TOW #19: Acute asthma

Our clinics and ED are starting to see increasing numbers of kids with acute asthma exacerbations, so it's an appropriate time to review the guidelines and resources to address these. The REACH pathway residents provided great updates to this topic and shared resources at morning report this week, some of which I have included below. 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 we will see 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 implentation of treatment. 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 so important to have follow-up within a few days (in person for more moderate cases, or possibly by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also really important. Refer to these great resources for home health assessments through the American Lung Association.

TOW #18: Lymphadenopathy

This week's topic is a review of lymphadenopathy and how to characterize those lumps and bumps that patients and parents worry about (and sometimes us too!). A refresher on this topic is always helpful around this time of year in the context of our emerging respiratory season. Interesting fact of the day: there are about 600 lymph nodes in the body!

The teaching materials for the week: Case and discussion and a Pediatrics in Review article on Lymphadenopathy in 2013

Take-home points on lymphadenopathy:

  1. Definition of lymphadenopathy: abnormality in size and consistency of lymph nodes (whereas lymphadenitis is an inflammatory or infectious enlargement of lymph nodes). 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 is two or more noncontiguous sites of lymph node enlargement.
  2. Why lymph: An "ultrafiltrate" of blood, lymph carries immune cells in lymph capillaries throughout the body except the brain and heart. The bone marrow and thymus are the primary lymphoid organs because they generate B lymphocytes 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 detect larger lymph nodes (at least after the newborn period).
  3. Differential diagnosis: The broad categories are infectious, immune disorders, and malignancy. Under age 5, we know cervical lymph nodes are almost always infectious-don't forget scalp and dental sources. Supraclavicular nodes are always abnormal, most commonly caused by lymphoma, tuberculous or atypical mycobacterial infection, or sarcoidosis. Generalized lymph node swelling is more likely to be systemic infection: viruses, including EBV, CMV, HIV, syphilis or  toxoplasmosis, and also may be a sign of autoimmune disorders or malignancy.
  4. Key history and physical exam: ask about systemic symptoms, including fever, weight loss, night sweats, poor appetite, and fatigue. Understand the time course of the lymphadenopathy, and increase in the size or number of lymph nodes. As appropriate, review exposure to insects, animal contacts, and immunizations. Determine locations of lymph nodes, whether unilateral versus bilateral, soft versus hard, mobile versus fixed, and tender versus non-tender. Focus remainder of exam on chief complaint/symptoms.
  5. Diagnostic workup: if nothing suggests malignancy, observe for 2-4 weeks, then follow-up. If not resolved, consider work-up such as viral serologies and basic studies including CBC, ESR and CRP. Biopsy should be considered when alarm features raise concern for malignancy, including issues of duration, location, large or increasing size, abnormal texture, and the presence of constitutional symptoms.

Good luck with assessing all of those lumps and bumps!

TOW #16: Breastfeeding

This week's topic is brought to us thanks in part to our local pediatric expert on breastfeeding, Dr. Nancy Danoff MD MPH, who has helped educate many of us about this important topic in the newborn nursery. For those of you who have been lucky enough to hear her there, this is bonus review to extend your knowledge in the clinic context.

This week's materials: Case and discussion addressing specific breastfeeding challenges in clinic by Dr. Danoff, additional case discussion to review general info on breastfeeding, and the AAP Policy Statement on Breastfeeding updated in 2012

Take-home points about breastfeeding:

1. Guidelines from AAP: American Academy of Pediatrics recommends exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.

2. Epidemiology on breastfeeding in US: While breastfeeding is recommended as the preferred exclusive nutrition for babies by the AAP, only 33% of babies in the US were exclusively breastfed by age 3 months, and only 14% by age 6 months as of 2007. Among the barriers in the US is that only 25% of employers have worksite lactation support and many parents do not have any family leave time.

3. Infant growth measurements: should be monitored with the World Health Organization (WHO) Growth Curve Standards (which is based on breastfed infants) to avoid mislabeling infants as underweight or failing to thrive.

4. Challenges with breastfeeding: usually lead to poor milk intake and transfer and the vast majority are treatable with support from us and lactation specialists. These include poor latch, sore nipples, engorgement, and perceived low milk supply. Only about 5% of moms actually have physiologic problems that lead to inadequate milk supply. Read more about all of these in Dr. Danoff's great handout linked above.

5. Why promoting breastfeeding is important: The benefits of breastfeeding are especially notable in decreasing rates of infant disease, as summarized by an AHRQ sponsored report on meta-analyses of breastfeeding outcomes. Among the findings, any breastfeeding was associated with 23% lower otitis media, 64% lower GI infections and a 36% lower rate of SIDS. Benefits are even more notable when infants are exclusively breastfed. There are also associations with lower rates of allergy, atopy, and auto-immune disease. Some studies have also documented cognitive benefits, too. There are also myriad benefits for mothers.

Check out resources and information about policies and promotion of breastfeeding through the US Breasfeeding Committee.

In spite of all of this, there are some situations in which breastfeeding is not possible, and we must be supportive of caregivers to make the choices that work for them around infant feeding. Thus, we will be reviewing formula feeding next week.


TOW #15: Identifying the Sick Child

As we enter fall season, we will see increasing sick visits that peak in the winter months. Many young children will present with fever and we will need to decide the degree of their 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: Case and Discussion and an article reviewing clinical prediction rules for assessing serious illness in ambulatory practice

Take-home points for identifying the sick child:

1. Epidemiology: 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%.

2. Diagnosis: 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. Importance of clinician instinct: among the best performing assessments is whether the clinician has the "gut instinct" that the child has a serious illness. This skill develops over time. Use active observation from the moment you 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.

Finally, don't forget to "phone a friend" in these situations – I have found the insight of colleagues invaluable in assessing children I am concerned about.

Hope you have a great week! – Mollie