2018-19 TOW #14: Antibiotics in primary care

School is in full swing, and we have already had the first cold of the season at our house. As we gear up for flu vaccines in preparation for viral season, it’s time to think about antibiotic use and stewardship in primary care setting. Our amazing general pediatrics and hospital medicine chair, Dr. Rita Mangione-Smith MD MPH, has been a lead researcher in informing this topic.

Materials for this week:

Take-home points:

  1. How often are antibiotics prescribed in outpt settings? More than 1 in 5 ambulatory visits for children results in antibiotic prescription. Studies have shown up to 1/3 of patients diagnosed with a common cold receive an antibiotic prescription. This increases up to 60% among patients presenting with bronchitis and other viral illnesses.
  2. What are some harms of antibiotic use from both an individual and a community-based standpoint? Individual harm includes diarrhea, upset stomach, adverse drug reactions, higher rates of resistant bacteria, and disruption of the gut microbiome. From a society standpoint, unnecessary antibiotic use contributes to excess health care costs and promotes antibiotic resistance.
  3. What situations trigger physicians to prescribe antibiotics for respiratory infections? Dr. Mangione-Smith and team found physicians were more likely to prescribe antibiotics for children with a cold if 1) they perceived the parent or patient expects it, 2) there is parental anxiety about the child’s illness before the visit, 3) they reported wheezing or rhonchi on exam, and 4) parents had very low SES (perhaps MDs may mistakenly believe it is faster to give ABX than explain what to do instead). Other studies have also found we prescribe more in visits that occur later in the day (consistent with decision fatigue).
  4. What are the principles of responsible antibiotic prescribing? 1) Determine the likelihood of a bacterial infection-use diagnostic criteria and guidelines, as well as tests to determine pre-test probability when possible, such as Centor criteria for sore throat and strep infection, and clear clinical findings for acute otitis media; 2) Weigh benefits and risks of ABX treatment to determine whether they should be given, and 3) Use judicious prescribing strategies (i.e., the most narrow-spectrum and effective antibiotic for the appropriate duration – this might include a watch and wait approach, if appropriate).
  5. What methods can we use to counsel family members about antibiotics? As per Dr. Mangione-Smith’s research, we are likely to get more questioning of the treatment if we specifically say “antibiotics are not needed” when we summarize the treatment plan, rather than focusing on positive, supportive treatment that parents can implement. When parents suggest a “candidate diagnosis” that might require antibiotics, like ear infection, sinusitis, or pneumonia, we should explain how we will determine the diagnosis based on the exam. Other strategies we can use: align with parents on goals of helping the child get well as quickly and safely as possible, legitimize symptoms and concerns for bringing the child in, and address parent anxiety and effort. Addressing specific ways to manage symptoms (analgesics, elevated head of bed, steam/ warm baths, honey for cough, etc.) is helpful. I’ve also taken to highlighting the benefit of building the immune system in young ages, as this potentially helps lower risk of autoimmune diseases later.

2018-19 TOW #13: Newborn screening

Newborn screening has helped revolutionize our ability to detect metabolic and hematologic diseases in infants. While the vast majority of screens are normal, when we catch those rare diseases before any symptoms start, we are reminded just how remarkable this process is (as per my experience in clinic last week). Two of our program graduates contributed to the materials for this topic, Drs Dave Higgins and Beth Tarini MD MPH, a national expert.

Materials to review:

Key points in newborn screening:

  1. When did it start and how is it done? 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 (we screen for about 30 on our state screening). Key criteria for screening is which diseases have accurate, safe, effective testing and follow-up treatment available.
  2. What are the 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. What’s the reliability 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? Key information we should review with parents includes basic description of the disease process in question, that there are false positives, especially for some diseases, and next steps in evaluation and treatment (e.g., repeat testing on same sample, speaking to a specialist early in the evaluation process). Refer to the WA state newborn screening website for more guidance.

2018-19 TOW #12: Autism Spectrum Disorder

Autism spectrum disorder (ASD) has emerged as one of the most important pediatric issues in recent decades. Fortunately, advocacy and investment has helped our understanding of the many facets of autism including risk factors, diagnosis and treatment. We have much yet to learn to better address ASD and support those affected by it.

Materials:

Take-home points:

  1. What are the criteria for diagnosing autism? The DSM criteria were revised for DSM-5 and include 2 major categories of symptoms: 1) persistent deficits in social communication and social interaction across multiple contexts, and 2) restricted, repetitive patterns of behavior, interests, or activities. These symptoms must be present in the early developmental periodcause clinically significant impairment, and not be better explained by intellectual disability or global developmental delay. Symptoms are also classified for severity and accompanying intellectual impairment(s).
  2. How prevalent is ASD? Prevalence has increased in recent decades with a 2012 CDC prevalence study reporting it to be as high as 1 in 88 in certain areas, and as many as 1 in 54 among boys. The increase in prevalence is due to multiple factors including greater awareness, earlier diagnosis, diagnostic substitution due to the ability to qualify for more services with autism, and broader diagnostic criteria. Certain genetic diseases have a higher prevalence of autism and should be considered in the diagnosis including Neurofibromatosis, Tuberous-Sclerosis, Fragile X, and Angelman.
  3. When should we screen? The AAP recommends formally screening for autism using a tool such as the M-CHAT at 18 and 24 month visits. We can also begin to screen prior to that, through developmental surveillance. Reimbursement for screening can be obtained using CPT codes 96110 (Developmental Testing, Limited).
  4. How should we screen? The M-CHAT-R/F was a revision with a 2-stage screening process to decrease false positives. Low-risk is a score 0-2. Medium risk is 3-7, and high risk is >=8 among the first set of 20 questions. Refer high risk children, and use the follow-ups questions for the medium risk group. If children continue to be >=2 after follow-up questions, they should be referred – they are likely to have ASD (~50%) or a developmental disorder (95%). Using the follow-up questions, the screener is 85% sensitive and 99% specific for ASD.
  5. What resources are available locally? Children under 3 should be referred to the Birth-to-Three resources while awaiting formal diagnostic evaluation through UW or SCH. We have an impressive local (and very busy) Autism Center at Seattle Children’s. In addition to the clinical resources, the Center hosts a series of free lectures for families and caregivers and a blog. Nationally, the Autism Speaks website has many great resources for families as well.

2018-19 TOW #11: Bullying

With return to school and National Bullying Prevention Month coming up, this is an opportune time to discuss bullying. Bullying 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 and internationally known child health and injury prevention expert at Harborview, Dr. Fred Rivara MD MPH, chaired a panel for the Institute of Medicine to report on bullying and how to prevent it.

Materials for this week:

Take-home points:

  1. How do we define bullying, and what are the forms? Bullying is an intentional, aggressive and repeated behavior that involves an imbalance of power or strength. The power difference can be in size, age, political, economic, or social advantage. Bullying includes physical, verbal, social (trying to hurt a person’s reputation within a group or organization), cyberbullying, and cyber harassment (bullying by an adult online).
  2. How frequent is bullying? Estimates are that ~20-30% of youth in the US report being bullied, and 1 in 3 youth is affected either as a victim or perpetrator or both. Cyberbullying is estimated for 7-15% of youth. While “bully” conjures up certain images, most kids who are bullying are typically developing boys and girls who are learning to navigate their social world.
  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, and 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.)” The motto often shared is “Telling is not tattling. It is getting someone help” (not just to get someone in trouble). When we identify bullying, we should take concerns seriously. We should talk to children and their parents and provide counseling about the importance of getting help from an adult. We should contact school personnel directly if we are concerned they are not adequately addressing it. We should also refer the child to a therapist or counselor for help.