Transcript HOT TOPICS AND PEARLS IN PEDIATRICS

HOT TOPICS AND PEARLS
IN
PEDIATRICS
AMY BROCHU PA-C
DISCLAIMER
• I received no commercial support , in-kind or
monetary, for this program
• I have no financial interest or relationship with
manufacturers, distributors, marketers, or
retailers of any products that may be
mentioned in this program
A
• Insert photo kids, medieval art of child.
VACCINES
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WHAT THEY ARE, HOW THEY ARE MADE
THEY ARE SAFE
WHO NEEDS WHAT -2016 CDC GUIDELINES
WHAT TO SAY TO NAY-SAYERS
WHAT ARE THE ABSOLUTE CONTRAINDICATIONS TO USE
Vaccines are…
• A (safe) way to impart active immunity to an
individual by administering an antigen, in a
controlled setting, into the host, who will then
develop antibodies against said antigen.
• How they work
Types of vaccines…
• Live cell (attenuated)
– MMR, Varivax, flu, yellow fever, polio; BCG, typhoid
• Inactivated Whole cell
– Flu, polio, HAV, rabies; typhoid, cholera, pertussis
• Inactivated fractionated-polysaccharides
– DTaP; PPSV23, MC, salmonella
• Inactivated conjugates
– PCV 7, PCV13, menactra, menveo
• Inactivated recombinant
– HBV, HPV, live and inactivated flu, typhoid
FAQs on vaccines…
• Doesn’t my baby have immunity from me? asks
the mother
• Doesn’t breast feeding give my baby immunity?
• Aren’t too many at once not safe?
• Are vaccines made from aborted fetuses? (or
stem cells)
• What about additives?
• What about egg allergies..?
• Please don’t tell me your patients still believe
autism is caused by vaccines…
The Vatican on Vaccines
• The NCBC, along with the Pontifical Academy for
Life -- a Vatican body established to provide
information about issues in law and biomedicine - have studied the moral issues surrounding
vaccines and have determined that it is morally
licit, and even morally responsible, for Catholics
to use even those vaccines developed from
aborted fetus cells. The Pontifical Academy for
Life determined that the good of public health
outweighs the distanced cooperation in the evil
of the abortions performed in the 1960s from
which the cell lines were developed
SMALL POX- variola
POLIOMYELITIS
NEISSERIA MENINGIDITIS
Informed Refusal
• Documenting Parental Refusal to Have Their Children Vaccinated
• All parents and patients should be informed about the risks and
benefits of preventive and therapeutic procedures, including
vaccination. In the case of vaccination, the American Academy of
Pediatrics (AAP) strongly recommends and federal law mandates
that this discussion include the provision of the Vaccine Information
Statements (VISs). Despite our best efforts to educate parents
about the effectiveness of vaccines and the realistic chances of
vaccine-associated adverse events, some will decline to have their
children vaccinated. This often results from families misinterpreting
or misunderstanding information presented by the media and on
unmonitored and biased Web sites, causing substantial and often
unrealistic fears.
CONTRAINDICATIONS
to vaccines
My approach to the cautionary
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Hear them out
Validate
Impart knowledge
Formulate a compromise if possible
I did not discharge from practice because of
vaccine refusal
SAFE WEBSITES FOR PARENTS
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VAERS http://vaers. hhs.gov/data/index
CDC http://www.cdc.gov/vaccines
AAP https://www.aap.org/
WEB MD www.webmd.com
2015 CDC RECOMMENDATIONS
BORDETELLA PERTUSSIS
whooping cough
• pic
MEASLES
RUBEOLA
Morbidity and Mortality Weekly Report
(MMWR)
• Measles Outbreak — California, December
2014–February 2015
• As of February 11, a total of 125 measles cases
with rash occurring during December 28,
2014–February 8, 2015
Haemophilus Influenza
STREPTOCOCCAL PNEUMONIAE
HUMAN PAPILLOMA VIRUS
OTITIS MEDIA
• WHAT IS OTITIS MEDIA
• STANDARD OF CARE- when to treat with
antibiotics
• ICD-10 codes- YIKES
AAP GUIDELINES
• Key Action Statement 3A: Severe AOM: The clinician should
prescribe antibiotic therapy for AOM (bilateral or unilateral) in
children 6 months and older with severe signs or symptoms (ie,
moderate or severe otalgia or otalgia for at least 48 hours or
temperature 39°C [102.2°F] or higher). Evidence Quality: Grade B.
Strength: Strong Recommendation.
• Key Action Statement 3C: Nonsevere unilateral AOM in young
children: The clinician should either prescribe antibiotic therapy or
offer observation with close follow-up based on joint decisionmaking with the parent(s)/caregiver for unilateral AOM in children 6
months to 23 months of age without severe signs or symptoms (ie,
mild otalgia for less than 48 hours and temperature less than 39°C
[102.2°F]). When observation is used, a mechanism must be in
place to ensure follow-up and begin antibiotic therapy if the child
worsens or fails to improve within 48 to 72 hours of onset of
symptoms. Evidence Quality: Grade B. Strength: Recommendation
m
DURATION OF THERAPY
• Age<<2yo
10 days
• Age 2-5yo
7 days is ok
• Age >>6yo
5-7 days is ok
ICD-10
Urinary Tract Infection
• CLINICAL PRACTICE GUIDELINE
• Urinary Tract Infection: Clinical Practice
Guideline for the Diagnosis and Management
of the Initial UTI in Febrile Infants and Children
2 to 24 Months
• From AAP PEDIATRICS Volume 128, Number
3, September 2011 609
UTI
• Action Statement 1
• If a clinician decides that a febrile infant with no
apparent source for the fever requires antimicrobial
therapy to be administered because of ill appearance
or another pressing reason, the clinician should ensure
that a urine specimen is obtained for both culture and
urinalysis before an antimicrobial agent is
administered; the specimen needs to be obtained
through catheterization or SPA, because the diagnosis
of UTI cannot be established reliably through culture
of urine collected in a bag
• (evidence quality: A; strong recommendation).
Did you say cath???!!???
Empiric Antimicrobial Agents for Oral
Treatment of UTI
• Amoxicillin-clavulanate 20–40 mg/kg per d in 3 doses
• Trimethoprim-sulfamethoxazole 6–12 mg/kg
trimethoprim and 30-60 mg/kg sulfamethoxazole
• per d in 2 doses
• Sulfisoxazole 120–150 mg/kg per d in 4 doses
• Cefixime (suprax) 8 mg/kg per d in 1 dose
• Cefpodoxime (vantin)10 mg/kg per d in 2 doses
• Cefprozil (cefzil)30 mg/kg per d in 2 doses
• Cefuroxime axetil (ceftin) 20–30 mg/kg per d in 2 doses
• Cephalexin (keflex) 50–100 mg/kg per d in 4 doses
Antibiograms
NT=not tested
SENSITIVITY TRENDING FOR MAINEGENERAL
COAG NEGATIVE STAPH
Cefazolin
Cipro
Erythro
Furadantin
Gentamicin
Nafcillin
Tmp/Smx
Vanco
Moxifloxacin
2000
39
62
47
100
77
40
61
100
2001
35
58
48
99
76
39
64
100
X
2002
42
54
43
99
81
42
64
99
X
2003
39
44
43
99
84
39
65
100
X
2004
41
39
46
100
90
41
71
100
X
2005
35
2006
40
39
99
93
35
65
100
42
100
78
40
58
100
X
X
2007
53
46
39
95
74
46
63
100
X
2008
57
45
30
99
96
51
99
100
74
2009
51
43
33
100
95
51
69
100
73
2010
39
45
48
100
87
39
69
100
55
2011
59
56
51
100
95
59
57
100
66
2008
70
42
67
74
42
70
2009
66
41
68
80
38
73
2010
67
41
65
80
37
71
2011
86
65
85
79
28
90
2012
66
67
48
98
94
66
75
100
NT
2013
66
63
53
100
92
61
69
100
NT
ENTEROCCUS
Ampicillin
Cipro
Furadantin
Gent/Amp
Tetracycline
Vanco
2000
93
59
99
75
45
98
2001
91
62
100
82
37
97
2002
95
52
97
74
45
99
2003
99
58
99
76
40
99
2004
95
57
99
77
32
97.5
2005
2006
94
85
34
85
95
83
44
89
2007
89
37
97
86
37
95
2000
66
2001
69
2002
62
2003
72
2004
69
2005
66
2006
78
2007
64
2008
74
2009
77
2010
84
2000
89
90
98
98
95
2001
90
91
100
100
90
2002
86
83
99
94
96
2003
94
94
100
94
96
2004
91
91
99
98
98
2005
88
87
99
89
98
2006
94
95
100
88
98
2007
85
92
98
84
98
2008
92
98
99
93
95
2009
84
94
96
83
97
2010
89
93
98
84
97
2012
86
61
85
76
25
90
2013
84
64
83
80
28
86
H. INFLUENZA
Ampicillin
2011
NT
2012
NT
2013
NT
PROTEUS M.
Ampicillin
Cefazolin
Ceftriaxone
Cipro
Gentamicin
2011
83
91
99
87
94
2012
85
90
98
91
96
2013
81
88
97
89
96
Action Statement 5, 6
• Febrile infants with UTIs should undergo renal
and bladder ultrasonography (RBUS) (evidence
quality: C; recommendation).
• VCUG should not be performed routinely after
the first febrile UTI; VCUG is indicated if RBUS
reveals hydronephrosis, scarring, or other
findings that would suggest either high-grade
VUR or obstructive uropathy, as well as in other
atypical or complex clinical circumstances
(evidence quality B, recommendation).
ASTHMA
• Know the classifications and how they are
different
– EIB, intermittent, ICS use bumps you up to persistent.
• EIB is only class does not need action plan,
management visits, or PFTs.
• 2 visits per year recommended for stable asthma.
• PFTs every 2 years =/> 5yo recommended.
(document you tried and child not capable)
Hot Topics
• ADHD
• Asthma and lipopolysaccharides
ADHD in Children With Comorbid Conditions:
Diagnosis, Misdiagnosis, and Keeping Tabs on Both
• Stephen V. Faraone, PhD; Arun R. Kunwar, MD
• Attention-deficit/hyperactivity disorder (ADHD) is one
of the most common childhood neuropsychiatric
disorders, affecting 3% to 5% of school-age children.
Children with ADHD often have other psychiatric
disorders, with epidemiologic studies suggesting
comorbidity rates of between 50% and 90%.[1,2] High
rates of psychiatric comorbidity have been reported
both in psychiatric and pediatric patient
populations.[3]
• J Clin Psychiatry. 1998;59 Suppl 7:50-8.
ADHD Stimulant Abuse Common
Among Young Adults
• Reasons for misuse include pressure to succeed
at school or work
• By Tara Haell, HealthDay Reporter
• THURSDAY, Nov. 13, 2014 (HealthDay News) -Nearly one in every five college students abuses
prescription stimulants, according to a new
survey sponsored by the Partnership for DrugFree Kids. The survey also found that one in
seven non-students of similar age also report
abusing stimulant medications.
ADHD Stimulant Abuse Common
Among Young Adults
• "The profile that emerges is less that of an
academic 'goof-off' who abuses prescription
stimulants to make up for lost study time than
a stressed out multitasker who is burning the
candle at both ends and trying to keep up,"
And what about driving….
• Driving — Adolescents with untreated ADHD are two to
four times more likely to have motor vehicle accidents than
those without ADHD. They also are more likely to have their
driver's license suspended or revoked.
• As a result, parents of adolescents with ADHD should
discuss the issues surrounding driving before the
adolescent is licensed to drive. A longer period of
supervision (eg, the adolescent drives with an adult) can
help to ensure that the teen is able to use good judgment,
can react quickly and carefully, and is safe to drive
independently.
• Psychiatr Clin North Am. 2004 Jun;27(2):233-60.
– Driving impairments in teens and adults with attentiondeficit/hyperactivity disorder.
Environmental Microbial Exposure and Protection
against Asthma
Patrick G. Holt, D.Sc., and Peter D. Sly, D.Sc.
From the NEJM 12/2015
PEARLS
PEARLS
• THE BASICS
• GETTING A STREP CULTURE
• Websites for teenagers...discussing privacy
rights
Strep swabbing made easy (I hope)
Teen friendly (and safe) websites
>>maineteenhealth.org<<
>>young womenshealth.org<<
>>youngmenshealth.org<<
>>www.prch.org<< for handouts on minor’s
rights to treatment:
My must haves for pediatric care
Web site: The Sports Medicine Patient Advisor….
Books for Parents
Thank you!