TOW #14: Sore throat

Flu vaccines are now available so 'tis the season to be preparing for URIs! As children have returned back to school, we now see the onslaught of the school fomite breeding ground! (We already have our first back-to-school cold at our house this week). One of our big roles as pediatricians when we see children with a sore throat is helping distinguish between viral infections and strep throat (Group A Strep Pharyngitis or GASP). Thanks to our incredibly knowledgeable general pediatrics guru Jeff Wright, we have a brief algorithm to help guide our decisions. *Reminder – you can also review our other general pediatrics outpatient guidelines posted here

This week's materials: Case and discussion by Dr. Wright and our general pediatrics' outpatient sore throat guideline. Infectious Disease Society 2012 clinical guidelines and an article reviewing performance characteristics of strep testing.

Take-home points for evaluating a possible diagnosis of strep throat:

  1. We now recommend that all children have a confirmed positive rapid strep or strep culture before being treated with antibiotics. This is due mostly to a larger concern about overuse of antibiotics and a prolonged and persistent decline in rate of rheumatic fever. Do not test children who have symptoms strongly suggesting a viral infection such as cough, rhinorrhea, hoarseness, or oral ulcers. Only test children under 3 who have a known contact or highly concerning exam.
  2. Treat confirmed strep throat with oral penicillin, amoxicillin, or cephalexin given for 10 days, a single injection of Benzathine G penicillin, or 5 days of oral azithromycin (for penicillin allergic patients).
  3. Presence of either a scarlitiniform rash or palatal petechiae are strong predictors of GASP, but not foolproof, so testing is recommended. 
  4. We should no longer presumptively treat sick contacts – clinical guidelines now recommend that all people who are treated have testing that confirms the presence of GAS.
  5. Remember, there is a fairly high normal carriage rate for Group A streptococcus in children – as high as 15%, so we do not test unless we have a higher concern for strep throat. There are also fairly high numbers of recurrence, so it is prudent to retest and retreat, as appropriate.

TOW #13: School Challenges

As school starts this year, we hope for everyone that it is a great experience and successful. Unfortunately, the literature tells us there is a reality that up to 1 in 6 children experience school failure. We have a role in primary care to support our patients and their families, hopefully to help identify early and/or support them through school challenges. 

Materials for this week: Case and Discussion and Pediatrics in Review on School Failure

Take-home points:

  • Epidemiology of school challenges: About 10% to 15% of school-age children repeat or fail a grade in school. Grade failure is more likely among males, minorities, children living in poverty, and those in single-parent homes. Children who have disabilities are nearly 3x as likely to repeat at least one grade as are children without disabilities. Similarly, children who were small for gestational age (SGA) are nearly 2x as likely to experience school failure.

  • Outcomes: Children who fail in school are more likely to engage in subsequent health-impairing behaviors as adolescents. Failing students also are more likely to drop out of school and have adverse adult health outcomes.

  • Differential diagnosis: Identification of possible causes of school challenges should include learning disabilities, ADHD, conflicts/stressors in the home and mental health disorders. Effectively treating known medical conditions to avoid school absences is also critical.

  • Our role: Clinicians can make a difference in outcomes by helping families identify the causes of failure and advocate for the resources to alter a child’s downward academic trajectory. It can be very important for a child's doctor to get involved with a child's school to ask questions, discuss resources, and advocate. Utilize the resources of school family advocates, omsbudsman, counselors, social workers, and medical-legal partners to advocate for children within their schools.

TOW #12: Literacy Promotion

Image result for literacy month 2015It's National Literacy Month! The perfect time to review the data about how to promote literacy in our practices. We have a terrific Reach Out and Read (ROR) program in our state run by Dr. Jill Sells, a former resident here. Check out the ROR website and email to sign up for training (see below) or the monthly newsletter.

Here are this month's materials: Case and Discussion and the recent AAP 2014 Clinical Guideline on Promoting Literacy

Take-home points for literacy promotion:

  1. Educate yourself: the #1 thing you can do to effectively use Reach Out and Read (ROR) is to get yourself trained through the online program (to get access contact ROR is an evidence-based, nationally recommended program started by pediatricians that improves literacy outcomes. Additional training / videos are available here.
  2. Advise: all parents that reading aloud with their young children enriches their relationships and enhances their children’s social-emotional development. This builds brain circuits to prepare children to learn language and early literacy skills.
  3. Counsel: all parents about developmentally appropriate reading activities.
  4. Provide: developmentally, culturally, and linguistically appropriate books at health supervision visits for all high-risk, low-income children. Also provide educational materials in clinic including info on local libraries.
  5. Review: the 5 R's of early education-1. Reading together as a daily fun family activity; 2. Rhyming, playing, talking, singing, and cuddling together; 3. Routines and regular times for meals, play, and sleeping; 4. Rewards for everyday successes, particularly for effort toward worthwhile goals such as helping; and 5. Relationships that are reciprocal, nurturing, purposeful, and enduring are the foundation of healthy early brain development.

Enjoy celebrating the return to school with your patients (hopefully soon for families at Seattle schools!)


TOW #11: Oral health

It's September – welcome to back-to-school time. Oral health is next week's topic with materials thanks to our great local expert, Dr. Charlotte Lewis. Sadly, dental caries have become epidemic – they are now the most common diagnosis among otherwise healthy kids, with about one third of children by age 3 with caries. Here's to a healthy start to school and reminding families about good snacks and lunches to pack that are healthy for teeth.

Materials for next week: Case and discussion and a Peds in Review article by Dr. Lewis

Take-home points for oral health:

  1. 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 child’s teeth with fluoridated toothpaste 2 times a day as soon as teeth start erupting, starting with a grain of rice sized amount of toothpaste, moving to pea-sized amount after age 2-3. Nighttime brushing is most important since we make less saliva at night to clean the teeth.
  2. Teach parents healthy food/drink choices: Limit sugary/high carbohydrate foods and drinks to meals; choose tooth friendly snacks between meals (whole fruits, veggies, protein snacks like cheese, water to drink). No bottles at bedtime with anything other than water. See AAP tips for parents on oral health.
  3. Baby teeth are important and decay can start as soon as the first tooth erupts. 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, among other topics.
  4. Parents' oral health is important, too, since they can transmit the bacteria causing decay to their children.
  5. Floss once a day for teeth that are touching – I highly recommend the preloaded "flossers" – they make it so much easier with young kids!