State, families who choose circumcision must pay for the procedure out of pocket. At the UW Northgate Clinic, one of the sites recommended from the UW nursery, it costs about $300. We are often called upon to discuss the procedure and evaluate complications, so let's review.

Materials for this week:

Key take-home points:

  1. What are the main benefits of circumcision and what are the main risks? Benefits include decreased risk of UTI before age 2, and decreased risk of heterosexual transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in female partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, and buried penis.
  2. What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
  3. What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw from lysing foreskin adhesions, and can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
  4. When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, phimosis or paraphimosis, or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves). 
  5. What advice do we give about care for the uncircumcised penis? The only care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractible foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 3 in about 90% of boys, and by teenage years in almost all boys.