TOW #30: Hematuria and proteinuria

We are mixing it up next week with an acute care topic on hematuria. In this era when we no longer routinely screen otherwise healthy children with urine samples, we may not encounter it 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 (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.

TOW #29: Promoting wellness/self-care with patients

Next week is the first Resident Wellness Week! While the residents are getting a wellness boost in the midst of winter, I thought it would be great to link to ways we can discuss these strategies with patients and review materials that are out there. Let's "walk the talk" – on both our own care and sharing these strategies with families.

Materials/Resources for this week:

Take-home points for promoting wellness and self-care among our patients:

  1. Rising concerns about teen stress and mental health: As rates of depression and anxiety have risen for kids and teens, we are called upon as pediatricians to become more comfortable discussing these conditions – and what we can do about them – with our patients. Many teens may take some time to warm up to the idea of seeing a therapist or another provider, so you will be their first stop, and sometimes the only one.
  2. Priorities for wellness promotion: just as for us, sleep, nutrition, and physical activity are all biggies for youth, but increasingly tools like relaxation skills (e.g. breathing techniques, stretching), biofeedback, mindfulness (consider Headspace app), and positive psychology practices like offering gratitude have shown success among youth.
  3. Wellness is a suite of activities, most are learned skills: long before the frontal lobe is fully developed, we can practice self-care and wellness. These skills are not necessarily innate, so we get better with practice: think of them like exercises for the mind. I also have found traction reminding patients that professional athletes get help to build these skills to perform at the top levels!
  4. Offer resources for parents to support their children/teens: Parents are critical in offering guidance, resources, and role modeling, so involve them. Many resources are available for parents to learn about self-care strategies for their teens, like this one on managing stress before it gets to be too much.
  5. Walk the talk: "doctor, heal thyself" is a well known expression in medicine. Be familiar with self-care techniques, find ones that work for you, and share options with your patients- we can be more deliberate about self-care/wellness before situations reach a crisis.

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.

TOW #27: Newborn screening

Newborn screening has helped revolutionize our ability to detect metabolic and hematologic diseases in infants. There are some complications of this technology, however, primarily false positives that require additional testing and parental anxiety. A big thanks to our own R3 Dave Higgins who updated the case and discussion for this topic. I also included a summary from one of our former graduates, Beth Tarini, who has become a national expert. 

Materials to review:

Key points in newborn screening:

  1. History: The first sensitive, inexpensive, and easily performed newborn screening test was developed by Dr. Robert Guthrie in 1962. Prior to Guthrie's assay for hyperphenyalaninemia, infants with suspected phenylketonuria (PKU) were diagnosed at 6-8 weeks of age. Within 10 years the testing was used nationwide. Now many diseases can be detected with tandem mass spectrometry technique. Key criteria for screening is which diseases have accurate, safe, effective testing and follow-up treatment available.
  2. Most common diseases detected: congenital hypothyroidism, hemoglobinopathies, congenital adrenal hyperplasia, CF, and galactosemia. In WA each year 174,000 specimens from about 86,000 newborns are tested. Approximately 170 – 200 infants have one of the conditions. A one-time fee ($69.00 in 2014) for each baby screened funds this testing.
  3. Reliabillity of screening tests: Sensitivity is approaching 99% for most disorders. However, false-positives remain a big problem, particularly for endocrinopathies: one study found as many as 50 false-positives for 1 true-positive. Studies have shown that up to 20% of families maintain some concern about the health of their child after false-positive screening results, so reviewing this information with families is key.
  4. Why a 2nd screening: A 2nd screening between 7-14 days of life is recommended (though not required in our state), primarily to detect congenital hypothyroidism. About 15% of hypothyroidism cases are missed on the first screen.
  5. What to do when a test is positive: don't panic! Know that you will not be addressing this alone. Most tests need to be repeated. For providers who are not expert in a particular diagnosis, the best idea is to contact a specialist to discuss next steps. Refer to the WA state newborn screening website for more guidance.

Enjoy all of the new year babies you're seeing right now!

TOW #26: Obesity screening and referral

Happy New Year to everyone! This is a time of new year's resolutions and we can harness the focus on wellness to address obesity and offer hope and encouragement for families. A big thanks to Allison LaRoche for her help updating the materials for this topic. Obesity prevention and intervention is a topic close to my heart, so I am so excited to review the great resources we have locally including the ACT! program in partnership with the YMCA, and the Child Wellness and Adolescent Wellness Clinics. In addition, the local research expertise for obesity is extraordinary in our clinics – including Lenna Liu, Jay Mendoza, and Pooja Tandon. Feel free to email any of us with questions.

Teaching materials for this week:

For our patients, the issue of childhood obesity is recognized as one of the most important concerns of our time. Much has been learned over the past 15 years and progress is being made, yet we still have a long way to go with overweight/obesity rates persistently high at 1 in 3 children. Some take home points to review:

  • Etiology of obesity is multifactorial, with higher rates among low-income families, and certain racial-ethnic groups including Hispanic, African American and American Indian youth. Prevention is much easier than weight loss, so focusing on behaviors/ environments that support healthy weight starts from infancy & we must review growth/BMI at all well visits.
  • Learn the Division of Responsibility for feeding ("parent is responsible for what, where, when and child is responsible for how much") and 75210 goals to help guide healthy weight behaviors among our children: goals are that each day we eat breakfast, eat 5 fruits and veggies, watch no more than 2 hours of screen time, get 1 hour or more of physical activity, and have 0 sugary drinks. The 5210 Let's Go campaign started by a pediatrician in Maine has been very succussful to help families learn healthier habits.
  • Recognize that obesity is highly stigmatizing-be aware of your own biases. We want to use sensitive language to be supportive of families: discuss “healthier weight/ unhealthy weight” and specific behaviors rather than a focus on being overweight/obese.
  • For youth with BMI >85th percentile (overweight), follow weight trajectory and family history to assess risk through screening labs. Refer to resources like the YMCA ACT! program – ACT! programs are enrolling this winter for 8-14 year olds around our area. See the website for more information.
  • For youth with BMI> 95th percentile (obese), consider early referral to SCH Wellness Clinics for multidisciplinary weight management, as well as the ACT! program.
  • For children at all weights, regular physical activity reduces the likelihood of comorbidities. See the attached article on management of comorbidities when risks are identified.