2018-19 TOW #29: Food allergy

Next week’s topic is on food allergies, a hot topic with the recently evolving literature and recommendations.

Materials for next week:

A few take-home points:

  1. What’s the epidemiology? As many as 1 in 13 children is thought to have a food allergy. Along with other allergies, the rate of rise of food allergies has been rapid. While well-meaning, the recommendation to delay introduction of foods probably led to an increase in allergy development as children were sensitized through exposure, such as through the skin. Generally, the most common allergens in childhood include egg, milk, peanut, tree nuts, wheat, soy, fish, shellfish,and sesame.
  2. How do we prevent food allergies? We’ve had a recent dramatic change in practice in solid food introduction: we are now recommending solids foods between 4-6 months to “teach the body” during the window of time when less reaction occurs. We should recommend introducing a variety of foods, including foods containing peanuts, eggs, and tree nuts soon after children start solids. Mixing a bit of water into peanut butter to make it soupy is one way to expose infants to peanut butter (more recipes/options in the appendices here). For eggs, baking them into foods denatures the proteins so may be the best initial exposure for babies with a higher food allergy risk based on family history. Also egg yolks are less allergenic than egg whites. Breastfeeding for at least 4 months and when new foods are introduced is associated with decreased risk of atopy, though doesn’t necessarily prevent food allergies.
  3. How do we diagnose food allergies? Symptom reaction to the food: usually these are Type-1 IgE-mediated hypersensitivity reactions that happen within minutes of ingestion: including skin (most common), oral or nasal mucosa, GI, or respiratory reactions, or a combination of these in full anaphylaxis. Typically symptoms resolve within 4-12 hours. There are also Type-4 cell-mediated hypersensitivity reactions to food, such as milk protein allergy, that cause mostly GI symptoms. Some children avoid foods due to symptoms, so pay attention to these behaviors. Once a reaction has occurred, testing may help evaluate the allergy but are not fully diagnostic. A skin-prick test for food is recommended but it’s not 100% specific, with high false positive rate. Serum specific IgE testing is useful for patients who cannot discontinue antihistamine therapy or for those with extensive skin disease or dermatographism. An oral food challenge is considered the gold standard and may be part of making the diagnosis when it’s in question.
  4. How do we manage food allergies? Strict avoidance of the allergenic food is the primary approach. Egg and milk may be tolerated in cooked forms, with exposure helping build tolerance to other forms of the foods. Treatments for allergies are evolving and it’s exciting to see emergence of more success with new immunotherapies.
  5. How do we treat reactions and prevent death from anaphylaxis? Food-induced anaphylaxis is a “rapidly progressive, multiorgan allergic reaction that can result in death.” Recognition and quick response is essential to save lives. Anaphylaxis symptoms may be uniphasic, biphasic, or protracted. In all cases, most important is rapid treatment with IM epinephrine. Repeated epinephrine dosing should be used when symptoms progress or response is not optimal. All patients with any moderate to severe IgE-mediated reactions to foods should have self-administered IM epinephrine available. Mild skin-only reactions may be treated with diphenhydramine.

2018-19 TOW #28: Constipation/Encopresis

Next week we are reviewing constipation/encopresis. Talking about poop may be uncomfortable for our patients, yet we know how important it is for us to be comfortable addressing this issue.

Materials for this week:

Review on constipation in pediatrics:

  1. Epidemiology: Constipation accounts for 3–10% of visits to general pediatric clinics and up to 25% of referrals to pediatric gastroenterologists worldwide. Genetics plays a role, and social/ environment risk factors include low consumption of fiber, low levels of physical activity, living in a highly-densely-populated community, and low parental education. In >90% of children with symptoms, no obvious organic cause is found.
  2. Clinical definition: Pediatric functional constipation is defined as at least 2 of the following (frequencies in parentheses): Two or fewer defecations per week (75%), At least one episode of fecal incontinence per week (75-90%), Stool retentive posturing (35-45%), Painful or hard bowel movements (50-80%), Large diameter stools that could obstruct the toilet (75%), Presence of a large fecal mass in the abdomen or rectum (30-75%).
  3. Physical exam: Many have normal exams. 30-50% have a palpable abdominal mass. 5-25% have anal fissures or hemorrhoids. 3% have anal prolapse. >40% have fecal impaction.
  4. Work-up: Diagnosis can be made with history and exam and rarely requires additional work-up, except for more severe persistent cases. Concerning history would include passage of meconium >48 h after birth, bloody diarrhea, fatigue, fever, bilious vomiting, and eczema.
  5. Management: a 4-step approach is recommended with 1) education, 2) disimpaction, 3) preventing stool reaccumulation, and 4) behavioral therapy. Oral laxatives with Polyethylene glycol (PEG) (1-1.5g/kg/day) or rectal enema are considered equivalent first-line therapy for disimpaction. Maintenance laxatives are needed for most children for months to years. In my experience, there also may be a role for increasing fiber through supplements, such as products like Benefiber, especially for more minor constipation, or when laxatives lead to incontinence. Protocols and education are provided through our GI department including their constipation protocol.

2018-19 TOW #24: Atopic dermatitis

With all of this cold, dry sunny weather we’re having, it’s the season for dry skin and flares of atopic dermatitis. (Indeed, one of my daughters is constantly complaining of dry lips right now, and we are trying to forestall lip lickers’ dermatitis, to which she is prone!) This is a great time to review some tools of the trade and recent data.

Key points to review:

  1. Epidemiology: Atopic dermatitis (AD) is one of the most common skin disorders in young children, with a prevalence of 10% to 20% in the first decade of life. It is a chronic illness with multiple etiologies and requires multifaceted treatments. Almost half of children with AD develop it before 1 year of age, and the majority by age 5.
  2. Pathophysiology: Defects in the epidermal barrier function and cutaneous inflammation are 2 hallmarks of AD, which is why we target therapy with emollient barrier agents and anti-inflammatory treatments. Both skin with lesions and without have shown defects in transepidermal water loss, even measured at 2 days of age. Mutations in filaggrin, an important protein in skin barrier function, are predictive of multiple forms of atopy, including atopic dermatitis, food allergies, and asthma.
  3. Topical corticosteroids are the mainstay of therapy for inflammatory skin diseases like AD. They reduce inflammation in the skin by causing vasoconstriction and preventing inflammatory cells from entering the affected area, so they also have an anti-pruritic effect. Potency is actually determined by how much vasoconstriction they cause. For children with rapid flares, a recommendation is short-term bursts of mid- to high-potency topical steroids, typically applied twice daily for 7 to 10 days, then tapering to lower potency daily, then to intermittent application, 2-3 times per week.
  4. Regular use of emollients to prevent drying of the skin is also important in managing AD. Patients should use a dye-free, fragrance-free moisturizer and apply it at least twice per day and after bathing. In practice (and personal experience with my kids), my go-to has been petroleum jelly / white petrolatum (Vaseline). It’s effective, does not sting like other creams/lotions can, and is affordable.
  5. Prevention of AD – yes it’s possible! Data from 2 RCTs, one in the US/UK and one in Japan, has shown that applying moisturizers daily for infants from birth to 6 months can forestall development of eczema among infants who have at least one family member with AD. In a cost analysis, the most cost effective emollient was petrolatum (i.e., Vaseline/petroleum jelly). In the lay press, NYT highlighted these AD prevention studies.
  6. Side effects of topical steroids and calcineurin inhibitor options: Steroid side effects are most problematic when applied to skin without inflammation. Steroids should be applied to affected skin until 3 days after resolution. For those with more severe AD, treatment may continue weekly (or more often) to prevent flares symptoms. Use lower potency especially in the face and groin area where the skin is thinner / more susceptible to damage. Topical calcineurin inhibitors provide another treatment option. They are considered second line therapy for short term and noncontinuous chronic treatment, with improving evidence for safety since the 2006 FDA black box warning.

2018-19 TOW #20: Tobacco Exposure and Cessation

This week’s topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up next week on Thursday November 15th. The American Cancer Society designates the 3rd Thursday of November (the Thursday before Thanksgiving) 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 cessation.

Materials for next week:

 

Take-home points:

  1. How many children are exposed to secondhand smoke? How does teen smoking relate to adult smoking? More than half of US children have secondhand smoke exposure (based on biological samples of population data). Approximately 90% of adults who smoke began smoking prior to age 19 (which is why tobacco companies target ads to youth…) Each day, an estimated 4400 American teenagers try their first cigarette. 80% of youth who smoke will continue to smoke into adulthood.
  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 non-respiratory 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.  Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking. 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. All states have quitlines with counselors who are trained specifically to help smokers quit. The quitline number is meant to be remembered: 800-QUIT-NOW (800-784-8669). There’s also an online chat via the National Cancer Institute.
  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 1-10 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.) This is a great stat to highlight: Getting help through medications and counseling doubles or even triples the chance of successfully quitting. 
  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, especially among teenagers.

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).

2018-19 TOW #18: Oral health

It’s Halloween next week, so that time of the year when children have access to ridiculous amounts of candy… thus a good opportunity to review oral health care! As far as Halloween goes, some dentists and parents have “buy-back” programs to replace candy with toys; others let kids binge eat one night, then throw away the rest (maybe best for the teeth, but I don’t love the message that sends about enjoying things in moderation…). I love that my daughter’s school collects it to send to the troops-she’s been very motivated to bring in as much as she can to win the class competition.

Materials for this week:

Take-home points for dental health:

  1. Who is most at risk for dental caries? Sadly, dental caries have become epidemic – they are now the most common diagnosis among otherwise healthy kids, with about one third of children with caries by age 3. Risk factors include children with special health care needs, parents with caries, especially during pregnancy, and low-income status. Parents’ oral health matters since they can transmit decay-causing bacteria like strep mutans to their children. Children can be colonized with the bacteria soon after birth, and earlier colonization increases risk for caries.
  2. When and how should we recommend fluoride? Use fluoride sources to protect teeth in 3 ways: brushing, fluoridated water, and fluoride varnish at the dentist and at well child checks (at least 2-3 times per year). Brush children’s teeth with fluoridated toothpaste 2 times a day as soon as teeth start erupting. Start with a grain of rice sized amount of toothpaste and move to a pea-sized amount about age 3 when kids can spit. Nighttime brushing is most important since we make less saliva at night to clean the teeth (my kids’ dentist has the motto “clean teeth before sleep”). Parents should help with nighttime brushing until children are about 7 or 8, and even a few times per week after that is recommended to monitor teeth. We should also recommend flossing once a day for teeth that are touching. I highly recommend the preloaded kids “flossers” – they were a game-changer for helping our kids to floss!
  3. What foods and drinks should we recommend to prevent cavities? The obvious ones are limiting sugary/high carbohydrate foods, especially sticky ones, and sugary drinks. When these are given, it’s best to offer at mealtime and let the pH come back into normal range between meals, which takes ~90 minutes. When children constantly have food/drinks in the mouth, such as with a bottle or sippy cup, the pH of the mouth never neutralizes, creating an ideal setup for cariogenic bacteria to collect and cause decay. That’s why it’s especially important to avoid grazing and offer tooth-friendly snacks between meals (whole fruits, veggies, protein snacks like cheese, water to drink). Once teeth are brushed, there should be no more bottles/breastfeeding at bedtime or overnight.
  4. What can we teach parents about how to check kids’ teeth? Baby teeth are important and decay can start as soon as the first tooth erupts. Decay is most likely to occur along the gum line of the upper incisors and also in the pits and in between the premolars and molars. Caries typically appear as white spots (decalcifications) and may progress to yellow/brown cavitations. Show parents how to “lift the lip” to check child for early signs of decay. Check out the AAP Flip Chart to learn more about oral health to review which teeth come in when and other topics. Did you know in a recent study of pediatric residents, only about 1/3 discussed sleeping at night with breast/bottle, only ~13% discussed the status of teeth, and <10% lifted the lip to examine front incisors. I know we can do better than that here!
  5. When should dental visits start? The ADA and AAP recommend children establish a dental home by 1 year of age, possibly earlier for children who are at very high risk of caries. Healthy teeth for parents is important, too. Encourage them to model good oral health and receive dental care as well.

 

2018-19 TOW #14: Antibiotics in primary care

School is in full swing, and we have already had the first cold of the season at our house. As we gear up for flu vaccines in preparation for viral season, it’s time to think about antibiotic use and stewardship in primary care setting. Our amazing general pediatrics and hospital medicine chair, Dr. Rita Mangione-Smith MD MPH, has been a lead researcher in informing this topic.

Materials for this week:

Take-home points:

  1. How often are antibiotics prescribed in outpt settings? More than 1 in 5 ambulatory visits for children results in antibiotic prescription. Studies have shown up to 1/3 of patients diagnosed with a common cold receive an antibiotic prescription. This increases up to 60% among patients presenting with bronchitis and other viral illnesses.
  2. What are some harms of antibiotic use from both an individual and a community-based standpoint? Individual harm includes diarrhea, upset stomach, adverse drug reactions, higher rates of resistant bacteria, and disruption of the gut microbiome. From a society standpoint, unnecessary antibiotic use contributes to excess health care costs and promotes antibiotic resistance.
  3. What situations trigger physicians to prescribe antibiotics for respiratory infections? Dr. Mangione-Smith and team found physicians were more likely to prescribe antibiotics for children with a cold if 1) they perceived the parent or patient expects it, 2) there is parental anxiety about the child’s illness before the visit, 3) they reported wheezing or rhonchi on exam, and 4) parents had very low SES (perhaps MDs may mistakenly believe it is faster to give ABX than explain what to do instead). Other studies have also found we prescribe more in visits that occur later in the day (consistent with decision fatigue).
  4. What are the principles of responsible antibiotic prescribing? 1) Determine the likelihood of a bacterial infection-use diagnostic criteria and guidelines, as well as tests to determine pre-test probability when possible, such as Centor criteria for sore throat and strep infection, and clear clinical findings for acute otitis media; 2) Weigh benefits and risks of ABX treatment to determine whether they should be given, and 3) Use judicious prescribing strategies (i.e., the most narrow-spectrum and effective antibiotic for the appropriate duration – this might include a watch and wait approach, if appropriate).
  5. What methods can we use to counsel family members about antibiotics? As per Dr. Mangione-Smith’s research, we are likely to get more questioning of the treatment if we specifically say “antibiotics are not needed” when we summarize the treatment plan, rather than focusing on positive, supportive treatment that parents can implement. When parents suggest a “candidate diagnosis” that might require antibiotics, like ear infection, sinusitis, or pneumonia, we should explain how we will determine the diagnosis based on the exam. Other strategies we can use: align with parents on goals of helping the child get well as quickly and safely as possible, legitimize symptoms and concerns for bringing the child in, and address parent anxiety and effort. Addressing specific ways to manage symptoms (analgesics, elevated head of bed, steam/ warm baths, honey for cough, etc.) is helpful. I’ve also taken to highlighting the benefit of building the immune system in young ages, as this potentially helps lower risk of autoimmune diseases later.

2018-19 TOW #9: Colic

Next week we are covering a bread and butter topic in outpatient pediatrics, the ever-so-challenging diagnosis of colic, or excessive crying. Dealing with an especially fussy infant as you’re just learning to be a parent can be among the most challenging experiences a parent can face. Think about the stress you’ve felt listening to an infant crying on a plane, then imagine a parent having to deal with it every day for hours at a time! We want to harness evidence and empathy to help families through this.

Here are the materials:

Take-home points about colic:

  1. Epidemiology: how do we define colic and how many babies have it? Colic was defined by Wessel in 1954 as rule of 3’s (crying for 3 hours or more per day on at least 3 days per week for >=3 weeks). The Rome group updated this definition (as these time markers are somewhat arbitrary) in the Rome IV criteria for functional gastrointestinal disorders as “recurrent crying or ‘fussiness’ in a thriving, afebrile, well infant less than 5 months of age, without apparent cause, that cannot be resolved by the caregiver.” It occurs in 5-20% of otherwise healthy babies (and is seen globally), and is most often benign and self-limited. Some have theorized babies who cried more had an evolutionary advantage for survival as it meant more holding and soothing. In clinic, I often say a baby has a “good survival instinct” when I am talking to families to normalize crying behaviors or other contact-seeking behaviors that get babies the help they need.
  2. What is the differential for excessive crying and what is the work-up? Less than 5% of cases have an identified cause. We need to think about cow’s milk protein intolerance, GERD, abuse, infantile migraines, isolated fructose intolerance, maternal medications in breast milk (like fluoxetine), hair tourniquet, occult infection (especially UTI), and corneal abrasion. Mothers of infants with colic are more likely to have depression, so this should be assessed and referrals made, as needed. If there is no sign of other illness or injury on exam (including red flags of distended abdomen, fever, or lethargy), then no routine work-up is needed.
  3. What is the natural history for colic? Colic begins at 2-4 weeks and worsens until 6-8 weeks then improves and usually resolves by 4 months of age. The increased crying behavior occurs in the afternoons and evenings, the same times of day as in non-colicky infants, often referred to as the “evening fussies.” Colic can be considered a more extreme end of the spectrum of normal emotional development. Often there is a connection to difficult feeding behaviors and sleep, so these should be assessed.
  4. What are the long-term outcomes among infants with colic? At 4 months, those who had colic may have more sleeping difficulties. There may be some differences in temperament and family functioning. But, there have been no long term differences found in cognitive development.
  5. What are the treatment options for colic? There are very few evidence-based treatments, including a lack of evidence from Cochrane reviews for various pain-relieving agents or for manipulative therapies. There is some evidence that babies with colic have different fecal microflora (including higher rates of Helicobacter pylori stool antigen positivity) and some signs of colonic irritation. Studies of probiotics as a treatment for colic have been somewhat mixed, but there is data from a recent meta-analysis to suggest Lactobacillus reuteri may be effective in reducing crying time in exclusively breast fed infants. Infant crying can lead to parents feeling anger, frustration, and inadequacy. Asking about and addressing these emotions are important parts of caring for the parents. Give parents permission to put their baby in a safe place and leave for 5-10 minutes to take a break.

2018-19 TOW #7: Concussions

In addition to summer recreational activities, youth around our area are doing camps and early practices for the fall sports season. This is an opportune time to review concussions, a very timely topic in pediatrics (and society-at-large). We as pediatricians are called upon to address these injuries in clinic and clear youth for return to activities, as mandated by the Lystedt law in Washington.

Links for this week’s materials:

Key take-home points for concussions:

  1. What is a concussion? A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
  2. What’s the epidemiology of concussions? Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, followed by girls’ soccer. Girls have higher concussion rates than boys do in similar sports (possibly due to both physiologic reasons and higher reporting). Loss of consciousness occurs in about 10% of concussions, but may signal a more severe injury.
  3. What work-up should be done when concussion is suspected? Workup should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Review any assessments done at the time of injury (e.g. on-field SCAT5, etc). Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation. Consider using standardized tools to complete the evaluation, such as the SCAT5 and Child SCAT5 for ages 5-12.
  4. When should imaging be done? CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See the HMC algorithm for determining need for CT after head injury, based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
  5. How should we treat? Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend moderate cognitive rest and a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games); this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here’s a handout that reviews symptoms and return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking. Check out sports concussion resources from our sports medicine experts here.

TOW #46: Hematuria

Until recommendations changed in 2008, pediatricians routinely performed urinalysis screening in otherwise healthy children. This is no longer recommended, so we may not encounter microscopic hematuria quite as often. However, knowledge of how we approach hematuria in the outpatient setting is helpful to review given the possibility of medical complications.

Materials for this week:

Take-home points for this week on hematuria (for this,focused on the heme part, but case also reviews the protein part):

  1. Definition of hematuria: presence of 5 or more RBCs per high-power (40) field in 3 consecutive fresh, centrifuged specimens obtained over several weeks. There is microscopic (visible only on testing) or macroscopic (gross) hematuria (visible to the eye). Beware of false hematuria from drugs, foods (e.g.,beets, blackberries), toxins (e.g., lead), and urate crystals in newborns.
  2. Epidemiology: population studies in Finland and Texas have shown a prevalence of 3-6% of asymptomatic microscopic hematuria in school-age children in a single urine sample. With repeat screenings, prevalence declines to 0.5% to 1%. There are no differences by race/ethnicity. Until 2008, the AAP recommended urine screening routinely at age 5 and during adolescence, but this was ended due to low rates of disease and high false positives.
  3. Types of hematuria: Diagnostic evaluation depends on the category: gross hematuria, symptomatic microscopic hematuria, asymptomatic microscopic hematuria with proteinuria, or isolated asymptomatic microscopic hematuria. Evaluating RBC morphology helps distinguish glomerular and extraglomerular sources. Glomerular bleeding is typically “cola-colored,” with RBC casts and distorted RBC morphology.
  4. Hematuria type determines need for work-up: see the above algorithm. We have to distinguish between asymptomatic microscopic hematuria which is usually benign and requires conservative management, and hematuria with accompanying proteinuria, edema, hypertension, or other symptoms which 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.