NCPS Annual Meeting 2011, Saturday, August 20

For reasons having to do with a flight of Spanish red wines I missed Dr. John Rusher’s 7:30 AM legislative update, but having had a preview Thursday I can report the NC Pediatric Society protected pediatricians from some major badness in the legislature this last session. So far our Medicaid reimbursements are largely preserved, unlike those for our colleagues in South Carolina. Malpractice reform was a huge victory, including a provision decreasing the statute of limitations for pediatricians from 19 years to 10 years. We worked hard with legislators to protect the patient centered medical home by ensuring pharmacists cannot vaccinate children under age 14 years without a doctor’s order to do so. A proposal to severely compromise the privacy of our teenaged patients failed to pass, and legislation that would have copied Florida’s repressive law against doctors discussing firearms with their patients also didn’t make it. In case you were thinking about not supporting our PAC this year, rest assured these bad ideas will all return in future sessions, with more to come.

8/20/2011

Dr. Rob Benjamin, DUMC Endocrinology

Vitamin D Deficiency, Diagnosis and Treatment

• Peak UVB is 10-3:00 in the spring, summer, and fall
• 7 dehydrocholesterol to previtamin D3 in skin, then converted to Vitamin D
• May get enough Vitamin D in 5-10 minutes of sun exposure or 30-60 minutes depending on skin tone
• You cannot exceed your vitamin D threshold with excess sun exposure
• Sunscreen and melanin both block UVB light, quite substantially
• Food sources of vitamin D (D2 from plants, D3 from animal sources)
• Breastmilk is a lousy source of vitamin D - you’d need 8 Liters of breast milk to get 400 IU of vitamin D
• Cheese is pretty low in Vitamin D, too
• Shitake mushrooms, fish with bones, cod liver oil very high in vitamin D3
• Frying kills vitamin D, baking and grilling preserve it
• Labs with vitamin D deficiency, don’t check OHD1-25, which may be normal in early D deficiency. PO4 falls FIRST, calcium later. Alkaline phosphatase increases with deficiency.
• PTH is what makes PO4 low and calcium normal. GI absorption of Ca and PO4 falls, PTH increases to compensate
• Increased PTH increases serum calcium by resorbing bone, increasing gut absorption and increasing renal calcium retention, but it lowers PO4 levels
• Specifically the kidney kicks out PO4 in the kidney in counter-transport with Ca
• PTH also increases the level of 1-25 hydroxy vitamin D by increasing 1-alpha-hydroxylase. This may cause brief peaks in vitamin D levels, but not sustained increases. That’s what makes the labs misleading
• If a healthy child has a low 25-D level, is that a disease? Does it need to be treated?
• Really sufficient levels are over 20 ng/ml
• We usually aim for 30 based in studies of fracture risk in post-menopausal women
• You cannot overdose 25-Vitamin D because negative feedback loops prevent conversion to 1-25 D
• There seems to be no additional benefit to getting Vitamin D levels over 20-30
• There is no convincing data that higher Vitamin D levels prevent cancer, type I DM, multiple sclerosis, or heart disease
• Prescription D2, Ergocalciferol, is quite expensive, often not covered by insurance companies. Can give 50,000 IU per week
• D3, cholecalciferol may be better than D2, many choices, inexpensive
• Calcitriol - Don’t use this! 1-25 D, useful in patients with renal or parathyroid disease, but otherwise not for general use, potential toxicity
• Daily dose should go up to 600 IU per day at 1-3 years of age
• Replacement dosing must be higher: 2000 IU per day in infants, 4000 IU per day for everyone else
• Deficiency treatment duration is 6-8 weeks
• Screening obese patients: what do you do if you get abnormal results? Only treat if under 20, use a D3 supplement
• Don’t screen everyone, but morbidly obese patients probably should be tested

Dr. Sandra Kim, UNC Gastroenterology

Pediatric Inflammatory Bowel Disease 101: A Primer For The Pediatrician

• Can email Sandy Kim at skim@med.unc.edu for questions, slides, information
• Two basic types of IBD: ulcerative colitis and Crohn’s
• UC starts at the distal colon, works proximally. Superficial inflammation and ulceration
• Crohn’s can be anywhere in the GI tract, up to the mouth or the perirectal area. It involves the entire thickness of the wall of the GI tract. May cause strictures, fistulas, and it can skip around throughout the GI tract
• IBD is both genetic and environmental in origin, close to evenly mixed
• Multiple possible triggers for development of IBD including food antigens, bacterial influences
• Greater than 120 genes implicated in development of IBD
• At least a quarter of all IBD patients will develop the disease before age 18, although they don’t all get diagnosed in a timely fashion. Usually > 1 year from onset of symptoms to diagnosis
• Annual incidence of IBD seems to be increasing in all demographic populations
• Annual disease costs are over $6 billion in the United States. Costs are higher for children compared to adults
• Children tend to present with more severe symptoms and manifestations such as pan-colitis, surgical disease
• Kids may also suffer delayed growth, skeletal development, and puberty as well as a dramatic psychosocial impact
• Growth failure may be the presenting symptom of Crohn’s disease
• Peri-anal disease may be the presenting complaint as well: TAGS or HEMORRHOIDS are CROHN’S until proven otherwise!
• Look for arthritis, arthralgias, erythema nodosum, other non-GI signs
• Growth failure affects about 10% of Crohn’s patients by age 10 years
• Growth failure tends to be not completely reversible, even with treatment
• Most important to diagnose and treat prior to puberty!
• Chronic inflammation is important in growth delay beyond just nutritional deficiency
• Same factors impact puberty
• If you notice one of these kids is not growing, talk to the GI specialist!
• Differential diagnosis: bacterial disease, viral disease, parasitic infections, rheumatologic disorder, Celiac disease, eosinophilic esophagitis/gastritis, irritable bowel
• Look for anemia, inflammatory markers, liver profile, albumin, protein, iron panel, calcium, magnesium, zinc, alkaline phosphatase, folate, transthyretin, fecal leukocytes, occult blood, calprotectin, lactoferrin, C. difficile, stool culture, ova and parasites
• There is a serologic panel for IBD, but usually GI orders this one
• May need UGI/SBFT, CT, MRI enterography
• EGD/colonoscopy, capsule imaging
• Must treat by suppressing inflammation, alleviating symptoms, preventing relapse, restoring normal growth and nutritional status
• Meds have major side effects: consider quality of life in treatment plans
• Steroids have the potential to make a child really miserable
• Lactobacillus may help, but the trials are not yet convincing, cannot replace medications for IBD

Dr. Beng Fuh, Hematology/Oncology at ECU

Congenital Macrocytic Anemia

• Abnormal digits and anemia, think Diamond-Blackfan Anemia
• Remember that physiologic nadir of Hgb is as low as 8 g/dL around 8 weeks of age. Occurs sooner and more severely in preterm babies, but if baby is doing well not alarming, but DO follow up to see CBC normalize!
• Hemoglobin rises with puberty in males, less so in females
• Lower level of normal for Hgb depends on altitude. In Leadville, CO the normal is 12 g/dL
• Anemia may cause conjunctival injection
• Remember to interpret reticulocyte count in light of current hemoglobin. It’s should rise with anemia
• Differential: poor production of RBC’s, increased destruction, defect in components of the hemoglobin
• Full differential diagnosis of anemia slide: way too much to transcribe. Check out www.ncpeds.org for more. Many of the lectures are available on streaming video.
• Thalassemia should have abnormal electrophoresis
• IDA makes small cells
• Check folate and B12 levels in macrocytic anemia
• Hemolytic anemia should come with an elevated reticulocyte count
• Marrow abnormalities should affect more than one cell line, not just the RBC’s in most cases
• Fanconi anemia affects more than one cell line, comes with abnormal chromosome breakage studies.
• Pure red blood cell aplasias include Diamond-Blackfan, transient erythroblastopenia of childhood (TEC)
• Diamond Blackfan anemia may arrest any point in the development of the erythrocyte from the stem cell all the way to the reticulocyte
• Six mutations have been described in DBA, but only account for 50% of patients. 25% to 50% are autosomal dominant
• Many children never require intervention, but some have quite severe disease
• Increased risk for hematopoietic malignancies
• Prior to bone marrow biopsy chromosome breakage studies are key to rule out Fanconi anemia
• Also check parvovirus/EBV studies in apparent marrow failure
• May treat with observation, transfusion, bone marrow transplant, corticosteroids
• Cord blood transplant may work prior to age 14 years
• TEC occurs at 1-3 years of life, where DBA occurs earlier, before one year of age. TEC is transient, DBA not, although there are rare cases of spontaneous recovery.
• TEC kids are usually asymptomatic, DBA with symptoms
• TEC does NOT need corticosteroid therapy
• Dysmorphic features differentiate Diamond-Blackfan from TEC, present in DBA, not in TEC

Dr. Alan Liles, UNC School Of Medicine

Cholesterol Screening In Children

• United States Preventive Services Task Force report 2007
• Evidence for or against screening before age 20 is ABSENT
• Childhood dyslipidemia does not necessarily lead to adulthood dyslipidemia
• Family history is actually a poor predictor of monogenetic hyperlipidemia
• Statins do seem to help lipid profiles and carotid intimal thickness in adolescent patients
• Diet and exercise actually seem to make little difference in multifactorial dyslipidemia in children
• The data in adults is quite strong that screening lipids is a good idea
• Behavior change seems to occur almost never, whether or not adults are aware they have an elevated lipid level
• AAP Committee on Nutrition put together an individual approach and a population approach in 2008
• Under age two no need to restrict dietary fat, but saturated fats are probably never a great idea
• Individual approach suggests finding high risk children to screen and intervene. Look for family history of premature heart disease, BMI > 85%ile, hypertension, diabetes, smoking
• For these kids screen with fasting lipid panel over 2 years of age, then recheck every 3-5 years. If over 8 and LDL-C over 190 (160 with risk factors, 130 with diabetes) treat with a drug, but not clear statins would be first line.
• National Cholesterol Education Program: screen adults 20 years or older every five years with fasting LDL-C
• Start with risk assessment, tailor therapy for level of risk. Algorithm gives you LDL levels to start lifestyle changes, medical therapy
• New LDL goal may be 70 in high risk patients, 100 in moderate risk patients
• West Of Scotland Trial showed a number needed to treat of 33 over six years to prevent one MI with pravastatin
• Curves stabilize five years out. Early effect is due to anti-inflammatory effect of statins
• Air Force primary prevention trial (AFCAPS) and TexCAPS looked at lovastatin versus placebo in lower risk groups, included women. The benefits were not overwhelming.
• Anglo Scandinavian Coronary Outcome Trial - Lipid Lowering Arm included atorvastatin versus placebo. Found a 1.1% absolute risk reduction over 3.5 years in fatal and non-fatal MI.
• METEOR and Jupiter trials looked at Rosuvastatin to produce end points, as opposed to prior trials which only looked at LDL levels. Showed 50% relative risk reduction.
• Take-home message: all these studies look at adults, generally in high risk groups
• Some concern exists that pharmaceutical industry trials are biased in favor of publishing positive results
• Yes, adult heart disease does start in childhood, but is there any reason to screen and even treat children? There is still no evidence that even begins to suggest treating children pays off.
• If a child is not at risk for homozygous familial hypercholesterolemia there is little reason to check kids before age 18 to 20 with significant CV risk factors and only age 35 for males and 45 for females otherwise
• Statins do have significant risks, including rhabdomyolysis which may progress to renal failure and death
• Atypical antipsychotics and statins together may put children at increased risk for myopathy
• There is good science to support use of omega-3 polyunsaturated fats for hypertriglyceridemia
• If you have questions you may email Alan at liles@med.unc.edu

Dr. Julia Byerly, UNC School Of Medicine

Avoiding Fatigue Of The Tired Teen: management Strategies for vague Complaints In Adolescents

• Fatigue/diffuse pain patients get labeled as “difficult”, and in pediatrics there is the additional component of a parent
• To deal with these patients, use a team approach and communicate well with your team members. Team should include psychology, physical therapy, nutrition.
• Modify scheduling to the extent that your office practice allows. These patients need time to be heard, but you can also set limits. Provide a structure.
• Recognize your role; you’re not their mother/father, you’re their doctor
• Take care of yourself!
• Prepare yourself prior to the visit. Relax your shoulders, take a deep breath.
• Prepare the patient and family: This may take multiple visits to get a full history and figure out what’s going on.
• Make it clear to the patient that you’re making a careful physical exam. The yield of these exams is quite low, but it’s very important to the child and her family.
• Comment that you’re going to listen to the child’s whole story first, in other words the parent needs to stay out of it until the child has spoken, but then reassure the parent she will also have a chance to say everything she needs to
• Social History: often talented, good students who suffer a first blemish on her record, perhaps makes a “B”
• Review of Systems is often positive for vague symptoms in multiple organ systems
• “Definitely not depressed!”
• Many of these kids are normal weight
• Differential is lengthy, include among others anemia, IBD, constipation, celiac disease, EBV, CMV, Lyme, cardiomyopathy, sleep disorder, brain tumor, etc.
• Approaching the problem: recognize and acknowledge that there is a problem.
• There are scales you can use to quantify fatigue in adolescence, but in practice they don’t add much. More than 15% of teenaged girls will be fatigued for more than a month at a time based on studies.
• Fatigue may lead to isolation, depression, school absence, anxiety, lack of productivity
• Chronic Fatigue Syndrome: must last >6 months, so by definition most of these patients don’t buy that label at presentation. Can reassure patients that we’re not going to let them go that long without treatment.
• Treat early and aggressively, shift frame to outcomes, not diagnosis. Allow a graceful way out: “We may never know what caused this, but we can help you improve how you are feeling. When you achieve the goals you set it will be a success.”
• Make sure teen and family state their goals for success.
• You can try extensive testing and referral, but the yield is incredibly low. Benevolent neglect is not productive.
• Instead perform a very directed workup and focus on symptom-driven therapy. If you feel the need to do labs check CBC, lytes, ESR, free T4/TSH
• A protocol has the power of giving the patient a written prescription for therapy and validates the reality of the problem. Gives patient and physician a sense of control.
• The “Five F’s”: Food, Fitness, Fresh Air, Fellowship, Friendship to Self And Soul
• Eat real food, pay attention to nutrition, decrease caffeine, increase fruit and vegetable intake, may use nutritionist
• Fitness includes 30 minutes daily of exercise that makes kids sweat, raises their heart rates. Physical therapist can show these kids how they can exercise despite their fatigue. Sleep is another key component. Sleep on a schedule, get enough sleep, go to bed and wake up at the same time every day.
• Fresh Air means get outside 30 minutes a day and get some sunlight. May improve vitamin D levels! Sometimes being outside improves social behavior as kids meet others.
• Fellowship: Get back to school! Attend activities in groups! Also important to get family support, conversations, especially at family mealtime. Turn off phones and TV at dinner time.
• Friendship with self and soul. Helps to involve a psychologist to help adolescent develop her identity. Cognitive behavioral therapy can be quite helpful. Sometimes depression diagnosis and therapy crop up from these visits.
• Can create a protocol in your EMR. Dr. Byerly will email you that protocol for your own clinical use.
• Race To Nowhere advocacy film/website can help families understand the pressures on these kids, shows the story of one of these kids

Dr. Susan Boutilier, Pediatric Neurology, Private Practice/ECU

Headaches In Children

• Many things in the head can hurt. Dura, veins, arteries, structures of the skull
• History: all the usual pain questions, but also what are the functional limitations imposed by the pain?
• Onset: sudden or gradual? Sudden is bad.
• Exacerbating factors: if posture or valsalva makes pain worse (cough) then be more worried
• In younger children with migraines vomiting and napping are a common presentation
• Occipital headaches and consistent location of headaches are both concerning, should drive earlier imaging. 2/3 of childhood tumors in the posterior fossa
• MRI is preferable to CT especially in posterior fossa. CT may be falsely reassuring
• Worsening in frequency or severity over weeks to months is always concerning
• Headache that awakes children at night is always worrisome, also early AM headaches
• Do consider sleep apnea in early morning headaches if there is other evidence to support the diagnosis
• Quality of pain is rarely useful in the pediatric pain history. The 1-10 numeric scale is not particularly useful compared to delineating functional limitation
• Major concerns are increased ICP, infection, hemorrhage
• A thorough neurologic exam is critical, including fundoscopy (good fundoscopy) and visual fields exam. Look for venous pulsations
• In younger children bring an object in from the periphery and watch to see if they look toward it
• Most chronic headaches in children are migraine variants, and even those that don’t often respond to migraine therapy
• It’s not a sinus headache unless it’s right over a sinus
• Neuralgias are brief, shooting. Have to treat prophylactically
• “Tension” headaches: disappearing from the differential, does not really tell you what to do for therapy
• Most consistent feature of migraine is that the child looks sick, pale, tired to parents. May also have aura, unilateral but shifting pain, photophobia, phonophobia.
• Nausea/emesis more common in young children, period is a matter of months in most cases
• Cyclic vomiting/abdominal migraine is a diagnosis of exclusion; you must exclude the other causes
• Confusional migraines tend to last long, hours/all day
• Most common paresthesia is lip/tongue/hand numbness
• Migraines usually don’t wake kids from sleep. Migraines usually do resolve with rest
• “Tension” headaches usually occur in the afternoon, feel band-like or squeezing
• Patients alway say they’re not stressed
• Sinus headache should occur with lots of nasal symptoms such as stuffiness and drainage, and they tend to stay for a while, not come and go.
• Sinusitis is present on lots of CNS imaging studies, not necessarily the cause of pain
• Treatment is based on the underlying cause of headache. For simple pain treat as soon as the pain starts, treat adequately. Use a good dose, early.
• Use a fire analogy for treating headache pain: 10 mg/kg/dose ibuprofen as early as possible. Tylenol does not work because there is an inflammatory component to migraines.
• Add triptans when NSAIDs fail, but start with NSAIDs and combine them so you still have an anti-inflammatory component!
• Never use triptans with sickle cell, hypertension, cardiovascular issues
• For 3-4 headaches a month or resistant headaches consider prophylaxis
• Kids need good sleep, a breakfast high in fiber and protein, hydration, sunglasses for bright light (but not polarized lenses!), cool down when it’s hot outside
• DO NOT treat with narcotics! May make things worse
• Use triptans over age 8, not below.
• Maxalt MLT, Zomig, and Imitrex injection/nasal have variable dosing, better for pediatric use
• Nitrates may exacerbate headaches in some kids, also MSG
• IV ketorolac and reglan, DHE may help
• Prophylaxis: amitriptyline, topiramate, amlodipine, SSRI’s, propranolol all at low doses. Topiramate works well, may reduce appetite
• Does not usually try propranolol, SSRI’s

Sadly I had to depart for Wilmington before the last session for Saturday, and I missed all of Sunday morning. But http://ncpeds.org should have video available of those sessions, so check out the website for more. And be sure to book your reservation for next year’s annual meeting, to be held for the first time in beautiful Wilmington, NC! I’ve heard it’s a pleasant town...