Subspecialist Consult

When you first observe or suspect an infant has hypotonia, you face a decision whether the condition is benign and likely to resolve over time vs. a more serious condition with an important neurologic basis.

You will be in a position to make that call in many cases in your practice. Related observations include spontaneous movement during a physical examination; basic laboratory testing; and any relevant family history of genetic-based disease. These can go a long way to guide your diagnosis. Any abnormality in growth, feeding patterns, or respiration also provides important clinical clues.

Pediatricians, depending on their experience, can determine when a "wait and watch" approach is appropriate. For example, benign hypotonia is more likely when there are no major delays in growth or motor milestones, no signs of abnormal respiration, and parents report normal feeding patterns.

Since we cannot test the strength of a 7- or 8-month-old infant by asking them to offer resistance with their arms and legs, it’s useful to observe the amount and quality of their spontaneous movements. Watch their head control when you pull the infant to sit from a supine position. Does the head lag behind at all? How vigorously does the infant kick or grasp? These signs can help examiners compare impressions of degree of weakness, if there is any, in hypotonic infants.

Parents may be unaware of any low muscle tone, so it’s important to include hypotonia on your physical examination checklist.

Ask parents about the strength of the infant during diaper or clothing changes. Often parents have a good sense of the amount of force their child displays, and it can be reassuring to make these observations in the examination room as well.

An infant with a benign form of congenital hypotonia will move her arms and legs frequently: batting, roving, and sometimes synchronous movements come and go depending on level of alertness. In contrast, an infant with hypotonia caused by a neurologic disease, such as spinal muscle atrophy, will move much less frequently and the initiation of the movement(s) is slower.

In some cases, the degree or cause of hypotonia may not be clear, and the question becomes what to do with that uncertainty. A creatine phosphokinase (CPK) assay, the most common initial laboratory test to assess low muscle tone, can be helpful, although a normal result doesn’t rule out muscle or nerve disease.

In addition, check the baby’s respiratory rate and listen for any stridor or other signs of obstruction in her breathing. Noisy breathing can suggest upper respiratory muscle involvement, in which case further work-up is warranted. How’s the head growth over time?

Testing deep tendon reflexes can be tricky. While the presence of reflexes is reassuring, absence suggests a peripheral nerve problem or anterior horn cell disease.

Ask parents about the baby’s typical feeding pattern. An infant that seems to take a long time to feed and/or has an interrupted pattern of feeding should raise your clinical suspicion about an important neurologic cause for their hypotonia.

Family history can be an independent risk factor for a more serious, inherited neurologic etiology. Many of the causes of hypotonia are genetic, and specialist input will be appropriate if you uncover relevant family history. Inquire about any first-degree relative or others with an inherited neurologic condition that could underlie the infant’s hypotonia. In some cases, a non-neurologic inherited disease such as Marfan syndrome can cause hypotonia as well.

Specialist input is indicated if you suspect a genetic basis for the hypotonia, even if the infant passes the other important elements of your evaluation (for example, normal milestones, eating, and breathing).

These patients are a pretty diverse group, and there are many infants with hypotonia who will ultimately do well. If you are unsure, it’s definitely worth tracking these patients a little closer using history and physical examination checklists. Check in with a specialist if you continue to be unsure as you move forward.

Dr. Bingham is a pediatric neurologist at Fletcher Allen Health Care and associate professor of neurology at the University of Vermont in Burlington. Dr. Bingham said he had no relevant financial disclosures. 

When you first observe or suspect an infant has hypotonia, you face a decision whether the condition is benign and likely to resolve over time vs. a more serious condition with an important neurologic basis.

You will be in a position to make that call in many cases in your practice. Related observations include spontaneous movement during a physical examination; basic laboratory testing; and any relevant family history of genetic-based disease. These can go a long way to guide your diagnosis. Any abnormality in growth, feeding patterns, or respiration also provides important clinical clues.

Pediatricians, depending on their experience, can determine when a "wait and watch" approach is appropriate. For example, benign hypotonia is more likely when there are no major delays in growth or motor milestones, no signs of abnormal respiration, and parents report normal feeding patterns.

Since we cannot test the strength of a 7- or 8-month-old infant by asking them to offer resistance with their arms and legs, it’s useful to observe the amount and quality of their spontaneous movements. Watch their head control when you pull the infant to sit from a supine position. Does the head lag behind at all? How vigorously does the infant kick or grasp? These signs can help examiners compare impressions of degree of weakness, if there is any, in hypotonic infants.

Parents may be unaware of any low muscle tone, so it’s important to include hypotonia on your physical examination checklist.

Ask parents about the strength of the infant during diaper or clothing changes. Often parents have a good sense of the amount of force their child displays, and it can be reassuring to make these observations in the examination room as well.

An infant with a benign form of congenital hypotonia will move her arms and legs frequently: batting, roving, and sometimes synchronous movements come and go depending on level of alertness. In contrast, an infant with hypotonia caused by a neurologic disease, such as spinal muscle atrophy, will move much less frequently and the initiation of the movement(s) is slower.

In some cases, the degree or cause of hypotonia may not be clear, and the question becomes what to do with that uncertainty. A creatine phosphokinase (CPK) assay, the most common initial laboratory test to assess low muscle tone, can be helpful, although a normal result doesn’t rule out muscle or nerve disease.

In addition, check the baby’s respiratory rate and listen for any stridor or other signs of obstruction in her breathing. Noisy breathing can suggest upper respiratory muscle involvement, in which case further work-up is warranted. How’s the head growth over time?

Testing deep tendon reflexes can be tricky. While the presence of reflexes is reassuring, absence suggests a peripheral nerve problem or anterior horn cell disease.

Ask parents about the baby’s typical feeding pattern. An infant that seems to take a long time to feed and/or has an interrupted pattern of feeding should raise your clinical suspicion about an important neurologic cause for their hypotonia.

Family history can be an independent risk factor for a more serious, inherited neurologic etiology. Many of the causes of hypotonia are genetic, and specialist input will be appropriate if you uncover relevant family history. Inquire about any first-degree relative or others with an inherited neurologic condition that could underlie the infant’s hypotonia. In some cases, a non-neurologic inherited disease such as Marfan syndrome can cause hypotonia as well.

Specialist input is indicated if you suspect a genetic basis for the hypotonia, even if the infant passes the other important elements of your evaluation (for example, normal milestones, eating, and breathing).

These patients are a pretty diverse group, and there are many infants with hypotonia who will ultimately do well. If you are unsure, it’s definitely worth tracking these patients a little closer using history and physical examination checklists. Check in with a specialist if you continue to be unsure as you move forward.

Dr. Bingham is a pediatric neurologist at Fletcher Allen Health Care and associate professor of neurology at the University of Vermont in Burlington. Dr. Bingham said he had no relevant financial disclosures. 

When you first observe or suspect an infant has hypotonia, you face a decision whether the condition is benign and likely to resolve over time vs. a more serious condition with an important neurologic basis.

You will be in a position to make that call in many cases in your practice. Related observations include spontaneous movement during a physical examination; basic laboratory testing; and any relevant family history of genetic-based disease. These can go a long way to guide your diagnosis. Any abnormality in growth, feeding patterns, or respiration also provides important clinical clues.

Pediatricians, depending on their experience, can determine when a "wait and watch" approach is appropriate. For example, benign hypotonia is more likely when there are no major delays in growth or motor milestones, no signs of abnormal respiration, and parents report normal feeding patterns.

Since we cannot test the strength of a 7- or 8-month-old infant by asking them to offer resistance with their arms and legs, it’s useful to observe the amount and quality of their spontaneous movements. Watch their head control when you pull the infant to sit from a supine position. Does the head lag behind at all? How vigorously does the infant kick or grasp? These signs can help examiners compare impressions of degree of weakness, if there is any, in hypotonic infants.

Parents may be unaware of any low muscle tone, so it’s important to include hypotonia on your physical examination checklist.

Ask parents about the strength of the infant during diaper or clothing changes. Often parents have a good sense of the amount of force their child displays, and it can be reassuring to make these observations in the examination room as well.

An infant with a benign form of congenital hypotonia will move her arms and legs frequently: batting, roving, and sometimes synchronous movements come and go depending on level of alertness. In contrast, an infant with hypotonia caused by a neurologic disease, such as spinal muscle atrophy, will move much less frequently and the initiation of the movement(s) is slower.

In some cases, the degree or cause of hypotonia may not be clear, and the question becomes what to do with that uncertainty. A creatine phosphokinase (CPK) assay, the most common initial laboratory test to assess low muscle tone, can be helpful, although a normal result doesn’t rule out muscle or nerve disease.

In addition, check the baby’s respiratory rate and listen for any stridor or other signs of obstruction in her breathing. Noisy breathing can suggest upper respiratory muscle involvement, in which case further work-up is warranted. How’s the head growth over time?

Testing deep tendon reflexes can be tricky. While the presence of reflexes is reassuring, absence suggests a peripheral nerve problem or anterior horn cell disease.

Ask parents about the baby’s typical feeding pattern. An infant that seems to take a long time to feed and/or has an interrupted pattern of feeding should raise your clinical suspicion about an important neurologic cause for their hypotonia.

Family history can be an independent risk factor for a more serious, inherited neurologic etiology. Many of the causes of hypotonia are genetic, and specialist input will be appropriate if you uncover relevant family history. Inquire about any first-degree relative or others with an inherited neurologic condition that could underlie the infant’s hypotonia. In some cases, a non-neurologic inherited disease such as Marfan syndrome can cause hypotonia as well.

Specialist input is indicated if you suspect a genetic basis for the hypotonia, even if the infant passes the other important elements of your evaluation (for example, normal milestones, eating, and breathing).

These patients are a pretty diverse group, and there are many infants with hypotonia who will ultimately do well. If you are unsure, it’s definitely worth tracking these patients a little closer using history and physical examination checklists. Check in with a specialist if you continue to be unsure as you move forward.

Dr. Bingham is a pediatric neurologist at Fletcher Allen Health Care and associate professor of neurology at the University of Vermont in Burlington. Dr. Bingham said he had no relevant financial disclosures. 

Growth is a terrific biomarker for general health, and a slowing of growth may be a sign of underlying disease. So which children deserve an evaluation?

Short stature is defined as growth below the third percentile. In addition to these children, a child who is crossing one percentile line on the growth chart also deserves evaluation. The sole exception is an otherwise healthy child developing well who may, in the second year of life, adjust to genetics (for example, a big baby born to short parents).

The key is to identify the short child by monitoring the growth pattern, evaluating him to find a specific diagnosis, and then targeting the clinical intervention.

Consistent measurement of a child’s height at every health care encounter is the most important strategy to identify a child with short stature. Some children do not go for regular well-child visits once they have most of their immunizations completed and may show up for sick visits only. In many cases, only weight but not height is measured during these acute care visits. For example, in my pediatric endocrinology practice, it is not unusual to see children who are 12 years old without a height measurement for the previous 7 years because the family did not present to the primary care physician for well care.

The benefits of these routine measurements go beyond identification of short stature. Any child with poor growth needs to be evaluated by a specialist who can go through an extensive differential diagnosis.

Helpful guidelines include the 2009 "Evidence-Based Clinical Practice Guideline on Linear Growth Measurement of Children" from clinicians at Blanks Children’s Hospital in Des Moines, Iowa, and "Development of an Evidence-Based Clinical Practice Guideline on Linear Growth Measurement of Children"’ (J. Pediatr. Nursing 2011;26:312-24).

Sometimes I hear families or primary care physicians say, "Let’s just wait and see." It is advisable to see a child back in 6 months to monitor growth velocity, but watching poor linear growth year after year will not optimize the height outcome. The problem with later intervention is that the older child with short stature does not have enough "catch up" time. Therefore, additional evaluation is warranted if you diagnose short stature and you remain concerned after 6 months.

For a child who warrants this additional evaluation, a bone age x-ray is helpful (although not diagnostic of a specific condition). Other recommended studies include a complete blood count; chemistry panel; free thyroxine (free T4) with thyroid stimulating hormone (TSH); insulinlike growth factor 1 (IGF-1), C-reactive protein, urinalysis, and a celiac panel (IgG and IgA class of anti–tissue transglutaminase [anti-tTG]; antiendomysial antibodies, IgA class [EMA-IgA]; and quantitative IgA). In addition, for girls, a karyotype can rule out Turner’s syndrome.

Obtaining the correct test can sometimes be a problem. For example, IGF-1 is similar to many other test names on a laboratory test list. The odds of a lab technician performing the right test are low, because on their alphabetical test list, IGF BP 1 appears at the top (and this test is not useful at all!). This pitfall can be avoided by including the lab specific test code for IGF-1, which your local pediatric endocrinologist can help you find.

Other testing may be warranted, based on history and physical findings. For example, if a child has a history of pneumonia and frequent sinusitis, I would order a sweat chloride test to rule out cystic fibrosis.

If there is no clear explanation, and the slowed growth does not respond to your intervention, refer the patient to a specialist.

The growth chart will help guide the type of referral. If linear growth is poor and weight gain is appropriate (that is, their body mass index is normal), consider referral to a pediatric endocrinologist.

If linear growth is poor, but weight gain is more strikingly affected (that is, BMI is low for age), consider referral instead to a pediatric gastroenterologist.

If testing reveals electrolyte abnormalities, consider referral to pediatric nephrology.

If the child has congenital anomalies or a developmental delay in addition to short stature, then referral to a geneticist becomes appropriate.

Once a short stature diagnosis is established, a targeted approach to optimization of growth can be planned. Human growth hormone therapy, for example, typically is ordered by a pediatric endocrinologist for a number of diagnoses. Indications include growth hormone deficiency, Turner’s syndrome, Noonan’s syndrome, Prader-Willi syndrome, and children born small for gestational age who fail to catch up. A pediatric nephrologist also might prescribe this therapy for a child with renal failure who is not growing.

Dr. Counts is an associate professor of pediatrics and chief of the division of pediatric endocrinology at the University of Maryland, Baltimore. She works on multiple research studies with funding to the University of Maryland, Baltimore, from Eli Lilly, Pfizer, and Novo Nordisk. 

Growth is a terrific biomarker for general health, and a slowing of growth may be a sign of underlying disease. So which children deserve an evaluation?

Short stature is defined as growth below the third percentile. In addition to these children, a child who is crossing one percentile line on the growth chart also deserves evaluation. The sole exception is an otherwise healthy child developing well who may, in the second year of life, adjust to genetics (for example, a big baby born to short parents).

The key is to identify the short child by monitoring the growth pattern, evaluating him to find a specific diagnosis, and then targeting the clinical intervention.

Consistent measurement of a child’s height at every health care encounter is the most important strategy to identify a child with short stature. Some children do not go for regular well-child visits once they have most of their immunizations completed and may show up for sick visits only. In many cases, only weight but not height is measured during these acute care visits. For example, in my pediatric endocrinology practice, it is not unusual to see children who are 12 years old without a height measurement for the previous 7 years because the family did not present to the primary care physician for well care.

The benefits of these routine measurements go beyond identification of short stature. Any child with poor growth needs to be evaluated by a specialist who can go through an extensive differential diagnosis.

Helpful guidelines include the 2009 "Evidence-Based Clinical Practice Guideline on Linear Growth Measurement of Children" from clinicians at Blanks Children’s Hospital in Des Moines, Iowa, and "Development of an Evidence-Based Clinical Practice Guideline on Linear Growth Measurement of Children"’ (J. Pediatr. Nursing 2011;26:312-24).

Sometimes I hear families or primary care physicians say, "Let’s just wait and see." It is advisable to see a child back in 6 months to monitor growth velocity, but watching poor linear growth year after year will not optimize the height outcome. The problem with later intervention is that the older child with short stature does not have enough "catch up" time. Therefore, additional evaluation is warranted if you diagnose short stature and you remain concerned after 6 months.

For a child who warrants this additional evaluation, a bone age x-ray is helpful (although not diagnostic of a specific condition). Other recommended studies include a complete blood count; chemistry panel; free thyroxine (free T4) with thyroid stimulating hormone (TSH); insulinlike growth factor 1 (IGF-1), C-reactive protein, urinalysis, and a celiac panel (IgG and IgA class of anti–tissue transglutaminase [anti-tTG]; antiendomysial antibodies, IgA class [EMA-IgA]; and quantitative IgA). In addition, for girls, a karyotype can rule out Turner’s syndrome.

Obtaining the correct test can sometimes be a problem. For example, IGF-1 is similar to many other test names on a laboratory test list. The odds of a lab technician performing the right test are low, because on their alphabetical test list, IGF BP 1 appears at the top (and this test is not useful at all!). This pitfall can be avoided by including the lab specific test code for IGF-1, which your local pediatric endocrinologist can help you find.

Other testing may be warranted, based on history and physical findings. For example, if a child has a history of pneumonia and frequent sinusitis, I would order a sweat chloride test to rule out cystic fibrosis.

If there is no clear explanation, and the slowed growth does not respond to your intervention, refer the patient to a specialist.

The growth chart will help guide the type of referral. If linear growth is poor and weight gain is appropriate (that is, their body mass index is normal), consider referral to a pediatric endocrinologist.

If linear growth is poor, but weight gain is more strikingly affected (that is, BMI is low for age), consider referral instead to a pediatric gastroenterologist.

If testing reveals electrolyte abnormalities, consider referral to pediatric nephrology.

If the child has congenital anomalies or a developmental delay in addition to short stature, then referral to a geneticist becomes appropriate.

Once a short stature diagnosis is established, a targeted approach to optimization of growth can be planned. Human growth hormone therapy, for example, typically is ordered by a pediatric endocrinologist for a number of diagnoses. Indications include growth hormone deficiency, Turner’s syndrome, Noonan’s syndrome, Prader-Willi syndrome, and children born small for gestational age who fail to catch up. A pediatric nephrologist also might prescribe this therapy for a child with renal failure who is not growing.

Dr. Counts is an associate professor of pediatrics and chief of the division of pediatric endocrinology at the University of Maryland, Baltimore. She works on multiple research studies with funding to the University of Maryland, Baltimore, from Eli Lilly, Pfizer, and Novo Nordisk. 

Growth is a terrific biomarker for general health, and a slowing of growth may be a sign of underlying disease. So which children deserve an evaluation?

Short stature is defined as growth below the third percentile. In addition to these children, a child who is crossing one percentile line on the growth chart also deserves evaluation. The sole exception is an otherwise healthy child developing well who may, in the second year of life, adjust to genetics (for example, a big baby born to short parents).

The key is to identify the short child by monitoring the growth pattern, evaluating him to find a specific diagnosis, and then targeting the clinical intervention.

Consistent measurement of a child’s height at every health care encounter is the most important strategy to identify a child with short stature. Some children do not go for regular well-child visits once they have most of their immunizations completed and may show up for sick visits only. In many cases, only weight but not height is measured during these acute care visits. For example, in my pediatric endocrinology practice, it is not unusual to see children who are 12 years old without a height measurement for the previous 7 years because the family did not present to the primary care physician for well care.

The benefits of these routine measurements go beyond identification of short stature. Any child with poor growth needs to be evaluated by a specialist who can go through an extensive differential diagnosis.

Helpful guidelines include the 2009 "Evidence-Based Clinical Practice Guideline on Linear Growth Measurement of Children" from clinicians at Blanks Children’s Hospital in Des Moines, Iowa, and "Development of an Evidence-Based Clinical Practice Guideline on Linear Growth Measurement of Children"’ (J. Pediatr. Nursing 2011;26:312-24).

Sometimes I hear families or primary care physicians say, "Let’s just wait and see." It is advisable to see a child back in 6 months to monitor growth velocity, but watching poor linear growth year after year will not optimize the height outcome. The problem with later intervention is that the older child with short stature does not have enough "catch up" time. Therefore, additional evaluation is warranted if you diagnose short stature and you remain concerned after 6 months.

For a child who warrants this additional evaluation, a bone age x-ray is helpful (although not diagnostic of a specific condition). Other recommended studies include a complete blood count; chemistry panel; free thyroxine (free T4) with thyroid stimulating hormone (TSH); insulinlike growth factor 1 (IGF-1), C-reactive protein, urinalysis, and a celiac panel (IgG and IgA class of anti–tissue transglutaminase [anti-tTG]; antiendomysial antibodies, IgA class [EMA-IgA]; and quantitative IgA). In addition, for girls, a karyotype can rule out Turner’s syndrome.

Obtaining the correct test can sometimes be a problem. For example, IGF-1 is similar to many other test names on a laboratory test list. The odds of a lab technician performing the right test are low, because on their alphabetical test list, IGF BP 1 appears at the top (and this test is not useful at all!). This pitfall can be avoided by including the lab specific test code for IGF-1, which your local pediatric endocrinologist can help you find.

Other testing may be warranted, based on history and physical findings. For example, if a child has a history of pneumonia and frequent sinusitis, I would order a sweat chloride test to rule out cystic fibrosis.

If there is no clear explanation, and the slowed growth does not respond to your intervention, refer the patient to a specialist.

The growth chart will help guide the type of referral. If linear growth is poor and weight gain is appropriate (that is, their body mass index is normal), consider referral to a pediatric endocrinologist.

If linear growth is poor, but weight gain is more strikingly affected (that is, BMI is low for age), consider referral instead to a pediatric gastroenterologist.

If testing reveals electrolyte abnormalities, consider referral to pediatric nephrology.

If the child has congenital anomalies or a developmental delay in addition to short stature, then referral to a geneticist becomes appropriate.

Once a short stature diagnosis is established, a targeted approach to optimization of growth can be planned. Human growth hormone therapy, for example, typically is ordered by a pediatric endocrinologist for a number of diagnoses. Indications include growth hormone deficiency, Turner’s syndrome, Noonan’s syndrome, Prader-Willi syndrome, and children born small for gestational age who fail to catch up. A pediatric nephrologist also might prescribe this therapy for a child with renal failure who is not growing.

Dr. Counts is an associate professor of pediatrics and chief of the division of pediatric endocrinology at the University of Maryland, Baltimore. She works on multiple research studies with funding to the University of Maryland, Baltimore, from Eli Lilly, Pfizer, and Novo Nordisk. 

When you assess a patient with a swollen joint, limited range of motion, and/or pain, consider a diagnosis of juvenile idiopathic arthritis.

Start with a detailed history and physical examination. Questions to ask include: How long have the symptoms been present? Was the onset acute or gradual? What is its severity? Ask the patient to rate the severity of pain. Use a 0-10 rating scale in older children and a faces scale in younger kids. Remember that not all children with oligoarticular juvenile idiopathic arthritis (JIA) experience pain.

Is there interference with school or any other activities? Are the symptoms improving or getting worse?

Also inquire about diurnal variation: Are symptoms more problematic in the morning or evening? Stiffness in the morning or following prolonged inactivity is a classic sign of arthritis in children as well as in adults. Also, what medications or other strategies has the patient tried, and how successful where they?

Inquire about associated symptoms. Fever, cutaneous eruption, weight loss, abdominal pain, diarrhea, and behavioral or visual changes are examples. Ocular inflammation is a common feature of some of the subtypes of juvenile arthritis.

Ask the patient or family about a history of trauma to rule out a fracture or significant intraarticular injury. Keep in mind that even chronic swelling of a joint sometimes may be an orthopedic issue.

One diagnosis you don’t want to miss is malignancy. You think automatically about arthritis when a child presents with joint pain, but all pediatric rheumatologists see a few children each year who turn out to have cancer instead. So be sure that pain truly is localized to the joint, and it’s not bone pain which may reflect the presence of leukemia, lymphoma, or another malignancy.

Remember arthritis is not always the primary disorder. During the initial evaluation you might see a child with inflammation of two of three joints. If you don’t ask about recurrent abdominal pain and/or low-grade fever, you may miss the fact that their arthritis is part of inflammatory bowel disease. If you have any questions about the primary vs. secondary nature of a child’s arthritis, refer the patient to a pediatric rheumatologist for further evaluation. The differential diagnosis for juvenile idiopathic arthritis (now the preferred name replacing "juvenile rheumatoid arthritis") can be lengthy.

Once a diagnosis of JIA is confirmed, a pediatric rheumatologist is best qualified to oversee ongoing care of the patient. Compared with 20 years ago, there are now a great many new agents specifically tailored to treat JIA (particularly biologics), and these medications require that those familiar with dosing schedules and side effects direct their administration. A medication that works well for one subtype of JIA may not work as well for another.

Physical and occupational therapists are critical for a successful approach to children with chronic arthritis. Their involvement helps to maintain range of motion, muscle strength, and endurance while preventing joint contractures and abnormalities of bone growth. The overall goal is to "mainstream" children back to their usual activities. However, if they participated in rugby, ice hockey, or tackle football, we will try to steer these patients to activities with a lower potential for direct trauma. We don’t want a child to be isolated from their peers.

It also is important not to overtest children with suspected arthritis. Laboratory testing is indicated if you strongly suspect an inflammatory process rather than for a child with vague aches and pains. Appropriate initial assays often include a complete blood count, urinalysis, sedimentation rate, and measurement of the C-reactive protein.

Tests such as an ANA (antinuclear antibody) and rheumatoid factor should be reserved for those children with symptoms and signs more likely to be associated with an inflammatory condition. These tests may be misleading with frequent false-positive results that cause undue anxiety for the patient and their family.

For more information on when to refer your patient, see the American College of Rheumatology’s 2010 Guidelines for the Referral of Children and Adolescents to Pediatric Rheumatologists.

Dr. Goldsmith is professor of pediatrics at Drexel University and chief of the rheumatology section at St. Christopher’s Hospital for Children, both in Philadelphia. Dr. Goldsmith said that he has no relevant financial disclosures.

This column, "Subspecialist Consult," appears regularly in Pediatric News, a publication of Elsevier.

When you assess a patient with a swollen joint, limited range of motion, and/or pain, consider a diagnosis of juvenile idiopathic arthritis.

Start with a detailed history and physical examination. Questions to ask include: How long have the symptoms been present? Was the onset acute or gradual? What is its severity? Ask the patient to rate the severity of pain. Use a 0-10 rating scale in older children and a faces scale in younger kids. Remember that not all children with oligoarticular juvenile idiopathic arthritis (JIA) experience pain.

Is there interference with school or any other activities? Are the symptoms improving or getting worse?

Also inquire about diurnal variation: Are symptoms more problematic in the morning or evening? Stiffness in the morning or following prolonged inactivity is a classic sign of arthritis in children as well as in adults. Also, what medications or other strategies has the patient tried, and how successful where they?

Inquire about associated symptoms. Fever, cutaneous eruption, weight loss, abdominal pain, diarrhea, and behavioral or visual changes are examples. Ocular inflammation is a common feature of some of the subtypes of juvenile arthritis.

Ask the patient or family about a history of trauma to rule out a fracture or significant intraarticular injury. Keep in mind that even chronic swelling of a joint sometimes may be an orthopedic issue.

One diagnosis you don’t want to miss is malignancy. You think automatically about arthritis when a child presents with joint pain, but all pediatric rheumatologists see a few children each year who turn out to have cancer instead. So be sure that pain truly is localized to the joint, and it’s not bone pain which may reflect the presence of leukemia, lymphoma, or another malignancy.

Remember arthritis is not always the primary disorder. During the initial evaluation you might see a child with inflammation of two of three joints. If you don’t ask about recurrent abdominal pain and/or low-grade fever, you may miss the fact that their arthritis is part of inflammatory bowel disease. If you have any questions about the primary vs. secondary nature of a child’s arthritis, refer the patient to a pediatric rheumatologist for further evaluation. The differential diagnosis for juvenile idiopathic arthritis (now the preferred name replacing "juvenile rheumatoid arthritis") can be lengthy.

Once a diagnosis of JIA is confirmed, a pediatric rheumatologist is best qualified to oversee ongoing care of the patient. Compared with 20 years ago, there are now a great many new agents specifically tailored to treat JIA (particularly biologics), and these medications require that those familiar with dosing schedules and side effects direct their administration. A medication that works well for one subtype of JIA may not work as well for another.

Physical and occupational therapists are critical for a successful approach to children with chronic arthritis. Their involvement helps to maintain range of motion, muscle strength, and endurance while preventing joint contractures and abnormalities of bone growth. The overall goal is to "mainstream" children back to their usual activities. However, if they participated in rugby, ice hockey, or tackle football, we will try to steer these patients to activities with a lower potential for direct trauma. We don’t want a child to be isolated from their peers.

It also is important not to overtest children with suspected arthritis. Laboratory testing is indicated if you strongly suspect an inflammatory process rather than for a child with vague aches and pains. Appropriate initial assays often include a complete blood count, urinalysis, sedimentation rate, and measurement of the C-reactive protein.

Tests such as an ANA (antinuclear antibody) and rheumatoid factor should be reserved for those children with symptoms and signs more likely to be associated with an inflammatory condition. These tests may be misleading with frequent false-positive results that cause undue anxiety for the patient and their family.

For more information on when to refer your patient, see the American College of Rheumatology’s 2010 Guidelines for the Referral of Children and Adolescents to Pediatric Rheumatologists.

Dr. Goldsmith is professor of pediatrics at Drexel University and chief of the rheumatology section at St. Christopher’s Hospital for Children, both in Philadelphia. Dr. Goldsmith said that he has no relevant financial disclosures.

This column, "Subspecialist Consult," appears regularly in Pediatric News, a publication of Elsevier.

When you assess a patient with a swollen joint, limited range of motion, and/or pain, consider a diagnosis of juvenile idiopathic arthritis.

Start with a detailed history and physical examination. Questions to ask include: How long have the symptoms been present? Was the onset acute or gradual? What is its severity? Ask the patient to rate the severity of pain. Use a 0-10 rating scale in older children and a faces scale in younger kids. Remember that not all children with oligoarticular juvenile idiopathic arthritis (JIA) experience pain.

Is there interference with school or any other activities? Are the symptoms improving or getting worse?

Also inquire about diurnal variation: Are symptoms more problematic in the morning or evening? Stiffness in the morning or following prolonged inactivity is a classic sign of arthritis in children as well as in adults. Also, what medications or other strategies has the patient tried, and how successful where they?

Inquire about associated symptoms. Fever, cutaneous eruption, weight loss, abdominal pain, diarrhea, and behavioral or visual changes are examples. Ocular inflammation is a common feature of some of the subtypes of juvenile arthritis.

Ask the patient or family about a history of trauma to rule out a fracture or significant intraarticular injury. Keep in mind that even chronic swelling of a joint sometimes may be an orthopedic issue.

One diagnosis you don’t want to miss is malignancy. You think automatically about arthritis when a child presents with joint pain, but all pediatric rheumatologists see a few children each year who turn out to have cancer instead. So be sure that pain truly is localized to the joint, and it’s not bone pain which may reflect the presence of leukemia, lymphoma, or another malignancy.

Remember arthritis is not always the primary disorder. During the initial evaluation you might see a child with inflammation of two of three joints. If you don’t ask about recurrent abdominal pain and/or low-grade fever, you may miss the fact that their arthritis is part of inflammatory bowel disease. If you have any questions about the primary vs. secondary nature of a child’s arthritis, refer the patient to a pediatric rheumatologist for further evaluation. The differential diagnosis for juvenile idiopathic arthritis (now the preferred name replacing "juvenile rheumatoid arthritis") can be lengthy.

Once a diagnosis of JIA is confirmed, a pediatric rheumatologist is best qualified to oversee ongoing care of the patient. Compared with 20 years ago, there are now a great many new agents specifically tailored to treat JIA (particularly biologics), and these medications require that those familiar with dosing schedules and side effects direct their administration. A medication that works well for one subtype of JIA may not work as well for another.

Physical and occupational therapists are critical for a successful approach to children with chronic arthritis. Their involvement helps to maintain range of motion, muscle strength, and endurance while preventing joint contractures and abnormalities of bone growth. The overall goal is to "mainstream" children back to their usual activities. However, if they participated in rugby, ice hockey, or tackle football, we will try to steer these patients to activities with a lower potential for direct trauma. We don’t want a child to be isolated from their peers.

It also is important not to overtest children with suspected arthritis. Laboratory testing is indicated if you strongly suspect an inflammatory process rather than for a child with vague aches and pains. Appropriate initial assays often include a complete blood count, urinalysis, sedimentation rate, and measurement of the C-reactive protein.

Tests such as an ANA (antinuclear antibody) and rheumatoid factor should be reserved for those children with symptoms and signs more likely to be associated with an inflammatory condition. These tests may be misleading with frequent false-positive results that cause undue anxiety for the patient and their family.

For more information on when to refer your patient, see the American College of Rheumatology’s 2010 Guidelines for the Referral of Children and Adolescents to Pediatric Rheumatologists.

Dr. Goldsmith is professor of pediatrics at Drexel University and chief of the rheumatology section at St. Christopher’s Hospital for Children, both in Philadelphia. Dr. Goldsmith said that he has no relevant financial disclosures.

This column, "Subspecialist Consult," appears regularly in Pediatric News, a publication of Elsevier.

As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.

Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.

Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.

Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.

The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.

Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.

Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.

An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.

Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.

Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.

Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.

As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.

If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.

Infants, children, or adolescents with severe, recalcitrant, or scarring acne should be referred to a specialist for more aggressive intervention. For adolescents with nodulocystic acne (severe acne characterized by inflammation, nodular breakouts, and cysts), early intervention with systemic therapies, including isotretinoin, is important to prevent scarring. Also refer patients to dermatologic surgeons for further evaluation and management if their acne causes them psychological distress, whether or not their clinical presentation is severe.

Dr. Sikora is a private practice dermatologist in Chestnut Hill, Mass., and a member of many professional organizations, including the American Society for Dermatologic Surgery (www.ASDS.net) and the American Academy of Dermatology. Dr. Sikora said she had no relevant financial disclosures.

As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.

Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.

Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.

Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.

The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.

Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.

Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.

An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.

Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.

Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.

Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.

As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.

If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.

Infants, children, or adolescents with severe, recalcitrant, or scarring acne should be referred to a specialist for more aggressive intervention. For adolescents with nodulocystic acne (severe acne characterized by inflammation, nodular breakouts, and cysts), early intervention with systemic therapies, including isotretinoin, is important to prevent scarring. Also refer patients to dermatologic surgeons for further evaluation and management if their acne causes them psychological distress, whether or not their clinical presentation is severe.

Dr. Sikora is a private practice dermatologist in Chestnut Hill, Mass., and a member of many professional organizations, including the American Society for Dermatologic Surgery (www.ASDS.net) and the American Academy of Dermatology. Dr. Sikora said she had no relevant financial disclosures.

As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.

Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.

Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.

Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.

The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.

Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.

Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.

An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.

Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.

Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.

Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.

As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.

If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.

Infants, children, or adolescents with severe, recalcitrant, or scarring acne should be referred to a specialist for more aggressive intervention. For adolescents with nodulocystic acne (severe acne characterized by inflammation, nodular breakouts, and cysts), early intervention with systemic therapies, including isotretinoin, is important to prevent scarring. Also refer patients to dermatologic surgeons for further evaluation and management if their acne causes them psychological distress, whether or not their clinical presentation is severe.

Dr. Sikora is a private practice dermatologist in Chestnut Hill, Mass., and a member of many professional organizations, including the American Society for Dermatologic Surgery (www.ASDS.net) and the American Academy of Dermatology. Dr. Sikora said she had no relevant financial disclosures.

Fainting in children most often is benign. Often from a history alone, you can determine critical information that will enable you to reassure the patient and family or to consider referral for a specialist evaluation.

The most important thing to determine is the course of events that preceded the syncopal event. That is, if the child just completed a sporting activity on a hot day, was in a hot shower, had a high fever, or was dehydrated before fainting, the level of anxiety about the event should be very low. The same applies if the syncope was triggered by a sudden fright or other strong emotional event.

If the child is old enough to provide a good description of the event, ask if they “knew” that something was about to happen before they fainted. Most patients with routine syncope report an “aura” that includes visual changes (tunnel vision or vision getting dark, for example) and dizziness. Also, witnesses will say that the child “woke up” quickly and without prolonged confusion after the event. Such a description helps to distinguish a simple syncopal event from a seizure or a life-threatening arrhythmia.

With most benign cases of syncope, the pediatrician should counsel the child and the parents about adequate hydration before participation in sports and to be mindful of getting enough salt in the diet.

A normal history and physical examination should reassure you. In most cases, these normal findings will mean that you can treat the child in your office without further referrals.

Don't forget to take the child's blood pressure. Low resting blood pressure, especially in rapidly growing teenagers, can predispose your patients to vasovagal syncope. Patients with low resting blood pressure often have a lower threshold for syncope, compared with children with normal pressure. Recommend addition of some salt to the patient's diet if he has low blood pressure – this can help to reduce the risk of future syncope.

Injury prevention is important, because children who experience syncope often fall unexpectedly. The best strategy to minimize this risk is to review the symptoms that herald the onset of syncope with each patient. Then instruct the child if she experiences any of the warning signs to get to the floor with her legs elevated as soon as possible. This also will reduce the severity and the length of the episode.

Patients and parents will naturally have questions after the child experiences syncope. Although noncardiac conditions such as hypothyroidism or epilepsy can cause a child to faint, fainting is usually a failure of the heart to pump enough blood to the brain. Syncope can result from low blood pressure (dehydration, vasodilation), poor pumping function of the heart, other structural heart issues, and/or from a change in the rhythm that leads to less-efficient pumping. Rhythm changes include both fast and slow heart rates.

In the absence of any structural or electrical abnormality of the heart, the most common reason for fainting is vasovagal syncope. There are two sets of nerves that connect the central nervous system to the heart. The sympathetic system sends the “speed up” signal to the heart and the vagus nerve sends the “slow-down” signal to the heart. Vasovagal syncope occurs when the body sends an erroneous signal to the heart to slow down, insufficient blood is pumped, blood pressure falls, and the child faints.

During a syncopal work-up, most important structural heart issues, which can cause fainting, will be obvious on a physical examination. In almost all cases, children with cardiac disease significant enough to cause syncope will have been diagnosed previously. The exam can feature significant cardiac murmurs, peripheral edema, chest pain, jugular venous distension, hepatomegaly, and absent or diminished pulses. Patients with significant congenital heart disease most often will present with shortness of breath on exertion. If you rule out these findings and the patient has a normal examination, you can be virtually certain that the event is not related to a structural heart problem.

If there is any doubt, an echocardiogram is the definitive test to rule out a subtle structural abnormality. Hypertrophic cardiomyopathies and coronary anomalies are among the conditions that may contribute to syncope and may only be detectable with specialized cardiac imaging.

The child with recurrent syncopal events or with an atypical history most often requires additional evaluation by a specialist, usually to reassure the family. When I see a patient for the first time, I take a thorough history and order an ECG to detect the most common electrical/arrhythmic reasons for syncope. A diagnosis of Wolff-Parkinson-White syndrome, heart block, and long QT syndrome can easily be identified from a routine ECG. Holter evaluations or 30-day home monitoring may be helpful in ruling out arrhythmias. Neurologic evaluation can be helpful to rule out seizure activity which may masquerade as syncope. Rarely, in teenagers and adults, atypical migraine headaches may present with alterations of consciousness. In these patients, there is often a strong family history of migraine. When these episodes recur, they are similar each time, as is stereotypical of other migraine aura.

Fainting in children most often is benign. Often from a history alone, you can determine critical information that will enable you to reassure the patient and family or to consider referral for a specialist evaluation.

The most important thing to determine is the course of events that preceded the syncopal event. That is, if the child just completed a sporting activity on a hot day, was in a hot shower, had a high fever, or was dehydrated before fainting, the level of anxiety about the event should be very low. The same applies if the syncope was triggered by a sudden fright or other strong emotional event.

If the child is old enough to provide a good description of the event, ask if they “knew” that something was about to happen before they fainted. Most patients with routine syncope report an “aura” that includes visual changes (tunnel vision or vision getting dark, for example) and dizziness. Also, witnesses will say that the child “woke up” quickly and without prolonged confusion after the event. Such a description helps to distinguish a simple syncopal event from a seizure or a life-threatening arrhythmia.

With most benign cases of syncope, the pediatrician should counsel the child and the parents about adequate hydration before participation in sports and to be mindful of getting enough salt in the diet.

A normal history and physical examination should reassure you. In most cases, these normal findings will mean that you can treat the child in your office without further referrals.

Don't forget to take the child's blood pressure. Low resting blood pressure, especially in rapidly growing teenagers, can predispose your patients to vasovagal syncope. Patients with low resting blood pressure often have a lower threshold for syncope, compared with children with normal pressure. Recommend addition of some salt to the patient's diet if he has low blood pressure – this can help to reduce the risk of future syncope.

Injury prevention is important, because children who experience syncope often fall unexpectedly. The best strategy to minimize this risk is to review the symptoms that herald the onset of syncope with each patient. Then instruct the child if she experiences any of the warning signs to get to the floor with her legs elevated as soon as possible. This also will reduce the severity and the length of the episode.

Patients and parents will naturally have questions after the child experiences syncope. Although noncardiac conditions such as hypothyroidism or epilepsy can cause a child to faint, fainting is usually a failure of the heart to pump enough blood to the brain. Syncope can result from low blood pressure (dehydration, vasodilation), poor pumping function of the heart, other structural heart issues, and/or from a change in the rhythm that leads to less-efficient pumping. Rhythm changes include both fast and slow heart rates.

In the absence of any structural or electrical abnormality of the heart, the most common reason for fainting is vasovagal syncope. There are two sets of nerves that connect the central nervous system to the heart. The sympathetic system sends the “speed up” signal to the heart and the vagus nerve sends the “slow-down” signal to the heart. Vasovagal syncope occurs when the body sends an erroneous signal to the heart to slow down, insufficient blood is pumped, blood pressure falls, and the child faints.

During a syncopal work-up, most important structural heart issues, which can cause fainting, will be obvious on a physical examination. In almost all cases, children with cardiac disease significant enough to cause syncope will have been diagnosed previously. The exam can feature significant cardiac murmurs, peripheral edema, chest pain, jugular venous distension, hepatomegaly, and absent or diminished pulses. Patients with significant congenital heart disease most often will present with shortness of breath on exertion. If you rule out these findings and the patient has a normal examination, you can be virtually certain that the event is not related to a structural heart problem.

If there is any doubt, an echocardiogram is the definitive test to rule out a subtle structural abnormality. Hypertrophic cardiomyopathies and coronary anomalies are among the conditions that may contribute to syncope and may only be detectable with specialized cardiac imaging.

The child with recurrent syncopal events or with an atypical history most often requires additional evaluation by a specialist, usually to reassure the family. When I see a patient for the first time, I take a thorough history and order an ECG to detect the most common electrical/arrhythmic reasons for syncope. A diagnosis of Wolff-Parkinson-White syndrome, heart block, and long QT syndrome can easily be identified from a routine ECG. Holter evaluations or 30-day home monitoring may be helpful in ruling out arrhythmias. Neurologic evaluation can be helpful to rule out seizure activity which may masquerade as syncope. Rarely, in teenagers and adults, atypical migraine headaches may present with alterations of consciousness. In these patients, there is often a strong family history of migraine. When these episodes recur, they are similar each time, as is stereotypical of other migraine aura.

Fainting in children most often is benign. Often from a history alone, you can determine critical information that will enable you to reassure the patient and family or to consider referral for a specialist evaluation.

The most important thing to determine is the course of events that preceded the syncopal event. That is, if the child just completed a sporting activity on a hot day, was in a hot shower, had a high fever, or was dehydrated before fainting, the level of anxiety about the event should be very low. The same applies if the syncope was triggered by a sudden fright or other strong emotional event.

If the child is old enough to provide a good description of the event, ask if they “knew” that something was about to happen before they fainted. Most patients with routine syncope report an “aura” that includes visual changes (tunnel vision or vision getting dark, for example) and dizziness. Also, witnesses will say that the child “woke up” quickly and without prolonged confusion after the event. Such a description helps to distinguish a simple syncopal event from a seizure or a life-threatening arrhythmia.

With most benign cases of syncope, the pediatrician should counsel the child and the parents about adequate hydration before participation in sports and to be mindful of getting enough salt in the diet.

A normal history and physical examination should reassure you. In most cases, these normal findings will mean that you can treat the child in your office without further referrals.

Don't forget to take the child's blood pressure. Low resting blood pressure, especially in rapidly growing teenagers, can predispose your patients to vasovagal syncope. Patients with low resting blood pressure often have a lower threshold for syncope, compared with children with normal pressure. Recommend addition of some salt to the patient's diet if he has low blood pressure – this can help to reduce the risk of future syncope.

Injury prevention is important, because children who experience syncope often fall unexpectedly. The best strategy to minimize this risk is to review the symptoms that herald the onset of syncope with each patient. Then instruct the child if she experiences any of the warning signs to get to the floor with her legs elevated as soon as possible. This also will reduce the severity and the length of the episode.

Patients and parents will naturally have questions after the child experiences syncope. Although noncardiac conditions such as hypothyroidism or epilepsy can cause a child to faint, fainting is usually a failure of the heart to pump enough blood to the brain. Syncope can result from low blood pressure (dehydration, vasodilation), poor pumping function of the heart, other structural heart issues, and/or from a change in the rhythm that leads to less-efficient pumping. Rhythm changes include both fast and slow heart rates.

In the absence of any structural or electrical abnormality of the heart, the most common reason for fainting is vasovagal syncope. There are two sets of nerves that connect the central nervous system to the heart. The sympathetic system sends the “speed up” signal to the heart and the vagus nerve sends the “slow-down” signal to the heart. Vasovagal syncope occurs when the body sends an erroneous signal to the heart to slow down, insufficient blood is pumped, blood pressure falls, and the child faints.

During a syncopal work-up, most important structural heart issues, which can cause fainting, will be obvious on a physical examination. In almost all cases, children with cardiac disease significant enough to cause syncope will have been diagnosed previously. The exam can feature significant cardiac murmurs, peripheral edema, chest pain, jugular venous distension, hepatomegaly, and absent or diminished pulses. Patients with significant congenital heart disease most often will present with shortness of breath on exertion. If you rule out these findings and the patient has a normal examination, you can be virtually certain that the event is not related to a structural heart problem.

If there is any doubt, an echocardiogram is the definitive test to rule out a subtle structural abnormality. Hypertrophic cardiomyopathies and coronary anomalies are among the conditions that may contribute to syncope and may only be detectable with specialized cardiac imaging.

The child with recurrent syncopal events or with an atypical history most often requires additional evaluation by a specialist, usually to reassure the family. When I see a patient for the first time, I take a thorough history and order an ECG to detect the most common electrical/arrhythmic reasons for syncope. A diagnosis of Wolff-Parkinson-White syndrome, heart block, and long QT syndrome can easily be identified from a routine ECG. Holter evaluations or 30-day home monitoring may be helpful in ruling out arrhythmias. Neurologic evaluation can be helpful to rule out seizure activity which may masquerade as syncope. Rarely, in teenagers and adults, atypical migraine headaches may present with alterations of consciousness. In these patients, there is often a strong family history of migraine. When these episodes recur, they are similar each time, as is stereotypical of other migraine aura.

All 50 states require newborn screening for cystic fibrosis, and pediatricians play an important role when a newborn is diagnosed. The positive screens from your state laboratory will include referral options for confirmatory testing and specialty care at an accredited Cystic Fibrosis Center or CF center affiliate in your area. Pediatricians remain the patient's “medical home,” help to coordinate this specialty care, and remain in close communication with the patient, families, and specialists at a CF center as these children grow.

Optimal outcomes come from assessment and treatment by a multidisciplinary team at an accredited CF center. Encourage your CF patient and families to be seen there regularly. You want those specialists on board to help you take optimal care of the child. Monitoring at least every 3 months is recommended and is called “expectant” or “proactive management” for an individual with CF. A more thorough assessment occurs at least annually.

Pediatricians are essential, in particular, when patients live far from a CF center. We have patients who live a 3-hour drive from our center at the University of Chicago. In some states, patients may live hundreds of miles from a center and can be seen for specialty care only once per year.

There are some specialist outreach efforts as well for children who live in extremely remote, rural areas: Clinicians in Seattle fly to Anchorage, Alaska, to monitor and treat children with CF.

If a sick child with CF comes as a new patient to your office and the records are not available, you should always feel free to call the closest CF center to speak to one of the specialists there and eventually refer them for care. Physicians at CF centers work in collaboration with primary care physicians who are the “go to” professionals, often treating other members of a CF child's family.

Consultation and referral are important. Pediatricians tend to be very, very busy and see 20-40 patients a day in their office for a wide range of indications, including earaches, stomach aches, and well-child exams. But if you are taking care of a sick child with CF who is just not getting better with antibiotic or other treatment, definitely communicate with a CF care provider.

Many pediatricians we know well in the Chicago area will call us up and say, “I have so-and-so in my office. They are coughing a little bit more. I know you sent a letter before saying I should try this particular antibiotic. Is there anything else I should do at this point?” They stay in close touch, and we always have a center physician or nurse available to speak with them.

Regular assessment by a pediatric pulmonologist is part of the CF center care. If a child has an increased cough and they have certain bacteria such as Pseudomonas, we aggressively treat them so they don't get worse. We monitor lung function and obtain frequent respiratory cultures.

In addition, up to 90% of these children and adolescents develop digestive problems and may benefit from consultation with a gastroenterologist. Some patients develop sinus-related problems and referral to an ENT may be warranted. Accredited centers are required to provide these specialists, as well as dieticians, social workers, and respiratory therapists, who are experienced and knowledgeable about CF and who are involved in providing a care plan for children with CF.

Pediatricians play an important role in the facilitation of regular testing of children and adolescents with cystic fibrosis. At a minimum of once a year, they require blood work and chest x-rays. Many patients do their annual visits in the summer because testing takes almost a whole day. The lab work and chest x-ray copy (on a CD) can then be brought to CF physicians on the day of that “annual” visit. Depending on the patient's insurance, it may be less expensive and more convenient for the family for the pediatrician to coordinate this annual testing at the local community hospital. Lung function testing typically needs to be done at the center.

We also now do an oral glucose tolerance test for CF-related diabetes in any patient older than 10 years. That often can be done locally as well. Patients with CF may develop a specific type of diabetes. Most patients with CF have pancreatic insufficiency, which results in problems with digestion and the need to take medication (pancreatic enzymes) with every meal. Over time, scarring of the pancreas results and insufficient insulin may be produced.

The Cystic Fibrosis Foundation, which approves and accredits CF centers, is a great source of information for patients and families. Advise parents to visit www.cff.org

All 50 states require newborn screening for cystic fibrosis, and pediatricians play an important role when a newborn is diagnosed. The positive screens from your state laboratory will include referral options for confirmatory testing and specialty care at an accredited Cystic Fibrosis Center or CF center affiliate in your area. Pediatricians remain the patient's “medical home,” help to coordinate this specialty care, and remain in close communication with the patient, families, and specialists at a CF center as these children grow.

Optimal outcomes come from assessment and treatment by a multidisciplinary team at an accredited CF center. Encourage your CF patient and families to be seen there regularly. You want those specialists on board to help you take optimal care of the child. Monitoring at least every 3 months is recommended and is called “expectant” or “proactive management” for an individual with CF. A more thorough assessment occurs at least annually.

Pediatricians are essential, in particular, when patients live far from a CF center. We have patients who live a 3-hour drive from our center at the University of Chicago. In some states, patients may live hundreds of miles from a center and can be seen for specialty care only once per year.

There are some specialist outreach efforts as well for children who live in extremely remote, rural areas: Clinicians in Seattle fly to Anchorage, Alaska, to monitor and treat children with CF.

If a sick child with CF comes as a new patient to your office and the records are not available, you should always feel free to call the closest CF center to speak to one of the specialists there and eventually refer them for care. Physicians at CF centers work in collaboration with primary care physicians who are the “go to” professionals, often treating other members of a CF child's family.

Consultation and referral are important. Pediatricians tend to be very, very busy and see 20-40 patients a day in their office for a wide range of indications, including earaches, stomach aches, and well-child exams. But if you are taking care of a sick child with CF who is just not getting better with antibiotic or other treatment, definitely communicate with a CF care provider.

Many pediatricians we know well in the Chicago area will call us up and say, “I have so-and-so in my office. They are coughing a little bit more. I know you sent a letter before saying I should try this particular antibiotic. Is there anything else I should do at this point?” They stay in close touch, and we always have a center physician or nurse available to speak with them.

Regular assessment by a pediatric pulmonologist is part of the CF center care. If a child has an increased cough and they have certain bacteria such as Pseudomonas, we aggressively treat them so they don't get worse. We monitor lung function and obtain frequent respiratory cultures.

In addition, up to 90% of these children and adolescents develop digestive problems and may benefit from consultation with a gastroenterologist. Some patients develop sinus-related problems and referral to an ENT may be warranted. Accredited centers are required to provide these specialists, as well as dieticians, social workers, and respiratory therapists, who are experienced and knowledgeable about CF and who are involved in providing a care plan for children with CF.

Pediatricians play an important role in the facilitation of regular testing of children and adolescents with cystic fibrosis. At a minimum of once a year, they require blood work and chest x-rays. Many patients do their annual visits in the summer because testing takes almost a whole day. The lab work and chest x-ray copy (on a CD) can then be brought to CF physicians on the day of that “annual” visit. Depending on the patient's insurance, it may be less expensive and more convenient for the family for the pediatrician to coordinate this annual testing at the local community hospital. Lung function testing typically needs to be done at the center.

We also now do an oral glucose tolerance test for CF-related diabetes in any patient older than 10 years. That often can be done locally as well. Patients with CF may develop a specific type of diabetes. Most patients with CF have pancreatic insufficiency, which results in problems with digestion and the need to take medication (pancreatic enzymes) with every meal. Over time, scarring of the pancreas results and insufficient insulin may be produced.

The Cystic Fibrosis Foundation, which approves and accredits CF centers, is a great source of information for patients and families. Advise parents to visit www.cff.org

All 50 states require newborn screening for cystic fibrosis, and pediatricians play an important role when a newborn is diagnosed. The positive screens from your state laboratory will include referral options for confirmatory testing and specialty care at an accredited Cystic Fibrosis Center or CF center affiliate in your area. Pediatricians remain the patient's “medical home,” help to coordinate this specialty care, and remain in close communication with the patient, families, and specialists at a CF center as these children grow.

Optimal outcomes come from assessment and treatment by a multidisciplinary team at an accredited CF center. Encourage your CF patient and families to be seen there regularly. You want those specialists on board to help you take optimal care of the child. Monitoring at least every 3 months is recommended and is called “expectant” or “proactive management” for an individual with CF. A more thorough assessment occurs at least annually.

Pediatricians are essential, in particular, when patients live far from a CF center. We have patients who live a 3-hour drive from our center at the University of Chicago. In some states, patients may live hundreds of miles from a center and can be seen for specialty care only once per year.

There are some specialist outreach efforts as well for children who live in extremely remote, rural areas: Clinicians in Seattle fly to Anchorage, Alaska, to monitor and treat children with CF.

If a sick child with CF comes as a new patient to your office and the records are not available, you should always feel free to call the closest CF center to speak to one of the specialists there and eventually refer them for care. Physicians at CF centers work in collaboration with primary care physicians who are the “go to” professionals, often treating other members of a CF child's family.

Consultation and referral are important. Pediatricians tend to be very, very busy and see 20-40 patients a day in their office for a wide range of indications, including earaches, stomach aches, and well-child exams. But if you are taking care of a sick child with CF who is just not getting better with antibiotic or other treatment, definitely communicate with a CF care provider.

Many pediatricians we know well in the Chicago area will call us up and say, “I have so-and-so in my office. They are coughing a little bit more. I know you sent a letter before saying I should try this particular antibiotic. Is there anything else I should do at this point?” They stay in close touch, and we always have a center physician or nurse available to speak with them.

Regular assessment by a pediatric pulmonologist is part of the CF center care. If a child has an increased cough and they have certain bacteria such as Pseudomonas, we aggressively treat them so they don't get worse. We monitor lung function and obtain frequent respiratory cultures.

In addition, up to 90% of these children and adolescents develop digestive problems and may benefit from consultation with a gastroenterologist. Some patients develop sinus-related problems and referral to an ENT may be warranted. Accredited centers are required to provide these specialists, as well as dieticians, social workers, and respiratory therapists, who are experienced and knowledgeable about CF and who are involved in providing a care plan for children with CF.

Pediatricians play an important role in the facilitation of regular testing of children and adolescents with cystic fibrosis. At a minimum of once a year, they require blood work and chest x-rays. Many patients do their annual visits in the summer because testing takes almost a whole day. The lab work and chest x-ray copy (on a CD) can then be brought to CF physicians on the day of that “annual” visit. Depending on the patient's insurance, it may be less expensive and more convenient for the family for the pediatrician to coordinate this annual testing at the local community hospital. Lung function testing typically needs to be done at the center.

We also now do an oral glucose tolerance test for CF-related diabetes in any patient older than 10 years. That often can be done locally as well. Patients with CF may develop a specific type of diabetes. Most patients with CF have pancreatic insufficiency, which results in problems with digestion and the need to take medication (pancreatic enzymes) with every meal. Over time, scarring of the pancreas results and insufficient insulin may be produced.

The Cystic Fibrosis Foundation, which approves and accredits CF centers, is a great source of information for patients and families. Advise parents to visit www.cff.org

Screen for vision concerns at every well-child visit. I recommend a consistent method of screening so you and your staff develop a skill set and yield consistent results. The screening method varies by the age and cooperation of the child, so it is useful to establish protocols for the preverbal child and for an older child who can actively participate in visual acuity testing.

The American Academy of Pediatrics has a wonderful publication with vision screening recommendations for pediatricians. The AAP's policy statement on “Eye Examination and Vision Screening in Infants, Children, and Young Adults” contains consensus-driven information of high value to pediatricians (http://tinyurl.com/3o6papp

Importantly, keep in mind that many children old enough to participate in vision testing often perform poorly on initial testing.

There is a large learning curve, and a child who performs poorly the first time will often do very well on the second test. So it's a good idea to retest before referring a child to a specialist for poor vision.

If the child is cooperative, you can retest during the same visit and save the patient a return trip to your office. If the child fails visual acuity testing twice, that is when I would refer to an eye specialist.

Pediatricians are essentially looking for reduced vision, misalignment of the eye, and any anatomic abnormalities of the eye.

More specifically, you are screening for amblyopia, which can occur in up to 4% of the population; strabismus or eye misalignment; and anatomic concerns including ptosis, abnormal size of the eye, or a white pupil that suggests a cataract or a retinoblastoma.

A positive finding on almost every aspect of screening indicates need for referral of the patient to a specialist.

In contrast, acute abnormalities such as redness of the eye, minor injuries, and allergic conjunctivitis can be managed well in your office.

Keep in mind that failure to respond to initial treatment is an indication for referral. If you treat a child for red eye, for example, and the eye does not improve quickly, referral is warranted. Importantly, it is not usually an indication to change their antibiotic drop or switch them to another treatment. Although most of the time a simple problem may be the culprit, a red eye also can signal a more serious condition.

Referral of any child who screens positive for an eye concern or fails to initially respond to treatment generally requires no additional evaluation in the primary care setting. Just send the child along with a note explaining your concern and outlining any special circumstances that might not emerge on routine history taking with the parents. We'll take it from there.

In addition to the AAP guidelines, I recommend two mnemonics to assist primary care physicians during eye evaluation. A stretched version of MVP, the MVPea mnemonic can guide assessment and ensure that a quick examination is complete:

▸ M stands for motility. Are the eyes straight and do they move normally?

▸ V is vision assessment.

▸ P is pupil assessment. Are the pupils equal, round, and reactive? Do you see an afferent defect (decreased pupillary response to light in the affected eye), or an abnormality such as a white pupil or pupillary asymmetry?

▸ e is external exam. Assess surrounding structures, including the eyelids and eyelashes, for any abnormality.

▸ a is for the anterior segment. Evaluate the cornea, the lens, and other structures.

These are the critical components of a pediatrician's regular eye examination. These steps should take you a very short amount of time.

If you have a particular interest in eye disorders and some practice and skill at ocular examinations, you can consider adding three supplementary components to your assessment. I call these the ophthalmic version of CPR for the pediatrician:

▸ C is for confrontational visual field testing.

▸ P is for pressure.

▸ R is for retina.

Screen for vision concerns at every well-child visit. I recommend a consistent method of screening so you and your staff develop a skill set and yield consistent results. The screening method varies by the age and cooperation of the child, so it is useful to establish protocols for the preverbal child and for an older child who can actively participate in visual acuity testing.

The American Academy of Pediatrics has a wonderful publication with vision screening recommendations for pediatricians. The AAP's policy statement on “Eye Examination and Vision Screening in Infants, Children, and Young Adults” contains consensus-driven information of high value to pediatricians (http://tinyurl.com/3o6papp

Importantly, keep in mind that many children old enough to participate in vision testing often perform poorly on initial testing.

There is a large learning curve, and a child who performs poorly the first time will often do very well on the second test. So it's a good idea to retest before referring a child to a specialist for poor vision.

If the child is cooperative, you can retest during the same visit and save the patient a return trip to your office. If the child fails visual acuity testing twice, that is when I would refer to an eye specialist.

Pediatricians are essentially looking for reduced vision, misalignment of the eye, and any anatomic abnormalities of the eye.

More specifically, you are screening for amblyopia, which can occur in up to 4% of the population; strabismus or eye misalignment; and anatomic concerns including ptosis, abnormal size of the eye, or a white pupil that suggests a cataract or a retinoblastoma.

A positive finding on almost every aspect of screening indicates need for referral of the patient to a specialist.

In contrast, acute abnormalities such as redness of the eye, minor injuries, and allergic conjunctivitis can be managed well in your office.

Keep in mind that failure to respond to initial treatment is an indication for referral. If you treat a child for red eye, for example, and the eye does not improve quickly, referral is warranted. Importantly, it is not usually an indication to change their antibiotic drop or switch them to another treatment. Although most of the time a simple problem may be the culprit, a red eye also can signal a more serious condition.

Referral of any child who screens positive for an eye concern or fails to initially respond to treatment generally requires no additional evaluation in the primary care setting. Just send the child along with a note explaining your concern and outlining any special circumstances that might not emerge on routine history taking with the parents. We'll take it from there.

In addition to the AAP guidelines, I recommend two mnemonics to assist primary care physicians during eye evaluation. A stretched version of MVP, the MVPea mnemonic can guide assessment and ensure that a quick examination is complete:

▸ M stands for motility. Are the eyes straight and do they move normally?

▸ V is vision assessment.

▸ P is pupil assessment. Are the pupils equal, round, and reactive? Do you see an afferent defect (decreased pupillary response to light in the affected eye), or an abnormality such as a white pupil or pupillary asymmetry?

▸ e is external exam. Assess surrounding structures, including the eyelids and eyelashes, for any abnormality.

▸ a is for the anterior segment. Evaluate the cornea, the lens, and other structures.

These are the critical components of a pediatrician's regular eye examination. These steps should take you a very short amount of time.

If you have a particular interest in eye disorders and some practice and skill at ocular examinations, you can consider adding three supplementary components to your assessment. I call these the ophthalmic version of CPR for the pediatrician:

▸ C is for confrontational visual field testing.

▸ P is for pressure.

▸ R is for retina.

Screen for vision concerns at every well-child visit. I recommend a consistent method of screening so you and your staff develop a skill set and yield consistent results. The screening method varies by the age and cooperation of the child, so it is useful to establish protocols for the preverbal child and for an older child who can actively participate in visual acuity testing.

The American Academy of Pediatrics has a wonderful publication with vision screening recommendations for pediatricians. The AAP's policy statement on “Eye Examination and Vision Screening in Infants, Children, and Young Adults” contains consensus-driven information of high value to pediatricians (http://tinyurl.com/3o6papp

Importantly, keep in mind that many children old enough to participate in vision testing often perform poorly on initial testing.

There is a large learning curve, and a child who performs poorly the first time will often do very well on the second test. So it's a good idea to retest before referring a child to a specialist for poor vision.

If the child is cooperative, you can retest during the same visit and save the patient a return trip to your office. If the child fails visual acuity testing twice, that is when I would refer to an eye specialist.

Pediatricians are essentially looking for reduced vision, misalignment of the eye, and any anatomic abnormalities of the eye.

More specifically, you are screening for amblyopia, which can occur in up to 4% of the population; strabismus or eye misalignment; and anatomic concerns including ptosis, abnormal size of the eye, or a white pupil that suggests a cataract or a retinoblastoma.

A positive finding on almost every aspect of screening indicates need for referral of the patient to a specialist.

In contrast, acute abnormalities such as redness of the eye, minor injuries, and allergic conjunctivitis can be managed well in your office.

Keep in mind that failure to respond to initial treatment is an indication for referral. If you treat a child for red eye, for example, and the eye does not improve quickly, referral is warranted. Importantly, it is not usually an indication to change their antibiotic drop or switch them to another treatment. Although most of the time a simple problem may be the culprit, a red eye also can signal a more serious condition.

Referral of any child who screens positive for an eye concern or fails to initially respond to treatment generally requires no additional evaluation in the primary care setting. Just send the child along with a note explaining your concern and outlining any special circumstances that might not emerge on routine history taking with the parents. We'll take it from there.

In addition to the AAP guidelines, I recommend two mnemonics to assist primary care physicians during eye evaluation. A stretched version of MVP, the MVPea mnemonic can guide assessment and ensure that a quick examination is complete:

▸ M stands for motility. Are the eyes straight and do they move normally?

▸ V is vision assessment.

▸ P is pupil assessment. Are the pupils equal, round, and reactive? Do you see an afferent defect (decreased pupillary response to light in the affected eye), or an abnormality such as a white pupil or pupillary asymmetry?

▸ e is external exam. Assess surrounding structures, including the eyelids and eyelashes, for any abnormality.

▸ a is for the anterior segment. Evaluate the cornea, the lens, and other structures.

These are the critical components of a pediatrician's regular eye examination. These steps should take you a very short amount of time.

If you have a particular interest in eye disorders and some practice and skill at ocular examinations, you can consider adding three supplementary components to your assessment. I call these the ophthalmic version of CPR for the pediatrician:

▸ C is for confrontational visual field testing.

▸ P is for pressure.

▸ R is for retina.

Although diagnosis of a bee sting allergy is often straightforward, it's important to go through the history. Ask when the children were stung, what type of reaction they had, and how soon after the sting they experienced symptoms.

A large local reaction can be impressive in size, but it may not be as serious as the child who presents with systemic symptoms such as hives or difficulty breathing.

Immediately direct a child experiencing acute anaphylaxis to emergency care. Acute effects will be seen right away, generally within 15-30 minutes. The parents of a child with a known sensitivity to bee stings, in particular, will know to head to the emergency department right away, especially after self-administration of epinephrine by an autoinjector.

It is more likely that a patient will come to you with a less severe reaction or for advice on how to manage a potential allergy. In general, local reactions are no larger than 10 cm, and you can treat the area with ice or cold compresses in your office. Typical local reactions are a little bump, a local hive, or an indurated area of swelling that is warm or hot.

Take photos of the allergic reaction. This can be very helpful if you later refer the child to a specialist. It helps us immediately see the size and location of the reaction.

Check to see if the stinger is still in place when a flustered child (or parent) comes in right after a bee sting. Although most people remove it immediately, some patients come in with the stinger still in the skin. You want to scrape or brush across the skin with a credit card or coin to remove the stinger. The removal technique is important because honey bees can leave both their stinger and venom sac behind as a last defense. If you just try to pull out the stinger, unintentional squeezing of the venom sac can mean more venom gets injected into the allergic child.

Consider referral to a pediatric allergy specialist if a child has a history of adverse or severe reactions to bee stings. The risk of future severe reactions, including anaphylaxis, will be elevated in a patient who has already spent any time in the emergency department, for example. When you refer, include a list of any local or systemic symptoms and any medications the child is taking.

Each subsequent exposure to bee venom increases the risk of a more severe reaction. One question I always get is: “I've been stung 15 times before. How come this time I developed an anaphylactic reaction?” I explain that a person needs to be stung only once before the body can develop an allergy, and any exposure after that may trigger a serious or life-threatening reaction.

You can perform allergy testing in your primary care office, but the question is what to do with the results. Such testing prior to referral does not tend to help us a lot. We often perform a more comprehensive evaluation. For example, as a general rule I order IgE protein-specific tests for the five common flying insect venoms, because most children cannot tell if a wasp, hornet, or bee stung them.

The good news is that if an individual meets criteria and is treated with immunotherapy or allergy shots, he or she has a success rate of about 98%. Even so, I recommend that a child with a history of bee sting adverse reactions carry an autoinjectable epinephrine device and practice bee avoidance measures.

You can teach children how to stay away from bees. Tell them not to play in or around woods, for example. Make sure they know not to provoke or aggravate any bees they encounter, and that bees are attracted by bright-colored clothing, perfume, and cologne. I tell patients to avoid drinking cans of soda outdoors. Bees attracted to the sweet soda will fly into these cans and, unfortunately, it is not uncommon for people to be very surprised and get stung in the mouth, on the tongue, or on the lips this way.

Although diagnosis of a bee sting allergy is often straightforward, it's important to go through the history. Ask when the children were stung, what type of reaction they had, and how soon after the sting they experienced symptoms.

A large local reaction can be impressive in size, but it may not be as serious as the child who presents with systemic symptoms such as hives or difficulty breathing.

Immediately direct a child experiencing acute anaphylaxis to emergency care. Acute effects will be seen right away, generally within 15-30 minutes. The parents of a child with a known sensitivity to bee stings, in particular, will know to head to the emergency department right away, especially after self-administration of epinephrine by an autoinjector.

It is more likely that a patient will come to you with a less severe reaction or for advice on how to manage a potential allergy. In general, local reactions are no larger than 10 cm, and you can treat the area with ice or cold compresses in your office. Typical local reactions are a little bump, a local hive, or an indurated area of swelling that is warm or hot.

Take photos of the allergic reaction. This can be very helpful if you later refer the child to a specialist. It helps us immediately see the size and location of the reaction.

Check to see if the stinger is still in place when a flustered child (or parent) comes in right after a bee sting. Although most people remove it immediately, some patients come in with the stinger still in the skin. You want to scrape or brush across the skin with a credit card or coin to remove the stinger. The removal technique is important because honey bees can leave both their stinger and venom sac behind as a last defense. If you just try to pull out the stinger, unintentional squeezing of the venom sac can mean more venom gets injected into the allergic child.

Consider referral to a pediatric allergy specialist if a child has a history of adverse or severe reactions to bee stings. The risk of future severe reactions, including anaphylaxis, will be elevated in a patient who has already spent any time in the emergency department, for example. When you refer, include a list of any local or systemic symptoms and any medications the child is taking.

Each subsequent exposure to bee venom increases the risk of a more severe reaction. One question I always get is: “I've been stung 15 times before. How come this time I developed an anaphylactic reaction?” I explain that a person needs to be stung only once before the body can develop an allergy, and any exposure after that may trigger a serious or life-threatening reaction.

You can perform allergy testing in your primary care office, but the question is what to do with the results. Such testing prior to referral does not tend to help us a lot. We often perform a more comprehensive evaluation. For example, as a general rule I order IgE protein-specific tests for the five common flying insect venoms, because most children cannot tell if a wasp, hornet, or bee stung them.

The good news is that if an individual meets criteria and is treated with immunotherapy or allergy shots, he or she has a success rate of about 98%. Even so, I recommend that a child with a history of bee sting adverse reactions carry an autoinjectable epinephrine device and practice bee avoidance measures.

You can teach children how to stay away from bees. Tell them not to play in or around woods, for example. Make sure they know not to provoke or aggravate any bees they encounter, and that bees are attracted by bright-colored clothing, perfume, and cologne. I tell patients to avoid drinking cans of soda outdoors. Bees attracted to the sweet soda will fly into these cans and, unfortunately, it is not uncommon for people to be very surprised and get stung in the mouth, on the tongue, or on the lips this way.

Although diagnosis of a bee sting allergy is often straightforward, it's important to go through the history. Ask when the children were stung, what type of reaction they had, and how soon after the sting they experienced symptoms.

A large local reaction can be impressive in size, but it may not be as serious as the child who presents with systemic symptoms such as hives or difficulty breathing.

Immediately direct a child experiencing acute anaphylaxis to emergency care. Acute effects will be seen right away, generally within 15-30 minutes. The parents of a child with a known sensitivity to bee stings, in particular, will know to head to the emergency department right away, especially after self-administration of epinephrine by an autoinjector.

It is more likely that a patient will come to you with a less severe reaction or for advice on how to manage a potential allergy. In general, local reactions are no larger than 10 cm, and you can treat the area with ice or cold compresses in your office. Typical local reactions are a little bump, a local hive, or an indurated area of swelling that is warm or hot.

Take photos of the allergic reaction. This can be very helpful if you later refer the child to a specialist. It helps us immediately see the size and location of the reaction.

Check to see if the stinger is still in place when a flustered child (or parent) comes in right after a bee sting. Although most people remove it immediately, some patients come in with the stinger still in the skin. You want to scrape or brush across the skin with a credit card or coin to remove the stinger. The removal technique is important because honey bees can leave both their stinger and venom sac behind as a last defense. If you just try to pull out the stinger, unintentional squeezing of the venom sac can mean more venom gets injected into the allergic child.

Consider referral to a pediatric allergy specialist if a child has a history of adverse or severe reactions to bee stings. The risk of future severe reactions, including anaphylaxis, will be elevated in a patient who has already spent any time in the emergency department, for example. When you refer, include a list of any local or systemic symptoms and any medications the child is taking.

Each subsequent exposure to bee venom increases the risk of a more severe reaction. One question I always get is: “I've been stung 15 times before. How come this time I developed an anaphylactic reaction?” I explain that a person needs to be stung only once before the body can develop an allergy, and any exposure after that may trigger a serious or life-threatening reaction.

You can perform allergy testing in your primary care office, but the question is what to do with the results. Such testing prior to referral does not tend to help us a lot. We often perform a more comprehensive evaluation. For example, as a general rule I order IgE protein-specific tests for the five common flying insect venoms, because most children cannot tell if a wasp, hornet, or bee stung them.

The good news is that if an individual meets criteria and is treated with immunotherapy or allergy shots, he or she has a success rate of about 98%. Even so, I recommend that a child with a history of bee sting adverse reactions carry an autoinjectable epinephrine device and practice bee avoidance measures.

You can teach children how to stay away from bees. Tell them not to play in or around woods, for example. Make sure they know not to provoke or aggravate any bees they encounter, and that bees are attracted by bright-colored clothing, perfume, and cologne. I tell patients to avoid drinking cans of soda outdoors. Bees attracted to the sweet soda will fly into these cans and, unfortunately, it is not uncommon for people to be very surprised and get stung in the mouth, on the tongue, or on the lips this way.

Overuse injuries are very common in children and teenagers, especially among kids who play sports throughout the year.

A high volume of sports puts your patients at higher risk for an overuse injury. Ask which sports they play, how often they play them, and how many teams they play for when taking the patient history. It is more and more common now that kids play on multiple teams at the same time or that sports seasons overlap. Here in the South, for example, baseball can start in January or February, while basketball – a winter sport – is still going on.

Year-round participation in multiple sports has an advantage as well – it becomes a form of built-in cross training. Your patients will be using the same muscles but developing them in different ways.

Encourage your athletic patients to play different sports and discourage “early specialization.” You can counsel patients regularly about sports diversification – during well-child visits and school or sports physical examinations. Patients who play football or soccer in the fall; basketball or wrestling in the winter; and then softball or lacrosse in the spring generally are at a lower risk for overuse injuries.

In contrast, specialization in the same sport throughout the year increases the risk for overuse injuries as well as “burnout.” For example, a child who starts at age 7 or 8 years and plays the same sport for years might find participation becomes less fun by age 13 or 14 years. In some cases, parents get enthusiastic, pay for private lessons to extend the “season” to 12 months, and the kids just never have a time to rest.

For some families, it seems like success of the team or success on the playing field becomes more important than the health of the child. You can face a dilemma if you recommend rest for a child about to play a big game or tournament. The best way I found around that is to spend sufficient time to explain why you are making your recommendations. If you just say, “His knee hurts, and he shouldn't play,” the patient and parents are less likely to be compliant.

We give advice. We rarely forbid a kid from playing. But you can explain what could happen if they don't follow recommendations. You might say something like, “Here is what I think you have, here is what I think you should do, and here's why. If you don't, the risk of making this a stress fracture is higher.” You can also explain that a nonsurgical elbow injury could become surgical if you continue to throw, play, or tumble.

Pediatricians can manage most overuse injuries. Watch for signs that can warrant referral, however, such as a swollen joint, limitation of joint movement, or symptoms of trauma/acute injury. Consider consulting a subspecialist when the child cannot completely bend or extend the elbow, for example. These findings suggest something worse than just overuse.

In general, the best way to treat an overuse injury is to underuse the affected area. Apply the PRICEMM techniques (protection, rest, ice, compression, elevation, medication, and [physical therapy] modalities) for 2 or 3 days. If there is no improvement, expand your differential diagnosis. Overuse injuries should improve quickly if patients start underusing the affected area in addition to modifying their workouts and using ice and anti-inflammatory medications.

Recommend the patient back off after you identify the likely source of pain. If a baseball player presents with elbow pain, for example, he might improve by pitching less or switching from shortstop to first base. Rarely do children need to stop playing altogether. Modification of the workout a little bit might be all it takes to give the body a chance to adapt. You could recommend a child play only part of the soccer game or avoid particular conditioning drills during practice, for example.

An overuse injury is defined as repetitive, submaximal stress applied to a tissue that occurs when the adaptive capability of the tissue is exceeded and injury results. A blister is a perfect example. If you put on a new shoe that starts rubbing your foot too much, eventually the skin breaks down. But if you wear the new shoes for a little bit, then switch to sandals, then boots, and finally put your new shoes back on, you slowly introduce those stresses. This way, the body has a chance to adapt, the skin will become callused, and you won't develop a blister.

Acute trauma is another reason to consider referring the child to a sports medicine specialist. If a child comes to you with instant pain from a jump off the monkey bars or a slide into home, she should be referred to rule out something more serious, such as a fracture or a cartilage or a ligament tear.

Another time to refer is anytime you feel uncomfortable. If you sense something isn't right, you will never be faulted for referring the patient to a specialist. So, when in doubt, go ahead and refer.

Typically, a good history and physical examination will be sufficient, with or without x-rays, for a pediatrician to determine the best recommendations for the patient.

Although x-rays are a necessity for evaluation of most orthopedic or sports injuries, it is preferable to refer the child and have the subspecialist order imaging tests. This avoids duplication of radiation exposure for the child and the unnecessary time and expense of repeated x-rays. In addition, laboratory assays typically do not help in the evaluation of a suspected overuse injury, unless you suspect a comorbid condition such as arthritis or joint infection.

Overuse injuries are very common in children and teenagers, especially among kids who play sports throughout the year.

A high volume of sports puts your patients at higher risk for an overuse injury. Ask which sports they play, how often they play them, and how many teams they play for when taking the patient history. It is more and more common now that kids play on multiple teams at the same time or that sports seasons overlap. Here in the South, for example, baseball can start in January or February, while basketball – a winter sport – is still going on.

Year-round participation in multiple sports has an advantage as well – it becomes a form of built-in cross training. Your patients will be using the same muscles but developing them in different ways.

Encourage your athletic patients to play different sports and discourage “early specialization.” You can counsel patients regularly about sports diversification – during well-child visits and school or sports physical examinations. Patients who play football or soccer in the fall; basketball or wrestling in the winter; and then softball or lacrosse in the spring generally are at a lower risk for overuse injuries.

In contrast, specialization in the same sport throughout the year increases the risk for overuse injuries as well as “burnout.” For example, a child who starts at age 7 or 8 years and plays the same sport for years might find participation becomes less fun by age 13 or 14 years. In some cases, parents get enthusiastic, pay for private lessons to extend the “season” to 12 months, and the kids just never have a time to rest.

For some families, it seems like success of the team or success on the playing field becomes more important than the health of the child. You can face a dilemma if you recommend rest for a child about to play a big game or tournament. The best way I found around that is to spend sufficient time to explain why you are making your recommendations. If you just say, “His knee hurts, and he shouldn't play,” the patient and parents are less likely to be compliant.

We give advice. We rarely forbid a kid from playing. But you can explain what could happen if they don't follow recommendations. You might say something like, “Here is what I think you have, here is what I think you should do, and here's why. If you don't, the risk of making this a stress fracture is higher.” You can also explain that a nonsurgical elbow injury could become surgical if you continue to throw, play, or tumble.

Pediatricians can manage most overuse injuries. Watch for signs that can warrant referral, however, such as a swollen joint, limitation of joint movement, or symptoms of trauma/acute injury. Consider consulting a subspecialist when the child cannot completely bend or extend the elbow, for example. These findings suggest something worse than just overuse.

In general, the best way to treat an overuse injury is to underuse the affected area. Apply the PRICEMM techniques (protection, rest, ice, compression, elevation, medication, and [physical therapy] modalities) for 2 or 3 days. If there is no improvement, expand your differential diagnosis. Overuse injuries should improve quickly if patients start underusing the affected area in addition to modifying their workouts and using ice and anti-inflammatory medications.

Recommend the patient back off after you identify the likely source of pain. If a baseball player presents with elbow pain, for example, he might improve by pitching less or switching from shortstop to first base. Rarely do children need to stop playing altogether. Modification of the workout a little bit might be all it takes to give the body a chance to adapt. You could recommend a child play only part of the soccer game or avoid particular conditioning drills during practice, for example.

An overuse injury is defined as repetitive, submaximal stress applied to a tissue that occurs when the adaptive capability of the tissue is exceeded and injury results. A blister is a perfect example. If you put on a new shoe that starts rubbing your foot too much, eventually the skin breaks down. But if you wear the new shoes for a little bit, then switch to sandals, then boots, and finally put your new shoes back on, you slowly introduce those stresses. This way, the body has a chance to adapt, the skin will become callused, and you won't develop a blister.

Acute trauma is another reason to consider referring the child to a sports medicine specialist. If a child comes to you with instant pain from a jump off the monkey bars or a slide into home, she should be referred to rule out something more serious, such as a fracture or a cartilage or a ligament tear.

Another time to refer is anytime you feel uncomfortable. If you sense something isn't right, you will never be faulted for referring the patient to a specialist. So, when in doubt, go ahead and refer.

Typically, a good history and physical examination will be sufficient, with or without x-rays, for a pediatrician to determine the best recommendations for the patient.

Although x-rays are a necessity for evaluation of most orthopedic or sports injuries, it is preferable to refer the child and have the subspecialist order imaging tests. This avoids duplication of radiation exposure for the child and the unnecessary time and expense of repeated x-rays. In addition, laboratory assays typically do not help in the evaluation of a suspected overuse injury, unless you suspect a comorbid condition such as arthritis or joint infection.

Overuse injuries are very common in children and teenagers, especially among kids who play sports throughout the year.

A high volume of sports puts your patients at higher risk for an overuse injury. Ask which sports they play, how often they play them, and how many teams they play for when taking the patient history. It is more and more common now that kids play on multiple teams at the same time or that sports seasons overlap. Here in the South, for example, baseball can start in January or February, while basketball – a winter sport – is still going on.

Year-round participation in multiple sports has an advantage as well – it becomes a form of built-in cross training. Your patients will be using the same muscles but developing them in different ways.

Encourage your athletic patients to play different sports and discourage “early specialization.” You can counsel patients regularly about sports diversification – during well-child visits and school or sports physical examinations. Patients who play football or soccer in the fall; basketball or wrestling in the winter; and then softball or lacrosse in the spring generally are at a lower risk for overuse injuries.

In contrast, specialization in the same sport throughout the year increases the risk for overuse injuries as well as “burnout.” For example, a child who starts at age 7 or 8 years and plays the same sport for years might find participation becomes less fun by age 13 or 14 years. In some cases, parents get enthusiastic, pay for private lessons to extend the “season” to 12 months, and the kids just never have a time to rest.

For some families, it seems like success of the team or success on the playing field becomes more important than the health of the child. You can face a dilemma if you recommend rest for a child about to play a big game or tournament. The best way I found around that is to spend sufficient time to explain why you are making your recommendations. If you just say, “His knee hurts, and he shouldn't play,” the patient and parents are less likely to be compliant.

We give advice. We rarely forbid a kid from playing. But you can explain what could happen if they don't follow recommendations. You might say something like, “Here is what I think you have, here is what I think you should do, and here's why. If you don't, the risk of making this a stress fracture is higher.” You can also explain that a nonsurgical elbow injury could become surgical if you continue to throw, play, or tumble.

Pediatricians can manage most overuse injuries. Watch for signs that can warrant referral, however, such as a swollen joint, limitation of joint movement, or symptoms of trauma/acute injury. Consider consulting a subspecialist when the child cannot completely bend or extend the elbow, for example. These findings suggest something worse than just overuse.

In general, the best way to treat an overuse injury is to underuse the affected area. Apply the PRICEMM techniques (protection, rest, ice, compression, elevation, medication, and [physical therapy] modalities) for 2 or 3 days. If there is no improvement, expand your differential diagnosis. Overuse injuries should improve quickly if patients start underusing the affected area in addition to modifying their workouts and using ice and anti-inflammatory medications.

Recommend the patient back off after you identify the likely source of pain. If a baseball player presents with elbow pain, for example, he might improve by pitching less or switching from shortstop to first base. Rarely do children need to stop playing altogether. Modification of the workout a little bit might be all it takes to give the body a chance to adapt. You could recommend a child play only part of the soccer game or avoid particular conditioning drills during practice, for example.

An overuse injury is defined as repetitive, submaximal stress applied to a tissue that occurs when the adaptive capability of the tissue is exceeded and injury results. A blister is a perfect example. If you put on a new shoe that starts rubbing your foot too much, eventually the skin breaks down. But if you wear the new shoes for a little bit, then switch to sandals, then boots, and finally put your new shoes back on, you slowly introduce those stresses. This way, the body has a chance to adapt, the skin will become callused, and you won't develop a blister.

Acute trauma is another reason to consider referring the child to a sports medicine specialist. If a child comes to you with instant pain from a jump off the monkey bars or a slide into home, she should be referred to rule out something more serious, such as a fracture or a cartilage or a ligament tear.

Another time to refer is anytime you feel uncomfortable. If you sense something isn't right, you will never be faulted for referring the patient to a specialist. So, when in doubt, go ahead and refer.

Typically, a good history and physical examination will be sufficient, with or without x-rays, for a pediatrician to determine the best recommendations for the patient.

Although x-rays are a necessity for evaluation of most orthopedic or sports injuries, it is preferable to refer the child and have the subspecialist order imaging tests. This avoids duplication of radiation exposure for the child and the unnecessary time and expense of repeated x-rays. In addition, laboratory assays typically do not help in the evaluation of a suspected overuse injury, unless you suspect a comorbid condition such as arthritis or joint infection.

It is important for pediatricians to recommend that their female patients seek gynecologic care by age 18 years at the latest. However, there is a role for gynecologic care as early as age 14 or 15 years in this patient population if a teenager is sexually active, is considering becoming sexually active, or has problems with her menstrual period.

Make it a policy to take the gynecologic history with the patient without the parent being present, starting at the age of 14 years or earlier, on an individualized basis. Asking the parent to leave the room as a part of routine practice makes this discussion far easier.

Start your consultation by asking specific questions about the girl's menstrual period. Oftentimes, their periods are irregular, painful, or heavier/longer than they think is normal. If this is the case, it is appropriate to refer your patient to a gynecologist. Also refer your patient if she expresses an interest in seeing a gynecologist for any reason.

Ask about boyfriends, sexual activity, and birth control. Often, girls do not want their parents to know about their sexual activity. I recommend you tell parents that you routinely recommend referral to a gynecologist at a certain age to address menstrual issues. This is an easy way to bring up the subject without making the patient or parent feel uncomfortable.

As a general pediatrician, you can manage this type of patient if you feel comfortable with discussion and management of problematic periods, birth control, and sexual activity. You also should be comfortable with counseling your patients on sexually transmitted disease (STD) prevention and other preventive tools, such as the human papillomavirus (HPV) vaccine.

I want pediatricians to routinely discuss the HPV vaccine with their patients and parents. The HPV vaccine is ideally given to young women before they are sexually active, as early as age 9 years. By the time most girls see a gynecologist for the first time, they are already sexually active and have already been exposed to HPV.

Pediatricians can help by encouraging parents to vaccinate their 9- to 13-year-olds. This discussion also should be taking place with parents of boys.

I realize that there is a wide range in how pediatricians practice. Some feel completely comfortable with gynecologic care in this age group and will perform gynecologic exams, STD testing, and prescribe birth control if necessary. Others might have the discussion and then refer if an exam or prescription for birth control is required. Others may not even feel comfortable having the discussion. So I think gynecologic referral of a patient in this age group is based on the comfort level of the pediatrician.

If you do refer to a gynecologist, you can help prepare a girl by letting her know what to expect. For example, if a girl is being sent for evaluation of vaginal discharge, the patient needs to understand that she is going to have an internal examination with a speculum. I have seen several young women for evaluation of this problem who were surprised that I had to examine them. Discharge cannot be appropriately evaluated simply by talking to the patient. So you can alleviate a lot of anxiety by explaining the exam to the patient ahead of time.

On the other hand, not every young woman needs to be examined during her first gynecologist visit. If her initial appointment is a discussion regarding menstrual cycles or birth control, I often just take a history to establish rapport with the patient. I often want to do this in private, without a parent, so that I can comfortably ask questions about personal issues such as sexual activity. It is very helpful if you can prepare the parent ahead of time that this private discussion will need to take place.

Several physician organizations provide recommendations and other guidance for management of these patients. The American Academy of Pediatrics provides relevant resources for pediatricians. For example, in September 2010, it published a Clinical Report on Gynecologic Examination for Adolescents in the Pediatric Office Setting (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/583

You also might consider consulting with colleagues, including an ob.gyn. or a pediatrician who is fellowship trained in adolescent pediatrics.

It is important for pediatricians to recommend that their female patients seek gynecologic care by age 18 years at the latest. However, there is a role for gynecologic care as early as age 14 or 15 years in this patient population if a teenager is sexually active, is considering becoming sexually active, or has problems with her menstrual period.

Make it a policy to take the gynecologic history with the patient without the parent being present, starting at the age of 14 years or earlier, on an individualized basis. Asking the parent to leave the room as a part of routine practice makes this discussion far easier.

Start your consultation by asking specific questions about the girl's menstrual period. Oftentimes, their periods are irregular, painful, or heavier/longer than they think is normal. If this is the case, it is appropriate to refer your patient to a gynecologist. Also refer your patient if she expresses an interest in seeing a gynecologist for any reason.

Ask about boyfriends, sexual activity, and birth control. Often, girls do not want their parents to know about their sexual activity. I recommend you tell parents that you routinely recommend referral to a gynecologist at a certain age to address menstrual issues. This is an easy way to bring up the subject without making the patient or parent feel uncomfortable.

As a general pediatrician, you can manage this type of patient if you feel comfortable with discussion and management of problematic periods, birth control, and sexual activity. You also should be comfortable with counseling your patients on sexually transmitted disease (STD) prevention and other preventive tools, such as the human papillomavirus (HPV) vaccine.

I want pediatricians to routinely discuss the HPV vaccine with their patients and parents. The HPV vaccine is ideally given to young women before they are sexually active, as early as age 9 years. By the time most girls see a gynecologist for the first time, they are already sexually active and have already been exposed to HPV.

Pediatricians can help by encouraging parents to vaccinate their 9- to 13-year-olds. This discussion also should be taking place with parents of boys.

I realize that there is a wide range in how pediatricians practice. Some feel completely comfortable with gynecologic care in this age group and will perform gynecologic exams, STD testing, and prescribe birth control if necessary. Others might have the discussion and then refer if an exam or prescription for birth control is required. Others may not even feel comfortable having the discussion. So I think gynecologic referral of a patient in this age group is based on the comfort level of the pediatrician.

If you do refer to a gynecologist, you can help prepare a girl by letting her know what to expect. For example, if a girl is being sent for evaluation of vaginal discharge, the patient needs to understand that she is going to have an internal examination with a speculum. I have seen several young women for evaluation of this problem who were surprised that I had to examine them. Discharge cannot be appropriately evaluated simply by talking to the patient. So you can alleviate a lot of anxiety by explaining the exam to the patient ahead of time.

On the other hand, not every young woman needs to be examined during her first gynecologist visit. If her initial appointment is a discussion regarding menstrual cycles or birth control, I often just take a history to establish rapport with the patient. I often want to do this in private, without a parent, so that I can comfortably ask questions about personal issues such as sexual activity. It is very helpful if you can prepare the parent ahead of time that this private discussion will need to take place.

Several physician organizations provide recommendations and other guidance for management of these patients. The American Academy of Pediatrics provides relevant resources for pediatricians. For example, in September 2010, it published a Clinical Report on Gynecologic Examination for Adolescents in the Pediatric Office Setting (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/583

You also might consider consulting with colleagues, including an ob.gyn. or a pediatrician who is fellowship trained in adolescent pediatrics.

It is important for pediatricians to recommend that their female patients seek gynecologic care by age 18 years at the latest. However, there is a role for gynecologic care as early as age 14 or 15 years in this patient population if a teenager is sexually active, is considering becoming sexually active, or has problems with her menstrual period.

Make it a policy to take the gynecologic history with the patient without the parent being present, starting at the age of 14 years or earlier, on an individualized basis. Asking the parent to leave the room as a part of routine practice makes this discussion far easier.

Start your consultation by asking specific questions about the girl's menstrual period. Oftentimes, their periods are irregular, painful, or heavier/longer than they think is normal. If this is the case, it is appropriate to refer your patient to a gynecologist. Also refer your patient if she expresses an interest in seeing a gynecologist for any reason.

Ask about boyfriends, sexual activity, and birth control. Often, girls do not want their parents to know about their sexual activity. I recommend you tell parents that you routinely recommend referral to a gynecologist at a certain age to address menstrual issues. This is an easy way to bring up the subject without making the patient or parent feel uncomfortable.

As a general pediatrician, you can manage this type of patient if you feel comfortable with discussion and management of problematic periods, birth control, and sexual activity. You also should be comfortable with counseling your patients on sexually transmitted disease (STD) prevention and other preventive tools, such as the human papillomavirus (HPV) vaccine.

I want pediatricians to routinely discuss the HPV vaccine with their patients and parents. The HPV vaccine is ideally given to young women before they are sexually active, as early as age 9 years. By the time most girls see a gynecologist for the first time, they are already sexually active and have already been exposed to HPV.

Pediatricians can help by encouraging parents to vaccinate their 9- to 13-year-olds. This discussion also should be taking place with parents of boys.

I realize that there is a wide range in how pediatricians practice. Some feel completely comfortable with gynecologic care in this age group and will perform gynecologic exams, STD testing, and prescribe birth control if necessary. Others might have the discussion and then refer if an exam or prescription for birth control is required. Others may not even feel comfortable having the discussion. So I think gynecologic referral of a patient in this age group is based on the comfort level of the pediatrician.

If you do refer to a gynecologist, you can help prepare a girl by letting her know what to expect. For example, if a girl is being sent for evaluation of vaginal discharge, the patient needs to understand that she is going to have an internal examination with a speculum. I have seen several young women for evaluation of this problem who were surprised that I had to examine them. Discharge cannot be appropriately evaluated simply by talking to the patient. So you can alleviate a lot of anxiety by explaining the exam to the patient ahead of time.

On the other hand, not every young woman needs to be examined during her first gynecologist visit. If her initial appointment is a discussion regarding menstrual cycles or birth control, I often just take a history to establish rapport with the patient. I often want to do this in private, without a parent, so that I can comfortably ask questions about personal issues such as sexual activity. It is very helpful if you can prepare the parent ahead of time that this private discussion will need to take place.

Several physician organizations provide recommendations and other guidance for management of these patients. The American Academy of Pediatrics provides relevant resources for pediatricians. For example, in September 2010, it published a Clinical Report on Gynecologic Examination for Adolescents in the Pediatric Office Setting (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/583

You also might consider consulting with colleagues, including an ob.gyn. or a pediatrician who is fellowship trained in adolescent pediatrics.