2018-19 TOW #47: Tuberculosis screening

We are fortunate to live in an increasingly diverse city with immigrants from around the world. At this time of year families are often planning summer travel to visit family members abroad, so this is a good time to think about how to screen for TB after travel. Materials for this week:

Key take-home points:

  1. What are the rates of TB in the US, and what are the risk factors among children? TB has been declining in the US and reached an historic low of 3.2 cases per 100,000 in 2012. The biggest risks are being born outside the US, or traveling to another country, especially for >1 week and staying with family. For children, additional risks include living among family members or visitors born in endemic countries, or living with high risk adults (including those affected by homelessness, incarceration, drug use or HIV). Those with chronic diseases, immunodeficiency, and/or those using high-dose steroids are also at higher risk of developing TB.
  2. Who do we need to screen for TB in clinic? It’s recommended to start screening for latent TB infection (LTBI) from the first time we meet patients and annually at well visits, or 10 weeks after return from travel (although considered acceptable to wait for annual check-ups). To assess LTBI risk factors, there are 4 validated questions: 1) Has a family member or contact had TB? 2) Has a family member had a positive TB test? 3) Was the child born in a high-risk country (i.e., outside US, Canada, Australia, New Zealand or Western Europe)? 4) Has the child traveled to a high-risk country for more than 1 week? (and SCH ID team adds: or has child had household visitors from a high-risk country?)
  3. Which screening tests do we use? Screening tests vary by age group: per the CDC, tuberculin skin test (TST or PPD) is still preferred for children less than 5. The preferred test for ages 5 and older is a blood test, the interferon gamma release assay (IGRA, e.g., QuantiFERON -TB Gold). IGRA tests measures interferon gamma response to mycobacterial antigens so are relatively specific to M. tuberculosis. They do not require a return visit, and are not cross-reactive with BCG vaccine. We can use a combination of tests to help establish diagnosis when there are indeterminate results, or concern for false positives or negatives.
  4. What happens if there is a positive TB screen? To establish a diagnosis of latent TB, rule out active disease through a chest x-ray, history and exam. The initial preferred treatment for positive latent TB is with isoniazid (INH) for 9 months (there are alternative schedules to this based on special patient needs).
  5. How common is BCG vaccine? How does BCG vaccine affect interpretation? Bacille Calmette-Guerin (BCG) immunization is widely used in TB endemic countries; the WHO estimates that 83% of the world’s population has received this vaccine. Most countries recommend giving the vaccine at birth, and the majority of children receive it before age 5. Because of the varying effects of BCG on interpreting TB tests, we use a conservative approach, and BCG status is not used in interpreting PPD reactions, and is not a contraindication for receiving PPD. Quantiferon gold testing is not affected by cross-reactivity with BCG, however the test has been less accurate for younger children, and may be more difficult to administer due to phlebotomy requirement.

2018-19 TOW #46: Adolescent immuniztions

There’s a lot going on in adolescence, including trying to complete additional recommended vaccines, the most challenging being HPV and flu. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of clinical settings do adolescents use? Most teenagers have a medical home in the US, and >90% of adolescent vaccinations are received in a pediatric, family medicine or community health clinic. A few receive vaccines in school clinics, internal medicine and OB-GYN settings.
  2. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series (1 dose at 11-12, 2nd at age 16), single dose of Tdap, 2-dose HPV vaccine series (separated by minimum of 5 months; it’s 3 doses if started at age 15 or older), and an annual influenza vaccine.
  3. What are adolescent immunization rates in the US? The 2016 National Immunization Survey showed that adolescents aged 13-15 years met the Healthy People 2020 goal of 80% coverage for Tdap (88% coverage) and first dose of meningococcal vaccine (82% coverage), but did not meet the HPV vaccine benchmark (50% of females, 38% of males). Flu vaccine rates are especially low for teens (49% of 13- to 17-year-olds).
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; family factors include not coming for annual wellness visits. There has been particular parental concern about the HPV vaccine safety and need for it at a younger age. The HPV vaccine is only effective against HPV strains before exposure to the strains. Even before teens start having sex, they may be at risk for HPV related disease. HPV DNA has been detected in cervicovaginal swabs from girls who report never having had vaginal intercourse, so the virus is also transmitted through other forms of sexual contact. Data suggest better immunogenicity to the vaccine when given at a younger age, and teens are motivated that it is only 2 doses if done before age 15.
  5. What are ways we can help increase vaccination rates? A strong provider recommendation is one of the most important factors that positively affects vaccination, as has been shown in several studies for the HPV vaccine. Other strategies are to review immunization records at visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccines due. System-level approaches include family-oriented ones like text reminders to families, web-based education and social marketing, as well as clinician-focused ones like automatic EMR reminders and incentives.

2018-19 TOW #45: Substance use

As pediatricians in primary care, our roles include universal screening, brief intervention, and referral to treatment (SBIRT) for adolescent substance use. After Washington state legalized adult use of marijuana in 2012, we entered a new era of adolescent substance use. One patient I saw under age 13 described in detail why marijuana was a “natural drug” that had medicinal properties to justify why she used it. The societal messages are confusing and often erroneous for teens, so it’s important for us to help provide accurate information and support.

Materials for this week:

Take-home points for substance use problems:

  1. What’s the epidemiology of youth substance use? Among US teens, average first use of alcohol is 13.1 years, ~50% have tried alcohol by 8th grade, and almost 80% have tried it by high school graduation. >50% have tried other drugs by the end of high school, most often marijuana, and ~20% have used prescription drugs non-medically (a BIG increase).
  2. What are the risk factors for substance abuse? Parents with substance abuse, history of abuse, depression or learning disabilities (especially ADHD), family conflict, friend use, and  living in a rural area. Data have shown that those who drink prior to age 15 years are 4 times more likely to develop alcohol use disorder than those who start at age 21. Protective factors include a stable, supportive home environment with clear parental expectation and rules, friends not involved with substances, and personal, academic and social success.
  3. What are the associated problems with substance use? There are many including school drop-out, violence, motor vehicle accidents, pregnancy, and permanent decrease in IQ with prolonged use. Youth getting Ds and Fs in school are 3x more likely to be using alcohol than those getting As.
  4. How should we screen? Use the HEADSSS assessment to screen all youth. It’s helpful to frame this as a “we care about you, teenage years can be hard, and we want to help.” It is also recommended to ask parents and teens together what they have talked about and their attitudes. If concerned, follow-up with the CRAFFT assessment: 2 or more positive responses are predictive of problem use.
  5. Where can we refer? Options to address problem use include mental health counseling and specific substance use treatment. Local resources: Adolescent medicine at SCH, and community programs such asRyther Center for Children and Youth and Therapeutic Health Services

2018-19 TOW #44: Circumcision

Newborn male circumcision is a topic that remains controversial in pediatrics, and overall the AAP has maintained a neutral stance on it. The most recent AAP report, issued in 2012, stated that overall, male circumcision has adequate benefits compared to risks to “justify access to the procedure for families who choose it.” In Washington State, families who choose circumcision must pay for the procedure out of pocket. At the UW Northgate Clinic, one of the available local sites, it costs about $300.

Materials for this week:

Key take-home points:

  1. What are the main benefits and risks of circumcision? Benefits include decreased risk of UTI before age 2, and decreased risk of heterosexual transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in female partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, and buried penis.
  2. What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
  3. What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw appearance from lysing foreskin adhesions, which can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
  4. When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, phimosis or paraphimosis, or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves).
  5. What advice do we give about care for the uncircumcised penis? The only care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractible foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 3 in about 90% of boys, and by teenage years in almost all boys.

2018-19 TOW #43: Hip dysplasia

Developmental dysplasia of the hip (DDH) is an important newborn-related topic. A 2016 report gave new updates that highlighted the “primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.”

Materials for this week:

Take-home points:

  1. What are the primary risk factors for DDH? Female gender (up to 75% of DDH), family history, and breech position in the 3rd trimester. As of the updated guideline, there is now also a risk factor noted for tight swaddling with legs adducted and extended. As many as one in six newborn babies have mild hip instability at birth, and approximately one per thousand has a dislocated hip.
  2. How do we screen for and prevent DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging. Hip-safe swaddling allows the legs to move into flexed and abducted hip position (i.e., legs not confined to a straight extended position). Safe baby carrying is the “Spread Squat position” – also known as the M-Position, or Jockey Position – with the thighs spread around the mother’s torso and the hips bent so the knees are level with or slightly higher than the buttocks. 
  3. What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy while supine with the hips and knees in straight leg position, and then with the hips and knees in flexed position (*be aware if hip dysplasia is bilateral, we obviously can’t compare sides). Galeazzi sign is unequal knee height when legs are flexed. Use Ortolani maneuver (abduction movement to detect a dislocated femoral head reducing into the acetabulum), which the newest guidelines say has the best predictive value. Barlow manuever may not be necessary and/or harmful if too much pressure is applied. If Barlow is used, it should be gentle pressure applied while adducting the hip after performing Ortolani. The Ortolani and Barlow maneuvers are really most reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds, hip movement, and leg length. Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred.
  4. What imaging do we use to screen? Ultrasound at age 6 weeks to 6 months, or plain x-rays at 4-6 months are considered fairly equivalent according to the data, and are implemented based on local availability of trained sonographers. Note, there are more false positives with early ultrasound, and many children with more subtle findings may be watched and rescreened.
  5. What constitutes a positive screen? Based on consensus, children who have unstable hips on exam (a “clunk” on Ortolani) or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Isolated hip clicks without the sensation of instability usually represent normal laxity and myofascial tissue movement over the bones and do not require referral.