Subspecialist Consult

Genetic testing has entered a new era in the past few years. Our ability to perform DNA-based tests and identify an individual's susceptibility to cancer, heart disease, diabetes, and so many other conditions is beginning to have a major impact on our practice of medicine.

Experts predict – thanks to advances in technology we already have – that in a few years we will be able to screen during the newborn period and identify every mutation and polymorphism present. This screening will permit us to predict a child's “medical life” through identification of individual susceptibilities to disease likely to develop during his or her lifetime. Although still in its infancy, this technology would revolutionize pediatrics from a field in which we wait for the child to develop symptoms and signs of disease and then react with medication and other treatments, to one where we can predict disease. This will give us the opportunity to help our patients in a whole new way: to prevent the symptoms and signs from arising in the first place.

With the good comes the bad, as with any new technology. For example, interpretation of results with this advanced testing will require special expertise in genetics and genomics. Unfortunately, interpretation of genetic findings often is not as “black and white” as diagnosis of anemia based on serum hemoglobin and hematocrit levels. Genetic test results often include polymorphisms, and most of these variations of normal are benign and not associated with disease. Subspecialist consultation may be needed to make these important distinctions.

General pediatricians play an essential role in interpretation of newborn screening tests. Fortunately, results are normal for the majority of children and no further follow-up is indicated. However, if an abnormality is detected, referral to a specialist is warranted to facilitate an early intervention that, in some cases, can make a difference in the long-term health of the child. You also can refer families who request consultation with a geneticist to discuss recurrence risk in future progeny and for additional genetic testing, as indicated.

Beyond standard newborn genetic screening, the role of the pediatrician is somewhat limited regarding the screening and testing for specific genetic disorders. However, there are situations in which the pediatrician should feel comfortable in ordering and interpreting genetic tests.

For example, testing in children with intellectual disabilities and autism spectrum disorder has become standard. As tier 1 testing in such children, I usually order a microarray-based comparative genomic hybridization (array CGH), a test that has largely replaced high-resolution chromosome analysis in this population. I also perform DNA testing for fragile X syndrome, the most common inherited cause of intellectual disabilities. Because the results of this testing will be normal in 80%–90% of these children, I encourage pediatricians to order these tests themselves. I then make myself available if genetic evaluation reveals an abnormality.

Another factor to consider is the recent direct-to-consumer marketing of genetic testing that expands standard newborn screening or uses genetic markers to predict susceptibility to specific conditions. These tests often require the family, with or without the assistance of the pediatrician, to send a sample of DNA to a reference lab. The lab returns the results directly to the family. Again, the laboratory results are difficult to interpret, and you may be called on to provide guidance. Sometimes interpretation is straightforward, but in other cases it can be tricky, and if you are uncomfortable you might want to refer them to a medical geneticist or genetic counselor.

When you refer a child to a geneticist, include all results of your previous testing, those performed by other specialists, and newborn screening. Genetic tests performed on the mother during the pregnancy (for example, amniocentesis, chorionic villus sampling, sonograms, and/or biochemical screening tests) also are important. Provide any imaging findings, including MRIs or CT scans.

Proceed cautiously when counseling families regarding results of genetic testing. It can be trickier than you might think. For example, results of a test for a single gene disorder might uncover a previously unknown change in the child's DNA. The finding could be a benign polymorphism that has no clinical consequences or it could be a pathogenic mutation responsible for the child's signs and symptoms.

Simply informing the family about this finding is inadequate. To be certain, the parents need to be tested. If one or both of them has the same genetic change, the polymorphism might be benign. In contrast, if neither parent has the mutation, the child's test result might reflect a spontaneous genetic change and increase the likelihood you have discovered the cause of the clinical condition.

In general, there are three categories of children who may require genetic testing. First, there are those children who have multiple congenital anomalies or dysmorphic features. These findings could be caused by chromosome abnormalities, single gene mutations, or teratogenic agents. In these children, in order to ensure that the appropriate tests are ordered, a genetic consultation is important.

A second group of children who may require genetic testing are those in whom deviation from typical development or “normal” growth parameters occur during the first few years of life. Such children may have chromosome abnormalities, single gene mutations, and/or an underlying metabolic disorder. Keep in mind seizures, developmental regression, failure to thrive, and respiratory disturbances can bolster the likelihood of a genetic or metabolic etiology.

Before ordering any genetic testing, it is essential to take a complete patient and family history and to perform a complete physical exam. Children with a family history of a first- or second-degree family member with a genetic disorder also might benefit from genetic evaluation, comprising the third group. For example, even before symptoms are present, testing a child who has a brother with Duchenne muscular dystrophy or a relative with cystic fibrosis may prove life saving if it uncovers a similar diagnosis.

Genetic testing has entered a new era in the past few years. Our ability to perform DNA-based tests and identify an individual's susceptibility to cancer, heart disease, diabetes, and so many other conditions is beginning to have a major impact on our practice of medicine.

Experts predict – thanks to advances in technology we already have – that in a few years we will be able to screen during the newborn period and identify every mutation and polymorphism present. This screening will permit us to predict a child's “medical life” through identification of individual susceptibilities to disease likely to develop during his or her lifetime. Although still in its infancy, this technology would revolutionize pediatrics from a field in which we wait for the child to develop symptoms and signs of disease and then react with medication and other treatments, to one where we can predict disease. This will give us the opportunity to help our patients in a whole new way: to prevent the symptoms and signs from arising in the first place.

With the good comes the bad, as with any new technology. For example, interpretation of results with this advanced testing will require special expertise in genetics and genomics. Unfortunately, interpretation of genetic findings often is not as “black and white” as diagnosis of anemia based on serum hemoglobin and hematocrit levels. Genetic test results often include polymorphisms, and most of these variations of normal are benign and not associated with disease. Subspecialist consultation may be needed to make these important distinctions.

General pediatricians play an essential role in interpretation of newborn screening tests. Fortunately, results are normal for the majority of children and no further follow-up is indicated. However, if an abnormality is detected, referral to a specialist is warranted to facilitate an early intervention that, in some cases, can make a difference in the long-term health of the child. You also can refer families who request consultation with a geneticist to discuss recurrence risk in future progeny and for additional genetic testing, as indicated.

Beyond standard newborn genetic screening, the role of the pediatrician is somewhat limited regarding the screening and testing for specific genetic disorders. However, there are situations in which the pediatrician should feel comfortable in ordering and interpreting genetic tests.

For example, testing in children with intellectual disabilities and autism spectrum disorder has become standard. As tier 1 testing in such children, I usually order a microarray-based comparative genomic hybridization (array CGH), a test that has largely replaced high-resolution chromosome analysis in this population. I also perform DNA testing for fragile X syndrome, the most common inherited cause of intellectual disabilities. Because the results of this testing will be normal in 80%–90% of these children, I encourage pediatricians to order these tests themselves. I then make myself available if genetic evaluation reveals an abnormality.

Another factor to consider is the recent direct-to-consumer marketing of genetic testing that expands standard newborn screening or uses genetic markers to predict susceptibility to specific conditions. These tests often require the family, with or without the assistance of the pediatrician, to send a sample of DNA to a reference lab. The lab returns the results directly to the family. Again, the laboratory results are difficult to interpret, and you may be called on to provide guidance. Sometimes interpretation is straightforward, but in other cases it can be tricky, and if you are uncomfortable you might want to refer them to a medical geneticist or genetic counselor.

When you refer a child to a geneticist, include all results of your previous testing, those performed by other specialists, and newborn screening. Genetic tests performed on the mother during the pregnancy (for example, amniocentesis, chorionic villus sampling, sonograms, and/or biochemical screening tests) also are important. Provide any imaging findings, including MRIs or CT scans.

Proceed cautiously when counseling families regarding results of genetic testing. It can be trickier than you might think. For example, results of a test for a single gene disorder might uncover a previously unknown change in the child's DNA. The finding could be a benign polymorphism that has no clinical consequences or it could be a pathogenic mutation responsible for the child's signs and symptoms.

Simply informing the family about this finding is inadequate. To be certain, the parents need to be tested. If one or both of them has the same genetic change, the polymorphism might be benign. In contrast, if neither parent has the mutation, the child's test result might reflect a spontaneous genetic change and increase the likelihood you have discovered the cause of the clinical condition.

In general, there are three categories of children who may require genetic testing. First, there are those children who have multiple congenital anomalies or dysmorphic features. These findings could be caused by chromosome abnormalities, single gene mutations, or teratogenic agents. In these children, in order to ensure that the appropriate tests are ordered, a genetic consultation is important.

A second group of children who may require genetic testing are those in whom deviation from typical development or “normal” growth parameters occur during the first few years of life. Such children may have chromosome abnormalities, single gene mutations, and/or an underlying metabolic disorder. Keep in mind seizures, developmental regression, failure to thrive, and respiratory disturbances can bolster the likelihood of a genetic or metabolic etiology.

Before ordering any genetic testing, it is essential to take a complete patient and family history and to perform a complete physical exam. Children with a family history of a first- or second-degree family member with a genetic disorder also might benefit from genetic evaluation, comprising the third group. For example, even before symptoms are present, testing a child who has a brother with Duchenne muscular dystrophy or a relative with cystic fibrosis may prove life saving if it uncovers a similar diagnosis.

Genetic testing has entered a new era in the past few years. Our ability to perform DNA-based tests and identify an individual's susceptibility to cancer, heart disease, diabetes, and so many other conditions is beginning to have a major impact on our practice of medicine.

Experts predict – thanks to advances in technology we already have – that in a few years we will be able to screen during the newborn period and identify every mutation and polymorphism present. This screening will permit us to predict a child's “medical life” through identification of individual susceptibilities to disease likely to develop during his or her lifetime. Although still in its infancy, this technology would revolutionize pediatrics from a field in which we wait for the child to develop symptoms and signs of disease and then react with medication and other treatments, to one where we can predict disease. This will give us the opportunity to help our patients in a whole new way: to prevent the symptoms and signs from arising in the first place.

With the good comes the bad, as with any new technology. For example, interpretation of results with this advanced testing will require special expertise in genetics and genomics. Unfortunately, interpretation of genetic findings often is not as “black and white” as diagnosis of anemia based on serum hemoglobin and hematocrit levels. Genetic test results often include polymorphisms, and most of these variations of normal are benign and not associated with disease. Subspecialist consultation may be needed to make these important distinctions.

General pediatricians play an essential role in interpretation of newborn screening tests. Fortunately, results are normal for the majority of children and no further follow-up is indicated. However, if an abnormality is detected, referral to a specialist is warranted to facilitate an early intervention that, in some cases, can make a difference in the long-term health of the child. You also can refer families who request consultation with a geneticist to discuss recurrence risk in future progeny and for additional genetic testing, as indicated.

Beyond standard newborn genetic screening, the role of the pediatrician is somewhat limited regarding the screening and testing for specific genetic disorders. However, there are situations in which the pediatrician should feel comfortable in ordering and interpreting genetic tests.

For example, testing in children with intellectual disabilities and autism spectrum disorder has become standard. As tier 1 testing in such children, I usually order a microarray-based comparative genomic hybridization (array CGH), a test that has largely replaced high-resolution chromosome analysis in this population. I also perform DNA testing for fragile X syndrome, the most common inherited cause of intellectual disabilities. Because the results of this testing will be normal in 80%–90% of these children, I encourage pediatricians to order these tests themselves. I then make myself available if genetic evaluation reveals an abnormality.

Another factor to consider is the recent direct-to-consumer marketing of genetic testing that expands standard newborn screening or uses genetic markers to predict susceptibility to specific conditions. These tests often require the family, with or without the assistance of the pediatrician, to send a sample of DNA to a reference lab. The lab returns the results directly to the family. Again, the laboratory results are difficult to interpret, and you may be called on to provide guidance. Sometimes interpretation is straightforward, but in other cases it can be tricky, and if you are uncomfortable you might want to refer them to a medical geneticist or genetic counselor.

When you refer a child to a geneticist, include all results of your previous testing, those performed by other specialists, and newborn screening. Genetic tests performed on the mother during the pregnancy (for example, amniocentesis, chorionic villus sampling, sonograms, and/or biochemical screening tests) also are important. Provide any imaging findings, including MRIs or CT scans.

Proceed cautiously when counseling families regarding results of genetic testing. It can be trickier than you might think. For example, results of a test for a single gene disorder might uncover a previously unknown change in the child's DNA. The finding could be a benign polymorphism that has no clinical consequences or it could be a pathogenic mutation responsible for the child's signs and symptoms.

Simply informing the family about this finding is inadequate. To be certain, the parents need to be tested. If one or both of them has the same genetic change, the polymorphism might be benign. In contrast, if neither parent has the mutation, the child's test result might reflect a spontaneous genetic change and increase the likelihood you have discovered the cause of the clinical condition.

In general, there are three categories of children who may require genetic testing. First, there are those children who have multiple congenital anomalies or dysmorphic features. These findings could be caused by chromosome abnormalities, single gene mutations, or teratogenic agents. In these children, in order to ensure that the appropriate tests are ordered, a genetic consultation is important.

A second group of children who may require genetic testing are those in whom deviation from typical development or “normal” growth parameters occur during the first few years of life. Such children may have chromosome abnormalities, single gene mutations, and/or an underlying metabolic disorder. Keep in mind seizures, developmental regression, failure to thrive, and respiratory disturbances can bolster the likelihood of a genetic or metabolic etiology.

Before ordering any genetic testing, it is essential to take a complete patient and family history and to perform a complete physical exam. Children with a family history of a first- or second-degree family member with a genetic disorder also might benefit from genetic evaluation, comprising the third group. For example, even before symptoms are present, testing a child who has a brother with Duchenne muscular dystrophy or a relative with cystic fibrosis may prove life saving if it uncovers a similar diagnosis.

Adolescents value confidentiality with their health care clinicians very highly. To support the opportunity for confidentiality, you should speak with female adolescents without a parent in the room for at least part of each visit. This fosters an honest conversation about the sensitive issues around contraception, including any intimate relationships, current or planned sexual activity, and the safety and protection afforded by contraception.

Girls are allowed to discuss sexually transmitted infections confidentially with their physicians, and hopefully can be offered a confidential discussion of their sexual activity as well. Ideally, a girl also feels comfortable talking with a parent about her concerns, but this scenario may not be an option for all your patients.

Begin with a discussion about relationships. Avoid preaching to them or asking blunt questions such as: “Hey, are you having sex?” Acknowledge that “sex” can refer to activities beyond sexual intercourse as well.

Ask your patients if they are in a relationship with a girl, a boy, or both. A teenager who is not heterosexual or is unsure will then know you are willing to discuss any specific concerns.

Make sure the teenager knows that abstinence is always the best protection against sexually transmitted infection and/or pregnancy.

Once you ascertain she is heterosexual or bisexual, is sexually active, and needs contraception, focus next on safety. Ask the patient: Are you doing anything to protect yourself against the consequences of sexual activity? Also ensure her participation in the intimate relationship is voluntary and free of any coercion, particularly among younger teenage girls.

There are multiple means of protection against sexually transmitted infections. Educate her that, aside from abstinence, the use of condoms is her best strategy. Make sure the girl understands that she is equally responsible for the proper use of condoms. If you take care of a lot of adolescents, it is reasonable to have a supply of condoms on hand so you can provide them.

Also consider providing a patient who is sexually active (or contemplating sexual activity) with a prescription for emergency, postcoital contraception. She could fill the prescription as needed, within 72 hours of sexual intercourse, to decrease the likelihood of pregnancy considerably. Even if she regularly uses a birth control method, this prescription provides a good backup plan.

Keep the child's developmental level in mind when discussing contraception and sexuality. In general, a 14-year-old girl who is sexually active or considering sex is vastly different from a 17-year-old patient. Also consider the patient and family's culture, ethnic, and/or religious background. For example, there are some religious groups where the kids cannot tell parents they have become sexually active – it could mortify the parents and be dangerous for the teenager.

Title X–funded projects are an option if a girl cannot tell her parent she wants to use contraception and/or if a third party (such as an insurance company) makes confidentiality impossible. Become familiar with the Title X–funded contraception projects in your area, which are frequently run through Planned Parenthood or a university obstetrics and gynecology program (www.hhs.gov/opa/familyplanning/index.html

You really should get to the point where you feel moderately comfortable talking about the basics of contraception and sexuality. There are not enough adolescent medicine specialists in the world to take care of all the teenagers out there, and most ob. gyns. do not see very many teenagers.

Some pediatricians may be comfortable prescribing the birth control pill, but they may not know much about the patch, the contraceptive ring, the implant, or the IUD. If a patient is interested in one of these options, you can refer her to a gynecologist or a family practitioner in your area who is particularly adept at young women's health issues. Planned Parenthood also is a good resource.

The birth control pill and the patch are the two most common birth control methods for first-time users. You do not need to know all the different types of birth control pills; it is sufficient to become comfortable prescribing one or two brands.

Check for any contraindications, such as a history of migraine headache with aura or a clotting abnormality (personal or in a first-degree relative) before prescribing oral contraception. If your patient is having regular, monthly periods, and she's had a period in the last month, some pediatricians still will feel comfortable prescribing only if they get a urine pregnancy test. On the other hand, if you give contraception without the test and the girl does miss her next period, you can always give the pregnancy test then.

If you prescribe contraception for sexual activity only, keep in mind that most teenagers have a passionate relationship that lasts a few months, followed by an interval without a relationship, followed by involvement with another person. These intermittent relationships mean that they are likely to start and stop contraception. Keep this in mind when discussing contraception options and monitor compliance with less-permanent options over time.

Children's Hospital of Boston produces www.youngwomenshealth.orgwww.acog.org/publications/patient_education/ab020.cfmaappolicy.aappublications.org/cgi/content/full/pediatrics;120/5/1135

Adolescents value confidentiality with their health care clinicians very highly. To support the opportunity for confidentiality, you should speak with female adolescents without a parent in the room for at least part of each visit. This fosters an honest conversation about the sensitive issues around contraception, including any intimate relationships, current or planned sexual activity, and the safety and protection afforded by contraception.

Girls are allowed to discuss sexually transmitted infections confidentially with their physicians, and hopefully can be offered a confidential discussion of their sexual activity as well. Ideally, a girl also feels comfortable talking with a parent about her concerns, but this scenario may not be an option for all your patients.

Begin with a discussion about relationships. Avoid preaching to them or asking blunt questions such as: “Hey, are you having sex?” Acknowledge that “sex” can refer to activities beyond sexual intercourse as well.

Ask your patients if they are in a relationship with a girl, a boy, or both. A teenager who is not heterosexual or is unsure will then know you are willing to discuss any specific concerns.

Make sure the teenager knows that abstinence is always the best protection against sexually transmitted infection and/or pregnancy.

Once you ascertain she is heterosexual or bisexual, is sexually active, and needs contraception, focus next on safety. Ask the patient: Are you doing anything to protect yourself against the consequences of sexual activity? Also ensure her participation in the intimate relationship is voluntary and free of any coercion, particularly among younger teenage girls.

There are multiple means of protection against sexually transmitted infections. Educate her that, aside from abstinence, the use of condoms is her best strategy. Make sure the girl understands that she is equally responsible for the proper use of condoms. If you take care of a lot of adolescents, it is reasonable to have a supply of condoms on hand so you can provide them.

Also consider providing a patient who is sexually active (or contemplating sexual activity) with a prescription for emergency, postcoital contraception. She could fill the prescription as needed, within 72 hours of sexual intercourse, to decrease the likelihood of pregnancy considerably. Even if she regularly uses a birth control method, this prescription provides a good backup plan.

Keep the child's developmental level in mind when discussing contraception and sexuality. In general, a 14-year-old girl who is sexually active or considering sex is vastly different from a 17-year-old patient. Also consider the patient and family's culture, ethnic, and/or religious background. For example, there are some religious groups where the kids cannot tell parents they have become sexually active – it could mortify the parents and be dangerous for the teenager.

Title X–funded projects are an option if a girl cannot tell her parent she wants to use contraception and/or if a third party (such as an insurance company) makes confidentiality impossible. Become familiar with the Title X–funded contraception projects in your area, which are frequently run through Planned Parenthood or a university obstetrics and gynecology program (www.hhs.gov/opa/familyplanning/index.html

You really should get to the point where you feel moderately comfortable talking about the basics of contraception and sexuality. There are not enough adolescent medicine specialists in the world to take care of all the teenagers out there, and most ob. gyns. do not see very many teenagers.

Some pediatricians may be comfortable prescribing the birth control pill, but they may not know much about the patch, the contraceptive ring, the implant, or the IUD. If a patient is interested in one of these options, you can refer her to a gynecologist or a family practitioner in your area who is particularly adept at young women's health issues. Planned Parenthood also is a good resource.

The birth control pill and the patch are the two most common birth control methods for first-time users. You do not need to know all the different types of birth control pills; it is sufficient to become comfortable prescribing one or two brands.

Check for any contraindications, such as a history of migraine headache with aura or a clotting abnormality (personal or in a first-degree relative) before prescribing oral contraception. If your patient is having regular, monthly periods, and she's had a period in the last month, some pediatricians still will feel comfortable prescribing only if they get a urine pregnancy test. On the other hand, if you give contraception without the test and the girl does miss her next period, you can always give the pregnancy test then.

If you prescribe contraception for sexual activity only, keep in mind that most teenagers have a passionate relationship that lasts a few months, followed by an interval without a relationship, followed by involvement with another person. These intermittent relationships mean that they are likely to start and stop contraception. Keep this in mind when discussing contraception options and monitor compliance with less-permanent options over time.

Children's Hospital of Boston produces www.youngwomenshealth.orgwww.acog.org/publications/patient_education/ab020.cfmaappolicy.aappublications.org/cgi/content/full/pediatrics;120/5/1135

Adolescents value confidentiality with their health care clinicians very highly. To support the opportunity for confidentiality, you should speak with female adolescents without a parent in the room for at least part of each visit. This fosters an honest conversation about the sensitive issues around contraception, including any intimate relationships, current or planned sexual activity, and the safety and protection afforded by contraception.

Girls are allowed to discuss sexually transmitted infections confidentially with their physicians, and hopefully can be offered a confidential discussion of their sexual activity as well. Ideally, a girl also feels comfortable talking with a parent about her concerns, but this scenario may not be an option for all your patients.

Begin with a discussion about relationships. Avoid preaching to them or asking blunt questions such as: “Hey, are you having sex?” Acknowledge that “sex” can refer to activities beyond sexual intercourse as well.

Ask your patients if they are in a relationship with a girl, a boy, or both. A teenager who is not heterosexual or is unsure will then know you are willing to discuss any specific concerns.

Make sure the teenager knows that abstinence is always the best protection against sexually transmitted infection and/or pregnancy.

Once you ascertain she is heterosexual or bisexual, is sexually active, and needs contraception, focus next on safety. Ask the patient: Are you doing anything to protect yourself against the consequences of sexual activity? Also ensure her participation in the intimate relationship is voluntary and free of any coercion, particularly among younger teenage girls.

There are multiple means of protection against sexually transmitted infections. Educate her that, aside from abstinence, the use of condoms is her best strategy. Make sure the girl understands that she is equally responsible for the proper use of condoms. If you take care of a lot of adolescents, it is reasonable to have a supply of condoms on hand so you can provide them.

Also consider providing a patient who is sexually active (or contemplating sexual activity) with a prescription for emergency, postcoital contraception. She could fill the prescription as needed, within 72 hours of sexual intercourse, to decrease the likelihood of pregnancy considerably. Even if she regularly uses a birth control method, this prescription provides a good backup plan.

Keep the child's developmental level in mind when discussing contraception and sexuality. In general, a 14-year-old girl who is sexually active or considering sex is vastly different from a 17-year-old patient. Also consider the patient and family's culture, ethnic, and/or religious background. For example, there are some religious groups where the kids cannot tell parents they have become sexually active – it could mortify the parents and be dangerous for the teenager.

Title X–funded projects are an option if a girl cannot tell her parent she wants to use contraception and/or if a third party (such as an insurance company) makes confidentiality impossible. Become familiar with the Title X–funded contraception projects in your area, which are frequently run through Planned Parenthood or a university obstetrics and gynecology program (www.hhs.gov/opa/familyplanning/index.html

You really should get to the point where you feel moderately comfortable talking about the basics of contraception and sexuality. There are not enough adolescent medicine specialists in the world to take care of all the teenagers out there, and most ob. gyns. do not see very many teenagers.

Some pediatricians may be comfortable prescribing the birth control pill, but they may not know much about the patch, the contraceptive ring, the implant, or the IUD. If a patient is interested in one of these options, you can refer her to a gynecologist or a family practitioner in your area who is particularly adept at young women's health issues. Planned Parenthood also is a good resource.

The birth control pill and the patch are the two most common birth control methods for first-time users. You do not need to know all the different types of birth control pills; it is sufficient to become comfortable prescribing one or two brands.

Check for any contraindications, such as a history of migraine headache with aura or a clotting abnormality (personal or in a first-degree relative) before prescribing oral contraception. If your patient is having regular, monthly periods, and she's had a period in the last month, some pediatricians still will feel comfortable prescribing only if they get a urine pregnancy test. On the other hand, if you give contraception without the test and the girl does miss her next period, you can always give the pregnancy test then.

If you prescribe contraception for sexual activity only, keep in mind that most teenagers have a passionate relationship that lasts a few months, followed by an interval without a relationship, followed by involvement with another person. These intermittent relationships mean that they are likely to start and stop contraception. Keep this in mind when discussing contraception options and monitor compliance with less-permanent options over time.

Children's Hospital of Boston produces www.youngwomenshealth.orgwww.acog.org/publications/patient_education/ab020.cfmaappolicy.aappublications.org/cgi/content/full/pediatrics;120/5/1135

Many children and teenagers are not getting enough vitamin D, and this is a common problem.

I started seeing medical consequences years ago. We did a study of breastfed African American infants who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7). Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We've had vitamin D–deficient teenagers present with seizures, and we see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: “How many glasses of milk do you drink a day?” For those who respond one glass or less, we check their serum vitamin D level.

When taking a history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It's not ideal, but it's better than no milk at all.

Make sure your patients get adequate calcium in their diet – about 700 mg/day for a young child anda1,200-1,300 mg for an adolescent. Recommend a multivitamin –, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut.

I recommend milk with 1% or less fat. A lot of people believe that whole milk provides more vitamin D, but that is not the case. If you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we're about 20 After that, if we live long enough, we're going to slide down the hill – we will all get osteoporosis. But if you've had your milk and followed recommendations, you'll start your slide downward from the top of the mountain.

In addition to those with poor diets, patients with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It's becoming like obesity. We need the general pediatrician's help to screen and treat most of these patients. We can help via phone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposuer week of sunshine if they are wearing only diapers, or 2 hours per week if fully clothed. That evidently provides an adequawe recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, when most get exposure, they're using sunscreens that block 95% of the rays. So we have become dependent on diet for our vitamin D, and we're not getting it.

Many children and teenagers are not getting enough vitamin D, and this is a common problem.

I started seeing medical consequences years ago. We did a study of breastfed African American infants who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7). Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We've had vitamin D–deficient teenagers present with seizures, and we see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: “How many glasses of milk do you drink a day?” For those who respond one glass or less, we check their serum vitamin D level.

When taking a history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It's not ideal, but it's better than no milk at all.

Make sure your patients get adequate calcium in their diet – about 700 mg/day for a young child anda1,200-1,300 mg for an adolescent. Recommend a multivitamin –, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut.

I recommend milk with 1% or less fat. A lot of people believe that whole milk provides more vitamin D, but that is not the case. If you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we're about 20 After that, if we live long enough, we're going to slide down the hill – we will all get osteoporosis. But if you've had your milk and followed recommendations, you'll start your slide downward from the top of the mountain.

In addition to those with poor diets, patients with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It's becoming like obesity. We need the general pediatrician's help to screen and treat most of these patients. We can help via phone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposuer week of sunshine if they are wearing only diapers, or 2 hours per week if fully clothed. That evidently provides an adequawe recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, when most get exposure, they're using sunscreens that block 95% of the rays. So we have become dependent on diet for our vitamin D, and we're not getting it.

Many children and teenagers are not getting enough vitamin D, and this is a common problem.

I started seeing medical consequences years ago. We did a study of breastfed African American infants who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7). Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We've had vitamin D–deficient teenagers present with seizures, and we see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: “How many glasses of milk do you drink a day?” For those who respond one glass or less, we check their serum vitamin D level.

When taking a history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It's not ideal, but it's better than no milk at all.

Make sure your patients get adequate calcium in their diet – about 700 mg/day for a young child anda1,200-1,300 mg for an adolescent. Recommend a multivitamin –, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut.

I recommend milk with 1% or less fat. A lot of people believe that whole milk provides more vitamin D, but that is not the case. If you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we're about 20 After that, if we live long enough, we're going to slide down the hill – we will all get osteoporosis. But if you've had your milk and followed recommendations, you'll start your slide downward from the top of the mountain.

In addition to those with poor diets, patients with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It's becoming like obesity. We need the general pediatrician's help to screen and treat most of these patients. We can help via phone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposuer week of sunshine if they are wearing only diapers, or 2 hours per week if fully clothed. That evidently provides an adequawe recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, when most get exposure, they're using sunscreens that block 95% of the rays. So we have become dependent on diet for our vitamin D, and we're not getting it.

First recognize that a child with precocious puberty might actually have a serious underlying medical condition that triggers puberty. It is appropriate for you to distinguish true precocious puberty from precocious puberty secondary to a general underlying medical condition if this is within your comfort zone.

Begin with a complete history and physical examination. If you see physical signs of puberty that are not simply caused by “early puberty,” consider looking for underlying thyroid disorders, ovarian tumors, central nervous system tumors, or even tumors of the adrenal gland.

Importantly, perform a complete evaluation before initiation of any “treatment.” Occasionally, a patient with premature vaginal bleeding undergoes a very thorough hormone evaluation only to find the cause of her bleeding is a foreign body. Therefore, inspect the vaginal cavity as part of your physical examination or include this in your gynecologist referral when a girl presents with vaginal bleeding and no other evident signs of puberty. You might spare the patient a full hormone work-up. Also refer the child to a gynecologist if you suspect an abnormality of the reproductive tract because of pelvic pain, vaginal discharge, and/or abnormal vaginal bleeding.

The treatment for precocious puberty is controversial itself. Administration of an injection that blocks gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus is the most commonly prescribed therapy (leuprolide acetate, Lupron Depot-PED). Consider referral of these patients because gynecologists and pediatric endocrinologists have the most experience with this medication.

Other medications and lifestyle modifications are not particularly effective at halting early puberty.

Optimally, I advocate a combined effort among the pediatrician, the pediatric endocrinologist, and the gynecologist with a special interest in children.

Consider ordering a bone age study during your initial evaluation. It is an easy-to-order test for early puberty. Determination of the bone age of the left wrist is particularly worthwhile and provides useful information should you decide to refer to a specialist. Referral is warranted if a child with precocious puberty has advanced bone age.

Although precocious puberty includes thelarche and adrenarche, some important differences exist. Breast development, the growth spurt, and menses are all under the control of one system, the hypothalamic-pituitary-ovarian axis. Adrenarche, or secondary sexual hair, is primarily under the control of the adrenal gland, although the ovary is a major contributor to circulating androgens. Clinically, evaluate adrenal pathology more aggressively in cases of precocious adrenarche than in cases of thelarche.

It is also appropriate for a child without precocious puberty concerns to see a gynecologist in the early teenage years. This specialist can help you educate patients on reproductive health, including when Pap testing needs to be done and strategies to prevent pregnancy and sexually transmitted infection.

First recognize that a child with precocious puberty might actually have a serious underlying medical condition that triggers puberty. It is appropriate for you to distinguish true precocious puberty from precocious puberty secondary to a general underlying medical condition if this is within your comfort zone.

Begin with a complete history and physical examination. If you see physical signs of puberty that are not simply caused by “early puberty,” consider looking for underlying thyroid disorders, ovarian tumors, central nervous system tumors, or even tumors of the adrenal gland.

Importantly, perform a complete evaluation before initiation of any “treatment.” Occasionally, a patient with premature vaginal bleeding undergoes a very thorough hormone evaluation only to find the cause of her bleeding is a foreign body. Therefore, inspect the vaginal cavity as part of your physical examination or include this in your gynecologist referral when a girl presents with vaginal bleeding and no other evident signs of puberty. You might spare the patient a full hormone work-up. Also refer the child to a gynecologist if you suspect an abnormality of the reproductive tract because of pelvic pain, vaginal discharge, and/or abnormal vaginal bleeding.

The treatment for precocious puberty is controversial itself. Administration of an injection that blocks gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus is the most commonly prescribed therapy (leuprolide acetate, Lupron Depot-PED). Consider referral of these patients because gynecologists and pediatric endocrinologists have the most experience with this medication.

Other medications and lifestyle modifications are not particularly effective at halting early puberty.

Optimally, I advocate a combined effort among the pediatrician, the pediatric endocrinologist, and the gynecologist with a special interest in children.

Consider ordering a bone age study during your initial evaluation. It is an easy-to-order test for early puberty. Determination of the bone age of the left wrist is particularly worthwhile and provides useful information should you decide to refer to a specialist. Referral is warranted if a child with precocious puberty has advanced bone age.

Although precocious puberty includes thelarche and adrenarche, some important differences exist. Breast development, the growth spurt, and menses are all under the control of one system, the hypothalamic-pituitary-ovarian axis. Adrenarche, or secondary sexual hair, is primarily under the control of the adrenal gland, although the ovary is a major contributor to circulating androgens. Clinically, evaluate adrenal pathology more aggressively in cases of precocious adrenarche than in cases of thelarche.

It is also appropriate for a child without precocious puberty concerns to see a gynecologist in the early teenage years. This specialist can help you educate patients on reproductive health, including when Pap testing needs to be done and strategies to prevent pregnancy and sexually transmitted infection.

First recognize that a child with precocious puberty might actually have a serious underlying medical condition that triggers puberty. It is appropriate for you to distinguish true precocious puberty from precocious puberty secondary to a general underlying medical condition if this is within your comfort zone.

Begin with a complete history and physical examination. If you see physical signs of puberty that are not simply caused by “early puberty,” consider looking for underlying thyroid disorders, ovarian tumors, central nervous system tumors, or even tumors of the adrenal gland.

Importantly, perform a complete evaluation before initiation of any “treatment.” Occasionally, a patient with premature vaginal bleeding undergoes a very thorough hormone evaluation only to find the cause of her bleeding is a foreign body. Therefore, inspect the vaginal cavity as part of your physical examination or include this in your gynecologist referral when a girl presents with vaginal bleeding and no other evident signs of puberty. You might spare the patient a full hormone work-up. Also refer the child to a gynecologist if you suspect an abnormality of the reproductive tract because of pelvic pain, vaginal discharge, and/or abnormal vaginal bleeding.

The treatment for precocious puberty is controversial itself. Administration of an injection that blocks gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus is the most commonly prescribed therapy (leuprolide acetate, Lupron Depot-PED). Consider referral of these patients because gynecologists and pediatric endocrinologists have the most experience with this medication.

Other medications and lifestyle modifications are not particularly effective at halting early puberty.

Optimally, I advocate a combined effort among the pediatrician, the pediatric endocrinologist, and the gynecologist with a special interest in children.

Consider ordering a bone age study during your initial evaluation. It is an easy-to-order test for early puberty. Determination of the bone age of the left wrist is particularly worthwhile and provides useful information should you decide to refer to a specialist. Referral is warranted if a child with precocious puberty has advanced bone age.

Although precocious puberty includes thelarche and adrenarche, some important differences exist. Breast development, the growth spurt, and menses are all under the control of one system, the hypothalamic-pituitary-ovarian axis. Adrenarche, or secondary sexual hair, is primarily under the control of the adrenal gland, although the ovary is a major contributor to circulating androgens. Clinically, evaluate adrenal pathology more aggressively in cases of precocious adrenarche than in cases of thelarche.

It is also appropriate for a child without precocious puberty concerns to see a gynecologist in the early teenage years. This specialist can help you educate patients on reproductive health, including when Pap testing needs to be done and strategies to prevent pregnancy and sexually transmitted infection.

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As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

[email protected]

As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

[email protected]

As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

Pediatricians play an integral role in the initial diagnosis and management of children with a suspected food allergy. History, some useful laboratory tests, and careful counseling can go a long way to identify these sometimes challenging patients.

A considerable amount of anxiety often surrounds food allergy concerns, and this should be addressed (or at least acknowledged) with patients and their families.

Start with history, the most important diagnostic factor: Ask children and parents about specific symptoms, their timing, and foods the child has ingested. If the child experienced anaphylaxis, then include medication and insect stings in your history taking. The good news for primary care is that 90% of food allergies are caused by a few foods: milk, egg, wheat, soy, peanut, fish, shellfish, and nuts. Other triggers are relatively rare.

Allergy skin testing and/or specific immunoglobulin E (IgE) blood tests can support your diagnosis. However, these findings need to be correlated with history because false-positive results occur frequently. It is important to realize that the level of specific IgE to a food is not correlated with the severity of a reaction, but instead is correlated with the likelihood of having a single reaction.

Determine if the child's symptoms truly suggest an allergic reaction or instead point to a non–food-related cause. Psychological conditions such bulimia, anorexia, or factitious disorder can mimic a food allergy, for example.

Your differential diagnosis also includes structural abnormalities of the GI tract; cystic fibrosis with chronic diarrhea from pancreatic insufficiency; and illness caused by contaminants and additives such as flavorings, dyes, preservatives, or infectious organisms. Also check for exposure to pharmacologic contaminants such as caffeine or tyramine in certain foods.

Rule out lactose intolerance and other disaccharidase deficiencies (especially if the symptoms are limited to the GI tract) and a non-IgE reaction called food protein-induced enterocolitis syndrome (FPIES). An FPIES diagnosis is based on clinical presentation and symptoms because allergy skin testing and specific IgE assays are not helpful.

Also consider gastroesophageal reflux. Children whose symptoms do not improve with proton pump inhibitors might have eosinophilic esophagitis. A food allergen sometimes triggers this condition, and consultation with a gastroenterologist and a biopsy are the best clinical strategies.

It is appropriate for a general pediatrician to treat children with a food allergy when the source of the reaction is easily identifiable, when their symptoms are consistent with an allergic reaction, and when their condition is non–life threatening (and supported by specific IgE test results, if obtained).

Avoidance of the culprit allergen is essential to management. Stress the importance of reading all food labels. Self-injectable epinephrine (such as Mylan Inc.'s EpiPen or EpiPen Jr.) is another essential component. Instruct patients on how and when to use epinephrine, including what to do when anaphylaxis starts in school or in a day care setting. In some cases, it may be appropriate to suggest that the patient wear a medical alert bracelet or necklace.

Education is probably the most important factor in management. Talk to patients and families about prognosis, cross-reactive allergens, and the nutritional needs of patients with multiple food allergies. Keep in mind that if the list of foods to avoid is extensive, this may interfere with normal growth and development. A dietician can help educate families not only on what foods to avoid, but on what foods are encouraged.

Make sure parents are comfortable with your treatment plan. If you are confident in your identification of the culprit food, you can implement a food-elimination diet based on details from the history. Prescribe the appropriate dose of epinephrine and outline an anaphylaxis plan (easily found on the Web site www.foodallergy.org

Pediatricians can order in vitro specific IgE blood tests such as Phadia AB's Pharmacia CAP or UniCAP. These are helpful when performed by a reliable laboratory and may obviate the need for the skin testing of some patients for some foods. These tests are relatively good predictors of peanut, milk, and egg allergies.

In contrast, total IgE and complete blood count assays generally are not helpful. Performance of specific IgE blood tests to foods that are known to be clinically tolerated should be avoided; this just leads to confusion by all parties. In addition, avoid testing for specific IgG to foods because this strategy is not helpful for diagnosis. IgG is a measure of exposure only, and therefore positive results are not uncommon.

Most commonly, I see food-allergic patients post diagnosis to explain the results of previous tests and to develop an ongoing plan for avoidance, which includes strategies in the case of future accidental exposure.

If tolerance is suspected, I discuss with children and parents when to consider a food challenge. Such a protocol is probably best performed at a specialist's office, particularly if a more comprehensive, double-blind, placebo-controlled challenge is warranted. Food challenges require significant time and resources, including advance preparations in case anaphylaxis occurs.

Also consider referral to a specialist when a food culprit is not easily identified; when there is disparity between diagnostic test findings and patient history; and when the patient and family require more comprehensive education.

Pediatricians play an integral role in the initial diagnosis and management of children with a suspected food allergy. History, some useful laboratory tests, and careful counseling can go a long way to identify these sometimes challenging patients.

A considerable amount of anxiety often surrounds food allergy concerns, and this should be addressed (or at least acknowledged) with patients and their families.

Start with history, the most important diagnostic factor: Ask children and parents about specific symptoms, their timing, and foods the child has ingested. If the child experienced anaphylaxis, then include medication and insect stings in your history taking. The good news for primary care is that 90% of food allergies are caused by a few foods: milk, egg, wheat, soy, peanut, fish, shellfish, and nuts. Other triggers are relatively rare.

Allergy skin testing and/or specific immunoglobulin E (IgE) blood tests can support your diagnosis. However, these findings need to be correlated with history because false-positive results occur frequently. It is important to realize that the level of specific IgE to a food is not correlated with the severity of a reaction, but instead is correlated with the likelihood of having a single reaction.

Determine if the child's symptoms truly suggest an allergic reaction or instead point to a non–food-related cause. Psychological conditions such bulimia, anorexia, or factitious disorder can mimic a food allergy, for example.

Your differential diagnosis also includes structural abnormalities of the GI tract; cystic fibrosis with chronic diarrhea from pancreatic insufficiency; and illness caused by contaminants and additives such as flavorings, dyes, preservatives, or infectious organisms. Also check for exposure to pharmacologic contaminants such as caffeine or tyramine in certain foods.

Rule out lactose intolerance and other disaccharidase deficiencies (especially if the symptoms are limited to the GI tract) and a non-IgE reaction called food protein-induced enterocolitis syndrome (FPIES). An FPIES diagnosis is based on clinical presentation and symptoms because allergy skin testing and specific IgE assays are not helpful.

Also consider gastroesophageal reflux. Children whose symptoms do not improve with proton pump inhibitors might have eosinophilic esophagitis. A food allergen sometimes triggers this condition, and consultation with a gastroenterologist and a biopsy are the best clinical strategies.

It is appropriate for a general pediatrician to treat children with a food allergy when the source of the reaction is easily identifiable, when their symptoms are consistent with an allergic reaction, and when their condition is non–life threatening (and supported by specific IgE test results, if obtained).

Avoidance of the culprit allergen is essential to management. Stress the importance of reading all food labels. Self-injectable epinephrine (such as Mylan Inc.'s EpiPen or EpiPen Jr.) is another essential component. Instruct patients on how and when to use epinephrine, including what to do when anaphylaxis starts in school or in a day care setting. In some cases, it may be appropriate to suggest that the patient wear a medical alert bracelet or necklace.

Education is probably the most important factor in management. Talk to patients and families about prognosis, cross-reactive allergens, and the nutritional needs of patients with multiple food allergies. Keep in mind that if the list of foods to avoid is extensive, this may interfere with normal growth and development. A dietician can help educate families not only on what foods to avoid, but on what foods are encouraged.

Make sure parents are comfortable with your treatment plan. If you are confident in your identification of the culprit food, you can implement a food-elimination diet based on details from the history. Prescribe the appropriate dose of epinephrine and outline an anaphylaxis plan (easily found on the Web site www.foodallergy.org

Pediatricians can order in vitro specific IgE blood tests such as Phadia AB's Pharmacia CAP or UniCAP. These are helpful when performed by a reliable laboratory and may obviate the need for the skin testing of some patients for some foods. These tests are relatively good predictors of peanut, milk, and egg allergies.

In contrast, total IgE and complete blood count assays generally are not helpful. Performance of specific IgE blood tests to foods that are known to be clinically tolerated should be avoided; this just leads to confusion by all parties. In addition, avoid testing for specific IgG to foods because this strategy is not helpful for diagnosis. IgG is a measure of exposure only, and therefore positive results are not uncommon.

Most commonly, I see food-allergic patients post diagnosis to explain the results of previous tests and to develop an ongoing plan for avoidance, which includes strategies in the case of future accidental exposure.

If tolerance is suspected, I discuss with children and parents when to consider a food challenge. Such a protocol is probably best performed at a specialist's office, particularly if a more comprehensive, double-blind, placebo-controlled challenge is warranted. Food challenges require significant time and resources, including advance preparations in case anaphylaxis occurs.

Also consider referral to a specialist when a food culprit is not easily identified; when there is disparity between diagnostic test findings and patient history; and when the patient and family require more comprehensive education.

Pediatricians play an integral role in the initial diagnosis and management of children with a suspected food allergy. History, some useful laboratory tests, and careful counseling can go a long way to identify these sometimes challenging patients.

A considerable amount of anxiety often surrounds food allergy concerns, and this should be addressed (or at least acknowledged) with patients and their families.

Start with history, the most important diagnostic factor: Ask children and parents about specific symptoms, their timing, and foods the child has ingested. If the child experienced anaphylaxis, then include medication and insect stings in your history taking. The good news for primary care is that 90% of food allergies are caused by a few foods: milk, egg, wheat, soy, peanut, fish, shellfish, and nuts. Other triggers are relatively rare.

Allergy skin testing and/or specific immunoglobulin E (IgE) blood tests can support your diagnosis. However, these findings need to be correlated with history because false-positive results occur frequently. It is important to realize that the level of specific IgE to a food is not correlated with the severity of a reaction, but instead is correlated with the likelihood of having a single reaction.

Determine if the child's symptoms truly suggest an allergic reaction or instead point to a non–food-related cause. Psychological conditions such bulimia, anorexia, or factitious disorder can mimic a food allergy, for example.

Your differential diagnosis also includes structural abnormalities of the GI tract; cystic fibrosis with chronic diarrhea from pancreatic insufficiency; and illness caused by contaminants and additives such as flavorings, dyes, preservatives, or infectious organisms. Also check for exposure to pharmacologic contaminants such as caffeine or tyramine in certain foods.

Rule out lactose intolerance and other disaccharidase deficiencies (especially if the symptoms are limited to the GI tract) and a non-IgE reaction called food protein-induced enterocolitis syndrome (FPIES). An FPIES diagnosis is based on clinical presentation and symptoms because allergy skin testing and specific IgE assays are not helpful.

Also consider gastroesophageal reflux. Children whose symptoms do not improve with proton pump inhibitors might have eosinophilic esophagitis. A food allergen sometimes triggers this condition, and consultation with a gastroenterologist and a biopsy are the best clinical strategies.

It is appropriate for a general pediatrician to treat children with a food allergy when the source of the reaction is easily identifiable, when their symptoms are consistent with an allergic reaction, and when their condition is non–life threatening (and supported by specific IgE test results, if obtained).

Avoidance of the culprit allergen is essential to management. Stress the importance of reading all food labels. Self-injectable epinephrine (such as Mylan Inc.'s EpiPen or EpiPen Jr.) is another essential component. Instruct patients on how and when to use epinephrine, including what to do when anaphylaxis starts in school or in a day care setting. In some cases, it may be appropriate to suggest that the patient wear a medical alert bracelet or necklace.

Education is probably the most important factor in management. Talk to patients and families about prognosis, cross-reactive allergens, and the nutritional needs of patients with multiple food allergies. Keep in mind that if the list of foods to avoid is extensive, this may interfere with normal growth and development. A dietician can help educate families not only on what foods to avoid, but on what foods are encouraged.

Make sure parents are comfortable with your treatment plan. If you are confident in your identification of the culprit food, you can implement a food-elimination diet based on details from the history. Prescribe the appropriate dose of epinephrine and outline an anaphylaxis plan (easily found on the Web site www.foodallergy.org

Pediatricians can order in vitro specific IgE blood tests such as Phadia AB's Pharmacia CAP or UniCAP. These are helpful when performed by a reliable laboratory and may obviate the need for the skin testing of some patients for some foods. These tests are relatively good predictors of peanut, milk, and egg allergies.

In contrast, total IgE and complete blood count assays generally are not helpful. Performance of specific IgE blood tests to foods that are known to be clinically tolerated should be avoided; this just leads to confusion by all parties. In addition, avoid testing for specific IgG to foods because this strategy is not helpful for diagnosis. IgG is a measure of exposure only, and therefore positive results are not uncommon.

Most commonly, I see food-allergic patients post diagnosis to explain the results of previous tests and to develop an ongoing plan for avoidance, which includes strategies in the case of future accidental exposure.

If tolerance is suspected, I discuss with children and parents when to consider a food challenge. Such a protocol is probably best performed at a specialist's office, particularly if a more comprehensive, double-blind, placebo-controlled challenge is warranted. Food challenges require significant time and resources, including advance preparations in case anaphylaxis occurs.

Also consider referral to a specialist when a food culprit is not easily identified; when there is disparity between diagnostic test findings and patient history; and when the patient and family require more comprehensive education.

Dysmenorrhea and menorrhagia beyond the norm often overlap in adolescents and can occur in up to 15% of these young women.

The normal time period from breast development (thelarche) and development of pubic hair to menses in young girls is about 2 years. A longer time course is cause for investigation.

The maturation of the hypothalamic-pituitary-ovarian axis occurs over approximately 5 years. After initiation of menses (menarche), some adolescents have anovulatory cycles, i.e., no luteinizing hormone surge with subsequent lack of ovulation and dysfunctional estrogen effect on the uterine endometrial lining. This can present with irregular bleeding that can be very heavy when the endometrial lining sheds in an unsynchronized manner. If no other cause for this bleeding is established (for example, endocrine, anatomic, or underlying chronic disease), then it is considered dysfunctional uterine bleeding (DUB).

In the same time period of 5 years from menarche, an estimated 15%-30% of young women will have primary dysmenorrhea strong enough to require pain medication, including nonsteroidal anti-inflammatory drugs (NSAIDs).

The vast majority of young adolescent girls experience some pain with their periods, ranging from discomfort to pain requiring medication to being unable to go to school.

When the pain is severe, these patients either miss school or just make it through the school day, but their attention and performance suffer. These girls with significant pain need more assistance because their dysmenorrhea may not subside for several years, and a referral to a subspecialist is warranted.

In terms of differential diagnosis, menstrual pain (dysmenorrhea) is a crampy, focal phenomenon in the mid-lower quadrant, sometimes with radiation to the back and the lower extremities. It starts with the onset of menses. If the pain precedes menses, it may be endometriosis and not primary dysmenorrhea, although there is an overlap in the pain symptoms between these two entities. A nonleading question to ask is whether the patient experiences pain before, during, or after her cycle.

A gastrointestinal etiology is more likely if the pain is nonfocal and present in all four quadrants. Ruling out other GI etiologies, particularly constipation, is important. A trial of Miralax over 2-3 weeks with a cessation in the pain easily confirms constipation as the underlying cause. Constipation is very common in children and adolescents, and the pain is not related to the menstrual cycle.

Dysmenorrhea is a clinical diagnosis. Laboratory tests for this condition are not needed. Instead, a good history, detailed description of the pain, and ultrasound examination (transabdominal, not transvaginal) aid the differential diagnosis. Ultrasound is reassuring, as it can show normal uterine development and no ovarian masses, including no benign childhood ovarian tumors. Rarely is a pelvic examination necessary.

Pediatricians are instrumental in terms of educating patients, encouraging these patients to keep a detailed menstrual and pain diary, and advocating appropriate use of NSAIDs. However, if the diagnosis and management of teenagers with dysmenorrhea are outside your comfort zone, or your focus is primarily on younger children, you can refer the patient to a pediatric and adolescent gynecologist or other adolescent medicine specialist.

One problem for these patients is the use of Tylenol, which does not work on the elevated prostaglandins in primary dysmenorrhea. Instead, recommend an NSAID such as ibuprofen (Motrin, Advil), naproxen (Naprosyn), or mefenamic acid (Ponstel).

If pain relief is inadequate, switch classes of NSAIDs instead of switching between drugs in the same class.

Birth control pills are another option for controlling painful periods. For most girls with menses painful enough to impair their activities of daily living, birth control pills are a huge benefit. Oral contraceptives for 1-2 years for irregular bleeding and dysmenorrhea can make a big difference, and then you can try a trial period without them. Prescription of birth control pills requires a lot of education, particularly because these young patients need to be compliant. Create a routine for them—such as suggesting their pills be stored in a secure location with their toothbrush.

Parents also need to be vested in this approach, and some will be resistant. I recommend that you discuss birth control pills as a strategy to control pain and bleeding when the parents and the patient are both present. Educate parents that birth control pills will not give their daughters breast cancer or cause them to become sexually active. Any generic monophasic oral contraceptive with 30 mcg of estradiol can be used.

If you add birth control pills to NSAIDs, 95% of patients experience no pain or bearable pain. It can take up to 6 months for maximum relief, however, and these teenagers need to keep a menstrual and pain diary to track and appreciate the improvements over time.

Heating pads can be a comforting, nonpharmacologic strategy for managing dysmenorrhea. Some girls who use them report taking fewer NSAIDs. There also is some literature on the benefits of acupuncture, but it is not always practical in the United States.

DUB is a diagnosis of exclusion. In your differential diagnosis, rule out thyroid dysfunction, prolactinoma (a rare brain tumor), or any underlying chronic diseases (such as lupus) that affect the menstrual cycle. If you suspect anatomic abnormalities, a transabdominal ultrasound examination is indicated. You also have to consider polycystic ovarian syndrome (PCOS), because teenagers with this syndrome can present with irregular bleeding.

Laboratory tests for DUB are thyroid function, prolactin, and markers for PCOS. These assays include free and total testosterone, sex hormone–binding globulin, and androstenedione.

Most pediatricians know this, but if the first menses (menarche) is very heavy, you have to think of a bleeding disorder. This is an important diagnostic sign that additional work-up is warranted, and early intervention may be possible. If there is a bleeding disorder, early diagnosis could mean a lesser chance of hemorrhage during childbirth. Awareness among pediatricians is important because young girls rarely see gynecologists.

Classic DUB is related to menstrual cycle irregularities. There is a cohort of eggs recruited in the first half of the cycle (follicular phase). One follicle emerges that will rupture and release the egg at midcycle after luteinizing hormone levels spike in the body. If this sequence does not occur, the menstrual cycle is affected. The endometrial lining has proliferated under the effect of estrogen, and unsynchronized shedding with irregular bleeding occurs.

Again, you can take control of the menstrual cycle with birth control pills.

Dysmenorrhea and menorrhagia beyond the norm often overlap in adolescents and can occur in up to 15% of these young women.

The normal time period from breast development (thelarche) and development of pubic hair to menses in young girls is about 2 years. A longer time course is cause for investigation.

The maturation of the hypothalamic-pituitary-ovarian axis occurs over approximately 5 years. After initiation of menses (menarche), some adolescents have anovulatory cycles, i.e., no luteinizing hormone surge with subsequent lack of ovulation and dysfunctional estrogen effect on the uterine endometrial lining. This can present with irregular bleeding that can be very heavy when the endometrial lining sheds in an unsynchronized manner. If no other cause for this bleeding is established (for example, endocrine, anatomic, or underlying chronic disease), then it is considered dysfunctional uterine bleeding (DUB).

In the same time period of 5 years from menarche, an estimated 15%-30% of young women will have primary dysmenorrhea strong enough to require pain medication, including nonsteroidal anti-inflammatory drugs (NSAIDs).

The vast majority of young adolescent girls experience some pain with their periods, ranging from discomfort to pain requiring medication to being unable to go to school.

When the pain is severe, these patients either miss school or just make it through the school day, but their attention and performance suffer. These girls with significant pain need more assistance because their dysmenorrhea may not subside for several years, and a referral to a subspecialist is warranted.

In terms of differential diagnosis, menstrual pain (dysmenorrhea) is a crampy, focal phenomenon in the mid-lower quadrant, sometimes with radiation to the back and the lower extremities. It starts with the onset of menses. If the pain precedes menses, it may be endometriosis and not primary dysmenorrhea, although there is an overlap in the pain symptoms between these two entities. A nonleading question to ask is whether the patient experiences pain before, during, or after her cycle.

A gastrointestinal etiology is more likely if the pain is nonfocal and present in all four quadrants. Ruling out other GI etiologies, particularly constipation, is important. A trial of Miralax over 2-3 weeks with a cessation in the pain easily confirms constipation as the underlying cause. Constipation is very common in children and adolescents, and the pain is not related to the menstrual cycle.

Dysmenorrhea is a clinical diagnosis. Laboratory tests for this condition are not needed. Instead, a good history, detailed description of the pain, and ultrasound examination (transabdominal, not transvaginal) aid the differential diagnosis. Ultrasound is reassuring, as it can show normal uterine development and no ovarian masses, including no benign childhood ovarian tumors. Rarely is a pelvic examination necessary.

Pediatricians are instrumental in terms of educating patients, encouraging these patients to keep a detailed menstrual and pain diary, and advocating appropriate use of NSAIDs. However, if the diagnosis and management of teenagers with dysmenorrhea are outside your comfort zone, or your focus is primarily on younger children, you can refer the patient to a pediatric and adolescent gynecologist or other adolescent medicine specialist.

One problem for these patients is the use of Tylenol, which does not work on the elevated prostaglandins in primary dysmenorrhea. Instead, recommend an NSAID such as ibuprofen (Motrin, Advil), naproxen (Naprosyn), or mefenamic acid (Ponstel).

If pain relief is inadequate, switch classes of NSAIDs instead of switching between drugs in the same class.

Birth control pills are another option for controlling painful periods. For most girls with menses painful enough to impair their activities of daily living, birth control pills are a huge benefit. Oral contraceptives for 1-2 years for irregular bleeding and dysmenorrhea can make a big difference, and then you can try a trial period without them. Prescription of birth control pills requires a lot of education, particularly because these young patients need to be compliant. Create a routine for them—such as suggesting their pills be stored in a secure location with their toothbrush.

Parents also need to be vested in this approach, and some will be resistant. I recommend that you discuss birth control pills as a strategy to control pain and bleeding when the parents and the patient are both present. Educate parents that birth control pills will not give their daughters breast cancer or cause them to become sexually active. Any generic monophasic oral contraceptive with 30 mcg of estradiol can be used.

If you add birth control pills to NSAIDs, 95% of patients experience no pain or bearable pain. It can take up to 6 months for maximum relief, however, and these teenagers need to keep a menstrual and pain diary to track and appreciate the improvements over time.

Heating pads can be a comforting, nonpharmacologic strategy for managing dysmenorrhea. Some girls who use them report taking fewer NSAIDs. There also is some literature on the benefits of acupuncture, but it is not always practical in the United States.

DUB is a diagnosis of exclusion. In your differential diagnosis, rule out thyroid dysfunction, prolactinoma (a rare brain tumor), or any underlying chronic diseases (such as lupus) that affect the menstrual cycle. If you suspect anatomic abnormalities, a transabdominal ultrasound examination is indicated. You also have to consider polycystic ovarian syndrome (PCOS), because teenagers with this syndrome can present with irregular bleeding.

Laboratory tests for DUB are thyroid function, prolactin, and markers for PCOS. These assays include free and total testosterone, sex hormone–binding globulin, and androstenedione.

Most pediatricians know this, but if the first menses (menarche) is very heavy, you have to think of a bleeding disorder. This is an important diagnostic sign that additional work-up is warranted, and early intervention may be possible. If there is a bleeding disorder, early diagnosis could mean a lesser chance of hemorrhage during childbirth. Awareness among pediatricians is important because young girls rarely see gynecologists.

Classic DUB is related to menstrual cycle irregularities. There is a cohort of eggs recruited in the first half of the cycle (follicular phase). One follicle emerges that will rupture and release the egg at midcycle after luteinizing hormone levels spike in the body. If this sequence does not occur, the menstrual cycle is affected. The endometrial lining has proliferated under the effect of estrogen, and unsynchronized shedding with irregular bleeding occurs.

Again, you can take control of the menstrual cycle with birth control pills.

Dysmenorrhea and menorrhagia beyond the norm often overlap in adolescents and can occur in up to 15% of these young women.

The normal time period from breast development (thelarche) and development of pubic hair to menses in young girls is about 2 years. A longer time course is cause for investigation.

The maturation of the hypothalamic-pituitary-ovarian axis occurs over approximately 5 years. After initiation of menses (menarche), some adolescents have anovulatory cycles, i.e., no luteinizing hormone surge with subsequent lack of ovulation and dysfunctional estrogen effect on the uterine endometrial lining. This can present with irregular bleeding that can be very heavy when the endometrial lining sheds in an unsynchronized manner. If no other cause for this bleeding is established (for example, endocrine, anatomic, or underlying chronic disease), then it is considered dysfunctional uterine bleeding (DUB).

In the same time period of 5 years from menarche, an estimated 15%-30% of young women will have primary dysmenorrhea strong enough to require pain medication, including nonsteroidal anti-inflammatory drugs (NSAIDs).

The vast majority of young adolescent girls experience some pain with their periods, ranging from discomfort to pain requiring medication to being unable to go to school.

When the pain is severe, these patients either miss school or just make it through the school day, but their attention and performance suffer. These girls with significant pain need more assistance because their dysmenorrhea may not subside for several years, and a referral to a subspecialist is warranted.

In terms of differential diagnosis, menstrual pain (dysmenorrhea) is a crampy, focal phenomenon in the mid-lower quadrant, sometimes with radiation to the back and the lower extremities. It starts with the onset of menses. If the pain precedes menses, it may be endometriosis and not primary dysmenorrhea, although there is an overlap in the pain symptoms between these two entities. A nonleading question to ask is whether the patient experiences pain before, during, or after her cycle.

A gastrointestinal etiology is more likely if the pain is nonfocal and present in all four quadrants. Ruling out other GI etiologies, particularly constipation, is important. A trial of Miralax over 2-3 weeks with a cessation in the pain easily confirms constipation as the underlying cause. Constipation is very common in children and adolescents, and the pain is not related to the menstrual cycle.

Dysmenorrhea is a clinical diagnosis. Laboratory tests for this condition are not needed. Instead, a good history, detailed description of the pain, and ultrasound examination (transabdominal, not transvaginal) aid the differential diagnosis. Ultrasound is reassuring, as it can show normal uterine development and no ovarian masses, including no benign childhood ovarian tumors. Rarely is a pelvic examination necessary.

Pediatricians are instrumental in terms of educating patients, encouraging these patients to keep a detailed menstrual and pain diary, and advocating appropriate use of NSAIDs. However, if the diagnosis and management of teenagers with dysmenorrhea are outside your comfort zone, or your focus is primarily on younger children, you can refer the patient to a pediatric and adolescent gynecologist or other adolescent medicine specialist.

One problem for these patients is the use of Tylenol, which does not work on the elevated prostaglandins in primary dysmenorrhea. Instead, recommend an NSAID such as ibuprofen (Motrin, Advil), naproxen (Naprosyn), or mefenamic acid (Ponstel).

If pain relief is inadequate, switch classes of NSAIDs instead of switching between drugs in the same class.

Birth control pills are another option for controlling painful periods. For most girls with menses painful enough to impair their activities of daily living, birth control pills are a huge benefit. Oral contraceptives for 1-2 years for irregular bleeding and dysmenorrhea can make a big difference, and then you can try a trial period without them. Prescription of birth control pills requires a lot of education, particularly because these young patients need to be compliant. Create a routine for them—such as suggesting their pills be stored in a secure location with their toothbrush.

Parents also need to be vested in this approach, and some will be resistant. I recommend that you discuss birth control pills as a strategy to control pain and bleeding when the parents and the patient are both present. Educate parents that birth control pills will not give their daughters breast cancer or cause them to become sexually active. Any generic monophasic oral contraceptive with 30 mcg of estradiol can be used.

If you add birth control pills to NSAIDs, 95% of patients experience no pain or bearable pain. It can take up to 6 months for maximum relief, however, and these teenagers need to keep a menstrual and pain diary to track and appreciate the improvements over time.

Heating pads can be a comforting, nonpharmacologic strategy for managing dysmenorrhea. Some girls who use them report taking fewer NSAIDs. There also is some literature on the benefits of acupuncture, but it is not always practical in the United States.

DUB is a diagnosis of exclusion. In your differential diagnosis, rule out thyroid dysfunction, prolactinoma (a rare brain tumor), or any underlying chronic diseases (such as lupus) that affect the menstrual cycle. If you suspect anatomic abnormalities, a transabdominal ultrasound examination is indicated. You also have to consider polycystic ovarian syndrome (PCOS), because teenagers with this syndrome can present with irregular bleeding.

Laboratory tests for DUB are thyroid function, prolactin, and markers for PCOS. These assays include free and total testosterone, sex hormone–binding globulin, and androstenedione.

Most pediatricians know this, but if the first menses (menarche) is very heavy, you have to think of a bleeding disorder. This is an important diagnostic sign that additional work-up is warranted, and early intervention may be possible. If there is a bleeding disorder, early diagnosis could mean a lesser chance of hemorrhage during childbirth. Awareness among pediatricians is important because young girls rarely see gynecologists.

Classic DUB is related to menstrual cycle irregularities. There is a cohort of eggs recruited in the first half of the cycle (follicular phase). One follicle emerges that will rupture and release the egg at midcycle after luteinizing hormone levels spike in the body. If this sequence does not occur, the menstrual cycle is affected. The endometrial lining has proliferated under the effect of estrogen, and unsynchronized shedding with irregular bleeding occurs.

Again, you can take control of the menstrual cycle with birth control pills.

[email protected]

Identification of children and adolescents with anxiety is important, so consider the diagnosis in your differential. Always think: Could this be anxiety?

Pediatricians are well trained to rule out medical or other causes of anxiety. Questions to ask include: Is the child hypoxic? Does the patient have hypothyroidism? Is the anxiety caused by stress or social factors, including sexual and/or physical abuse? Do the symptoms come from a general adjustment disorder from a major life change or event, such as a move or divorce?

Does the patient have a secret she is afraid to share with anyone else? A shy child, for example, may have something she is afraid to discuss that, together with stressors, can lead her into a true anxiety disorder.

Panic attacks, in particular, can be clinically challenging. Is the attack anxiety driven or caused by an underlying medical problem? We tend to minimize cardiac symptoms, for example, in some children because it is easier to say these symptoms are related only to anxiety. But we need due diligence to rule out any major cardiac or pulmonary etiologies.

When screening patients for anxiety disorders, child and adolescent psychiatrists use comprehensive instruments like the Screen for Child Anxiety-Related Emotional Disorders (SCARED). In a busy primary care setting, I would recommend that pediatricians use the SCARED tool. It is available at no cost and features separate rating scales that can be completed by the child and parent.

For a more comprehensive screening tool, use the Child Behavior Checklist (CBCL), the Child Symptom Inventory (CSI), or the Behavior Assessment Symptom for Children (BASC). Other screening instruments are available that are more disease specific, such as the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) for obsessive-compulsive disorder (OCD).

It is appropriate for pediatricians to manage the treatment of an anxious child or adolescent when the patient is stabilized and continues to improve with treatment. In this way, a child with anxiety is managed no differently than a patient with asthma or diabetes.

Some pediatricians refer a child with a suspected anxiety disorder for an initial evaluation by a mental health specialist such as a child and adolescent psychiatrist, followed by annual consultations. We are happy to consult with pediatricians. One challenge, however, is an overall workforce shortage of child and adolescent psychiatrists. The American Academy of Child & Adolescent Psychiatry offers an online map of the United States that shows the number of specialists per county (www.aacap.org/cs/physicians.AlliedProfessionals/workforce_issues

When is it appropriate for a pediatrician to initiate medication in this patient population? Any time it is indicated! And that really depends on the diagnosis: for OCD, yes; for PTSD, maybe; and for social phobias, probably not. Medication use also is based on symptom severity, especially in generalized anxiety disorder. If the child is not sleeping well or participating in activities of daily living, you have to get him or her stabilized first. The bulk of our treatment for anxiety disorders is psychotherapy, but the child is less likely to benefit from therapy if anxiety impedes the ability to participate in therapy.

Referral to a specialist is indicated when anxiety symptoms interfere with activities of daily living. School refusal is another scenario that warrants immediate referral. Some parents will allow anxious children to stay out of school, so try to determine the reason: Is the parent making it more comfortable for the child to stay at home? Or is the patient avoiding school because they are the target of teasing?

Copies of a recent physical examination, growth chart, and any laboratory work already ordered are helpful with a referral to a child and adolescent psychiatrist. In addition, a detailed clinical assessment facilitates management by a child and adolescent psychiatrist. In other words, it is helpful to get a note that states: “Referring Johnny to you. He was a developmentally normal 5-year-old until he nearly drowned in a pool last summer. He now refuses to sleep alone.” In contrast, a less helpful note might read: “Here is a 5-year-old named Johnny. Please assess.”

Unless you suspect a true organic etiology, such as an abnormal neurologic examination, avoid ordering routine imaging studies for a child with anxiety prior to referral. I am concerned about the risks of sedation for pediatric patients and risks associated with radiation exposure (with CT scans, for example).

Avoid excessive laboratory testing as well, unless there is a clear indication that results could rule out a suspected medical diagnosis.

[email protected]

Identification of children and adolescents with anxiety is important, so consider the diagnosis in your differential. Always think: Could this be anxiety?

Pediatricians are well trained to rule out medical or other causes of anxiety. Questions to ask include: Is the child hypoxic? Does the patient have hypothyroidism? Is the anxiety caused by stress or social factors, including sexual and/or physical abuse? Do the symptoms come from a general adjustment disorder from a major life change or event, such as a move or divorce?

Does the patient have a secret she is afraid to share with anyone else? A shy child, for example, may have something she is afraid to discuss that, together with stressors, can lead her into a true anxiety disorder.

Panic attacks, in particular, can be clinically challenging. Is the attack anxiety driven or caused by an underlying medical problem? We tend to minimize cardiac symptoms, for example, in some children because it is easier to say these symptoms are related only to anxiety. But we need due diligence to rule out any major cardiac or pulmonary etiologies.

When screening patients for anxiety disorders, child and adolescent psychiatrists use comprehensive instruments like the Screen for Child Anxiety-Related Emotional Disorders (SCARED). In a busy primary care setting, I would recommend that pediatricians use the SCARED tool. It is available at no cost and features separate rating scales that can be completed by the child and parent.

For a more comprehensive screening tool, use the Child Behavior Checklist (CBCL), the Child Symptom Inventory (CSI), or the Behavior Assessment Symptom for Children (BASC). Other screening instruments are available that are more disease specific, such as the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) for obsessive-compulsive disorder (OCD).

It is appropriate for pediatricians to manage the treatment of an anxious child or adolescent when the patient is stabilized and continues to improve with treatment. In this way, a child with anxiety is managed no differently than a patient with asthma or diabetes.

Some pediatricians refer a child with a suspected anxiety disorder for an initial evaluation by a mental health specialist such as a child and adolescent psychiatrist, followed by annual consultations. We are happy to consult with pediatricians. One challenge, however, is an overall workforce shortage of child and adolescent psychiatrists. The American Academy of Child & Adolescent Psychiatry offers an online map of the United States that shows the number of specialists per county (www.aacap.org/cs/physicians.AlliedProfessionals/workforce_issues

When is it appropriate for a pediatrician to initiate medication in this patient population? Any time it is indicated! And that really depends on the diagnosis: for OCD, yes; for PTSD, maybe; and for social phobias, probably not. Medication use also is based on symptom severity, especially in generalized anxiety disorder. If the child is not sleeping well or participating in activities of daily living, you have to get him or her stabilized first. The bulk of our treatment for anxiety disorders is psychotherapy, but the child is less likely to benefit from therapy if anxiety impedes the ability to participate in therapy.

Referral to a specialist is indicated when anxiety symptoms interfere with activities of daily living. School refusal is another scenario that warrants immediate referral. Some parents will allow anxious children to stay out of school, so try to determine the reason: Is the parent making it more comfortable for the child to stay at home? Or is the patient avoiding school because they are the target of teasing?

Copies of a recent physical examination, growth chart, and any laboratory work already ordered are helpful with a referral to a child and adolescent psychiatrist. In addition, a detailed clinical assessment facilitates management by a child and adolescent psychiatrist. In other words, it is helpful to get a note that states: “Referring Johnny to you. He was a developmentally normal 5-year-old until he nearly drowned in a pool last summer. He now refuses to sleep alone.” In contrast, a less helpful note might read: “Here is a 5-year-old named Johnny. Please assess.”

Unless you suspect a true organic etiology, such as an abnormal neurologic examination, avoid ordering routine imaging studies for a child with anxiety prior to referral. I am concerned about the risks of sedation for pediatric patients and risks associated with radiation exposure (with CT scans, for example).

Avoid excessive laboratory testing as well, unless there is a clear indication that results could rule out a suspected medical diagnosis.

[email protected]

Identification of children and adolescents with anxiety is important, so consider the diagnosis in your differential. Always think: Could this be anxiety?

Pediatricians are well trained to rule out medical or other causes of anxiety. Questions to ask include: Is the child hypoxic? Does the patient have hypothyroidism? Is the anxiety caused by stress or social factors, including sexual and/or physical abuse? Do the symptoms come from a general adjustment disorder from a major life change or event, such as a move or divorce?

Does the patient have a secret she is afraid to share with anyone else? A shy child, for example, may have something she is afraid to discuss that, together with stressors, can lead her into a true anxiety disorder.

Panic attacks, in particular, can be clinically challenging. Is the attack anxiety driven or caused by an underlying medical problem? We tend to minimize cardiac symptoms, for example, in some children because it is easier to say these symptoms are related only to anxiety. But we need due diligence to rule out any major cardiac or pulmonary etiologies.

When screening patients for anxiety disorders, child and adolescent psychiatrists use comprehensive instruments like the Screen for Child Anxiety-Related Emotional Disorders (SCARED). In a busy primary care setting, I would recommend that pediatricians use the SCARED tool. It is available at no cost and features separate rating scales that can be completed by the child and parent.

For a more comprehensive screening tool, use the Child Behavior Checklist (CBCL), the Child Symptom Inventory (CSI), or the Behavior Assessment Symptom for Children (BASC). Other screening instruments are available that are more disease specific, such as the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) for obsessive-compulsive disorder (OCD).

It is appropriate for pediatricians to manage the treatment of an anxious child or adolescent when the patient is stabilized and continues to improve with treatment. In this way, a child with anxiety is managed no differently than a patient with asthma or diabetes.

Some pediatricians refer a child with a suspected anxiety disorder for an initial evaluation by a mental health specialist such as a child and adolescent psychiatrist, followed by annual consultations. We are happy to consult with pediatricians. One challenge, however, is an overall workforce shortage of child and adolescent psychiatrists. The American Academy of Child & Adolescent Psychiatry offers an online map of the United States that shows the number of specialists per county (www.aacap.org/cs/physicians.AlliedProfessionals/workforce_issues

When is it appropriate for a pediatrician to initiate medication in this patient population? Any time it is indicated! And that really depends on the diagnosis: for OCD, yes; for PTSD, maybe; and for social phobias, probably not. Medication use also is based on symptom severity, especially in generalized anxiety disorder. If the child is not sleeping well or participating in activities of daily living, you have to get him or her stabilized first. The bulk of our treatment for anxiety disorders is psychotherapy, but the child is less likely to benefit from therapy if anxiety impedes the ability to participate in therapy.

Referral to a specialist is indicated when anxiety symptoms interfere with activities of daily living. School refusal is another scenario that warrants immediate referral. Some parents will allow anxious children to stay out of school, so try to determine the reason: Is the parent making it more comfortable for the child to stay at home? Or is the patient avoiding school because they are the target of teasing?

Copies of a recent physical examination, growth chart, and any laboratory work already ordered are helpful with a referral to a child and adolescent psychiatrist. In addition, a detailed clinical assessment facilitates management by a child and adolescent psychiatrist. In other words, it is helpful to get a note that states: “Referring Johnny to you. He was a developmentally normal 5-year-old until he nearly drowned in a pool last summer. He now refuses to sleep alone.” In contrast, a less helpful note might read: “Here is a 5-year-old named Johnny. Please assess.”

Unless you suspect a true organic etiology, such as an abnormal neurologic examination, avoid ordering routine imaging studies for a child with anxiety prior to referral. I am concerned about the risks of sedation for pediatric patients and risks associated with radiation exposure (with CT scans, for example).

Avoid excessive laboratory testing as well, unless there is a clear indication that results could rule out a suspected medical diagnosis.

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When children or adolescents present complaining of heart palpitations, first determine just what they are describing. “Heart palpitation” is a very vague term and could mean anything: Patients might say their “heart is racing,” they feel like they “skipped a heartbeat,” or it could just be a greater awareness of their heart beating.

A comprehensive history is important in determining the possibility of a significant arrhythmia. Every child walking in with a history of palpitation does not have a cardiac arrhythmia.

Significant arrhythmias are far fewer in children than adults. More common in children are noncardiac issues, such as heart palpitations associated with anxiety and panic attacks or minor arrhythmias such as premature atrial and ventricular beats.

Normal heart rhythm is sinus rhythm, and sinus tachycardia is not a problem most of the time. Sinus tachycardia has many possible etiologies. It can occur when a child or adolescent exercises, feels anxious, or is running a fever. Fortunately, sinus tachycardia is not something we normally worry about. Children are easily excited and may experience their heart racing. They may report that they feel short of breath during an episode, which may point to anxiety. In some cases, excessive caffeine intake may be responsible for these symptoms.

Ask about onset and duration of symptoms during history taking. For example, patients who report a rapid heartbeat that lasts a half-hour or longer are more of a concern than those who report a few minutes or seconds of symptoms where it feels like “their heart is popping out of their chest.” Also inquire about dizziness, which could indicate their blood pressure falls during an episode.

Pediatricians who feel comfortable addressing cardiac issues should try to differentiate benign sinus tachycardia from the more concerning forms: supraventricular tachycardia and ventricular tachycardia.

If parents report the child's heart was racing and it was 120 beats per minute (bpm), you can reassure them. If the heart rate is 120, 130, 140, 150, or even 160, it is generally nothing to worry about—it is bound to be sinus tachycardia. Even very fast sinus tachycardia may be normal given the circumstances. For example, a 16-year-old athlete at the peak of physical activity might have a heart rate closer to 190 or 200 bpm. That is fast, but it is appropriate for the age and level of activity.

More worrisome is supraventricular tachycardia (SVT), which has an entirely different mechanism in terms of electrophysiology of the heart, reentry being responsible for most. The electrical conduction system of the heart may have a bypass tract or a dual atrioventricular node which allows for reentry to occur. In general, the heart rate of 200 bpm or higher is likely to be SVT and warrants referral to a cardiac specialist.

Patients with heart rates falling in the in-between range (170-200 bpm) may have sinus tachycardia or SVT and should also have a work-up. Attempting to document the rhythm during episodes becomes important in these children.

SVT can occur in children of any age, including newborns and infants. It usually starts abruptly and unpredictably—out of the blue, the heart starts racing. The child can be completely inactive at the time. For a minority, exercise may be the trigger. The rapid heartbeat may be short or last for many hours, and then the episode stops as suddenly as it started. It is not life threatening unless the child is in incessant SVT for hours.

A routine ECG can sometimes help pediatricians with their differential diagnosis. Markers, such as a bypass tract, can show up on the ECG tracing. If a pre-excitement pattern is seen, further work-up may be needed, even in asymptomatic children incidentally discovered on routine testing for other reasons. Unequivocal diagnosis of SVT requires ECG documentation of the abnormal rhythm during an episode.

Because episodes of SVT tend to be unpredictable, trying to record the rhythm during the episode is not an easy exercise. One solution is to ask parents to record the child's pulse rate or heart rate during an episode, while the patient is complaining of symptoms. Going to the nearest emergency department increases the possibility of ECG identification of the SVT.

A pediatrician can also prescribe 24-hour Holter monitoring to try to catch an episode. If a patient is referred to a pediatric cardiologist, the patient is often monitored for a longer period of time in an attempt to catch the arrhythmia, such as 48-72 hours. Another helpful device is a loop recorder, which is worn constantly; it records and erases the ECG data after each half-hour. Parents are instructed to save the data after the episode by pushing a button. The data can then be transmitted to the monitoring company via telephone. The signal is turned into an ECG rhythm strip and sent to the physician for further analysis and necessary action.

The most worrisome arrhythmia in children is ventricular tachycardia (VT). It is a life-threatening arrhythmia. Fortunately, it is the most uncommon. Nonetheless, people who treat children have to be aware of conditions that are a setup for this kind of arrhythmia.

Hypertrophic cardiomyopathy is one such condition. It is a genetic condition leading to abnormality of the ventricular muscle. The abnormality produces a structural change with thickening of the heart muscle in an asymmetric fashion. The thickness may cause obstruction of the left ventricular outflow tract. In addition, such an individual is prone to VT. The presenting symptom for such individuals tends to be loss of consciousness or a fainting episode with the arrhythmia, generally occurring in the setting of vigorous physical activity. It can be a silent condition, fainting or collapse being the first symptom for some patients. Diagnosis is made by a combination of tests, including echocardiogram and ECG. Genetic testing is now available for the condition but does not help with practical management issues.

If a child is reporting other problems, such as constant fatigue and/or symptoms with minor daily activities, it suggests the possibility of myocarditis, usually related to viral infections. The heart of a child with such an infection becomes dilated and does not contract well. These patients are prone to VT. While some children with myocarditis recover, others may suffer permanent damage. The heart may remain dilated and prone to VT.

Another rare condition to include in your differential diagnosis is prolonged QT interval syndrome. The condition is genetic in nature and tends to run in families. The mechanism involves gates or ion channels in cell membranes that normally regulate the influx of sodium, potassium, and calcium. In a child with the syndrome, the gates remain open too long, thereby allowing too much sodium or calcium to enter the cells, and VT can ensue. ECG tracings and a history of syncope can be diagnostic. Genetic testing is available and helpful.

Ventricular tachycardia is very worrisome because it can be fatal within minutes. Therefore, VT is an emergency in most instances, although there are some benign forms that are well tolerated. The distinction can sometimes require an electrophysiology study. The placement of automatic external defibrillators in public places has enhanced the chances of survival in patients who experience rapid VT.

[email protected]

When children or adolescents present complaining of heart palpitations, first determine just what they are describing. “Heart palpitation” is a very vague term and could mean anything: Patients might say their “heart is racing,” they feel like they “skipped a heartbeat,” or it could just be a greater awareness of their heart beating.

A comprehensive history is important in determining the possibility of a significant arrhythmia. Every child walking in with a history of palpitation does not have a cardiac arrhythmia.

Significant arrhythmias are far fewer in children than adults. More common in children are noncardiac issues, such as heart palpitations associated with anxiety and panic attacks or minor arrhythmias such as premature atrial and ventricular beats.

Normal heart rhythm is sinus rhythm, and sinus tachycardia is not a problem most of the time. Sinus tachycardia has many possible etiologies. It can occur when a child or adolescent exercises, feels anxious, or is running a fever. Fortunately, sinus tachycardia is not something we normally worry about. Children are easily excited and may experience their heart racing. They may report that they feel short of breath during an episode, which may point to anxiety. In some cases, excessive caffeine intake may be responsible for these symptoms.

Ask about onset and duration of symptoms during history taking. For example, patients who report a rapid heartbeat that lasts a half-hour or longer are more of a concern than those who report a few minutes or seconds of symptoms where it feels like “their heart is popping out of their chest.” Also inquire about dizziness, which could indicate their blood pressure falls during an episode.

Pediatricians who feel comfortable addressing cardiac issues should try to differentiate benign sinus tachycardia from the more concerning forms: supraventricular tachycardia and ventricular tachycardia.

If parents report the child's heart was racing and it was 120 beats per minute (bpm), you can reassure them. If the heart rate is 120, 130, 140, 150, or even 160, it is generally nothing to worry about—it is bound to be sinus tachycardia. Even very fast sinus tachycardia may be normal given the circumstances. For example, a 16-year-old athlete at the peak of physical activity might have a heart rate closer to 190 or 200 bpm. That is fast, but it is appropriate for the age and level of activity.

More worrisome is supraventricular tachycardia (SVT), which has an entirely different mechanism in terms of electrophysiology of the heart, reentry being responsible for most. The electrical conduction system of the heart may have a bypass tract or a dual atrioventricular node which allows for reentry to occur. In general, the heart rate of 200 bpm or higher is likely to be SVT and warrants referral to a cardiac specialist.

Patients with heart rates falling in the in-between range (170-200 bpm) may have sinus tachycardia or SVT and should also have a work-up. Attempting to document the rhythm during episodes becomes important in these children.

SVT can occur in children of any age, including newborns and infants. It usually starts abruptly and unpredictably—out of the blue, the heart starts racing. The child can be completely inactive at the time. For a minority, exercise may be the trigger. The rapid heartbeat may be short or last for many hours, and then the episode stops as suddenly as it started. It is not life threatening unless the child is in incessant SVT for hours.

A routine ECG can sometimes help pediatricians with their differential diagnosis. Markers, such as a bypass tract, can show up on the ECG tracing. If a pre-excitement pattern is seen, further work-up may be needed, even in asymptomatic children incidentally discovered on routine testing for other reasons. Unequivocal diagnosis of SVT requires ECG documentation of the abnormal rhythm during an episode.

Because episodes of SVT tend to be unpredictable, trying to record the rhythm during the episode is not an easy exercise. One solution is to ask parents to record the child's pulse rate or heart rate during an episode, while the patient is complaining of symptoms. Going to the nearest emergency department increases the possibility of ECG identification of the SVT.

A pediatrician can also prescribe 24-hour Holter monitoring to try to catch an episode. If a patient is referred to a pediatric cardiologist, the patient is often monitored for a longer period of time in an attempt to catch the arrhythmia, such as 48-72 hours. Another helpful device is a loop recorder, which is worn constantly; it records and erases the ECG data after each half-hour. Parents are instructed to save the data after the episode by pushing a button. The data can then be transmitted to the monitoring company via telephone. The signal is turned into an ECG rhythm strip and sent to the physician for further analysis and necessary action.

The most worrisome arrhythmia in children is ventricular tachycardia (VT). It is a life-threatening arrhythmia. Fortunately, it is the most uncommon. Nonetheless, people who treat children have to be aware of conditions that are a setup for this kind of arrhythmia.

Hypertrophic cardiomyopathy is one such condition. It is a genetic condition leading to abnormality of the ventricular muscle. The abnormality produces a structural change with thickening of the heart muscle in an asymmetric fashion. The thickness may cause obstruction of the left ventricular outflow tract. In addition, such an individual is prone to VT. The presenting symptom for such individuals tends to be loss of consciousness or a fainting episode with the arrhythmia, generally occurring in the setting of vigorous physical activity. It can be a silent condition, fainting or collapse being the first symptom for some patients. Diagnosis is made by a combination of tests, including echocardiogram and ECG. Genetic testing is now available for the condition but does not help with practical management issues.

If a child is reporting other problems, such as constant fatigue and/or symptoms with minor daily activities, it suggests the possibility of myocarditis, usually related to viral infections. The heart of a child with such an infection becomes dilated and does not contract well. These patients are prone to VT. While some children with myocarditis recover, others may suffer permanent damage. The heart may remain dilated and prone to VT.

Another rare condition to include in your differential diagnosis is prolonged QT interval syndrome. The condition is genetic in nature and tends to run in families. The mechanism involves gates or ion channels in cell membranes that normally regulate the influx of sodium, potassium, and calcium. In a child with the syndrome, the gates remain open too long, thereby allowing too much sodium or calcium to enter the cells, and VT can ensue. ECG tracings and a history of syncope can be diagnostic. Genetic testing is available and helpful.

Ventricular tachycardia is very worrisome because it can be fatal within minutes. Therefore, VT is an emergency in most instances, although there are some benign forms that are well tolerated. The distinction can sometimes require an electrophysiology study. The placement of automatic external defibrillators in public places has enhanced the chances of survival in patients who experience rapid VT.

[email protected]

When children or adolescents present complaining of heart palpitations, first determine just what they are describing. “Heart palpitation” is a very vague term and could mean anything: Patients might say their “heart is racing,” they feel like they “skipped a heartbeat,” or it could just be a greater awareness of their heart beating.

A comprehensive history is important in determining the possibility of a significant arrhythmia. Every child walking in with a history of palpitation does not have a cardiac arrhythmia.

Significant arrhythmias are far fewer in children than adults. More common in children are noncardiac issues, such as heart palpitations associated with anxiety and panic attacks or minor arrhythmias such as premature atrial and ventricular beats.

Normal heart rhythm is sinus rhythm, and sinus tachycardia is not a problem most of the time. Sinus tachycardia has many possible etiologies. It can occur when a child or adolescent exercises, feels anxious, or is running a fever. Fortunately, sinus tachycardia is not something we normally worry about. Children are easily excited and may experience their heart racing. They may report that they feel short of breath during an episode, which may point to anxiety. In some cases, excessive caffeine intake may be responsible for these symptoms.

Ask about onset and duration of symptoms during history taking. For example, patients who report a rapid heartbeat that lasts a half-hour or longer are more of a concern than those who report a few minutes or seconds of symptoms where it feels like “their heart is popping out of their chest.” Also inquire about dizziness, which could indicate their blood pressure falls during an episode.

Pediatricians who feel comfortable addressing cardiac issues should try to differentiate benign sinus tachycardia from the more concerning forms: supraventricular tachycardia and ventricular tachycardia.

If parents report the child's heart was racing and it was 120 beats per minute (bpm), you can reassure them. If the heart rate is 120, 130, 140, 150, or even 160, it is generally nothing to worry about—it is bound to be sinus tachycardia. Even very fast sinus tachycardia may be normal given the circumstances. For example, a 16-year-old athlete at the peak of physical activity might have a heart rate closer to 190 or 200 bpm. That is fast, but it is appropriate for the age and level of activity.

More worrisome is supraventricular tachycardia (SVT), which has an entirely different mechanism in terms of electrophysiology of the heart, reentry being responsible for most. The electrical conduction system of the heart may have a bypass tract or a dual atrioventricular node which allows for reentry to occur. In general, the heart rate of 200 bpm or higher is likely to be SVT and warrants referral to a cardiac specialist.

Patients with heart rates falling in the in-between range (170-200 bpm) may have sinus tachycardia or SVT and should also have a work-up. Attempting to document the rhythm during episodes becomes important in these children.

SVT can occur in children of any age, including newborns and infants. It usually starts abruptly and unpredictably—out of the blue, the heart starts racing. The child can be completely inactive at the time. For a minority, exercise may be the trigger. The rapid heartbeat may be short or last for many hours, and then the episode stops as suddenly as it started. It is not life threatening unless the child is in incessant SVT for hours.

A routine ECG can sometimes help pediatricians with their differential diagnosis. Markers, such as a bypass tract, can show up on the ECG tracing. If a pre-excitement pattern is seen, further work-up may be needed, even in asymptomatic children incidentally discovered on routine testing for other reasons. Unequivocal diagnosis of SVT requires ECG documentation of the abnormal rhythm during an episode.

Because episodes of SVT tend to be unpredictable, trying to record the rhythm during the episode is not an easy exercise. One solution is to ask parents to record the child's pulse rate or heart rate during an episode, while the patient is complaining of symptoms. Going to the nearest emergency department increases the possibility of ECG identification of the SVT.

A pediatrician can also prescribe 24-hour Holter monitoring to try to catch an episode. If a patient is referred to a pediatric cardiologist, the patient is often monitored for a longer period of time in an attempt to catch the arrhythmia, such as 48-72 hours. Another helpful device is a loop recorder, which is worn constantly; it records and erases the ECG data after each half-hour. Parents are instructed to save the data after the episode by pushing a button. The data can then be transmitted to the monitoring company via telephone. The signal is turned into an ECG rhythm strip and sent to the physician for further analysis and necessary action.

The most worrisome arrhythmia in children is ventricular tachycardia (VT). It is a life-threatening arrhythmia. Fortunately, it is the most uncommon. Nonetheless, people who treat children have to be aware of conditions that are a setup for this kind of arrhythmia.

Hypertrophic cardiomyopathy is one such condition. It is a genetic condition leading to abnormality of the ventricular muscle. The abnormality produces a structural change with thickening of the heart muscle in an asymmetric fashion. The thickness may cause obstruction of the left ventricular outflow tract. In addition, such an individual is prone to VT. The presenting symptom for such individuals tends to be loss of consciousness or a fainting episode with the arrhythmia, generally occurring in the setting of vigorous physical activity. It can be a silent condition, fainting or collapse being the first symptom for some patients. Diagnosis is made by a combination of tests, including echocardiogram and ECG. Genetic testing is now available for the condition but does not help with practical management issues.

If a child is reporting other problems, such as constant fatigue and/or symptoms with minor daily activities, it suggests the possibility of myocarditis, usually related to viral infections. The heart of a child with such an infection becomes dilated and does not contract well. These patients are prone to VT. While some children with myocarditis recover, others may suffer permanent damage. The heart may remain dilated and prone to VT.

Another rare condition to include in your differential diagnosis is prolonged QT interval syndrome. The condition is genetic in nature and tends to run in families. The mechanism involves gates or ion channels in cell membranes that normally regulate the influx of sodium, potassium, and calcium. In a child with the syndrome, the gates remain open too long, thereby allowing too much sodium or calcium to enter the cells, and VT can ensue. ECG tracings and a history of syncope can be diagnostic. Genetic testing is available and helpful.

Ventricular tachycardia is very worrisome because it can be fatal within minutes. Therefore, VT is an emergency in most instances, although there are some benign forms that are well tolerated. The distinction can sometimes require an electrophysiology study. The placement of automatic external defibrillators in public places has enhanced the chances of survival in patients who experience rapid VT.

[email protected]

Ask about fever duration during your history taking. The main question is how to define “persistent.” If the fever lasts fewer than 5 days and everything else looks fine, most of the time the child will have whatever illness is going around.

If the fever lasts closer to 10 days, and especially if new symptoms appear, it could be a complication of what is going around. Obviously, once you go beyond 10 days, it is a more significant clinical situation. Then we are in the “fever of unknown origin” (FUO) range, which may require a subspecialist evaluation. The current official definition of FUO is fever lasting greater than 3 weeks with no diagnosis after reasonable outpatient or inpatient evaluation. Shorter episodes of unexplained fever are referred to as “fever without a source.” Most of these will resolve spontaneously or evolve into more easily recognized conditions, usually infections.

The best way to proceed really depends on the presentation. The initial evaluation always includes a careful history, physical examination, and screening labs as needed. Start a more thorough evaluation or refer when things are not adding up. How sick does the child look? Are there atypical findings? Remember your training about the typical course of strep throat, mono, or bronchitis—if you see a significant deviation, evaluate the child more thoroughly. Always ask: Do I have a reasonable working diagnosis that I am comfortable with?

Fever is a common symptom and most often is a feature of a routine viral infection. The bigger concern is a serious condition, such as a bloodstream infection; this child needs to get to the emergency room right away. A child with an unusual rash, especially with petechiae and purpura, would need an immediate referral.

Kawasaki disease is another major concern. If you suspect Kawasaki disease, the child needs to be evaluated by a subspecialist. The diagnosis is based on a fever lasting at least 4 or 5 days and associated findings, such as a rash, red strawberry tongue, or very red lips. The patient will need immediate treatment, ideally within 10 days, to minimize the risk for cardiac and coronary inflammation.

Helpful tests include a complete blood count, sedimentation rate, and C-reactive protein assay. Serum chemistries including liver function tests also may be useful. I do a urinalysis and a urine culture because urinary tract infections are common and a common cause of fever. Blood cultures should be considered.

These screening tests can be reassuring. When the clinical evaluation is benign, the white blood cell count is 5,000 cells/mcL with a normal differential; then you can tell the parent to come back in a few days for follow-up. In contrast, if a child with a persistent fever has a white count of 30,000, you really have to be more careful—it could be a sinus infection, pneumonia, or bacteremia. The other extreme, a child with a white blood count of 1,000, also requires more careful evaluation.

The pace of evaluation depends on how ill the child is, any associated findings, and whether one has a diagnosis or not. Time is your ally when the child is not very ill; watchful waiting will often reveal the nature of the problem.

It is important to take a good travel history. We saw a child with malaria last year, and the key to recognition was the history of a recent return from Ghana. Also ask about animal exposures and if anyone else at home is sick. Those can be important clinical clues for diagnosis of a child with prolonged fever.

Consider the time of year. A test that is not useful, but is often obtained, is a Lyme disease test. Lyme is rarely a cause of prolonged fever, especially in winter. Also, sometimes an extensive evaluation for autoimmune disease is performed too early in the diagnostic process. If you do an initial evaluation and do not have a diagnosis, and the fever persists, then you can move on to secondary and tertiary evaluations, such as you would with an FUO. Also, tests for mono are ordered way too often. The diagnosis of mono depends on more than a prolonged fever, and there are some very specific associated features, such as tonsils that look awful, large cervical nodes, and a palpable spleen.

Make sure the fever is real. Sometimes we see a child who reports persistent fever but is afebrile during each clinical visit. In this case, ask the parents how they take the child's temperature. Do they use a thermometer strip, or do they just touch the child and say the child feels warm? There should be some documentation of a persistent fever before you embark on additional, expensive evaluation.

Occasionally I have a child come to see me who is referred with say, 25 days of fever. Does the child really have one prolonged fever? It is more likely two different episodes—a child has illness No. 1, then a break, followed by illness No. 2. Use the history and clinical findings to distinguish between these two scenarios.

[email protected]

Ask about fever duration during your history taking. The main question is how to define “persistent.” If the fever lasts fewer than 5 days and everything else looks fine, most of the time the child will have whatever illness is going around.

If the fever lasts closer to 10 days, and especially if new symptoms appear, it could be a complication of what is going around. Obviously, once you go beyond 10 days, it is a more significant clinical situation. Then we are in the “fever of unknown origin” (FUO) range, which may require a subspecialist evaluation. The current official definition of FUO is fever lasting greater than 3 weeks with no diagnosis after reasonable outpatient or inpatient evaluation. Shorter episodes of unexplained fever are referred to as “fever without a source.” Most of these will resolve spontaneously or evolve into more easily recognized conditions, usually infections.

The best way to proceed really depends on the presentation. The initial evaluation always includes a careful history, physical examination, and screening labs as needed. Start a more thorough evaluation or refer when things are not adding up. How sick does the child look? Are there atypical findings? Remember your training about the typical course of strep throat, mono, or bronchitis—if you see a significant deviation, evaluate the child more thoroughly. Always ask: Do I have a reasonable working diagnosis that I am comfortable with?

Fever is a common symptom and most often is a feature of a routine viral infection. The bigger concern is a serious condition, such as a bloodstream infection; this child needs to get to the emergency room right away. A child with an unusual rash, especially with petechiae and purpura, would need an immediate referral.

Kawasaki disease is another major concern. If you suspect Kawasaki disease, the child needs to be evaluated by a subspecialist. The diagnosis is based on a fever lasting at least 4 or 5 days and associated findings, such as a rash, red strawberry tongue, or very red lips. The patient will need immediate treatment, ideally within 10 days, to minimize the risk for cardiac and coronary inflammation.

Helpful tests include a complete blood count, sedimentation rate, and C-reactive protein assay. Serum chemistries including liver function tests also may be useful. I do a urinalysis and a urine culture because urinary tract infections are common and a common cause of fever. Blood cultures should be considered.

These screening tests can be reassuring. When the clinical evaluation is benign, the white blood cell count is 5,000 cells/mcL with a normal differential; then you can tell the parent to come back in a few days for follow-up. In contrast, if a child with a persistent fever has a white count of 30,000, you really have to be more careful—it could be a sinus infection, pneumonia, or bacteremia. The other extreme, a child with a white blood count of 1,000, also requires more careful evaluation.

The pace of evaluation depends on how ill the child is, any associated findings, and whether one has a diagnosis or not. Time is your ally when the child is not very ill; watchful waiting will often reveal the nature of the problem.

It is important to take a good travel history. We saw a child with malaria last year, and the key to recognition was the history of a recent return from Ghana. Also ask about animal exposures and if anyone else at home is sick. Those can be important clinical clues for diagnosis of a child with prolonged fever.

Consider the time of year. A test that is not useful, but is often obtained, is a Lyme disease test. Lyme is rarely a cause of prolonged fever, especially in winter. Also, sometimes an extensive evaluation for autoimmune disease is performed too early in the diagnostic process. If you do an initial evaluation and do not have a diagnosis, and the fever persists, then you can move on to secondary and tertiary evaluations, such as you would with an FUO. Also, tests for mono are ordered way too often. The diagnosis of mono depends on more than a prolonged fever, and there are some very specific associated features, such as tonsils that look awful, large cervical nodes, and a palpable spleen.

Make sure the fever is real. Sometimes we see a child who reports persistent fever but is afebrile during each clinical visit. In this case, ask the parents how they take the child's temperature. Do they use a thermometer strip, or do they just touch the child and say the child feels warm? There should be some documentation of a persistent fever before you embark on additional, expensive evaluation.

Occasionally I have a child come to see me who is referred with say, 25 days of fever. Does the child really have one prolonged fever? It is more likely two different episodes—a child has illness No. 1, then a break, followed by illness No. 2. Use the history and clinical findings to distinguish between these two scenarios.

[email protected]

Ask about fever duration during your history taking. The main question is how to define “persistent.” If the fever lasts fewer than 5 days and everything else looks fine, most of the time the child will have whatever illness is going around.

If the fever lasts closer to 10 days, and especially if new symptoms appear, it could be a complication of what is going around. Obviously, once you go beyond 10 days, it is a more significant clinical situation. Then we are in the “fever of unknown origin” (FUO) range, which may require a subspecialist evaluation. The current official definition of FUO is fever lasting greater than 3 weeks with no diagnosis after reasonable outpatient or inpatient evaluation. Shorter episodes of unexplained fever are referred to as “fever without a source.” Most of these will resolve spontaneously or evolve into more easily recognized conditions, usually infections.

The best way to proceed really depends on the presentation. The initial evaluation always includes a careful history, physical examination, and screening labs as needed. Start a more thorough evaluation or refer when things are not adding up. How sick does the child look? Are there atypical findings? Remember your training about the typical course of strep throat, mono, or bronchitis—if you see a significant deviation, evaluate the child more thoroughly. Always ask: Do I have a reasonable working diagnosis that I am comfortable with?

Fever is a common symptom and most often is a feature of a routine viral infection. The bigger concern is a serious condition, such as a bloodstream infection; this child needs to get to the emergency room right away. A child with an unusual rash, especially with petechiae and purpura, would need an immediate referral.

Kawasaki disease is another major concern. If you suspect Kawasaki disease, the child needs to be evaluated by a subspecialist. The diagnosis is based on a fever lasting at least 4 or 5 days and associated findings, such as a rash, red strawberry tongue, or very red lips. The patient will need immediate treatment, ideally within 10 days, to minimize the risk for cardiac and coronary inflammation.

Helpful tests include a complete blood count, sedimentation rate, and C-reactive protein assay. Serum chemistries including liver function tests also may be useful. I do a urinalysis and a urine culture because urinary tract infections are common and a common cause of fever. Blood cultures should be considered.

These screening tests can be reassuring. When the clinical evaluation is benign, the white blood cell count is 5,000 cells/mcL with a normal differential; then you can tell the parent to come back in a few days for follow-up. In contrast, if a child with a persistent fever has a white count of 30,000, you really have to be more careful—it could be a sinus infection, pneumonia, or bacteremia. The other extreme, a child with a white blood count of 1,000, also requires more careful evaluation.

The pace of evaluation depends on how ill the child is, any associated findings, and whether one has a diagnosis or not. Time is your ally when the child is not very ill; watchful waiting will often reveal the nature of the problem.

It is important to take a good travel history. We saw a child with malaria last year, and the key to recognition was the history of a recent return from Ghana. Also ask about animal exposures and if anyone else at home is sick. Those can be important clinical clues for diagnosis of a child with prolonged fever.

Consider the time of year. A test that is not useful, but is often obtained, is a Lyme disease test. Lyme is rarely a cause of prolonged fever, especially in winter. Also, sometimes an extensive evaluation for autoimmune disease is performed too early in the diagnostic process. If you do an initial evaluation and do not have a diagnosis, and the fever persists, then you can move on to secondary and tertiary evaluations, such as you would with an FUO. Also, tests for mono are ordered way too often. The diagnosis of mono depends on more than a prolonged fever, and there are some very specific associated features, such as tonsils that look awful, large cervical nodes, and a palpable spleen.

Make sure the fever is real. Sometimes we see a child who reports persistent fever but is afebrile during each clinical visit. In this case, ask the parents how they take the child's temperature. Do they use a thermometer strip, or do they just touch the child and say the child feels warm? There should be some documentation of a persistent fever before you embark on additional, expensive evaluation.

Occasionally I have a child come to see me who is referred with say, 25 days of fever. Does the child really have one prolonged fever? It is more likely two different episodes—a child has illness No. 1, then a break, followed by illness No. 2. Use the history and clinical findings to distinguish between these two scenarios.