AAP NCE 2009 Day #1

AAP NCE 2009

Friday, Otctober 16th

If you decide to drive up to DC and need gas around Manassas, Virginia, and also think perhaps you’ll use the restroom while you’re there, skip the Shell station at exit 164 unless you bring Chlorox wipes. That’s all I’m gonna say about that.

The evening started with a reception for Dr. David Tayloe over in the Hyatt. The Hyatt is only two blocks from the Renaissance, where Dad and I are staying. But in 39 degree drizzle it’s a long, blazer-wilting trudge. I’m hoping someone is giving away umbrellas in the exhibit hall. In addition to current AAP President and fellow North Carolinian David Tayloe, we were visited by past president Rene Jenkins, new president Judith Palfrey, and president-elect Marion Burton.

From there it was back through the drizzle to the Renaissance for the grand opening reception. The drinks were FREE! There was food, a great live band, and colored lights. Some pediatricians were getting down on the dance floor. And did I mention the free drinks (courtesy of Sciele Pharmaceuticals, makers of fine medications for the whole family).

Saturday, October 17th

Let me say in advance there's some stuff left out, but this is what I could glean and type at the same time while drinking coffee.

Five Critical Cardiac Problems Commonly MIssed In Office Practice

Stuart Berger, MD, FAAP

Okay, I know I went to a similar talk at the NCPS meeting, but missing a serious cardiac issue is something I worry about every day, so here’s another one.

Critical Left Heart Obstruction

• This lesion is ductal-dependent - keep it open!
• Typical anatomy includes hypoplastic left heart, critical coarctation/interrupted arch, critical aortic stenosis.
• Once the ductus closes child decompensates nothing perfuses the aorta.
• Hypoplastic left heart: impaired inflow and outflow to left ventricle.
• Presentation:
• varies by lesion, but may have no symptoms initially, go into cardiogenic shock once the ductus closes.
• Tachypnea is common, early presentation, worsens as ductus closes.
• Also see hepatomegaly, decreased pulses, gallop rhythm.
• Not all babies are diagnosed in utero.
• Therapies/Intervention:
• Prostaglandin immediately, as soon as lesion is suspected. Low down-side.
• Usually require surgical intervention
• How can we optimize detection of these lesions?
• Routine echocardiography neither feasible nor cost-effective.
• Observing babies for four or five days in nursery also not feasible.
• Routine upper and lower extremity SpO2 may be useful.
• Routine UE and LE blood pressures may also be helpful.
• AAP/AHA joint consensus statement, estimated sensitivity of routine SpO2 is 70%, positive predictive value around 50%, high rate of false-positive screens. So far not recommended, but further study warranted.
• Be sensitive to signs of tachypnea, tachycardia, active precordium, gallop rhythm, decreased pulses, poor capillary refill, differential pulses or perfusion.

Cyanotic Congenital Heart Disease With Minimal Cyanosis

• Tetralogy of Fallot
• Tends to be progressive
• Loud murmur just after birth due to muscle bundles obstructing RV outflow
• Pulmonary atresia with intact Interventricular Septum
• Ductus is the only source of flow to the pulmonary artery
• Progressive cyanosis with ductus closing
• May present in extremis
• Murmur may not be present.
• Transposition of the Great Arteries
• Most common in the cyanotic congenital heart disease in the newborn period
• Two parallel circuits, if no mixing then profound cyanosis.
• May not have a murmur
• PDA can allow some mixing and keep patients alive.
• Buy time with balloon atrial septotomy
• Truncus Arteriosus
• Cyanosis minimal at first, progresses
• Murmur may or may not be present, to and fro across truncal valve.
• As pulmonary resistance drops failure occurs
• Total anomalous pulmonary venous return
• Oxygenated blood may return to any number of places, but not the LA
• Obligate right to left shunt
• Cyanotic early on.
• In this case Prostaglandin may make things worse, although this is controversial.
• Typical scenario varies by lesion. Be on the lookout for DiGeorge Syndrome.
• How do we optimize detection of these babies?
• Even minimal cyanosis deserves evaluation
• Murmur may be a clue, although it may not be present
• Active precordium is nonspecific but useful: always lay a hand on the chest.
• Tachypnea is a sensitive sign.
• Consider pulse oximetry.

Dilated Cardiomyopathy

• Systolic function of left venticle, right ventricle impaired
• Over time LV function worsens.
• MV and TV dilate, AV becomes insufficient
• Presentation
• May be acute, may present in extremis
• May also present insidiously
• Acute presentation: respiratory distress, cool and clammy, poor urine output, hepatomegaly, gallop
• Chronic: tacypnea, tachycardia, failure to thrive, irritability
• Etiologies
• Myocarditis common, often preceded by viral illness.
• May be familial
• Many other possible causes including metabolic, toxic, neuromuscular, arhythmia
• Critical to recognize symptoms early, start supportive therapy early.
• 1/3 survive with full recovery
• 1/3 survive with chronic heart failure
• 1/3 are likely to die, but this number is falling.
• Treatment
• Diuretics, inodilators, ACE, aldactone, beta blockers, ventillation, mechanical cardiac support
• Even the sickest patient may recover with appropriate support.
• Clues to diagnosis
• Acute collapse
• Chronic chest pain, abdominal pain, vomiting
• Chronic tachycardia
• Cardiomegaly
• Failure to thrive
• NOT BLOOD PRESSURE! This is the last thing to change. If BP is low, it’s very, very late.
• Chronic unresponsive wheezing
• When in doubt check a chest x-ray, consult your cardiologist
• Chronic tachycardia and tachycaria-induced cardiomyopathy
• Rare cause of dilated CM
• Potentially reversible
• Comes from chronic SVT or ventricular tachycardia
• Can be challenging to diagnose: is the tachycardia primary or secondary?
• Tend not to present with acute collapse
• Failure to thrive common presentation
• Make sure to get a good EKG with any cardiomyopathy, confirm sinus rhythm
• Immediate consultation required with pediatric cardiology, electrophysiology

Long QT syndrome and other channelopathies

• Prolongation of QT varies, and sometimes falls within the “normal” range.
• May be difficult to diagnose, may present with no symptoms at all.
• Gene testing is now available for some forms of long QTc.
• R on T phenomenon, Torsades de Pointes
• May present with seizures, “drop attacks.”
• May be associated with deafness
• EKG may have bradycardia, U waves, bizarre ST-T wave findings.
• Family history may provide clue to diagnosis
• Therapies
• Beta blockers
• Implantable defibrillator
• Other medications
• Stellectomy
• Can definitely prolong life, reduce risk for sudden death

Syncope

• Typically occurs from cerebral hypoperfusion
• Many etiologies
• Must differentiate between benign and life-threatening causes.
• May occur with or without provocation
• History, family history, and physical exam are critical
• Was it with exercise?
• Has it happened before?
• Is there a family history?
• Were the usual vasovagal triggers present?
• Is there an irregular heartbeat or heart murmur?
• Exercise-induced syncope is VERY concerning
• Tilt testing has plenty of false positives and false negatives, may occasionally be helpful.
• Neurocardiogenic syncope is a clinical diagnosis, responds to supportive care in most cases.
• Bad syncope
• HOCM
• Congenital CA abnormalities
• Dilated CM
• Long QT
• WPW
• Syncope may be an early sign of risk for sudden cardiac death. Up to 1/4 of these patients have had an earlier episode of syncope

Plenary Sessions

Maryland Classic Youth Orchestra opening program

Musical slide show with pediatric heroes, quotes from nominations

Michael Foulds, MD, Chair NCE Planning Group

• Joseph Peter, MD, Pediatric Hero
• Hosts free clinics
• Conducts free exams
• Makes sure children get medications and studies they need

Dr. David Tayloe, President, AAP: Major Challenges in Pediatrics

• Healthcare Reform
• Reform at the federal level is necessary
• Medicaid and CHIP payments remain lower than Medicare and private payments
• Many health insurance plans do not honor CPT and RBRVS packages
• ERISA exempts many health insurers from providing adequate coverage for children
• The pediatric subspecialty workforce is inadequate to the needs
• Our health outcomes for children are embarrassingly low for the richest nation on earth.
• Can we bend the cost curve so we can afford to provide all people access to high quality care in a medical home?
• Can we get reimbursed Per Member Per Month based on the complexity of the patients?
• Can we get community based care coordination?
• All children need 24/7 care in a medical home
• Compared to adult medicine pediatrics is far ahead in implementing the medical home model and thus bending the cost curve.
• Health Information Technology
• A longitudinal record is the key to the medical home
• Interoperability is key.
• Data sets can assure quality improvement
• AAP Child Health Information Center will make sure pediatricians can access federal funding for advancement of health information technology
• Pediatric quality measures to be published in 2010
• AAP hopes to develop model pediatric electronic health record
• H1N1 Pandemic
• Pediatricians are funcitoning as the public health infrastructure for childhood immunization initiatives

Pediatric Urinary Infections: Management Controversies Faced by the Primary Care Physician

Alicia M. Neu, MD and Ranjiv Matthews, MD

• UTI is the second most common bacterial infection in children
• Affects 7.8% of girls
• Pooled prevalence 5%
• Of febrile children suspected of UTI 7% of infants and 7.8% of children are positive
• Occult bacteriuria occurs more in uncircumcised boys than in girls during infancy.
• In children girls have 20 times as much occult bacteruria.
• But no one knows how occult bacteruria relates to ultimate development of UTI.
• Renal scarring occurs in 6 to 10% of children with UTI
• VUR is a risk factor for cortical defects, but up to 60% of children with defects do not have VUR.
• Renal scarring is associated with increased risk for hypertension.
• Important history:
• Antenatal US
• Family history
• Toilet training
• Prior infections
• VOIDING DYSFUNCTION
• Exam:
• Any other genetic anomaly
• Renal anomalies
• Full bladder
• Constipation
• Genital exam
• Neurologic exam
• Sacral spine: pits, hair, tufts
• UA
• Make sure there is pyuria with ++LE, > 10 WBC per HPF
• Urine culture
• Suprapubic aspirate with any bacteria at all
• Catheterized urine >50,000 CFU
• Cean catch urine >100,000
• Bag too likely to be contaminated
• Imaging
• Ultrasound
• VCUG
• Abdominal x-ray
• DMSA scan
• PICC cystogram
• Likelyhood goes up with ill appearance # to 24 months).
• Jaundice
• Suprabupid tenderness
• Uncircumcised males.
• Temperature >39 degrees C over 48 hours
• Circumcision number needed to treat: 111 to prevent one UTI
• Chances of significant reflux or obstruction with normal ultrasound are quite low
• Remember to obtain test of cure prior to VCUG
• In children over age 12 months screen for UTI if
• prior UTI
• Temp > 39 C
• Fever without an apparent source
• Ill appearance
• Suprapubic tenerness
• Fever >24 hours
• Nonblack race
• (3% to 8% will have UTI)
• New trend: start with DMSA renal scan prior to VCUG, only VCUG if kidneys demonstrate scarring
• DMSA scans take 3-4 hours, require sedation for young children, and cost around $1200, increases radiation dose compared to VCUG
• Remains unclear whether to treat with antibiotic prophylaxis for grade I or grade II reflux. Not done in Europe, but done here.
• Five studies in literature suggest prophylaxis doesn’t help, although there are flaws with each of them. Often use bag urine specimens. Some patients dropped from studies. River Study hopes to solve this question with 600 patients over 2 years.

Evidence-Based Treatment of Depression and Anxiety

John Walkup, MD

• Specific phobias
• Animals, insects, etc.
• Environmental
• Blood, injection, or painful event
• Tunnels, bridges, elevators
• 70% have anxiety disorder as well
• OCD
• Dirt, germs, contamination - specific to OCD. Other symptoms are found in other disorders like anxiety. Very sensitive to treatment.
• Ordering and arranging
• Checking
• Repetitive acts
• Impairing or time consuming
• Separation Anxiety
• Single concern: bad things will happen to parent or child if they’re allowed to separate
• Worse at start of school, end of weekend, after vacation periods
• Generalized Anxiety Disorder
• Restless, keyed up
• Fatigued at end of school day
• Sleep problems
• Get very tense about performance on tests, tend to “choke”
• Unable to control the worry
• Leads to impairment or distress
• Consider this diagnosis in children who are inattentive.
• Social Anxiety
• Fear of social or performance situations
• May appear as shyness, but more severe
• Number one cause of non-academic school dropout.
• Worse in the teenaged years
• Selective Mutism
• Can speak but will not speak in school or social situations
• Pre-pubertal social anxiety condition
• Low volume speakers or low frequency speakers
• Responds well to treatment, so don’t ignore it.
• Acute stress disorder
• True stressful event, life-threatening
• Re-experiencing the event
• Jitteriness, increased arousal
• Lasts 4 to 6 months and resolves.
• Post-Traumatic Stress Disorder
• Similar to acute stress, but persistent
• Higher risk with pre-existent psychiatric disorder
• So don’t ignore whatever pathology was present prior to the traumatic event
• Proximity to stressful event makes PTSD more likely.
• Post-traumatic environment can determine response to traumatic event, if it’s negative then it may prolong the trauma.
• Panic disorder
• Increased heart rate, pounding heart, palpitations
• Hyperventilation, dyspnea
• Choking sensation
• Cest discomfort ot pain
• Abdominal pain
• Assessment strategies
• Screen for Child Anxiety Related Emotional Disorders Scale (SCARED) can be downloaded from the Internet, scoring sheet included.
• Achenbach Child Behavior Checklist
• If kids are positive two years in a row it’s time to refer to psychiatry
• Things to look for
• Physical complaints without medical cause, especially in the pre-pubertal age range
• Problems falling asleep and awakening in the middle of the night
• Eating problems
• Avoidance of outside and interpersonal activities like school, parties, camp, and sleepovers
• Excessive need for reassurance
• Inattention and poor performance at school
• Separation, Generalized Anxiety Disorder, and Social Phobia on fluvoxamine
• Response rate to fluvoxamine was massive, 76%
• Almost no response to placebo
• Number needed to treat = 2
• Best results from Sertraline combined with cognitive-behavior therapy
• CBT alone gets a 60% response
• Sertraline alone gets 56% response
• Placebo only led to a 24% resolution
• How long do you treat anxiety disorders?
• When kids are better they have to learn again who they are
• Sometimes kids don’t want to come off.
• Goal is for the risk of relapse to be the same as the risk of new-onset diagnosis in the general population.
• Treat for a year so each of the major milestones that year go past without anxiety
• Don’t stop if child has ongoing anxiety symptoms, only if they’re symptom-free, including seasonal slumps
• If they get anxious when they miss a dose of medication, they should probably stay on meds.
• Lower the dose slowly
• Observe very carefully for a year after coming off the medication.
• Pick a time that’s most convenient for the family and your practice if the child relapses (spring is nice).
• SSRI Side Effects
• Activation: restlessness, hyperactivity, disinhibition.
• Occurs early in dose or dose escalation.
• 100% reversible.
• Bipolar switching: very rare, much more specific (grandiosity, euphoria), decreased need for sleep, increased goal-directed activity.
• Occurs after weeks on the drug
• Not as reversible with discontinuation of medication.
• Celebration: know this is not bipolar switching, it’s just the release from the constraints of depression and anxiety.
• Dimensional Issues and Comorbid Disorders
• Sometimes so ill with anxiety and depression the ADHD was masked
• Now that kid is feeling better he expresses his ADHD or conduct disorder
• Anxiety was the source of discipline, now there needs to be a new source
• Evolving psychopathology
• Anxiety may grow into other anxieties
• Mood disorders may evolve into other mood disorders or bipolar disorder
• Frontal Lobe Symptoms: Apathy
• Occurs at high dose of medications
• Not depression or sedation
• Disinterest, lack of motivation, not caring about consequences
• Gastrointestinal symptoms
• nausea, dyspepsia
• Hey! (What happened to my sex life?)
• Little information from young people
• Less an issue for teens than for adults
• May cause unexplained discontinuation of medication
• Hematologic
• Easy bruising, nosebleeds
• Prolonged bleeding times, platelet dysfunction
• Inhibited growth
• Secondary to poor sleep
• Could it be due to serotonin induced growth hormone suppression?
• Four case reports
• Suicidality
• NNT for depression is 10
• NNT for anxiety is 3
• Number needed to harm for suicidality = 143
• Depression
• 20% lifetime risk
• 17% of high school kids contemplate suicide
• 1/100,000 complete it
• Fluoxetine got a 53% response rate
• Paroxetine ineffective
• Sertraline not very effective compared to placebo, but trials poorly done
• Escitalopram effective, approved down to age 12 years
• Psychotherapy works best for acute-onset kids with high SES and good grades.
• Combination therapy & medication works best.
• Only suicide risk identified with ideation, not attempts, only found by pooling multiple studies.
• Unknown how many kids got suicidal when they discontinued their medications
• Close monitoring will decrease suicide risk. Need to be seen every couple of weeks.
• When you look at the well-constructed trials benefits of treating depression clearly outweigh the risks.