TOW #33: Eating disorders

This week’s topic is Eating Disorders, in recognition of National Eating Disorders Awareness week. This is a tough diagnosis for multiple reasons. Thankfully we have our wonderful adolescent medicine colleagues locally to provide expert guidance on this topic, so help is close by.

Materials for this week:

Take home points to review about Eating Disorders:

  1. Epidemiology: Once thought of as primarily a problem for white upper middle class females, unfortunately, the number of males and minority tweens/teens of both genders with disordered eating has increased in recent years, with up to 14% meeting criteria for disordered eating NOS. About 0.5% of female adolescents are diagnosed with anorexia and 1.5% with bulimia. Teens are particularly high risk during times of transition, and also in highly competitive athletics.
  2. Clinical definition: Eating disorders involve dysfunctional eating habits (may include restrictive eating and binge/purging), weight changes, and body image distortion with intense fear of gaining wt. Suspect in patients who fail to maintain weight in adolescence (especially concerning if <85% of ideal body wt, IBW), or who have amenorrhea, cold intolerance, constipation, headaches, fainting or dizziness. Ask about satisfaction with weight, efforts to control weight, exercise, and changes in diet. The female athlete triad is defined by low energy with or without eating disorder, hypothalamic amenorrhea, and osteoporosis. (DSM-5 criteria are in Tables 1 & 6 in the Peds in Review article).
  3. Physical exam: Some patients have normal exams, and patients with bulimia may have normal weight. Vital sign changes are important including bradycardia, hypothermia, and orthostatic changes. Skin findings may include acrocyanosis, lanugo, peripheral edema, and muscle atrophy. “Russell sign” is callus/abrasion over the MCP/PIP joints from tooth scraping while inducing vomiting. Also look for worn tooth enamel and salivary gland enlargement from purging.
  4. Work-up: Review wt trajectories/changes, and compare weight to median BMI (50th percentile BMI for age on growth chart, which is the ideal body wt). The current weight is divided by the IBW. In primary care it is more important to diagnose medical complications of eating disorders and refer for psychological management. Labs to consider initially are BMP (electrolyte, BUN, glucose abnormalities), ESR (to rule out systemic inflammation), and CBC (assess for malignancy/anemia).
  5. Management: Eating disorders represent complex physical and mental health disorders with high mortality rates. Refer to adolescent medicine for multidisciplinary care. If acutely ill/worsening, determine if patient meets criteria for inpatient admission in consultation with adolescent specialists (see AAP guidelines for hospitalization in Table 4 of this review). Provide regular follow-up as PCP for overall health/support and encouragement to engage in treatment. SSRIs may be considered for concurrent depression/anxiety, especially with bulimia.

TOW #32: Heart murmurs

February is Heart Month. In honor of Valentine’s Day this week, 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. What do typical innocent murmurs sound like? These 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. What murmurs are loudest at LLSB and LUSB? At the left lower sternal border (LLSB), 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. What are two continuous murmurs? Common continuous murmurs 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. What clinical features are 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. What further evaluation of murmurs should we consider? 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.

TOW #31: Sick child

Many young children present with fever this time of year (indeed, it’s been record census at Children’s throughout recent weeks). We need to decide the degree of 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:

Take-home points for identifying the sick child:

  1. What’s the frequency of febrile illnesses in young children?: 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%. The epidemiology of these illnesses has evolved over time with our immunization available and new viral testing available, as highlighted in this review in JAMA Peds.
  2. How do we make a diagnosis of serious illness?: 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. How important is our “instinct” in these situations? Clinician instinct (“gut instinct”) is among the best performing assessments among clinicians when trying to determine whether a child has a serious illness. This skill develops over time. We can use active observation from the moment we 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.
  5. Finally, don’t forget to “phone a friend” in these situations – without doubt, I have found the insight of colleagues invaluable in assessing children I am concerned about, and helping make a plan.

TOW #30: Headache

Next week’s topic is headaches. Evaluating them in our patients can sometimes feel like they result in our own, so I am hoping a review of this topic can result in fewer for all involved. Our own local expert neurologist, Dr. Heidi Blume, wrote the Pediatrics in Review article, which is really comprehensive.

Materials for this week:

Take-home points for pediatric headaches:

  1. How many children report headaches? Depending on the study definition and time period, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. By adolescence, girls report headaches more often than boys.
  2. What are the main types of headaches? Classifying the headache into one of 4 basic patterns helps with evaluation and diagnosis of the cause: 1) acute; 2) acute recurrent (or episodic); 3) chronic progressive; and 4) chronic nonprogressive. Most primary headache disorders are of an acute recurrent or chronic non-progressive type. Most concerning for something serious is the chronic progressive pattern.
  3. What are the red-flags for secondary headache from space-occupying lesions? Progressive pattern of severity or frequency; sleep-related headache, absence of family history of migraine, headache <6 months’ duration, change in headache type, confusion, abnormal neurologic findings, lack of visual aura symptoms, and vomiting.
  4. What work-up should be done? Neuroimaging should be considered in children who have abnormal results on neurologic examination, seizures, or red-flags by history. It should not be used routinely when there’s a normal neuro exam and recurrent headaches that are non-progressive. Some recommend using imaging for chronic headaches as a tool to reassure the patient and family, which may be therapeutic in and of itself.
  5. How should we manage headaches? Use SMART  as an acronym for headache management: regular S=sleep, M=meals, A=activity, R=relaxation & stress management, T=trigger avoidance. (See our expert Dr. Blume’s thorough review!) I really like Dr. Julie Bledsoe’s reminder to her patients when there are brain-related diagnoses: “we have to do the basics well” including sleep routine, nutrition, and physical activity. We can avoid triggers, and maybe even medications, through doing the basics well. When we do have to use medications for frequent headaches, it’s recommended to limit to one rescue and one prophylactic medicine, and to try to use rescue only 2-3 times per week to avoid medication rebound headaches. One option to consider for analgesia is Naproxen, which has longer duration and is not typically associated with rebound headaches.