Subspecialist Consult

Most pediatricians manage children and adolescents with mild to moderate nutritional deficiencies appropriately in the primary care setting. However, some of your patients with more complex clinical concerns can benefit from consultation with a subspecialty colleague.

It can be challenging to digest all the information, advice, and trends regarding vitamins and nutritional supplements, but staying up to date is important. This awareness will help you formulate an opinion before a patient or family member asks about a new "miracle" modality or "megadose" supplement cure.

Courtesy La Rabida Children\'s Hospital

Some supplementation advice for well children is old, well known, and time honored, such as vitamin K supplementation at birth and vitamin D supplementation for breastfeeding infants during their first 6 months of life.

The American Academy of Pediatrics is your best source of guidance on newer ideas and more recent developments. The academy also provides dependable guidance and thoughtful recommendations on overall nutritional supplementation. Stick with their evidence-based practice guidelines and policies whenever possible.

Also, consult their online publication resources often, as the academy updates their guidance frequently.

The website not only is a perfect entry point for accessing comprehensive practice advice, including the Bright Futures program and other recommended sources, but also features advice for parents.

The Pediatric Nutrition Handbook is a useful offline reference. This wonderful resource has been prepared by the AAP Committee on Nutrition and is now in its sixth edition.

Patient and family counseling to optimize vitamin and supplement intake is important. Compared with prescription and over-the-counter medicines, vitamins and supplements are marketed with surprising freedom in the United States, although the Food and Drug Administration assumes some monitoring responsibilities once they are available to consumers. The agency’s involvement is surprisingly limited.

Your guidance, therefore, is crucial because vitamins, even the most familiar ones, are not harmless. Vitamins are sold openly in "health stores" and people assume they are safe. However, high doses of many vitamins can cause effects from discomfort to even life-threatening events. For example, too much vitamin A can damage the liver, and excess vitamin D can be toxic. Unfortunately, megadoses of most vitamins are not simply excreted in the urine, as is vitamin C.

Herbal supplements are even more mysterious, and there is simply not enough research to separate chaff from grain or to confidently advise patients on the benefits and harm.

There’s another issue: It does not occur to some families that supplements – especially the herbal ones – could be of interest to their medical doctor. They think of supplements in a domain that is separate from that of medical care, and forget or neglect to mention their use. In some cases, families will not disclose their use of herbal supplements because they fear your disapproval. This is a particular problem if anxiety about a child’s condition motivates parents to seek alternative therapies or unproven methods.

The best and perhaps only way of overcoming these hurdles is to ask the question about herbal supplements directly. Ideally, you already have a safe and trusting relationship with the family, one in which the family feels that you are interested and willing to listen with an open mind, and to research the subject on their behalf. If trust is established early on, before disagreements crop up, then the family knows everyone is on the same side – that is, on the child’s side – even if a disagreement does come up.

Although the issues surrounding supplementation can be complex, start with the basics. Diagnose and manage your patients who have nutritional issues by taking comprehensive histories and performing skillful physical examinations.

Signs and symptoms elicited by your evaluation drive your diagnostic work-up. No screening battery is specifically designed to catch undiagnosed nutritional deficiencies in the primary care of well children. Health maintenance guidelines support a complete blood count and comprehensive metabolic panel as being sufficient to screen healthy children. These panels also provide a good starting point to work up any nutritional deficiencies and growth problems.

Other children require special consideration, but the general rule is the same. Tailor any diagnostic work-up beyond established well-child primary care guidelines to your individual patient’s underlying condition, history, and physical examination.

Some of your patients will be at high risk for nutritional deficiency. Chronic kidney disease; growth issues related to failure to thrive; feeding challenges stemming from a neurodevelopmental disability; and deficiencies because of poverty or homelessness are examples. Because these conditions can inhibit the intake, absorption, or metabolism of nutrients, consider referral and comanagement of children with a subspecialist colleague.

In some more-acute situations, hospitalization might be indicated. For example, the initial feeding of a severely malnourished child or the rectifying of a profound and long-lasting deficiency can cause complications such as refeeding syndrome or electrolyte imbalances. Programs that are specialized for failure to thrive cases can help when the etiology is multifactorial and complicated by psychological, social, and/or economic problems. These cases require long-term management by multidisciplinary teams, and often take too much time and resources for the regular pediatric office.

Dr. Bishku is an attending physician and vice president of medical affairs at La Rabida Children’s Hospital in Chicago. She had no relevant financial disclosures.

Most pediatricians manage children and adolescents with mild to moderate nutritional deficiencies appropriately in the primary care setting. However, some of your patients with more complex clinical concerns can benefit from consultation with a subspecialty colleague.

It can be challenging to digest all the information, advice, and trends regarding vitamins and nutritional supplements, but staying up to date is important. This awareness will help you formulate an opinion before a patient or family member asks about a new "miracle" modality or "megadose" supplement cure.

Courtesy La Rabida Children\'s Hospital

Some supplementation advice for well children is old, well known, and time honored, such as vitamin K supplementation at birth and vitamin D supplementation for breastfeeding infants during their first 6 months of life.

The American Academy of Pediatrics is your best source of guidance on newer ideas and more recent developments. The academy also provides dependable guidance and thoughtful recommendations on overall nutritional supplementation. Stick with their evidence-based practice guidelines and policies whenever possible.

Also, consult their online publication resources often, as the academy updates their guidance frequently.

The website not only is a perfect entry point for accessing comprehensive practice advice, including the Bright Futures program and other recommended sources, but also features advice for parents.

The Pediatric Nutrition Handbook is a useful offline reference. This wonderful resource has been prepared by the AAP Committee on Nutrition and is now in its sixth edition.

Patient and family counseling to optimize vitamin and supplement intake is important. Compared with prescription and over-the-counter medicines, vitamins and supplements are marketed with surprising freedom in the United States, although the Food and Drug Administration assumes some monitoring responsibilities once they are available to consumers. The agency’s involvement is surprisingly limited.

Your guidance, therefore, is crucial because vitamins, even the most familiar ones, are not harmless. Vitamins are sold openly in "health stores" and people assume they are safe. However, high doses of many vitamins can cause effects from discomfort to even life-threatening events. For example, too much vitamin A can damage the liver, and excess vitamin D can be toxic. Unfortunately, megadoses of most vitamins are not simply excreted in the urine, as is vitamin C.

Herbal supplements are even more mysterious, and there is simply not enough research to separate chaff from grain or to confidently advise patients on the benefits and harm.

There’s another issue: It does not occur to some families that supplements – especially the herbal ones – could be of interest to their medical doctor. They think of supplements in a domain that is separate from that of medical care, and forget or neglect to mention their use. In some cases, families will not disclose their use of herbal supplements because they fear your disapproval. This is a particular problem if anxiety about a child’s condition motivates parents to seek alternative therapies or unproven methods.

The best and perhaps only way of overcoming these hurdles is to ask the question about herbal supplements directly. Ideally, you already have a safe and trusting relationship with the family, one in which the family feels that you are interested and willing to listen with an open mind, and to research the subject on their behalf. If trust is established early on, before disagreements crop up, then the family knows everyone is on the same side – that is, on the child’s side – even if a disagreement does come up.

Although the issues surrounding supplementation can be complex, start with the basics. Diagnose and manage your patients who have nutritional issues by taking comprehensive histories and performing skillful physical examinations.

Signs and symptoms elicited by your evaluation drive your diagnostic work-up. No screening battery is specifically designed to catch undiagnosed nutritional deficiencies in the primary care of well children. Health maintenance guidelines support a complete blood count and comprehensive metabolic panel as being sufficient to screen healthy children. These panels also provide a good starting point to work up any nutritional deficiencies and growth problems.

Other children require special consideration, but the general rule is the same. Tailor any diagnostic work-up beyond established well-child primary care guidelines to your individual patient’s underlying condition, history, and physical examination.

Some of your patients will be at high risk for nutritional deficiency. Chronic kidney disease; growth issues related to failure to thrive; feeding challenges stemming from a neurodevelopmental disability; and deficiencies because of poverty or homelessness are examples. Because these conditions can inhibit the intake, absorption, or metabolism of nutrients, consider referral and comanagement of children with a subspecialist colleague.

In some more-acute situations, hospitalization might be indicated. For example, the initial feeding of a severely malnourished child or the rectifying of a profound and long-lasting deficiency can cause complications such as refeeding syndrome or electrolyte imbalances. Programs that are specialized for failure to thrive cases can help when the etiology is multifactorial and complicated by psychological, social, and/or economic problems. These cases require long-term management by multidisciplinary teams, and often take too much time and resources for the regular pediatric office.

Dr. Bishku is an attending physician and vice president of medical affairs at La Rabida Children’s Hospital in Chicago. She had no relevant financial disclosures.

Most pediatricians manage children and adolescents with mild to moderate nutritional deficiencies appropriately in the primary care setting. However, some of your patients with more complex clinical concerns can benefit from consultation with a subspecialty colleague.

It can be challenging to digest all the information, advice, and trends regarding vitamins and nutritional supplements, but staying up to date is important. This awareness will help you formulate an opinion before a patient or family member asks about a new "miracle" modality or "megadose" supplement cure.

Courtesy La Rabida Children\'s Hospital

Some supplementation advice for well children is old, well known, and time honored, such as vitamin K supplementation at birth and vitamin D supplementation for breastfeeding infants during their first 6 months of life.

The American Academy of Pediatrics is your best source of guidance on newer ideas and more recent developments. The academy also provides dependable guidance and thoughtful recommendations on overall nutritional supplementation. Stick with their evidence-based practice guidelines and policies whenever possible.

Also, consult their online publication resources often, as the academy updates their guidance frequently.

The website not only is a perfect entry point for accessing comprehensive practice advice, including the Bright Futures program and other recommended sources, but also features advice for parents.

The Pediatric Nutrition Handbook is a useful offline reference. This wonderful resource has been prepared by the AAP Committee on Nutrition and is now in its sixth edition.

Patient and family counseling to optimize vitamin and supplement intake is important. Compared with prescription and over-the-counter medicines, vitamins and supplements are marketed with surprising freedom in the United States, although the Food and Drug Administration assumes some monitoring responsibilities once they are available to consumers. The agency’s involvement is surprisingly limited.

Your guidance, therefore, is crucial because vitamins, even the most familiar ones, are not harmless. Vitamins are sold openly in "health stores" and people assume they are safe. However, high doses of many vitamins can cause effects from discomfort to even life-threatening events. For example, too much vitamin A can damage the liver, and excess vitamin D can be toxic. Unfortunately, megadoses of most vitamins are not simply excreted in the urine, as is vitamin C.

Herbal supplements are even more mysterious, and there is simply not enough research to separate chaff from grain or to confidently advise patients on the benefits and harm.

There’s another issue: It does not occur to some families that supplements – especially the herbal ones – could be of interest to their medical doctor. They think of supplements in a domain that is separate from that of medical care, and forget or neglect to mention their use. In some cases, families will not disclose their use of herbal supplements because they fear your disapproval. This is a particular problem if anxiety about a child’s condition motivates parents to seek alternative therapies or unproven methods.

The best and perhaps only way of overcoming these hurdles is to ask the question about herbal supplements directly. Ideally, you already have a safe and trusting relationship with the family, one in which the family feels that you are interested and willing to listen with an open mind, and to research the subject on their behalf. If trust is established early on, before disagreements crop up, then the family knows everyone is on the same side – that is, on the child’s side – even if a disagreement does come up.

Although the issues surrounding supplementation can be complex, start with the basics. Diagnose and manage your patients who have nutritional issues by taking comprehensive histories and performing skillful physical examinations.

Signs and symptoms elicited by your evaluation drive your diagnostic work-up. No screening battery is specifically designed to catch undiagnosed nutritional deficiencies in the primary care of well children. Health maintenance guidelines support a complete blood count and comprehensive metabolic panel as being sufficient to screen healthy children. These panels also provide a good starting point to work up any nutritional deficiencies and growth problems.

Other children require special consideration, but the general rule is the same. Tailor any diagnostic work-up beyond established well-child primary care guidelines to your individual patient’s underlying condition, history, and physical examination.

Some of your patients will be at high risk for nutritional deficiency. Chronic kidney disease; growth issues related to failure to thrive; feeding challenges stemming from a neurodevelopmental disability; and deficiencies because of poverty or homelessness are examples. Because these conditions can inhibit the intake, absorption, or metabolism of nutrients, consider referral and comanagement of children with a subspecialist colleague.

In some more-acute situations, hospitalization might be indicated. For example, the initial feeding of a severely malnourished child or the rectifying of a profound and long-lasting deficiency can cause complications such as refeeding syndrome or electrolyte imbalances. Programs that are specialized for failure to thrive cases can help when the etiology is multifactorial and complicated by psychological, social, and/or economic problems. These cases require long-term management by multidisciplinary teams, and often take too much time and resources for the regular pediatric office.

Dr. Bishku is an attending physician and vice president of medical affairs at La Rabida Children’s Hospital in Chicago. She had no relevant financial disclosures.

Electrocardiography to test a child’s heart prior to sports participation can help identify some – but not all – causes of sudden cardiac death.

Offering this test is not without debate, however, whether your patient is a young athlete about to start a sports program or a student about to start stimulant medication for attention-deficit/hyperactivity disorder.

Your clinical judgment remains paramount, as ECG screening before sports is not mandated in the United States, but placing your patient in one of the following three categories can help guide diagnosis and management:

Photo courtesy Loyola University Chicago Stritch School of Medicine

• Asymptomatic child, normal physical exam. Most of the patients you see for a sports evaluation will be asymptomatic. Perform the physical examination and take a thorough history, with a specific look for any signs of sudden cardiac death such as family history or previous symptoms. In general, this evaluation will suffice and you will not need to order blood assays or other tests. If you want to augment your evaluation by ordering an ECG, you will be ahead of the curve. Most pediatricians manage these kids whether they order an ECG or not. If you’re uncertain or uncomfortable for any reason at this point, consider referral.

• Symptomatic child. Children in this group may describe palpitations, chest pain, and/or an instance when they felt they were about to pass out (syncope or presyncope). The symptomatic child should be evaluated further if you have any clinical concerns, and ECG is a good starting point. Unless you feel very comfortable, consider specialist consultation and comanagement of these patients. Watch especially for exercise-related syncope. For me, passing out with exercise is a red flag because it’s one of the few specific signs of structural heart disease. At a minimum, evaluations of rhythm (ECG) and structure (echocardiography) are indicated, and sometimes an electrophysiology work-up can be helpful.

• Asymptomatic child, some examination findings. Some asymptomatic children have a potentially relevant clinical finding, such as a murmur. Most innocent murmurs are monitored appropriately in the primary care setting, but referral is more strongly suggested for murmurs of concern, which include holosystolic murmurs, grade 3-6 murmurs, and diastolic murmurs. An ECG is still an excellent starting point, but you have a choice. Some pediatric cardiologists also would recommend an echocardiogram or just a referral to them for further work-up. You don’t always have to rush to echocardiography. (Some would argue there are too many echoes ordered right off the bat, and I think there are too few initial ECGs ordered.)

Much of your management strategy depends on your comfort level. Most pediatricians can read an ECG and immediately know that something is not right if they see a significantly prolonged QT interval or WPW (Wolff-Parkinson-White syndrome) changes. I’ve learned, however, that most of the pediatricians at our institution would be uncomfortable making the call regarding some of the more subtle ECG findings. Many pediatricians’ offices do not have ECG equipment, so the patient will be sent elsewhere anyway.

Screening Before an ADHD Regimen

Consideration of ECG screening also comes up prior to prescription of an ADHD stimulant medication.

Unfortunately, a small number of deaths have been associated with use of these medications. Some of those patients had underlying congenital and structural heart disease that some believe could have been identified with a simple ECG. Most people would agree to some sort of cardiovascular monitoring, such as blood pressure or heart rate measurements. Complicating matters is the increased risk of ADHD in children with congenital heart anomalies.

Proceeding with an ECG screen doesn’t rule out prescribing the ADHD medicine, according to the recommendation, but it might be worthwhile to have a pediatric cardiologist manage any particular clinical concerns.

False-Positive Results

ECGs are safe and very inexpensive if you already have the equipment. The biggest debate about ECGs in the world of sports medicine centers on high false-positive rates. Depending on how the ECG is read and which criteria you use, the false positive rate can be as low as 2% or as high as 15%. Using the right criteria removes some of the unnecessary false positives and can reduce the rate to a more acceptable 2%-5%. In my opinion, that rate is low enough to justify offering low-cost ECGs for those who would like to be screened.

Interestingly, some of the false-positive findings are not as concerning among young athletes. Examples are an incomplete right bundle branch block, early repolarization, isolated QRS voltage criteria for left ventricular hypertrophy, and first-degree atrioventricular block. Some experts argue that if we remove these specific findings, we will be left primarily with the most concerning ones and thus can improve the false-positive rate.

This greater reliability may be reflected by emerging ECG-screening programs across this country. We at Loyola University Health System are in the process of trying to develop one of the first ECG-screening programs at a medical center. Precedents from ECG guidelines for older athletes may be adaptable to protect pediatric patients; about half of large university athletic programs perform ECG screening. In addition, the majority of professional athletes undergo cardiac evaluations.

Dr. Jayanthi is with the department of family medicine and the department of orthopaedic surgery and rehabilitation and also the medical director of primary care sports medicine at Loyola University Chicago in Maywood, Ill. Dr. Jayanthi said that he had no relevant financial disclosures.

Electrocardiography to test a child’s heart prior to sports participation can help identify some – but not all – causes of sudden cardiac death.

Offering this test is not without debate, however, whether your patient is a young athlete about to start a sports program or a student about to start stimulant medication for attention-deficit/hyperactivity disorder.

Your clinical judgment remains paramount, as ECG screening before sports is not mandated in the United States, but placing your patient in one of the following three categories can help guide diagnosis and management:

Photo courtesy Loyola University Chicago Stritch School of Medicine

• Asymptomatic child, normal physical exam. Most of the patients you see for a sports evaluation will be asymptomatic. Perform the physical examination and take a thorough history, with a specific look for any signs of sudden cardiac death such as family history or previous symptoms. In general, this evaluation will suffice and you will not need to order blood assays or other tests. If you want to augment your evaluation by ordering an ECG, you will be ahead of the curve. Most pediatricians manage these kids whether they order an ECG or not. If you’re uncertain or uncomfortable for any reason at this point, consider referral.

• Symptomatic child. Children in this group may describe palpitations, chest pain, and/or an instance when they felt they were about to pass out (syncope or presyncope). The symptomatic child should be evaluated further if you have any clinical concerns, and ECG is a good starting point. Unless you feel very comfortable, consider specialist consultation and comanagement of these patients. Watch especially for exercise-related syncope. For me, passing out with exercise is a red flag because it’s one of the few specific signs of structural heart disease. At a minimum, evaluations of rhythm (ECG) and structure (echocardiography) are indicated, and sometimes an electrophysiology work-up can be helpful.

• Asymptomatic child, some examination findings. Some asymptomatic children have a potentially relevant clinical finding, such as a murmur. Most innocent murmurs are monitored appropriately in the primary care setting, but referral is more strongly suggested for murmurs of concern, which include holosystolic murmurs, grade 3-6 murmurs, and diastolic murmurs. An ECG is still an excellent starting point, but you have a choice. Some pediatric cardiologists also would recommend an echocardiogram or just a referral to them for further work-up. You don’t always have to rush to echocardiography. (Some would argue there are too many echoes ordered right off the bat, and I think there are too few initial ECGs ordered.)

Much of your management strategy depends on your comfort level. Most pediatricians can read an ECG and immediately know that something is not right if they see a significantly prolonged QT interval or WPW (Wolff-Parkinson-White syndrome) changes. I’ve learned, however, that most of the pediatricians at our institution would be uncomfortable making the call regarding some of the more subtle ECG findings. Many pediatricians’ offices do not have ECG equipment, so the patient will be sent elsewhere anyway.

Screening Before an ADHD Regimen

Consideration of ECG screening also comes up prior to prescription of an ADHD stimulant medication.

Unfortunately, a small number of deaths have been associated with use of these medications. Some of those patients had underlying congenital and structural heart disease that some believe could have been identified with a simple ECG. Most people would agree to some sort of cardiovascular monitoring, such as blood pressure or heart rate measurements. Complicating matters is the increased risk of ADHD in children with congenital heart anomalies.

Proceeding with an ECG screen doesn’t rule out prescribing the ADHD medicine, according to the recommendation, but it might be worthwhile to have a pediatric cardiologist manage any particular clinical concerns.

False-Positive Results

ECGs are safe and very inexpensive if you already have the equipment. The biggest debate about ECGs in the world of sports medicine centers on high false-positive rates. Depending on how the ECG is read and which criteria you use, the false positive rate can be as low as 2% or as high as 15%. Using the right criteria removes some of the unnecessary false positives and can reduce the rate to a more acceptable 2%-5%. In my opinion, that rate is low enough to justify offering low-cost ECGs for those who would like to be screened.

Interestingly, some of the false-positive findings are not as concerning among young athletes. Examples are an incomplete right bundle branch block, early repolarization, isolated QRS voltage criteria for left ventricular hypertrophy, and first-degree atrioventricular block. Some experts argue that if we remove these specific findings, we will be left primarily with the most concerning ones and thus can improve the false-positive rate.

This greater reliability may be reflected by emerging ECG-screening programs across this country. We at Loyola University Health System are in the process of trying to develop one of the first ECG-screening programs at a medical center. Precedents from ECG guidelines for older athletes may be adaptable to protect pediatric patients; about half of large university athletic programs perform ECG screening. In addition, the majority of professional athletes undergo cardiac evaluations.

Dr. Jayanthi is with the department of family medicine and the department of orthopaedic surgery and rehabilitation and also the medical director of primary care sports medicine at Loyola University Chicago in Maywood, Ill. Dr. Jayanthi said that he had no relevant financial disclosures.

Electrocardiography to test a child’s heart prior to sports participation can help identify some – but not all – causes of sudden cardiac death.

Offering this test is not without debate, however, whether your patient is a young athlete about to start a sports program or a student about to start stimulant medication for attention-deficit/hyperactivity disorder.

Your clinical judgment remains paramount, as ECG screening before sports is not mandated in the United States, but placing your patient in one of the following three categories can help guide diagnosis and management:

Photo courtesy Loyola University Chicago Stritch School of Medicine

• Asymptomatic child, normal physical exam. Most of the patients you see for a sports evaluation will be asymptomatic. Perform the physical examination and take a thorough history, with a specific look for any signs of sudden cardiac death such as family history or previous symptoms. In general, this evaluation will suffice and you will not need to order blood assays or other tests. If you want to augment your evaluation by ordering an ECG, you will be ahead of the curve. Most pediatricians manage these kids whether they order an ECG or not. If you’re uncertain or uncomfortable for any reason at this point, consider referral.

• Symptomatic child. Children in this group may describe palpitations, chest pain, and/or an instance when they felt they were about to pass out (syncope or presyncope). The symptomatic child should be evaluated further if you have any clinical concerns, and ECG is a good starting point. Unless you feel very comfortable, consider specialist consultation and comanagement of these patients. Watch especially for exercise-related syncope. For me, passing out with exercise is a red flag because it’s one of the few specific signs of structural heart disease. At a minimum, evaluations of rhythm (ECG) and structure (echocardiography) are indicated, and sometimes an electrophysiology work-up can be helpful.

• Asymptomatic child, some examination findings. Some asymptomatic children have a potentially relevant clinical finding, such as a murmur. Most innocent murmurs are monitored appropriately in the primary care setting, but referral is more strongly suggested for murmurs of concern, which include holosystolic murmurs, grade 3-6 murmurs, and diastolic murmurs. An ECG is still an excellent starting point, but you have a choice. Some pediatric cardiologists also would recommend an echocardiogram or just a referral to them for further work-up. You don’t always have to rush to echocardiography. (Some would argue there are too many echoes ordered right off the bat, and I think there are too few initial ECGs ordered.)

Much of your management strategy depends on your comfort level. Most pediatricians can read an ECG and immediately know that something is not right if they see a significantly prolonged QT interval or WPW (Wolff-Parkinson-White syndrome) changes. I’ve learned, however, that most of the pediatricians at our institution would be uncomfortable making the call regarding some of the more subtle ECG findings. Many pediatricians’ offices do not have ECG equipment, so the patient will be sent elsewhere anyway.

Screening Before an ADHD Regimen

Consideration of ECG screening also comes up prior to prescription of an ADHD stimulant medication.

Unfortunately, a small number of deaths have been associated with use of these medications. Some of those patients had underlying congenital and structural heart disease that some believe could have been identified with a simple ECG. Most people would agree to some sort of cardiovascular monitoring, such as blood pressure or heart rate measurements. Complicating matters is the increased risk of ADHD in children with congenital heart anomalies.

Proceeding with an ECG screen doesn’t rule out prescribing the ADHD medicine, according to the recommendation, but it might be worthwhile to have a pediatric cardiologist manage any particular clinical concerns.

False-Positive Results

ECGs are safe and very inexpensive if you already have the equipment. The biggest debate about ECGs in the world of sports medicine centers on high false-positive rates. Depending on how the ECG is read and which criteria you use, the false positive rate can be as low as 2% or as high as 15%. Using the right criteria removes some of the unnecessary false positives and can reduce the rate to a more acceptable 2%-5%. In my opinion, that rate is low enough to justify offering low-cost ECGs for those who would like to be screened.

Interestingly, some of the false-positive findings are not as concerning among young athletes. Examples are an incomplete right bundle branch block, early repolarization, isolated QRS voltage criteria for left ventricular hypertrophy, and first-degree atrioventricular block. Some experts argue that if we remove these specific findings, we will be left primarily with the most concerning ones and thus can improve the false-positive rate.

This greater reliability may be reflected by emerging ECG-screening programs across this country. We at Loyola University Health System are in the process of trying to develop one of the first ECG-screening programs at a medical center. Precedents from ECG guidelines for older athletes may be adaptable to protect pediatric patients; about half of large university athletic programs perform ECG screening. In addition, the majority of professional athletes undergo cardiac evaluations.

Dr. Jayanthi is with the department of family medicine and the department of orthopaedic surgery and rehabilitation and also the medical director of primary care sports medicine at Loyola University Chicago in Maywood, Ill. Dr. Jayanthi said that he had no relevant financial disclosures.

When parents say their child stopped breathing for a few seconds, suddenly fell to the floor, or sometimes stares off into space, you might immediately think "epilepsy." But several conditions can trigger these events and should be included in your differential diagnosis.

Breath-holding spells, staring off, and gastroesophageal reflux are probably the most common conditions that can mimic epilepsy, but there are many others. Awareness of all the possible etiologies is important because pediatricians are on the front line for diagnosis and initial management of these patients.

Begin by asking for a very detailed description of the spells, including circumstances, timing, and any triggers. Even neurologists who specialize in epilepsy may not spend enough time getting a very, very precise description from the patient and witnesses. Take a thorough medical history of the patient and family to narrow down your differential possibilities. Combined, this information will foster an accurate diagnosis or determine which tests or referrals are indicated.

Depending on your initial assessment, consider blood tests for glucose, calcium, electrolytes, and thyroid function. In some cases, a toxic screen also is appropriate. ECGs and EEGs can be diagnostic as well, although not every pediatrician’s office has these capabilities. It also may be appropriate to refer for polysomnography if you suspect a sleep disorder, including apnea.

In contrast, a CT scan is rarely helpful and in general should not be ordered for these patients. If epilepsy remains a consideration, a head MRI is the more appropriate test.

Because only rarely will you witness a spell in your office, you have to rely on patient and caregiver reports. A useful tip is to ask parents for a video of the event. This is very feasible given the widespread use of smart phones.

Most pediatricians feel comfortable managing the patient with breath-holding spells, tics (including those associated with Tourette syndrome), self-stimulatory behavior, head banging, and night terrors. In contrast, a specialist referral might be appropriate for the child with more severe gastroesophageal reflux, opsoclonus (rapid and irregular eye movements), or one of the psychiatric disorders with manifestations that can mimic epileptic seizures.

Do not hesitate to refer if you remain at all unsure after going through your differential diagnosis. Most pediatricians appropriately refer children to me for further evaluation; only infrequently do I assess a child who obviously does not have epilepsy.

Within the following broad categories are some specific conditions and potential concerns:

• Unusual movements. Newborns can experience seizures, jitteriness, and nonepileptic jerks. Benign sleep myoclonus is very common but parents may come in concerned about these jerky movements. Tics (including motor and vocal tics that characterize Tourette syndrome) can look like seizures. Tics also can point to epileptic myoclonus, in which case further evaluation with EEG is warranted.

Paroxysmal torticollis or head turning in infants is generally benign and well within the purview of pediatricians to diagnose and manage. Different eye movement disorders occur both with and without seizures as well. Be more concerned if you see opsoclonus or "dancing eyes," because you may need to rule out neuroblastoma.

"Paroxysmal kinesigenic dyskinesia" is a good example of a condition that can mimic epilepsy. The characteristic unusual writhing of extremities that is triggered by movement (such as rising from a chair) is a relatively rare condition.

Self-stimulatory behavior also is commonly mistaken for seizures. Typically children place their hands between their thighs, thrust their pelvis back and forth, and then after a few minutes fall asleep. Some refer to this behavior as "infantile masturbation.’"

• Loss of tone or consciousness. Syncope or fainting spells are common and can appear similar to seizures as well.

The typical loss of consciousness presentation is orthostatic. These patients reliably will say that they faint upon standing.

Occasionally, you may hear about patients whose knees buckle and they fall, right after a surge of negative emotion such anger. This is called cataplexy, and it’s one of the symptoms of narcolepsy; it is not epilepsy.

Hemiplegia and certain migraines can mimic seizures as well, so keep these in mind with your differential diagnosis.

You are more likely to hear reports about children who "stare off" for minutes at a time. If you hyperventilate a child in your office and this triggers a staring spell, the child might have absence seizures. In contrast, these spells are less concerning if parents report they can get the child’s attention during the staring. So, as part of your differential, ask parents if they can get the child’s attention during one of these spells. Another tip is to test recall: Instruct the parents to tell the child to remember a specific color and number during the spell; if the child can recall the information a few minutes later, this helps to rule out absence seizures.

• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.

• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.

Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.

• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.

Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.

Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.

• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.

• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.

In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.

A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.

Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.

When parents say their child stopped breathing for a few seconds, suddenly fell to the floor, or sometimes stares off into space, you might immediately think "epilepsy." But several conditions can trigger these events and should be included in your differential diagnosis.

Breath-holding spells, staring off, and gastroesophageal reflux are probably the most common conditions that can mimic epilepsy, but there are many others. Awareness of all the possible etiologies is important because pediatricians are on the front line for diagnosis and initial management of these patients.

Begin by asking for a very detailed description of the spells, including circumstances, timing, and any triggers. Even neurologists who specialize in epilepsy may not spend enough time getting a very, very precise description from the patient and witnesses. Take a thorough medical history of the patient and family to narrow down your differential possibilities. Combined, this information will foster an accurate diagnosis or determine which tests or referrals are indicated.

Depending on your initial assessment, consider blood tests for glucose, calcium, electrolytes, and thyroid function. In some cases, a toxic screen also is appropriate. ECGs and EEGs can be diagnostic as well, although not every pediatrician’s office has these capabilities. It also may be appropriate to refer for polysomnography if you suspect a sleep disorder, including apnea.

In contrast, a CT scan is rarely helpful and in general should not be ordered for these patients. If epilepsy remains a consideration, a head MRI is the more appropriate test.

Because only rarely will you witness a spell in your office, you have to rely on patient and caregiver reports. A useful tip is to ask parents for a video of the event. This is very feasible given the widespread use of smart phones.

Most pediatricians feel comfortable managing the patient with breath-holding spells, tics (including those associated with Tourette syndrome), self-stimulatory behavior, head banging, and night terrors. In contrast, a specialist referral might be appropriate for the child with more severe gastroesophageal reflux, opsoclonus (rapid and irregular eye movements), or one of the psychiatric disorders with manifestations that can mimic epileptic seizures.

Do not hesitate to refer if you remain at all unsure after going through your differential diagnosis. Most pediatricians appropriately refer children to me for further evaluation; only infrequently do I assess a child who obviously does not have epilepsy.

Within the following broad categories are some specific conditions and potential concerns:

• Unusual movements. Newborns can experience seizures, jitteriness, and nonepileptic jerks. Benign sleep myoclonus is very common but parents may come in concerned about these jerky movements. Tics (including motor and vocal tics that characterize Tourette syndrome) can look like seizures. Tics also can point to epileptic myoclonus, in which case further evaluation with EEG is warranted.

Paroxysmal torticollis or head turning in infants is generally benign and well within the purview of pediatricians to diagnose and manage. Different eye movement disorders occur both with and without seizures as well. Be more concerned if you see opsoclonus or "dancing eyes," because you may need to rule out neuroblastoma.

"Paroxysmal kinesigenic dyskinesia" is a good example of a condition that can mimic epilepsy. The characteristic unusual writhing of extremities that is triggered by movement (such as rising from a chair) is a relatively rare condition.

Self-stimulatory behavior also is commonly mistaken for seizures. Typically children place their hands between their thighs, thrust their pelvis back and forth, and then after a few minutes fall asleep. Some refer to this behavior as "infantile masturbation.’"

• Loss of tone or consciousness. Syncope or fainting spells are common and can appear similar to seizures as well.

The typical loss of consciousness presentation is orthostatic. These patients reliably will say that they faint upon standing.

Occasionally, you may hear about patients whose knees buckle and they fall, right after a surge of negative emotion such anger. This is called cataplexy, and it’s one of the symptoms of narcolepsy; it is not epilepsy.

Hemiplegia and certain migraines can mimic seizures as well, so keep these in mind with your differential diagnosis.

You are more likely to hear reports about children who "stare off" for minutes at a time. If you hyperventilate a child in your office and this triggers a staring spell, the child might have absence seizures. In contrast, these spells are less concerning if parents report they can get the child’s attention during the staring. So, as part of your differential, ask parents if they can get the child’s attention during one of these spells. Another tip is to test recall: Instruct the parents to tell the child to remember a specific color and number during the spell; if the child can recall the information a few minutes later, this helps to rule out absence seizures.

• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.

• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.

Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.

• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.

Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.

Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.

• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.

• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.

In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.

A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.

Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.

When parents say their child stopped breathing for a few seconds, suddenly fell to the floor, or sometimes stares off into space, you might immediately think "epilepsy." But several conditions can trigger these events and should be included in your differential diagnosis.

Breath-holding spells, staring off, and gastroesophageal reflux are probably the most common conditions that can mimic epilepsy, but there are many others. Awareness of all the possible etiologies is important because pediatricians are on the front line for diagnosis and initial management of these patients.

Begin by asking for a very detailed description of the spells, including circumstances, timing, and any triggers. Even neurologists who specialize in epilepsy may not spend enough time getting a very, very precise description from the patient and witnesses. Take a thorough medical history of the patient and family to narrow down your differential possibilities. Combined, this information will foster an accurate diagnosis or determine which tests or referrals are indicated.

Depending on your initial assessment, consider blood tests for glucose, calcium, electrolytes, and thyroid function. In some cases, a toxic screen also is appropriate. ECGs and EEGs can be diagnostic as well, although not every pediatrician’s office has these capabilities. It also may be appropriate to refer for polysomnography if you suspect a sleep disorder, including apnea.

In contrast, a CT scan is rarely helpful and in general should not be ordered for these patients. If epilepsy remains a consideration, a head MRI is the more appropriate test.

Because only rarely will you witness a spell in your office, you have to rely on patient and caregiver reports. A useful tip is to ask parents for a video of the event. This is very feasible given the widespread use of smart phones.

Most pediatricians feel comfortable managing the patient with breath-holding spells, tics (including those associated with Tourette syndrome), self-stimulatory behavior, head banging, and night terrors. In contrast, a specialist referral might be appropriate for the child with more severe gastroesophageal reflux, opsoclonus (rapid and irregular eye movements), or one of the psychiatric disorders with manifestations that can mimic epileptic seizures.

Do not hesitate to refer if you remain at all unsure after going through your differential diagnosis. Most pediatricians appropriately refer children to me for further evaluation; only infrequently do I assess a child who obviously does not have epilepsy.

Within the following broad categories are some specific conditions and potential concerns:

• Unusual movements. Newborns can experience seizures, jitteriness, and nonepileptic jerks. Benign sleep myoclonus is very common but parents may come in concerned about these jerky movements. Tics (including motor and vocal tics that characterize Tourette syndrome) can look like seizures. Tics also can point to epileptic myoclonus, in which case further evaluation with EEG is warranted.

Paroxysmal torticollis or head turning in infants is generally benign and well within the purview of pediatricians to diagnose and manage. Different eye movement disorders occur both with and without seizures as well. Be more concerned if you see opsoclonus or "dancing eyes," because you may need to rule out neuroblastoma.

"Paroxysmal kinesigenic dyskinesia" is a good example of a condition that can mimic epilepsy. The characteristic unusual writhing of extremities that is triggered by movement (such as rising from a chair) is a relatively rare condition.

Self-stimulatory behavior also is commonly mistaken for seizures. Typically children place their hands between their thighs, thrust their pelvis back and forth, and then after a few minutes fall asleep. Some refer to this behavior as "infantile masturbation.’"

• Loss of tone or consciousness. Syncope or fainting spells are common and can appear similar to seizures as well.

The typical loss of consciousness presentation is orthostatic. These patients reliably will say that they faint upon standing.

Occasionally, you may hear about patients whose knees buckle and they fall, right after a surge of negative emotion such anger. This is called cataplexy, and it’s one of the symptoms of narcolepsy; it is not epilepsy.

Hemiplegia and certain migraines can mimic seizures as well, so keep these in mind with your differential diagnosis.

You are more likely to hear reports about children who "stare off" for minutes at a time. If you hyperventilate a child in your office and this triggers a staring spell, the child might have absence seizures. In contrast, these spells are less concerning if parents report they can get the child’s attention during the staring. So, as part of your differential, ask parents if they can get the child’s attention during one of these spells. Another tip is to test recall: Instruct the parents to tell the child to remember a specific color and number during the spell; if the child can recall the information a few minutes later, this helps to rule out absence seizures.

• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.

• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.

Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.

• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.

Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.

Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.

• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.

• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.

In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.

A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.

Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.

A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?

It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.

It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.

Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.

In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.

Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.

Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.

Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.

A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.

I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.

Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.

However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.

Also keep in mind that some headache complaints may be functional in nature. For example, if a particular child gets significant attention with their headaches, there may be some associated secondary gain. A child also might be mimicking adult behavior. If the parents complain frequently about headaches, you might find the kid also complains about headaches.

Although pediatric and adult migraines share many of the same features, the good news is pediatric migraines are frequently not as severe or as protracted in children as they are for adults, and are often highly responsive to treatment. It can be very rewarding managing children with headaches because so many do well.

Dr. Berenson is a pediatric neurologist and section chief of neurology at Children’s Healthcare of Atlanta at Scottish Rite. He is also in private practice at Atlanta Headache Specialists and Pediatric and Adolescent NeuroDevelopmental Associates (PANDA) Neurology. He said he had no relevant financial disclosures.

A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?

It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.

It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.

Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.

In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.

Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.

Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.

Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.

A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.

I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.

Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.

However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.

Also keep in mind that some headache complaints may be functional in nature. For example, if a particular child gets significant attention with their headaches, there may be some associated secondary gain. A child also might be mimicking adult behavior. If the parents complain frequently about headaches, you might find the kid also complains about headaches.

Although pediatric and adult migraines share many of the same features, the good news is pediatric migraines are frequently not as severe or as protracted in children as they are for adults, and are often highly responsive to treatment. It can be very rewarding managing children with headaches because so many do well.

Dr. Berenson is a pediatric neurologist and section chief of neurology at Children’s Healthcare of Atlanta at Scottish Rite. He is also in private practice at Atlanta Headache Specialists and Pediatric and Adolescent NeuroDevelopmental Associates (PANDA) Neurology. He said he had no relevant financial disclosures.

A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?

It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.

It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.

Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.

In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.

Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.

Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.

Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.

A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.

I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.

Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.

However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.

Also keep in mind that some headache complaints may be functional in nature. For example, if a particular child gets significant attention with their headaches, there may be some associated secondary gain. A child also might be mimicking adult behavior. If the parents complain frequently about headaches, you might find the kid also complains about headaches.

Although pediatric and adult migraines share many of the same features, the good news is pediatric migraines are frequently not as severe or as protracted in children as they are for adults, and are often highly responsive to treatment. It can be very rewarding managing children with headaches because so many do well.

Dr. Berenson is a pediatric neurologist and section chief of neurology at Children’s Healthcare of Atlanta at Scottish Rite. He is also in private practice at Atlanta Headache Specialists and Pediatric and Adolescent NeuroDevelopmental Associates (PANDA) Neurology. He said he had no relevant financial disclosures.

The benefits of physical activity for younger children are particularly evident when they participate in a variety of sports.

When you encourage patients and families to pursue multiple activities, you can foster normal physical and emotional development in your preschool and elementary school–age patients. Children aged 6-12 years typically experiment and explore before figuring out what they like to do. This is a crucial time to expose children to a number of different activities.

A limited, one-dimensional sense of self is a risk for a 5- or 6-year-old who "specializes" in one sport year round. Many will perceive themselves only as an athlete.

Many parents ask me, "Okay, if my child cannot specialize in sports now, when can they?" I tell them, in general, around sixth grade or age 12 years, because the child will developmentally be at an age when they can understand what they are going to give up if they specialize. They also understand the importance of school and education. Ideally, I encourage patients to wait until high school to specialize in the one or two sports they really like.

Some families will say, "Well, if my kid is not doing this, Johnny down the street is doing this, and he’s going to get way more advanced." I tell these families that if they look at how most professional athletes grew up, most played different sports year round. A professional basketball player likely played soccer, football, and a different sport each season. It’s only been in the last 10-15 years that the culture really changed, and children have been encouraged at younger and younger ages to choose just one sport.

A family also might say, "My kid really loves playing football." I point out that their child doesn’t know anything else, and the child might also like basketball, and might even be better at it.

Well-child visits are a good time to ask about sports and how often your patients play them. Good questions to ask include: How often do you play sports? Is it year round? Do you play multiple sports? Do you take any time off during the year?

If a parent seems convinced that a single sport is best for their young child, it’s a good time for you to step in and explain that most kids do better in the long run when they develop the motor skills that come only from a variety of sports. Also encourage parents to allow their child to take 2 days off a week from structured activities. A pick-up game with their friends is okay, but they really need the time to recover while they are growing.

Sports-specializing children generally peak in their sport much earlier than do kids who play a variety of sports, and they also tend to burn out more. If they eventually start performing for everybody else rather than for themselves, they lose their intrinsic motivation.

Sometimes, the signs of burnout will be subtle at first. If one of your young athletes starts complaining of more injuries that take longer than expected to heal, you might start to suspect that your patient doesn’t really want to be playing. These children might feel uncomfortable being forthright with their parents, especially if a significant amount of time and money has been invested in their sport.

If you don’t feel entirely comfortable sharing your suspicions with the parents, that is a perfect time to refer the family to a sports medicine specialist. I often spend more time counseling parents than children about burnout, and it’s a difficult conversation that often better comes from specialists who deal more directly with sports psychology.

Photo credit: kali9/iStockphoto.com

It’s helpful if you call your sports medicine colleague and tell him or her that you’re referring the kid for his knee pain, but you’re really concerned about burnout, parental pressure, or something else. It’s nice for us to get that heads up from the pediatrician before we see the patient.

When a child does specialize in a sport, recommend a good core-strengthening program. We see overuse injuries from the core musculature breaking down. For example, our overhead athletes (swimmers and baseball/softball players) typically develop overuse injuries at 1 to 2 years after they begin specializing in these sports, often because they lose the core stability that playing multiple sports gave them.

Many youth groups train in Phoenix. We get kids from all over the country who live here and train in their sport year round because of the Arizona weather. Unfortunately, this intensive training isolates a lot of children from their peer groups. Playing a single sport on a competitive travel team becomes a kind of a job for them. Often, they are pulled from school and, unfortunately, academics become less of a focus.

Considerable pressure from some coaches is another concern with very early sports specialization. Some coaches have a list of intense requirements that a child needs to meet in order to excel in that sport. This can be lot of pressure on a 7-year-old.

My general advice is that when you counsel parents, tell them to make sure their kid is having fun. The point of playing and joining sports teams is to have a good time. Take the emphasis off being competitive; that’s something that adults think is more important. Kids start playing sports because it’s fun.

Dr. Wilson is a sports medicine specialist at Phoenix Children’s Hospital and a member of the pediatric faculty at the University of Arizona, Phoenix. She said she has no relevant financial disclosures.

The benefits of physical activity for younger children are particularly evident when they participate in a variety of sports.

When you encourage patients and families to pursue multiple activities, you can foster normal physical and emotional development in your preschool and elementary school–age patients. Children aged 6-12 years typically experiment and explore before figuring out what they like to do. This is a crucial time to expose children to a number of different activities.

A limited, one-dimensional sense of self is a risk for a 5- or 6-year-old who "specializes" in one sport year round. Many will perceive themselves only as an athlete.

Many parents ask me, "Okay, if my child cannot specialize in sports now, when can they?" I tell them, in general, around sixth grade or age 12 years, because the child will developmentally be at an age when they can understand what they are going to give up if they specialize. They also understand the importance of school and education. Ideally, I encourage patients to wait until high school to specialize in the one or two sports they really like.

Some families will say, "Well, if my kid is not doing this, Johnny down the street is doing this, and he’s going to get way more advanced." I tell these families that if they look at how most professional athletes grew up, most played different sports year round. A professional basketball player likely played soccer, football, and a different sport each season. It’s only been in the last 10-15 years that the culture really changed, and children have been encouraged at younger and younger ages to choose just one sport.

A family also might say, "My kid really loves playing football." I point out that their child doesn’t know anything else, and the child might also like basketball, and might even be better at it.

Well-child visits are a good time to ask about sports and how often your patients play them. Good questions to ask include: How often do you play sports? Is it year round? Do you play multiple sports? Do you take any time off during the year?

If a parent seems convinced that a single sport is best for their young child, it’s a good time for you to step in and explain that most kids do better in the long run when they develop the motor skills that come only from a variety of sports. Also encourage parents to allow their child to take 2 days off a week from structured activities. A pick-up game with their friends is okay, but they really need the time to recover while they are growing.

Sports-specializing children generally peak in their sport much earlier than do kids who play a variety of sports, and they also tend to burn out more. If they eventually start performing for everybody else rather than for themselves, they lose their intrinsic motivation.

Sometimes, the signs of burnout will be subtle at first. If one of your young athletes starts complaining of more injuries that take longer than expected to heal, you might start to suspect that your patient doesn’t really want to be playing. These children might feel uncomfortable being forthright with their parents, especially if a significant amount of time and money has been invested in their sport.

If you don’t feel entirely comfortable sharing your suspicions with the parents, that is a perfect time to refer the family to a sports medicine specialist. I often spend more time counseling parents than children about burnout, and it’s a difficult conversation that often better comes from specialists who deal more directly with sports psychology.

Photo credit: kali9/iStockphoto.com

It’s helpful if you call your sports medicine colleague and tell him or her that you’re referring the kid for his knee pain, but you’re really concerned about burnout, parental pressure, or something else. It’s nice for us to get that heads up from the pediatrician before we see the patient.

When a child does specialize in a sport, recommend a good core-strengthening program. We see overuse injuries from the core musculature breaking down. For example, our overhead athletes (swimmers and baseball/softball players) typically develop overuse injuries at 1 to 2 years after they begin specializing in these sports, often because they lose the core stability that playing multiple sports gave them.

Many youth groups train in Phoenix. We get kids from all over the country who live here and train in their sport year round because of the Arizona weather. Unfortunately, this intensive training isolates a lot of children from their peer groups. Playing a single sport on a competitive travel team becomes a kind of a job for them. Often, they are pulled from school and, unfortunately, academics become less of a focus.

Considerable pressure from some coaches is another concern with very early sports specialization. Some coaches have a list of intense requirements that a child needs to meet in order to excel in that sport. This can be lot of pressure on a 7-year-old.

My general advice is that when you counsel parents, tell them to make sure their kid is having fun. The point of playing and joining sports teams is to have a good time. Take the emphasis off being competitive; that’s something that adults think is more important. Kids start playing sports because it’s fun.

Dr. Wilson is a sports medicine specialist at Phoenix Children’s Hospital and a member of the pediatric faculty at the University of Arizona, Phoenix. She said she has no relevant financial disclosures.

The benefits of physical activity for younger children are particularly evident when they participate in a variety of sports.

When you encourage patients and families to pursue multiple activities, you can foster normal physical and emotional development in your preschool and elementary school–age patients. Children aged 6-12 years typically experiment and explore before figuring out what they like to do. This is a crucial time to expose children to a number of different activities.

A limited, one-dimensional sense of self is a risk for a 5- or 6-year-old who "specializes" in one sport year round. Many will perceive themselves only as an athlete.

Many parents ask me, "Okay, if my child cannot specialize in sports now, when can they?" I tell them, in general, around sixth grade or age 12 years, because the child will developmentally be at an age when they can understand what they are going to give up if they specialize. They also understand the importance of school and education. Ideally, I encourage patients to wait until high school to specialize in the one or two sports they really like.

Some families will say, "Well, if my kid is not doing this, Johnny down the street is doing this, and he’s going to get way more advanced." I tell these families that if they look at how most professional athletes grew up, most played different sports year round. A professional basketball player likely played soccer, football, and a different sport each season. It’s only been in the last 10-15 years that the culture really changed, and children have been encouraged at younger and younger ages to choose just one sport.

A family also might say, "My kid really loves playing football." I point out that their child doesn’t know anything else, and the child might also like basketball, and might even be better at it.

Well-child visits are a good time to ask about sports and how often your patients play them. Good questions to ask include: How often do you play sports? Is it year round? Do you play multiple sports? Do you take any time off during the year?

If a parent seems convinced that a single sport is best for their young child, it’s a good time for you to step in and explain that most kids do better in the long run when they develop the motor skills that come only from a variety of sports. Also encourage parents to allow their child to take 2 days off a week from structured activities. A pick-up game with their friends is okay, but they really need the time to recover while they are growing.

Sports-specializing children generally peak in their sport much earlier than do kids who play a variety of sports, and they also tend to burn out more. If they eventually start performing for everybody else rather than for themselves, they lose their intrinsic motivation.

Sometimes, the signs of burnout will be subtle at first. If one of your young athletes starts complaining of more injuries that take longer than expected to heal, you might start to suspect that your patient doesn’t really want to be playing. These children might feel uncomfortable being forthright with their parents, especially if a significant amount of time and money has been invested in their sport.

If you don’t feel entirely comfortable sharing your suspicions with the parents, that is a perfect time to refer the family to a sports medicine specialist. I often spend more time counseling parents than children about burnout, and it’s a difficult conversation that often better comes from specialists who deal more directly with sports psychology.

Photo credit: kali9/iStockphoto.com

It’s helpful if you call your sports medicine colleague and tell him or her that you’re referring the kid for his knee pain, but you’re really concerned about burnout, parental pressure, or something else. It’s nice for us to get that heads up from the pediatrician before we see the patient.

When a child does specialize in a sport, recommend a good core-strengthening program. We see overuse injuries from the core musculature breaking down. For example, our overhead athletes (swimmers and baseball/softball players) typically develop overuse injuries at 1 to 2 years after they begin specializing in these sports, often because they lose the core stability that playing multiple sports gave them.

Many youth groups train in Phoenix. We get kids from all over the country who live here and train in their sport year round because of the Arizona weather. Unfortunately, this intensive training isolates a lot of children from their peer groups. Playing a single sport on a competitive travel team becomes a kind of a job for them. Often, they are pulled from school and, unfortunately, academics become less of a focus.

Considerable pressure from some coaches is another concern with very early sports specialization. Some coaches have a list of intense requirements that a child needs to meet in order to excel in that sport. This can be lot of pressure on a 7-year-old.

My general advice is that when you counsel parents, tell them to make sure their kid is having fun. The point of playing and joining sports teams is to have a good time. Take the emphasis off being competitive; that’s something that adults think is more important. Kids start playing sports because it’s fun.

Dr. Wilson is a sports medicine specialist at Phoenix Children’s Hospital and a member of the pediatric faculty at the University of Arizona, Phoenix. She said she has no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

First be on the lookout for an adolescent girl in your practice who might have the "female athletic triad," which is characterized by disordered eating, amenorrhea, and osteoporosis.

Many girls are involved in sports these days, which is fantastic. But there are some girls and/or their families or coaches who take training to the extreme. Some patients are driven to be the best in their sport or to win an athletic scholarship, whether it’s in track, ice skating, or gymnastics. Some of these girls purposely do not eat right and develop disordered eating to maintain a body weight that they believe is optimal for their sport.

Maintain a high index of clinical suspicion. Adolescence is a crucial time of bone and body development, a time when healthy girls reach their optimal adult height. A really important message to deliver to your athletic patients is that a negative energy balance – that is really what this is about – puts their body and health at risk.

A simple way to start screening for the female athletic triad is to ask all adolescent girls about their periods. Inquire during each visit, whether it’s an annual checkup or routine physical examination. Consider further evaluation if she reports any recent menstrual changes. The benefits of such a screening go beyond diagnosis of the triad – a regular period every month really connotes health in many ways.

If a girl is not getting her period at all, rule out an endocrinologic problem. Girls who have a hyperactive thyroid might not have regular periods and can lose a lot of weight because their bodies are hypermetabolic. So keep this and other endocrinologic disorders in your differential diagnosis of the female athletic triad.

A comprehensive nutrition and exercise history is essential. Ask your patient to complete a 24-hour diet recall. When you take an exercise history, determine exactly what the adolescent girl is doing. Is she training for a specific event? How frequently does she train and for how long?

Once you diagnose female athletic triad in a patient, you can perform her medical management if you feel comfortable doing so. Generally there is a team approach. I often refer patients to a nutritionist – ideally a sports nutritionist – and consider a mental health referral for some girls.

A nutrition specialist can provide general counseling about why the girl has to eat right to maintain her body in a healthy way. Most of the time these patients do not have a sense of what they need to eat to maintain caloric intake and prevent significant weight loss and subsequent amenorrhea. In some cases, patients will report frequent fainting following their weight loss.

You can also refer your patient to an adolescent medicine specialist, who, in some cases, can address the nutritional aspects as well. A consult also can evaluate your patient for risk of anorexia nervosa, particularly if she has lost a tremendous amount of weight.

When you counsel these girls, particularly if they seem reluctant to change their diet or cut back on training, warn them about the long-term risk for osteoporosis. While it’s true that most adolescents with the female athletic triad do not have frank osteoporosis, they might have osteopenia and be at elevated risk for osteoporosis in the future. The few patients who do have osteoporosis often experience bone fractures, even during the teenage years.

Although risk of osteopenia and osteoporosis is part of the triad, I generally don’t order a DXA scan unless a girl has a history of fractures or has missed her periods for close to 1 year. Maintaining proper intake of calcium and vitamin D is important for bone health, and strength exercises also help.

Many girls need supplementation of vitamin D, so obtaining a level might guide treatment. Calcium supplementation also is important because dietary intake is generally not sufficient.

Dr. Alderman is an adolescent medicine specialist at the Children’s Hospital at Montefiore and professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York. She said she had no relevant financial disclosures.

First be on the lookout for an adolescent girl in your practice who might have the "female athletic triad," which is characterized by disordered eating, amenorrhea, and osteoporosis.

Many girls are involved in sports these days, which is fantastic. But there are some girls and/or their families or coaches who take training to the extreme. Some patients are driven to be the best in their sport or to win an athletic scholarship, whether it’s in track, ice skating, or gymnastics. Some of these girls purposely do not eat right and develop disordered eating to maintain a body weight that they believe is optimal for their sport.

Maintain a high index of clinical suspicion. Adolescence is a crucial time of bone and body development, a time when healthy girls reach their optimal adult height. A really important message to deliver to your athletic patients is that a negative energy balance – that is really what this is about – puts their body and health at risk.

A simple way to start screening for the female athletic triad is to ask all adolescent girls about their periods. Inquire during each visit, whether it’s an annual checkup or routine physical examination. Consider further evaluation if she reports any recent menstrual changes. The benefits of such a screening go beyond diagnosis of the triad – a regular period every month really connotes health in many ways.

If a girl is not getting her period at all, rule out an endocrinologic problem. Girls who have a hyperactive thyroid might not have regular periods and can lose a lot of weight because their bodies are hypermetabolic. So keep this and other endocrinologic disorders in your differential diagnosis of the female athletic triad.

A comprehensive nutrition and exercise history is essential. Ask your patient to complete a 24-hour diet recall. When you take an exercise history, determine exactly what the adolescent girl is doing. Is she training for a specific event? How frequently does she train and for how long?

Once you diagnose female athletic triad in a patient, you can perform her medical management if you feel comfortable doing so. Generally there is a team approach. I often refer patients to a nutritionist – ideally a sports nutritionist – and consider a mental health referral for some girls.

A nutrition specialist can provide general counseling about why the girl has to eat right to maintain her body in a healthy way. Most of the time these patients do not have a sense of what they need to eat to maintain caloric intake and prevent significant weight loss and subsequent amenorrhea. In some cases, patients will report frequent fainting following their weight loss.

You can also refer your patient to an adolescent medicine specialist, who, in some cases, can address the nutritional aspects as well. A consult also can evaluate your patient for risk of anorexia nervosa, particularly if she has lost a tremendous amount of weight.

When you counsel these girls, particularly if they seem reluctant to change their diet or cut back on training, warn them about the long-term risk for osteoporosis. While it’s true that most adolescents with the female athletic triad do not have frank osteoporosis, they might have osteopenia and be at elevated risk for osteoporosis in the future. The few patients who do have osteoporosis often experience bone fractures, even during the teenage years.

Although risk of osteopenia and osteoporosis is part of the triad, I generally don’t order a DXA scan unless a girl has a history of fractures or has missed her periods for close to 1 year. Maintaining proper intake of calcium and vitamin D is important for bone health, and strength exercises also help.

Many girls need supplementation of vitamin D, so obtaining a level might guide treatment. Calcium supplementation also is important because dietary intake is generally not sufficient.

Dr. Alderman is an adolescent medicine specialist at the Children’s Hospital at Montefiore and professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York. She said she had no relevant financial disclosures.

First be on the lookout for an adolescent girl in your practice who might have the "female athletic triad," which is characterized by disordered eating, amenorrhea, and osteoporosis.

Many girls are involved in sports these days, which is fantastic. But there are some girls and/or their families or coaches who take training to the extreme. Some patients are driven to be the best in their sport or to win an athletic scholarship, whether it’s in track, ice skating, or gymnastics. Some of these girls purposely do not eat right and develop disordered eating to maintain a body weight that they believe is optimal for their sport.

Maintain a high index of clinical suspicion. Adolescence is a crucial time of bone and body development, a time when healthy girls reach their optimal adult height. A really important message to deliver to your athletic patients is that a negative energy balance – that is really what this is about – puts their body and health at risk.

A simple way to start screening for the female athletic triad is to ask all adolescent girls about their periods. Inquire during each visit, whether it’s an annual checkup or routine physical examination. Consider further evaluation if she reports any recent menstrual changes. The benefits of such a screening go beyond diagnosis of the triad – a regular period every month really connotes health in many ways.

If a girl is not getting her period at all, rule out an endocrinologic problem. Girls who have a hyperactive thyroid might not have regular periods and can lose a lot of weight because their bodies are hypermetabolic. So keep this and other endocrinologic disorders in your differential diagnosis of the female athletic triad.

A comprehensive nutrition and exercise history is essential. Ask your patient to complete a 24-hour diet recall. When you take an exercise history, determine exactly what the adolescent girl is doing. Is she training for a specific event? How frequently does she train and for how long?

Once you diagnose female athletic triad in a patient, you can perform her medical management if you feel comfortable doing so. Generally there is a team approach. I often refer patients to a nutritionist – ideally a sports nutritionist – and consider a mental health referral for some girls.

A nutrition specialist can provide general counseling about why the girl has to eat right to maintain her body in a healthy way. Most of the time these patients do not have a sense of what they need to eat to maintain caloric intake and prevent significant weight loss and subsequent amenorrhea. In some cases, patients will report frequent fainting following their weight loss.

You can also refer your patient to an adolescent medicine specialist, who, in some cases, can address the nutritional aspects as well. A consult also can evaluate your patient for risk of anorexia nervosa, particularly if she has lost a tremendous amount of weight.

When you counsel these girls, particularly if they seem reluctant to change their diet or cut back on training, warn them about the long-term risk for osteoporosis. While it’s true that most adolescents with the female athletic triad do not have frank osteoporosis, they might have osteopenia and be at elevated risk for osteoporosis in the future. The few patients who do have osteoporosis often experience bone fractures, even during the teenage years.

Although risk of osteopenia and osteoporosis is part of the triad, I generally don’t order a DXA scan unless a girl has a history of fractures or has missed her periods for close to 1 year. Maintaining proper intake of calcium and vitamin D is important for bone health, and strength exercises also help.

Many girls need supplementation of vitamin D, so obtaining a level might guide treatment. Calcium supplementation also is important because dietary intake is generally not sufficient.

Dr. Alderman is an adolescent medicine specialist at the Children’s Hospital at Montefiore and professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York. She said she had no relevant financial disclosures.

With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.

This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.

In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.

Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.

The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.

I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.

Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.

Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.

If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).

This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.

If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.

Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.

Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.

With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.

This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.

In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.

Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.

The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.

I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.

Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.

Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.

If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).

This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.

If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.

Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.

Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.

With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.

This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.

In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.

Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.

The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.

I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.

Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.

Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.

If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).

This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.

If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.

Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.

Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Begin by thinking about this diagnosis. If you don’t consider immunodeficiency during your routine evaluations, you are likely to miss one of these relatively rare conditions. Screening is of the utmost importance with more than 175 pediatric primary immunodeficiencies identified.

Considering immunodeficiencies appropriately is important – they represent sharp needles in the pediatrician’s haystack. You might be thinking: How am I going to recognize these important needles in my busy practice? My advice is to look for the hallmarks – infections that are recurrent, severe, or unusual.

Courtesy Children's Hospital of Philadelphia

I use a Statue of Liberty analogy. Give me your five sickest kids – the ones who hound your triage nurse, the ones who always page you after hours – and then think about immunodeficiency as a possible diagnosis. A child with recurrent infections who requires and responds to antibiotics frequently is a likely candidate.

Upper and lower respiratory tract infections are common in this patient population. About half of children with an immunodeficiency will have antibodies and will most typically present with involvement of the sinuses and/or the ears, including in some cases, bronchitis or pneumonia.

Severe combined immunodeficiency syndrome (SCIDS) is particularly alarming. If you practice in one of the states that require newborn screening for this condition – California, Louisiana, Massachusetts, New York, or Wisconsin – you are likely to receive a call at some point from your state laboratory. The number of calls you get alerting you to a positive result will vary by the size of your practice: SCIDS affects about 1 in 50,000 live births. There was a case in Wisconsin where a baby with SCIDS was identified quickly and cured (J. Allergy Clin. Immunol. 2011;127:535-38).

A newborn with SCIDS lacks the capacity to make functional T cells, and there is a movement to expand this screening to all 50 states.

As with any confirmed immunodeficiency, working in concert with an immunologist becomes essential. Expertise is important because there are therapeutic options for almost every patient with a primary immunodeficiency diagnosis. A subspecialist can help you devise an effective management plan. It is a matter of pediatricians feeling empowered, not feeling that children with primary immunodeficiencies are too complex to manage.

I am fine with a pediatrician calling for a direct referral. It is appropriate not to manage the diagnostic evaluation of these children if you feel uncomfortable. With that said, there are opportunities for pediatricians to manage these patients as well. I know some pediatricians are as adept at this as I am.

For example, you can screen a child with a suspected immunodeficiency for the presence of antibodies. Keep quantity and quality in mind. Quantity is a check of how full the tank is; for example, assess their levels of IgG, IgM, and IgA.

Quality assessment can be more challenging, but there are appropriate, point-of-contact screenings you can perform without too much effort. Most importantly these would include checking the antibody titers against vaccines you have provided, such as a tetanus titer or pneumococcal titers.

A complete blood count with differential, for example, provides important information, including the percentage and number of lymphocytes and neutrophils. If the absolute levels are low, then it becomes relevant to think: Why? Viral suppression is a true cause, but it’s overrated, so be sure to reevaluate a low count and remember to consider immunodeficiency if a low value persists.

If you suspect immunodeficiency in a baby, for example, check the infant’s lymphocyte count against the age-specific normal value. This varies, but the lower limit for normal for a healthy child under 1 year of age is about 3,500/mcL.

This might surprise you, but a child with low or no lymphocytes can quickly require emergency medical attention.

Other tests are more in the domain of the specialist or more appropriate in specific situations. In addition, the assay order forms and specialty laboratories can be tricky. Right next to IgG, for example, the IgG subclasses are often listed. These subclass evaluations are expensive and of little value in routine clinical assessment.

The bottom line is: Think about primary immunodeficiency. If you are uncomfortable in carrying forward a diagnostic evaluation – call an immunologist. We are happy to help. Statistically speaking, the needle is in your haystack. A pediatric practice looking after 10,000 children should be following 5 with primary immunodeficiency. Do you know who yours are?

This column, "Subspecialist Consult," appears regularly in Pediatric News, an Elsevier publication. Dr. Orange is a pediatric immunologist in the division of allergy and immunology at Children’s Hospital of Philadelphia. He disclosed that he is a medical adviser to the Immunodeficiency Foundation and a consultant to three manufacturers of immunoglobulin therapies: Baxter Healthcare, Talecris Biotherapeutics, and CSL Behring. He also receives research grants from Octapharma USA.

Begin by thinking about this diagnosis. If you don’t consider immunodeficiency during your routine evaluations, you are likely to miss one of these relatively rare conditions. Screening is of the utmost importance with more than 175 pediatric primary immunodeficiencies identified.

Considering immunodeficiencies appropriately is important – they represent sharp needles in the pediatrician’s haystack. You might be thinking: How am I going to recognize these important needles in my busy practice? My advice is to look for the hallmarks – infections that are recurrent, severe, or unusual.

Courtesy Children's Hospital of Philadelphia

I use a Statue of Liberty analogy. Give me your five sickest kids – the ones who hound your triage nurse, the ones who always page you after hours – and then think about immunodeficiency as a possible diagnosis. A child with recurrent infections who requires and responds to antibiotics frequently is a likely candidate.

Upper and lower respiratory tract infections are common in this patient population. About half of children with an immunodeficiency will have antibodies and will most typically present with involvement of the sinuses and/or the ears, including in some cases, bronchitis or pneumonia.

Severe combined immunodeficiency syndrome (SCIDS) is particularly alarming. If you practice in one of the states that require newborn screening for this condition – California, Louisiana, Massachusetts, New York, or Wisconsin – you are likely to receive a call at some point from your state laboratory. The number of calls you get alerting you to a positive result will vary by the size of your practice: SCIDS affects about 1 in 50,000 live births. There was a case in Wisconsin where a baby with SCIDS was identified quickly and cured (J. Allergy Clin. Immunol. 2011;127:535-38).

A newborn with SCIDS lacks the capacity to make functional T cells, and there is a movement to expand this screening to all 50 states.

As with any confirmed immunodeficiency, working in concert with an immunologist becomes essential. Expertise is important because there are therapeutic options for almost every patient with a primary immunodeficiency diagnosis. A subspecialist can help you devise an effective management plan. It is a matter of pediatricians feeling empowered, not feeling that children with primary immunodeficiencies are too complex to manage.

I am fine with a pediatrician calling for a direct referral. It is appropriate not to manage the diagnostic evaluation of these children if you feel uncomfortable. With that said, there are opportunities for pediatricians to manage these patients as well. I know some pediatricians are as adept at this as I am.

For example, you can screen a child with a suspected immunodeficiency for the presence of antibodies. Keep quantity and quality in mind. Quantity is a check of how full the tank is; for example, assess their levels of IgG, IgM, and IgA.

Quality assessment can be more challenging, but there are appropriate, point-of-contact screenings you can perform without too much effort. Most importantly these would include checking the antibody titers against vaccines you have provided, such as a tetanus titer or pneumococcal titers.

A complete blood count with differential, for example, provides important information, including the percentage and number of lymphocytes and neutrophils. If the absolute levels are low, then it becomes relevant to think: Why? Viral suppression is a true cause, but it’s overrated, so be sure to reevaluate a low count and remember to consider immunodeficiency if a low value persists.

If you suspect immunodeficiency in a baby, for example, check the infant’s lymphocyte count against the age-specific normal value. This varies, but the lower limit for normal for a healthy child under 1 year of age is about 3,500/mcL.

This might surprise you, but a child with low or no lymphocytes can quickly require emergency medical attention.

Other tests are more in the domain of the specialist or more appropriate in specific situations. In addition, the assay order forms and specialty laboratories can be tricky. Right next to IgG, for example, the IgG subclasses are often listed. These subclass evaluations are expensive and of little value in routine clinical assessment.

The bottom line is: Think about primary immunodeficiency. If you are uncomfortable in carrying forward a diagnostic evaluation – call an immunologist. We are happy to help. Statistically speaking, the needle is in your haystack. A pediatric practice looking after 10,000 children should be following 5 with primary immunodeficiency. Do you know who yours are?

This column, "Subspecialist Consult," appears regularly in Pediatric News, an Elsevier publication. Dr. Orange is a pediatric immunologist in the division of allergy and immunology at Children’s Hospital of Philadelphia. He disclosed that he is a medical adviser to the Immunodeficiency Foundation and a consultant to three manufacturers of immunoglobulin therapies: Baxter Healthcare, Talecris Biotherapeutics, and CSL Behring. He also receives research grants from Octapharma USA.

Begin by thinking about this diagnosis. If you don’t consider immunodeficiency during your routine evaluations, you are likely to miss one of these relatively rare conditions. Screening is of the utmost importance with more than 175 pediatric primary immunodeficiencies identified.

Considering immunodeficiencies appropriately is important – they represent sharp needles in the pediatrician’s haystack. You might be thinking: How am I going to recognize these important needles in my busy practice? My advice is to look for the hallmarks – infections that are recurrent, severe, or unusual.

Courtesy Children's Hospital of Philadelphia

I use a Statue of Liberty analogy. Give me your five sickest kids – the ones who hound your triage nurse, the ones who always page you after hours – and then think about immunodeficiency as a possible diagnosis. A child with recurrent infections who requires and responds to antibiotics frequently is a likely candidate.

Upper and lower respiratory tract infections are common in this patient population. About half of children with an immunodeficiency will have antibodies and will most typically present with involvement of the sinuses and/or the ears, including in some cases, bronchitis or pneumonia.

Severe combined immunodeficiency syndrome (SCIDS) is particularly alarming. If you practice in one of the states that require newborn screening for this condition – California, Louisiana, Massachusetts, New York, or Wisconsin – you are likely to receive a call at some point from your state laboratory. The number of calls you get alerting you to a positive result will vary by the size of your practice: SCIDS affects about 1 in 50,000 live births. There was a case in Wisconsin where a baby with SCIDS was identified quickly and cured (J. Allergy Clin. Immunol. 2011;127:535-38).

A newborn with SCIDS lacks the capacity to make functional T cells, and there is a movement to expand this screening to all 50 states.

As with any confirmed immunodeficiency, working in concert with an immunologist becomes essential. Expertise is important because there are therapeutic options for almost every patient with a primary immunodeficiency diagnosis. A subspecialist can help you devise an effective management plan. It is a matter of pediatricians feeling empowered, not feeling that children with primary immunodeficiencies are too complex to manage.

I am fine with a pediatrician calling for a direct referral. It is appropriate not to manage the diagnostic evaluation of these children if you feel uncomfortable. With that said, there are opportunities for pediatricians to manage these patients as well. I know some pediatricians are as adept at this as I am.

For example, you can screen a child with a suspected immunodeficiency for the presence of antibodies. Keep quantity and quality in mind. Quantity is a check of how full the tank is; for example, assess their levels of IgG, IgM, and IgA.

Quality assessment can be more challenging, but there are appropriate, point-of-contact screenings you can perform without too much effort. Most importantly these would include checking the antibody titers against vaccines you have provided, such as a tetanus titer or pneumococcal titers.

A complete blood count with differential, for example, provides important information, including the percentage and number of lymphocytes and neutrophils. If the absolute levels are low, then it becomes relevant to think: Why? Viral suppression is a true cause, but it’s overrated, so be sure to reevaluate a low count and remember to consider immunodeficiency if a low value persists.

If you suspect immunodeficiency in a baby, for example, check the infant’s lymphocyte count against the age-specific normal value. This varies, but the lower limit for normal for a healthy child under 1 year of age is about 3,500/mcL.

This might surprise you, but a child with low or no lymphocytes can quickly require emergency medical attention.

Other tests are more in the domain of the specialist or more appropriate in specific situations. In addition, the assay order forms and specialty laboratories can be tricky. Right next to IgG, for example, the IgG subclasses are often listed. These subclass evaluations are expensive and of little value in routine clinical assessment.

The bottom line is: Think about primary immunodeficiency. If you are uncomfortable in carrying forward a diagnostic evaluation – call an immunologist. We are happy to help. Statistically speaking, the needle is in your haystack. A pediatric practice looking after 10,000 children should be following 5 with primary immunodeficiency. Do you know who yours are?

This column, "Subspecialist Consult," appears regularly in Pediatric News, an Elsevier publication. Dr. Orange is a pediatric immunologist in the division of allergy and immunology at Children’s Hospital of Philadelphia. He disclosed that he is a medical adviser to the Immunodeficiency Foundation and a consultant to three manufacturers of immunoglobulin therapies: Baxter Healthcare, Talecris Biotherapeutics, and CSL Behring. He also receives research grants from Octapharma USA.