TOW #22: Community Acquired Pneumonia

Next week’s topic is community acquired pneumonia (CAP), a relevant topic as we enter the winter months.

Materials for this week

A few take home points to review:

  1. What is the global burden of pneumonia? The WHO reports pneumonia is the single highest cause of death in children worldwide under 5, accounting for 18% of deaths. Fortunately it has become much less of a problem for us in an era of widespread access to vaccines against pneumococcal and HIB. In the US, pneumonia occurs in an estimated ~2.6% of children under age 17.
  2. How do we diagnose pneumonia? Pneumonia is a clinical diagnosis that can be challenging to confirm, and no single definition is used in pediatrics. In diagnosing it, we look for the most common symptoms of cough, fever, and/or tachypnea in the setting of findings of parenchymal disease by either physical exam or chest x-ray. Crackles (rales) are the most common exam finding, but we should also look for decreased breath sounds, egophany, tactile fremitus, and/or dullness to percussion. X-rays are not needed to confirm diagnosis or resolution of pneumonia, but should be obtained when diagnosis is less certain and/or patient symptoms are more severe. Labs such as blood cultures are not routinely indicated for children treated as outpatients.
  3. What is the recommended treatment? Treatment is based on age and severity. Viral pneumonia is much more common in preschool age children, so observation and supportive care is often appropriate. Older children are more likely to have bacterial pneumonia and are treated as appropriate with high-dose amoxicillin as first line therapy for lobar disease. Use azithromycin for suspected atypical pneumonia, or both amox and a macrolide, especially if they are sicker.
  4. Who can be managed as an outpatient? Outpatient management of pneumonia is appropriate for mild-to-moderate disease for children who are not hypoxic or in distress who can tolerate oral antibiotics. The Pediatric Infectious Diseases Society guidelines  recommend hospitalization for children with moderate to severe CAP including respiratory distress and/or hypoxemia (pulse ox <= 90%).

TOW #21: Sore throat

As we prepare for the holidays, ’tis the season to be preparing for viral respiratory season as well! 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 emeritus general pediatrics guru Dr. Jeff Wright, we have a brief algorithm to help guide our decisions. *Reminder – you can review our other general pediatrics outpatient guidelines posted here.

This week’s materials:

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

  1. Which children with sore throat should we test for strep infection? We can use the Centor criteria to help. Positive criteria include age 3-14, exudate or swelling on tonsils, tender/swollen anterior lymph nodes, temp >38.0, and absence of cough. We should not test children who have symptoms strongly suggesting a viral infection such as cough, rhinorrhea, hoarseness, or oral ulcers. Presence of either a scarlitiniform rash or palatal petechiae are also predictors of GASP, but not foolproof, so testing is recommended for these symptoms as well. Only test children under 3 who have a known contact or highly concerning exam.
  2. When should we initiate antibiotics for strep pharyngitis? Contrary to prior practices, 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.
  3. What should we use to treat GASP? 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 (reserved for penicillin allergic patients).
  4. Should we treat sick contacts without testing? It is no longer recommended to presumptively treat sick contacts – clinical guidelines now recommend that all people who are treated have testing that confirms the presence of GAS. (We just had an example of this in clinic for a sibling sick contact who had some concerning symptoms, but did not test positive, even on culture. That sibling then infected the first one with the virus!)
  5. How many kids are GAS carriers? There is a fairly high normal carriage rate for Group A streptococcus in children – as high as 15%. This really reinforces we do not test unless we have a higher concern for strep throat.

TOW #20: Child poverty

As we head into the holiday season, this is an opportune time to reflect on the impact of poverty and how to serve our vulnerable children. With the help of many wonderful faculty and residents including Dr. Abby Grant and REACH Pathway residents, we have a comprehensive list of resources to draw upon to support families.

Materials for this week:

Take-home points:

  1. How many children live in poverty? Unfortunately, children represent the group with the highest poverty rates in the US, with 22% living below the federal poverty level (FPL). In 2017, the FPL is $24,600 in annual income for a family of 4. If you include those living at 200% of the FPL, or “near poor”, that represents 43% of children – almost half – I find this statistic quite shocking. Since 2013, the majority of children enrolled in public school live in poverty. The FPL method was developed in the 1960s, and many argue that it is outdated and understates the true scope of poverty in the nation. There are major inequities in poverty rates, with non-white children experiencing much higher rates of poverty. The PBS series “America by the Numbers” highlights the striking disparities in health related to poverty.
  2. What are the effects of poverty on health? Poverty represents one of the biggest threats to children’s health. The effects are far-reaching: “Poor children are almost twice as likely to be in fair or poor health, are 1.7 times more likely to be born low birth weight, are 3.5 times more likely to suffer from lead poisoning, are twice as likely to experience stunting, and are more likely to be diagnosed with severe chronic health conditions. Poor children are 1.7 times more likely to die in infancy and 1.5 times more likely to die in childhood.” – Bauman Pediatrics 2006
  3. Where can we learn more about the science of poverty and its effects on children? The Academic Pediatric Association (APA) Task Force on Child Poverty developed the U.S. Child Poverty Curriculum​, a series of 4 stand-alone modules to promote understanding of the impact of poverty and other social determinants of health on child well-being, the biomedical influences of poverty, and advocacy. The AAP resident section conducted a FACE poverty campaign and developed many teaching tools and resources specific to residents.
  4. How do we tackle poverty in the office? Dr. Benard Dreyer, past president of the AAP, helped develop the AAP’s first policy statement on poverty and recommended that pediatricians screen for poverty risk factors. As we reviewed last week, I-HELP is a screening tool to remember ways we can address concrete needs by asking and linking to resources for Income, Housing, Education, Legal (immigration), Personal & Family stability. Other screening tools including for food insecurity are reviewed here. We can also help parents develop positive relationships with their children that are protective and build resilience, such as those approaches taught in the Promoting First Relationships curriculum. It’s also exciting to consider more sweeping structural changes including revamping primary care delivery, providing home visitation, care coordination, and parenting programs, all described by Drs. Beck et. al (see above).
  5. What can we do to address poverty at a policy level? We can advocate with our national organizations for policies that benefit families including benefits and tax support-many outlined by Dr. Dreyer in his Case For Ending Childhood Poverty.

TOW #19: Asthma diagnosis and management

This week our REACH pathway R2s shared some asthma management tips and tricks for morning report and featured R2 Bryan Fate’s new hit song “IHELP You”! As one of our most common childhood conditions, asthma diagnosis and outcomes highlight the effects of social determinants of health and the resulting health disparities that unfortunately exist. Our residents reminded us how we can recognize and address social needs through screening, referral and use of support systems. The IHELP mnemonic is used to screen for Income, Housing, Education, Legal/Literacy and Personal safety needs that affect overall health, including asthma. We want to provide effective care for children of all backgrounds and to recognize and address the powerful influence of social factors on health. Let’s keep this in mind as we discuss asthma.

A BIG thank you to Dr. Cathy Pew our intrepid gen peds team leader at Neighborcare – Meridian who tackled being lead author for our local outpatient asthma management guidelines and to the wise Dr. Jeff Wright, emeritus faculty, who initially designed the algorithms to accompany them.

Materials:

Asthma Diagnosis and Management take-home points:

  1. Epidemiology: 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. Asthma diagnosis and management is based on age, severity, and level of control. “Severity” is the intrinsic intensity of the disease process, which is based on impairment and risk. Severity is classified as “intermittent” or as “persistent” with mild, moderate, or severe levels. “Control” refers to the degree to which manifestations of asthma are minimized and the goals of therapy are met. This is classified as “well controlled,” “not well controlled”, or “very poorly controlled.” To help make this diagnostic process easier, please 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 (as above).
  3. We use a step-wise treatment to help manage asthma. The National Asthma Control Initiative outlines 6 priority messages for clinicians to help control asthma:
  4. To reduce environmental exposures for children, there are a number of resources we can use. Key resources locally include the American Lung Association home health assessment program and the King County asthma program, both of which have home visiting programs that we can refer families to that will help identify environmental exposures. The Medical-Legal Partnership is also helpful to access the legal system to ensure environmental triggers are minimized in rental properties where children live.
  5. Be sure to review your clinic’s management approaches and tools including action plans, EMR tools, screening questionnaires, and spirometry options. For clinics using EPIC, there is a great smartset for asthma that Dr. Sheryl Morelli helped champion based on the outpt guidelines.

Thanks for all you do to care for our community’s children and address their needs at many levels.