TOW #34: Iron deficiency anemia

Next week’s topic is on iron deficiency anemia (IDA). Always an important topic in gen peds, as IDA is the most significant nutrient deficiency worldwide and also in the US.


Take home points on IDA:

  1. Epidemiology: Since the 1970s we have made significant progress identifying and screening for iron deficiency, but it remains the most common nutrient deficiency worldwide. Almost 10% of toddlers have been diagnosed with iron deficiency in a national U.S. sample, and many believe this may be underestimated.
  2. Significance: Iron deficiency is associated with poorer cognitive and social-emotional outcomes and has  persistent effects, but treatment can improve outcomes.
  3. Risk factors: include prematurity, cow milk consumption before 1 year of age, drinking more than 24 oz/day of cow’s milk per day after 1 year, low income status, menstruating adolescents, elite athletes, and restricted diets for any reason.
  4. Screening: Iron deficiency screening is recommended for all children between 9-12 months and again among adolescent females within a year of menstruation. Labs recommended vary. At a minimum Hct/Hgb identifies anemia and adding ZPPH (inexpensive and widely available) can help identify iron deficiency that precedes anemia (but note ZPPH is also elevated from lead and anemia of chronic disease). The Mentzer index, equal to the MCV divided by the RBC count, can help to pinpoint iron deficiency. An index >13.5 is suggestive of iron deficiency, <11.5 is suggestive of thalassemia minor. (Remember, the bone marrow cannot produce RBCs normally in IDA, so the RBC count is lower and the ratio is higher.)
  5. Treatment: treat iron deficient children with 3-6 mg/kg of elemental iron daily until sufficient and then 2-3 months after to ensure adequate iron stores. Typically we repeat measures 1 month after starting therapy to ensure a response and ensure compliance and/or do additional work-up if not improving.

TOW #33: Adolescent contraception

Next week’s topic is on adolescent contraception. This is an exciting time, so to speak, in options for preventing adolescent pregnancy. A big thank you to adolescent specialist Taraneh Shafii MD MPH for sharing her terrific expertise in this topic: she recommended the powerpoint training from Physicians for Reproductive Health and the teen resource below. Emily Ruedinger MD MPH, another adolescent med specialist, has been a wonderful resource and provided many of us access to Nexplanon training. Contact Emily if you are interested in this for your practice.

Materials for next week:

Take-home points:

  1. Epidemiology: Whereas rates of teen sexual activity between 15-19 have been relatively stable, the rates of teen pregnancy, birth, and abortion have all been declining thanks to more appropriate condom and birth control use. About 47% of 9-12 graders report having had sex in national surveys, with 59% having used a condom before last sex and 19% having used birth control pill and 5% using other forms. Even with decreasing rates, the 2011 rates of teen pregnancy were still highest in the US (among 21 countries with complete data), and more than twice that of most European countries.
  2. Most common birth control among adolescents: condoms are the most commonly used form by teens, with 90% having used at least once. Condoms have a failure rate up to 25%. Next most common are combined oral contraceptive pills (COCs); the failure rate is 8-9% for typical use and up to 25% for teens. Other combined hormonal forms including the transdermal patch and vaginal ring, which may be more effective among teens as they don't require daily dosing. Injectable progestin-only hormonal method (Depo-provera) lasts for 12 weeks and is more effective, but is associated with weight gain and some bone density loss with longer term use.
  3. Most effective birth control: Remember, IDEAL is DUAL USE = CONDOMS + another form. The long-acting reversible contraceptives (LARCs) including implantable (e.g., Nexplanon) and intrauterine devices (IUDs) are most effective birth control (less than 1% failure rate), and are now recommended as first-line for adolescents. Nexplanon is inserted into the subcutaneous tissue of the upper extremity and lasts for three years; the main side effect is irregular menstrual bleeding, 15% of individuals are amenorrheic at one year. IUDs are the longest lasting, but require pelvic exam to insert. The hormonal IUDs Mirena (lasts 5 years) and Skyla (lasts 3 years and has a smaller diameter which may be better for teens) are better for decreasing bleeding overall. The copper IUD (ParaGard) has no hormones, lasts up to 10 years, but is associated with more bleeding and cramping.
  4. Myths about IUDs: 1) IUDs do not increase a woman’s risk of pelvic inflammatory disease (PID), as long as she's not infected at the time of insertion. 2) If exposed to gonorrhea or Chlamydia post-insertion, treatment can occur without IUD removal. 3) IUDs can be used in females who have not yet conceived and do not increase the risk of infertility; fertility returns to baseline within 1-2 months post-removal.
  5. Streamlined approach to starting COCs (pelvic exam no longer needed):
  • Rule out absolute contraindications like migraines with aura, history of DVT/PE, or personal or family history of clotting disorder (see the US Medical Eligibillity Criteria for Contraceptive Use -USMEC)
  • Negative pregnancy test
  • Brief medical history, including date of last unprotected sex and current meds/supplements
  • Blood pressure and weight
  • Provide condoms and advance emergency contraception

TOW #32: Heart Murmurs

February is Heart Month. In honor of Valentine's Day, we will do a heart-related topic and review one of the biggies in evaluating pediatric hearts: assessing heart murmurs!

Materials for this week:

Take-home points for heart murmurs:

  1. Innocent murmurs are typically vibratory (or musical), of low intensity, and best audible at the left-sternal border (LSB). They are usually midsystolic—never purely diastolic—and nonradiating. Their intensity varies with position-typically loudest lying down and decreased while sitting up. Innocent murmurs (like pathologic ones) are louder with fever, anemia, or any increased cardiac output. The two most common innocent murmurs are Still's murmur (typically early systole vibratory "twangy" murmur at LLSB most common in ages 2-6) and pulmonary outflow murmurs (mid-systolic crescendo-decrescendo murmur at LUSB).
  2. Murmurs loudest at LLSB: here we are usually dealing with Still's murmur but the most common pathologic murmur to consider is VSD – typically holosystolic and may radiate more than Still's. Murmurs loudest at the LUSB: usually pulmonary outflow murmurs, but also consider supraclavicular murmur (also innocent) or ASD or pulmonary stenosis.
  3. Two continuous murmurs: common in childhood are venous hum and PDA. Venous hum is an innocent murmur heard on the low anterior part of the neck lateral to the sternocleidomastoid muscle, but can extend below the clavicle (usually on the right). It is usually louder during diastole and while the patient is upright. PDA is the classic "machinery" like murmur heard most often during S2 over the second left intercostal space, or in the left infra- or supraclavicular region.
  4. Clinical features suggestive of pathologic murmurs: Murmurs with long duration (pansystolic/holosystolic), greater intensity (grade≥3), and harsh quality are more suggestive of cardiac lesion/defect. Be concerned about murmurs in the setting of decreased exercise/activity tolerance, palpitations, chest pain, syncope, or a family history of congenital heart disease, arrhythmias, or sudden cardiac death. A systolic murmur that gets louder with Valsalva is consistent with hypertrophic cardiomyopathy (due to reduction of venous return to the heart and resultant narrowing of the left ventricular outflow).
  5. Further evaluation of murmurs: To avoid unnecessary costs, most often it is helpful to directly refer a suspected pathologic murmur to a pediatric cardiologist for further workup. If you are going to a study first, an EKG has the lowest cost and may help identify some patients at risk.

Wishing you all a happy heart day and month!


We are in the heart of the school year and ADHD assessment is on the agenda for many patient visits. ADHD has been a diagnosis which pediatricians have felt less comfortable treating due to lack of training, and we hope that can change for the current generation of trainees. Fortunately, we have more data and tools than ever to diagnosis and treat ADHD.

Materials for this week:

Take-home points for ADHD:

  1. Epidemiology: Estimates by the CDC are that 8-10% of youth in the US have been diagnosed with ADHD. Prevalence increased by ~1/3 between the 1990s to 2000s, but this coincided with increased marketing of ADHD medications. Concern remains about overdiagnosis, particularly among younger children where behavior may be developmentally appropriate. For example, children who are the youngest in their classrooms are more likely to be diagnosed with ADHD. However, girls with ADHD may be underrecognized, and most children with ADHD go under-treated.
  2. Risk factors: Both genes and environment contribute to ADHD risk. Twin studies suggest a strong genetic component, with up to 76% heritability. Environmental risk factors include perinatal and early childhood stress from toxins, compromised prenatal nutrition or birth complications, chronic deprivation, and early childhood adversity. Up to 2/3 of youth with ADHD have a comorbidity including anxiety, mood disorders, autism, ODD, tics, and/or substance abuse.
  3. Diagnosis: ADHD has 3 primary components: inattention, hyperactivity, and impulsivity, present to varying degrees. To diagnose ADHD, these must be present beyond appropriate for developmental stage, must cause significant impairment, should be present before age 12, and should be present in 2 or more settings (school, home, day care, camp, etc). In diagnosing ADHD, we should use clinical assessment along with ADHD rating scales (e.g., Vanderbilt), and also assess for co-morbidities with broad symptom checklists (e.g., Pediatric Symptom Checklist).
  4. Treatment: Behavioral (parent and/or classroom) and pharmacological treatments have been shown to work well, especially in combination. Usually, one of the two stimulant classes of medicines will be tried first: methylphenidate products (such as Ritalin, Concerta and Daytrana) or amphetamine products (such as Adderall and Vyvanse). Both stimulant classes are generally tried before switching to one of the non-stimulants: atomoxetine (Strattera), clonidine, or guanfacine, which have shown lower efficacy. However, atomoxetine would be considered first-line for treating ADHD with concurrent anxiety, or when there's a risk of medication abuse with a stimulant. As above, given the high prevalence of co-morbidities, we must also screen for and treat these conditions.
  5. Local resources: Our state has terrific resources through the Partnership Access Line and SCH. For more complex cases and/or those where diagnosis / treatment is in question, consult the SCH Psychiatry and Behavioral Medicine team including ADHD specialists Mark Stein PhD and Will French MD. Dr. Sam Zinner's developmental-behavioral screening tools webpage is a great resource to bookmark.