TOW #19: Acute asthma

It's the time of year when our clinics and the ED are starting to see more kids with acute asthma exacerbations, so it's an opportune time to review the guidelines and resources to address these. The REACH pathway residents provided super helpful updates to this topic this week for morning report, 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.
  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 critical. Refer to these great resources for home health assessments through the American Lung Association.

TOW #18: Delayed puberty

Ah, the fun topic of puberty – always a good one to review in general pediatrics!

Here are the materials for this week:

Normal and delayed puberty take-home points:

  1. What is puberty and what triggers it? Puberty is the process of normal sexual maturation culminating in full reproductive capability. Pubertal changes are due to increased secretion of sex steroids (gonadarche). The genetic trigger for puberty is still not well understood.
  2. When does puberty start for girls? For females, average puberty onset is 11 years, but normal range is considered from 8-14 years. The average duration of pubertal development is 3 years (range of 2-6 years). Thelarche, the onset of breast development, is usually the first visible evidence of puberty in girls. The growth of pubic hair usually follows within the next 6 months, along with a growth spurt. Menarche usually occurs 2 years after the onset of pubertal breast growth and coincides with Tanner Stage IV. After menarche, girls grow 4-6 cm on average (varies a lot), and finish growing within two years. Generally, early menarche is correlated with shorter adult height.
  3. When does it start for males? For males, average puberty onset is 12 years (normal range 8-14). Increased LH, FSH, and testosterone cause testicular maturation as well as virilization of physical features including increased muscle mass and voice deepening. Increased testicle size is the first visible evidence of gonadarche, though often not recognized until the growth of pubic hair, typically within 6 months. Facial hair growth usually happens 3 years after pubic hair onset. Pubertal growth spurt is later in males, and puberty lasts longer (typically 5 years).
  4. How do we identify delayed puberty? Delayed puberty is more common in boys than girls. Delay is considered no pubertal changes by 13 in girls and 14 in boys-these patients should be referred to endocrinology. Work-up for both sexes includes reviewing weight gain and linear growth, obtaining a bone age, and looking for other evidence of endocrinopathy such as panhypopituitarism or hypothyroidism. Laboratory studies include serum LH and FSH levels, growth hormone secretion, thyroid function and, in males, a morning testosterone level.
  5. What are the causes of delayed puberty? Delayed puberty is divided into causes based on serum LH/FSH levels: 1) normal/low (constitutional delay and hypogonadotropic hypogonadism (e.g., CNS tumors, endocrinopathies) and 2) elevated (hypergonadotropic hypogonadism or gonadal failure)-most common cause is Klinefelter Syndrome in boys and Turner Syndrome in girls.

TOW #17: Community Pediatrics

In honor of the REACH Pathway curriculum block starting tomorrow for some of the R2s and the national AAP conference next week, this TOW highlights our role as pediatricians in the community to serve our patients and advocate for their needs. No matter where we practice pediatrics, we can have a role in advocacy. Especially in primary care, we have an opportunity (and an obligation) to address health needs in a broader context.

Materials for this week:

Take-home points for this week:

  1. What are some of the social and environmental needs our patients face that can affect their care? Many children being cared for in community-based pediatric settings, including our residency clinics, face numerous social needs that affect their health: food insecurity, poor housing, parent substance use or mental illness, family violence, and unsafe neighborhoods. Most of these have now been characterized as Adverse Childhood Experiences (ACEs) and are associated with developing toxic levels of stress that can impact long-term health. There is evidence that when we address these needs by helping parents and families, children fare far better over the lifetime. 
  2. How do we prioritize addressing these needs? Henize et al. propose that one way to prioritize these is using the Maslow Hierarchy of Needs, i.e., addressing the most basic needs should be the focus before ones higher up on the pyramid. First are Physiologic needs for food and housing, then Safety from violence and mental health problems, then Love/Belonging, with children supported by loving parents who have community support, then Esteem and Respect, with education and employment, and finally, as these other needs met can come Self-Actualization or Achieving One's Potential. Another helpful way to think about needs is the IHELLP mnemonic: Income, Housing, Education, Legal, Literacy and Personal Safety.
  3. Where do we find the community resources? Bright Futures divides potential community resources among 4 major categories that we should access for our patients: health, development, family support, and adult assistance. In our area, two key ways to find needed assistance is through Within Reach and Washington State 2-1-1. Dr. Abby Grant, one of the former REACH residents and now REACH faculty and pediatrician at Harborview prepared this amazing list of community resources for our area.
  4. What are some of the recommended skills for engaging as pediatricians serving the community? The AAP policy statement defines some key skills: 1) working effectively in interdisciplinary settings, 2) partnering with public health, community organizations, and child welfare agencies, 3) recognizing root sources of health and pathology from children’s social, economic, physical, and educational environments, and 4) advocating on multiple levels including at the local, state, and national levels.
  5. If collaboration and partnerships are key to addressing social determinants of health, how do we do this? Henize and colleagues outlined a set of steps: 1) build a case through family-centered needs assessment, 2) organize and prioritize appropriate interventions, 3) work with key community partners to build and sustain interventions, and 4) operationalize interventions in the clinical setting. If you want to learn more about becoming an advocate, the AAP Committee on Community Pediatrics has advocacy training modules available.

TOW #16: Bullying

October happens to be National Bullying Prevention Month, so a great time for us to discuss this topic, which has received increasing attention and concern for children's health in recent years. The effects of bullying can be devastating and our role in identifying, discussing, and addressing bullying is really important. Our esteemed child health and injury prevention expert, Dr. Fred Rivara MD MPH, faculty at Harborview, chaired a panel for the Institute of Medicine in 2015 to develop a report on the evidence about bullying and how to prevent it.

Materials for this week:

Take-home points:

  1. How frequent is bullying? Estimates are that ~20% of youth in the US report being bullied, but observations of playground behavior suggest it is much higher than that. While "bully" conjures up certain images, most kids are typically developing boys and girls who are learning to navigate their social world.
  2. What is the definition and what are the forms of bullying? Olweus, a pioneer in research on bullying said it is aggression against those perceived as less powerful repeated in a systematic, patterned way. The power difference can be in size, age, political, economic, or social advantage. Bullying includes physical, verbal, cyberbullying, social (trying to hurt a person's reputation with a group or organization), and cyber harassment (bullying by an adult online).
  3. What are the effects of bullying? All forms of bullying can lead to physical illness, low self-esteem, anxiety and depression, including becoming suicidal. Some victims may also become bullies themselves.
  4. What are risk factors and how do we identify it? Risk factors for aggressive behavior include depression, school problems, living in violent communities, having parents who are absent, abusive, or disengaged. Risk factors for being a victim include developmental or physical differences such as intellectual disability or obesity and LGBT status. Red flags include somatic complaints, decreased motivation/school performance, avoiding school, frequently losing items or asking for money, unexplained injuries, and threatening to hurt self or others.
  5. What can we do to help prevent bullying? Ask questions to help screen. “Do you ever see kids picking on other kids?” “Do kids ever pick on you?” “Do you ever pick on kids? (And tell the truth; you’re not in trouble.)” When we identify bullying, we should talk to children and their parents, take concerns seriously, provide counseling about the importance of getting help from an adult (which is not "tattling" simply to get someone in trouble), contact school personnel (especially if concerned they are not adequately addressing it), and refer the child to a therapist or counselor for help.