Subspecialist Consult

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Acanthosis nigricans is one of the most common skin signs of obesity and hyperinsulinism and is a valuable predictor of insulin resistance in obese children. Patients with both obesity and acanthosis nigricans, compared with those with obesity alone, tend to have higher body mass indexes and increased fasting and evening insulin levels.

Early recognition and intervention are crucial to avoid complications of insulin resistance. The general pediatrician is in the best position to perform the initial assessment. Begin with measuring body mass index (BMI). Then evaluate the patient for the associated risk factors. If you diagnose acanthosis nigricans, screen the patient for associated conditions such as Cushing's syndrome; hypothyroidism; coexisting syndromes (including Prader-Willi, Bardet-Biedl, and leprechaunism); lipodystrophy; or psychiatric disorders including depression or eating disorders.

Children with a BMI under the 85th percentile and no complications can be managed well by their pediatrician. Early intervention is key. Focus on healthful living, increased physical activity, and education of the family regarding associated conditions and the adverse effects that obesity can have on the child's health and quality of life.

The best strategy is to treat the underlying cause of acanthosis nigricans. Address obesity and any secondary insulin resistance because obesity is the No. 1 cause of acanthosis nigricans. Although topical keratolytic lotions or other topical therapies may be of some benefit, results are often disappointing.

It is also important to involve the entire family in the treatment plan. If everyone is not ready for change, success will be limited. Because much embarrassment and stigma are often associated with obesity, discuss treatment, diet, and weight loss in an objective, nonjudgmental, and nonaccusatory fashion. Consider the family's schedule, financial situation, and lifestyle.

Educate patients and family members about appropriate weight for age and height, self-management skills, and a healthy, balanced diet with lower levels of carbohydrates and fats. It is easy for patients and parents to become discouraged, so institute changes gradually.

If a patient presents with obesity and acanthosis nigricans, evaluate the child for other insulin risk factors. These include a BMI above the 85th percentile for age and sex, polycystic ovarian syndrome, hypertension, dyslipidemia, a history of small size for gestational age at birth, premature pubarche, allergic diathesis, and/or a family history of these conditions. Also note that children of certain ethnicities are at higher risk as well, including African, Indian subcontinent, American Indian, and Hispanic populations.

Children with obesity and insulin resistance are at increased future risk for associated complications including orthopedic problems, fatty liver or gallbladder disease, infertility, hyperandrogenism, coronary artery disease and stroke, type 2 diabetes, predisposition to certain cancers, and Alzheimer's disease.

In addition to measurements of blood pressure, height, weight, and BMI, helpful laboratory studies include nonfasting lipid, hemoglobin A_1c, and insulin and glucose levels. Fasting glucose, insulin, and lipid tests are especially recommended for a child whose BMI is at the 85th percentile or greater.

Conditions that can mimic acanthosis nigricans include postinflammatory hyperpigmentation; chronic eczema (especially in children with darker skin and secondary hyperpigmentation or lichenification); and confluent and reticulated papillomatosis of Gougerot and Carteaud (the plaques in this condition are very similar to acanthosis nigricans, but are more reticulated and located on the chest and back). Other conditions to consider in your differential diagnosis include linear epidermal nevi and retained keratin (which presents as brownish patches on the neck or postauricular areas that are easily removed with alcohol, but not with water).

If the diagnosis of acanthosis nigricans is uncertain, referral to a pediatric dermatologist is recommended. Also refer a girl with suspected PCOS or hyperandrogenism and associated acne, which can be difficult to manage, as well as a girl with male-pattern hair loss.

The following criteria can warrant referral of the patient to a specialist other than a pediatric dermatologist:

▸ A child with a BMI at the 85th percentile or greater and any associated complications or any child with a BMI greater than the 95th percentile should be referred to a pediatric obesity treatment specialist, if available.

▸ Referral to a pediatric cardiologist may be needed if hypertension or dyslipidemia is present.

▸ Referral for a sleep study or for evaluation by a pediatric otolaryngologist may be indicated if signs of sleep disturbance suggest sleep apnea or obesity hypoventilation syndrome.

▸ Persistent headaches could indicate pseudotumor cerebri requiring neurologic evaluation.

▸ Referral to an endocrinologist would be indicated if Cushing's syndrome, type 2 diabetes, or hypothyroidism is suspected, or for girls with signs of PCOS or hyperandrogenism. The guidance of a pediatric endocrinologist may be required with certain medications, such as metformin, to decrease insulin resistance and hyperglycemia.

▸ Children with knee or hip pain and x-ray findings suggestive of slipped capital femoral epiphysis or Blount's disease (tibia vara) may need orthopedic evaluation.

▸ Children with abdominal pain may require referral to a pediatric gastroenterologist for evaluation of obesity-associated liver or gallbladder disease.

Regular monitoring of the overweight child with acanthosis nigricans is recommended. If initial screening is negative for type 2 diabetes or insulin resistance, the American Diabetes Association recommends repeating the screening every 2 years for at-risk children. Follow-up screening can also include thyroid studies to evaluate for hypothyroidism and dehydroepiandrosterone sulfate, free testosterone, and a luteinizing hormone to follicle-stimulating hormone (LH:FSH) ratio to screen for hyperandrogenism.

[email protected]

Acanthosis nigricans is one of the most common skin signs of obesity and hyperinsulinism and is a valuable predictor of insulin resistance in obese children. Patients with both obesity and acanthosis nigricans, compared with those with obesity alone, tend to have higher body mass indexes and increased fasting and evening insulin levels.

Early recognition and intervention are crucial to avoid complications of insulin resistance. The general pediatrician is in the best position to perform the initial assessment. Begin with measuring body mass index (BMI). Then evaluate the patient for the associated risk factors. If you diagnose acanthosis nigricans, screen the patient for associated conditions such as Cushing's syndrome; hypothyroidism; coexisting syndromes (including Prader-Willi, Bardet-Biedl, and leprechaunism); lipodystrophy; or psychiatric disorders including depression or eating disorders.

Children with a BMI under the 85th percentile and no complications can be managed well by their pediatrician. Early intervention is key. Focus on healthful living, increased physical activity, and education of the family regarding associated conditions and the adverse effects that obesity can have on the child's health and quality of life.

The best strategy is to treat the underlying cause of acanthosis nigricans. Address obesity and any secondary insulin resistance because obesity is the No. 1 cause of acanthosis nigricans. Although topical keratolytic lotions or other topical therapies may be of some benefit, results are often disappointing.

It is also important to involve the entire family in the treatment plan. If everyone is not ready for change, success will be limited. Because much embarrassment and stigma are often associated with obesity, discuss treatment, diet, and weight loss in an objective, nonjudgmental, and nonaccusatory fashion. Consider the family's schedule, financial situation, and lifestyle.

Educate patients and family members about appropriate weight for age and height, self-management skills, and a healthy, balanced diet with lower levels of carbohydrates and fats. It is easy for patients and parents to become discouraged, so institute changes gradually.

If a patient presents with obesity and acanthosis nigricans, evaluate the child for other insulin risk factors. These include a BMI above the 85th percentile for age and sex, polycystic ovarian syndrome, hypertension, dyslipidemia, a history of small size for gestational age at birth, premature pubarche, allergic diathesis, and/or a family history of these conditions. Also note that children of certain ethnicities are at higher risk as well, including African, Indian subcontinent, American Indian, and Hispanic populations.

Children with obesity and insulin resistance are at increased future risk for associated complications including orthopedic problems, fatty liver or gallbladder disease, infertility, hyperandrogenism, coronary artery disease and stroke, type 2 diabetes, predisposition to certain cancers, and Alzheimer's disease.

In addition to measurements of blood pressure, height, weight, and BMI, helpful laboratory studies include nonfasting lipid, hemoglobin A_1c, and insulin and glucose levels. Fasting glucose, insulin, and lipid tests are especially recommended for a child whose BMI is at the 85th percentile or greater.

Conditions that can mimic acanthosis nigricans include postinflammatory hyperpigmentation; chronic eczema (especially in children with darker skin and secondary hyperpigmentation or lichenification); and confluent and reticulated papillomatosis of Gougerot and Carteaud (the plaques in this condition are very similar to acanthosis nigricans, but are more reticulated and located on the chest and back). Other conditions to consider in your differential diagnosis include linear epidermal nevi and retained keratin (which presents as brownish patches on the neck or postauricular areas that are easily removed with alcohol, but not with water).

If the diagnosis of acanthosis nigricans is uncertain, referral to a pediatric dermatologist is recommended. Also refer a girl with suspected PCOS or hyperandrogenism and associated acne, which can be difficult to manage, as well as a girl with male-pattern hair loss.

The following criteria can warrant referral of the patient to a specialist other than a pediatric dermatologist:

▸ A child with a BMI at the 85th percentile or greater and any associated complications or any child with a BMI greater than the 95th percentile should be referred to a pediatric obesity treatment specialist, if available.

▸ Referral to a pediatric cardiologist may be needed if hypertension or dyslipidemia is present.

▸ Referral for a sleep study or for evaluation by a pediatric otolaryngologist may be indicated if signs of sleep disturbance suggest sleep apnea or obesity hypoventilation syndrome.

▸ Persistent headaches could indicate pseudotumor cerebri requiring neurologic evaluation.

▸ Referral to an endocrinologist would be indicated if Cushing's syndrome, type 2 diabetes, or hypothyroidism is suspected, or for girls with signs of PCOS or hyperandrogenism. The guidance of a pediatric endocrinologist may be required with certain medications, such as metformin, to decrease insulin resistance and hyperglycemia.

▸ Children with knee or hip pain and x-ray findings suggestive of slipped capital femoral epiphysis or Blount's disease (tibia vara) may need orthopedic evaluation.

▸ Children with abdominal pain may require referral to a pediatric gastroenterologist for evaluation of obesity-associated liver or gallbladder disease.

Regular monitoring of the overweight child with acanthosis nigricans is recommended. If initial screening is negative for type 2 diabetes or insulin resistance, the American Diabetes Association recommends repeating the screening every 2 years for at-risk children. Follow-up screening can also include thyroid studies to evaluate for hypothyroidism and dehydroepiandrosterone sulfate, free testosterone, and a luteinizing hormone to follicle-stimulating hormone (LH:FSH) ratio to screen for hyperandrogenism.

[email protected]

Acanthosis nigricans is one of the most common skin signs of obesity and hyperinsulinism and is a valuable predictor of insulin resistance in obese children. Patients with both obesity and acanthosis nigricans, compared with those with obesity alone, tend to have higher body mass indexes and increased fasting and evening insulin levels.

Early recognition and intervention are crucial to avoid complications of insulin resistance. The general pediatrician is in the best position to perform the initial assessment. Begin with measuring body mass index (BMI). Then evaluate the patient for the associated risk factors. If you diagnose acanthosis nigricans, screen the patient for associated conditions such as Cushing's syndrome; hypothyroidism; coexisting syndromes (including Prader-Willi, Bardet-Biedl, and leprechaunism); lipodystrophy; or psychiatric disorders including depression or eating disorders.

Children with a BMI under the 85th percentile and no complications can be managed well by their pediatrician. Early intervention is key. Focus on healthful living, increased physical activity, and education of the family regarding associated conditions and the adverse effects that obesity can have on the child's health and quality of life.

The best strategy is to treat the underlying cause of acanthosis nigricans. Address obesity and any secondary insulin resistance because obesity is the No. 1 cause of acanthosis nigricans. Although topical keratolytic lotions or other topical therapies may be of some benefit, results are often disappointing.

It is also important to involve the entire family in the treatment plan. If everyone is not ready for change, success will be limited. Because much embarrassment and stigma are often associated with obesity, discuss treatment, diet, and weight loss in an objective, nonjudgmental, and nonaccusatory fashion. Consider the family's schedule, financial situation, and lifestyle.

Educate patients and family members about appropriate weight for age and height, self-management skills, and a healthy, balanced diet with lower levels of carbohydrates and fats. It is easy for patients and parents to become discouraged, so institute changes gradually.

If a patient presents with obesity and acanthosis nigricans, evaluate the child for other insulin risk factors. These include a BMI above the 85th percentile for age and sex, polycystic ovarian syndrome, hypertension, dyslipidemia, a history of small size for gestational age at birth, premature pubarche, allergic diathesis, and/or a family history of these conditions. Also note that children of certain ethnicities are at higher risk as well, including African, Indian subcontinent, American Indian, and Hispanic populations.

Children with obesity and insulin resistance are at increased future risk for associated complications including orthopedic problems, fatty liver or gallbladder disease, infertility, hyperandrogenism, coronary artery disease and stroke, type 2 diabetes, predisposition to certain cancers, and Alzheimer's disease.

In addition to measurements of blood pressure, height, weight, and BMI, helpful laboratory studies include nonfasting lipid, hemoglobin A_1c, and insulin and glucose levels. Fasting glucose, insulin, and lipid tests are especially recommended for a child whose BMI is at the 85th percentile or greater.

Conditions that can mimic acanthosis nigricans include postinflammatory hyperpigmentation; chronic eczema (especially in children with darker skin and secondary hyperpigmentation or lichenification); and confluent and reticulated papillomatosis of Gougerot and Carteaud (the plaques in this condition are very similar to acanthosis nigricans, but are more reticulated and located on the chest and back). Other conditions to consider in your differential diagnosis include linear epidermal nevi and retained keratin (which presents as brownish patches on the neck or postauricular areas that are easily removed with alcohol, but not with water).

If the diagnosis of acanthosis nigricans is uncertain, referral to a pediatric dermatologist is recommended. Also refer a girl with suspected PCOS or hyperandrogenism and associated acne, which can be difficult to manage, as well as a girl with male-pattern hair loss.

The following criteria can warrant referral of the patient to a specialist other than a pediatric dermatologist:

▸ A child with a BMI at the 85th percentile or greater and any associated complications or any child with a BMI greater than the 95th percentile should be referred to a pediatric obesity treatment specialist, if available.

▸ Referral to a pediatric cardiologist may be needed if hypertension or dyslipidemia is present.

▸ Referral for a sleep study or for evaluation by a pediatric otolaryngologist may be indicated if signs of sleep disturbance suggest sleep apnea or obesity hypoventilation syndrome.

▸ Persistent headaches could indicate pseudotumor cerebri requiring neurologic evaluation.

▸ Referral to an endocrinologist would be indicated if Cushing's syndrome, type 2 diabetes, or hypothyroidism is suspected, or for girls with signs of PCOS or hyperandrogenism. The guidance of a pediatric endocrinologist may be required with certain medications, such as metformin, to decrease insulin resistance and hyperglycemia.

▸ Children with knee or hip pain and x-ray findings suggestive of slipped capital femoral epiphysis or Blount's disease (tibia vara) may need orthopedic evaluation.

▸ Children with abdominal pain may require referral to a pediatric gastroenterologist for evaluation of obesity-associated liver or gallbladder disease.

Regular monitoring of the overweight child with acanthosis nigricans is recommended. If initial screening is negative for type 2 diabetes or insulin resistance, the American Diabetes Association recommends repeating the screening every 2 years for at-risk children. Follow-up screening can also include thyroid studies to evaluate for hypothyroidism and dehydroepiandrosterone sulfate, free testosterone, and a luteinizing hormone to follicle-stimulating hormone (LH:FSH) ratio to screen for hyperandrogenism.

[email protected]

Start with identification of a possible delay by reviewing developmental milestones. Most general pediatricians do this routinely. For example, being able to grab and transfer an object is a milestone at about 5 months of age. Some infants develop this fine motor skill at 4 months or 6 months, so sometimes delays are within a reasonable time frame.

Be aware of who is at high-risk for delayed development. Consider pregnancy, labor and delivery, and birth history. Did the infant have any acquired illnesses during the first few months of life? There could be a setup in utero for subtle presentations in the first few months of life.

If you suspect that an infant or toddler is experiencing developmental delay, close monitoring is warranted. Have the patient return sooner and more frequently than you would otherwise with routine well-child visits.

If a suspected delay becomes more prominent, consider referral to a subspecialist. When to refer a patient for further evaluation can be subjective, but it is better to err on the safe side. As a general rule, if the child is more than 3 months behind in any developmental area, referral is warranted.

A concern for me is that some pediatricians tend to underplay a possible developmental delay for too long. Telling concerned parents to “just give it some time” can be dangerous, particularly if suspicions about a true clinical delay are ultimately confirmed.

Early diagnosis and identification of the cause for the delay increase the likelihood it can be corrected or treated more effectively.

Seizure, congenital brain abnormality, and metabolic disorder are potential etiologies for developmental delay.

Remember to assess the four general areas of infant and toddler development: gross motor skills, fine motor skills, language, and social interaction. The delay or delays demonstrated by an individual child guides the patient's management. For example, an infant with gross motor deficits could benefit from consultation with a physical therapist. A toddler with fine motor delay could improve with the assistance of an occupational therapist.

Speech therapy might be warranted, as well, depending on the age of the child. At around 18 months, for example, most toddlers display significant gains in language and socialization skills. Always keep autism in mind with speech and socialization delays—this is a big area of concern today.

Ask yourself if the child has a global delay or a specific delay. The more global the delay, the more I worry about brain involvement. If an infant presents with low muscle tone, try to determine if the brain, spinal cord, nerve and/or muscle systems are involved. Deficits in each system necessitate different treatment approaches.

When performing a physical examination, look for an asymmetrical head or dysmorphic appearance. If the child does not look like the rest of the family—for example, has a small jaw, a small head, or rotational ears—the developmental delay could have a genetic basis.

We know a lot more about genetic causes now than we did even just 5 years ago, in part because microarray assessment allows us to detect genetic microdeletions.

Although some general pediatricians can and do order diagnostic tests and imaging to confirm delayed development, many rely on a subspecialist for further work-up of the child. Often subspecialists do an MRI scan after initial screening and examination. Metabolic laboratory tests also are useful for screening and diagnosis.

Be careful about what I call “scam” treatments. For example, some families might consider trying bariatric oxygen, stem cell treatments, or vitamin therapies. While omega-3 fish oil supplements may not hurt the child, they are not necessarily helpful either.

Follow these patients regularly for progress to guide families and determine appropriate treatment over time.

[email protected]

Start with identification of a possible delay by reviewing developmental milestones. Most general pediatricians do this routinely. For example, being able to grab and transfer an object is a milestone at about 5 months of age. Some infants develop this fine motor skill at 4 months or 6 months, so sometimes delays are within a reasonable time frame.

Be aware of who is at high-risk for delayed development. Consider pregnancy, labor and delivery, and birth history. Did the infant have any acquired illnesses during the first few months of life? There could be a setup in utero for subtle presentations in the first few months of life.

If you suspect that an infant or toddler is experiencing developmental delay, close monitoring is warranted. Have the patient return sooner and more frequently than you would otherwise with routine well-child visits.

If a suspected delay becomes more prominent, consider referral to a subspecialist. When to refer a patient for further evaluation can be subjective, but it is better to err on the safe side. As a general rule, if the child is more than 3 months behind in any developmental area, referral is warranted.

A concern for me is that some pediatricians tend to underplay a possible developmental delay for too long. Telling concerned parents to “just give it some time” can be dangerous, particularly if suspicions about a true clinical delay are ultimately confirmed.

Early diagnosis and identification of the cause for the delay increase the likelihood it can be corrected or treated more effectively.

Seizure, congenital brain abnormality, and metabolic disorder are potential etiologies for developmental delay.

Remember to assess the four general areas of infant and toddler development: gross motor skills, fine motor skills, language, and social interaction. The delay or delays demonstrated by an individual child guides the patient's management. For example, an infant with gross motor deficits could benefit from consultation with a physical therapist. A toddler with fine motor delay could improve with the assistance of an occupational therapist.

Speech therapy might be warranted, as well, depending on the age of the child. At around 18 months, for example, most toddlers display significant gains in language and socialization skills. Always keep autism in mind with speech and socialization delays—this is a big area of concern today.

Ask yourself if the child has a global delay or a specific delay. The more global the delay, the more I worry about brain involvement. If an infant presents with low muscle tone, try to determine if the brain, spinal cord, nerve and/or muscle systems are involved. Deficits in each system necessitate different treatment approaches.

When performing a physical examination, look for an asymmetrical head or dysmorphic appearance. If the child does not look like the rest of the family—for example, has a small jaw, a small head, or rotational ears—the developmental delay could have a genetic basis.

We know a lot more about genetic causes now than we did even just 5 years ago, in part because microarray assessment allows us to detect genetic microdeletions.

Although some general pediatricians can and do order diagnostic tests and imaging to confirm delayed development, many rely on a subspecialist for further work-up of the child. Often subspecialists do an MRI scan after initial screening and examination. Metabolic laboratory tests also are useful for screening and diagnosis.

Be careful about what I call “scam” treatments. For example, some families might consider trying bariatric oxygen, stem cell treatments, or vitamin therapies. While omega-3 fish oil supplements may not hurt the child, they are not necessarily helpful either.

Follow these patients regularly for progress to guide families and determine appropriate treatment over time.

[email protected]

Start with identification of a possible delay by reviewing developmental milestones. Most general pediatricians do this routinely. For example, being able to grab and transfer an object is a milestone at about 5 months of age. Some infants develop this fine motor skill at 4 months or 6 months, so sometimes delays are within a reasonable time frame.

Be aware of who is at high-risk for delayed development. Consider pregnancy, labor and delivery, and birth history. Did the infant have any acquired illnesses during the first few months of life? There could be a setup in utero for subtle presentations in the first few months of life.

If you suspect that an infant or toddler is experiencing developmental delay, close monitoring is warranted. Have the patient return sooner and more frequently than you would otherwise with routine well-child visits.

If a suspected delay becomes more prominent, consider referral to a subspecialist. When to refer a patient for further evaluation can be subjective, but it is better to err on the safe side. As a general rule, if the child is more than 3 months behind in any developmental area, referral is warranted.

A concern for me is that some pediatricians tend to underplay a possible developmental delay for too long. Telling concerned parents to “just give it some time” can be dangerous, particularly if suspicions about a true clinical delay are ultimately confirmed.

Early diagnosis and identification of the cause for the delay increase the likelihood it can be corrected or treated more effectively.

Seizure, congenital brain abnormality, and metabolic disorder are potential etiologies for developmental delay.

Remember to assess the four general areas of infant and toddler development: gross motor skills, fine motor skills, language, and social interaction. The delay or delays demonstrated by an individual child guides the patient's management. For example, an infant with gross motor deficits could benefit from consultation with a physical therapist. A toddler with fine motor delay could improve with the assistance of an occupational therapist.

Speech therapy might be warranted, as well, depending on the age of the child. At around 18 months, for example, most toddlers display significant gains in language and socialization skills. Always keep autism in mind with speech and socialization delays—this is a big area of concern today.

Ask yourself if the child has a global delay or a specific delay. The more global the delay, the more I worry about brain involvement. If an infant presents with low muscle tone, try to determine if the brain, spinal cord, nerve and/or muscle systems are involved. Deficits in each system necessitate different treatment approaches.

When performing a physical examination, look for an asymmetrical head or dysmorphic appearance. If the child does not look like the rest of the family—for example, has a small jaw, a small head, or rotational ears—the developmental delay could have a genetic basis.

We know a lot more about genetic causes now than we did even just 5 years ago, in part because microarray assessment allows us to detect genetic microdeletions.

Although some general pediatricians can and do order diagnostic tests and imaging to confirm delayed development, many rely on a subspecialist for further work-up of the child. Often subspecialists do an MRI scan after initial screening and examination. Metabolic laboratory tests also are useful for screening and diagnosis.

Be careful about what I call “scam” treatments. For example, some families might consider trying bariatric oxygen, stem cell treatments, or vitamin therapies. While omega-3 fish oil supplements may not hurt the child, they are not necessarily helpful either.

Follow these patients regularly for progress to guide families and determine appropriate treatment over time.

[email protected]

Persistent hives, or chronic urticaria, can be challenging to diagnose, treat, and manage. This condition is also somewhat common—I see it often at Miami Children's Hospital.

Persistent hives are distinctive from an acute presentation because they typically last 6 weeks or longer. They are not only frustrating for physicians—the etiology is identified in only a minority of affected children, but this disease can significantly impair quality of life for patients and their families.

Infections are a common cause of persistent hives. Other conditions to consider in your differential diagnosis include drug and food allergies, physical urticaria (caused by exposure to heat or cold), autoimmune disease, erythema multiforme minor, and dermatographism. Dermatographism is a condition in which stroking or scratching the skin with a dull instrument causes a raised welt, or wheal, to appear because of increased mast cell activation. The skin generally appears pale in the center with a red flare on either side. A physical allergy causes this type of urticaria.

In conjunction with the physical examination, review all medications taken in the last 6 weeks, including but not limited to new agents. Also ask the patient and parents about the type of foods the child consumed within the last several weeks with regularity.

A long-acting antihistamine, with 24-hour coverage, can be helpful. For some children with persistent hives, you may need to think outside the box and prescribe both a short-acting and long-acting antihistamine. The short-acting agent can be used to control an acute presentation while the long-acting drug provides maintenance.

If the condition improves with antihistamines and the hives are not interfering with quality of life or sleep, then you should feel comfortable treating the child.

If antihistamine therapy is not helpful, the lesions are interfering with lifestyle or sleep, or the patient complains of swelling, it is appropriate to refer the child to a specialist for additional work-up. Swelling is often a presenting sign with chronic urticaria, and typically it is generalized or affects the hands or face. The swelling often makes the patient and family uncomfortable.

If you decide to order laboratory testing prior to a specialist referral, a complete blood count, an erythrocyte sedimentation rate assay, a liver function test, and thyroid studies can be useful. But you also can simply refer the patient to an allergist or immunologist, and we can order the testing.

In contrast, a food-specific immunoglobulin G test is not helpful for the assessment of a child with persistent hives. This laboratory assay should not be ordered because it only adds to the cost of the diagnosis without aiding in the clinical diagnosis.

If you are fortunate and can identify the cause of the chronic urticaria—which only occurs in 5%-20% of cases—it calls for strict avoidance. This is another aspect where persistent hives differ from an acute presentation, because the etiology of an acute condition is more frequently found and subsequently may be avoided by the child.

Also educate the patient that persistent hives can be daily or episodic. Again, if the patient is lucky, the lesions resolve in less than 1 year. However, inform the patient that—in some cases—the hives can persist for several years.

[email protected]

Persistent hives, or chronic urticaria, can be challenging to diagnose, treat, and manage. This condition is also somewhat common—I see it often at Miami Children's Hospital.

Persistent hives are distinctive from an acute presentation because they typically last 6 weeks or longer. They are not only frustrating for physicians—the etiology is identified in only a minority of affected children, but this disease can significantly impair quality of life for patients and their families.

Infections are a common cause of persistent hives. Other conditions to consider in your differential diagnosis include drug and food allergies, physical urticaria (caused by exposure to heat or cold), autoimmune disease, erythema multiforme minor, and dermatographism. Dermatographism is a condition in which stroking or scratching the skin with a dull instrument causes a raised welt, or wheal, to appear because of increased mast cell activation. The skin generally appears pale in the center with a red flare on either side. A physical allergy causes this type of urticaria.

In conjunction with the physical examination, review all medications taken in the last 6 weeks, including but not limited to new agents. Also ask the patient and parents about the type of foods the child consumed within the last several weeks with regularity.

A long-acting antihistamine, with 24-hour coverage, can be helpful. For some children with persistent hives, you may need to think outside the box and prescribe both a short-acting and long-acting antihistamine. The short-acting agent can be used to control an acute presentation while the long-acting drug provides maintenance.

If the condition improves with antihistamines and the hives are not interfering with quality of life or sleep, then you should feel comfortable treating the child.

If antihistamine therapy is not helpful, the lesions are interfering with lifestyle or sleep, or the patient complains of swelling, it is appropriate to refer the child to a specialist for additional work-up. Swelling is often a presenting sign with chronic urticaria, and typically it is generalized or affects the hands or face. The swelling often makes the patient and family uncomfortable.

If you decide to order laboratory testing prior to a specialist referral, a complete blood count, an erythrocyte sedimentation rate assay, a liver function test, and thyroid studies can be useful. But you also can simply refer the patient to an allergist or immunologist, and we can order the testing.

In contrast, a food-specific immunoglobulin G test is not helpful for the assessment of a child with persistent hives. This laboratory assay should not be ordered because it only adds to the cost of the diagnosis without aiding in the clinical diagnosis.

If you are fortunate and can identify the cause of the chronic urticaria—which only occurs in 5%-20% of cases—it calls for strict avoidance. This is another aspect where persistent hives differ from an acute presentation, because the etiology of an acute condition is more frequently found and subsequently may be avoided by the child.

Also educate the patient that persistent hives can be daily or episodic. Again, if the patient is lucky, the lesions resolve in less than 1 year. However, inform the patient that—in some cases—the hives can persist for several years.

[email protected]

Persistent hives, or chronic urticaria, can be challenging to diagnose, treat, and manage. This condition is also somewhat common—I see it often at Miami Children's Hospital.

Persistent hives are distinctive from an acute presentation because they typically last 6 weeks or longer. They are not only frustrating for physicians—the etiology is identified in only a minority of affected children, but this disease can significantly impair quality of life for patients and their families.

Infections are a common cause of persistent hives. Other conditions to consider in your differential diagnosis include drug and food allergies, physical urticaria (caused by exposure to heat or cold), autoimmune disease, erythema multiforme minor, and dermatographism. Dermatographism is a condition in which stroking or scratching the skin with a dull instrument causes a raised welt, or wheal, to appear because of increased mast cell activation. The skin generally appears pale in the center with a red flare on either side. A physical allergy causes this type of urticaria.

In conjunction with the physical examination, review all medications taken in the last 6 weeks, including but not limited to new agents. Also ask the patient and parents about the type of foods the child consumed within the last several weeks with regularity.

A long-acting antihistamine, with 24-hour coverage, can be helpful. For some children with persistent hives, you may need to think outside the box and prescribe both a short-acting and long-acting antihistamine. The short-acting agent can be used to control an acute presentation while the long-acting drug provides maintenance.

If the condition improves with antihistamines and the hives are not interfering with quality of life or sleep, then you should feel comfortable treating the child.

If antihistamine therapy is not helpful, the lesions are interfering with lifestyle or sleep, or the patient complains of swelling, it is appropriate to refer the child to a specialist for additional work-up. Swelling is often a presenting sign with chronic urticaria, and typically it is generalized or affects the hands or face. The swelling often makes the patient and family uncomfortable.

If you decide to order laboratory testing prior to a specialist referral, a complete blood count, an erythrocyte sedimentation rate assay, a liver function test, and thyroid studies can be useful. But you also can simply refer the patient to an allergist or immunologist, and we can order the testing.

In contrast, a food-specific immunoglobulin G test is not helpful for the assessment of a child with persistent hives. This laboratory assay should not be ordered because it only adds to the cost of the diagnosis without aiding in the clinical diagnosis.

If you are fortunate and can identify the cause of the chronic urticaria—which only occurs in 5%-20% of cases—it calls for strict avoidance. This is another aspect where persistent hives differ from an acute presentation, because the etiology of an acute condition is more frequently found and subsequently may be avoided by the child.

Also educate the patient that persistent hives can be daily or episodic. Again, if the patient is lucky, the lesions resolve in less than 1 year. However, inform the patient that—in some cases—the hives can persist for several years.

[email protected]

Start with the most important thing—education of the child and the family. This condition is familial, so relatives are more likely to have this form of hyperlipidemia as well.

Ask families about relevant history of early heart disease. “Early familial heart disease” is defined as a father or grandfather younger than age 55 years and/or mother or grandmother younger than 65 years with known heart disease.

We recommend screening all children by the age of 2 years for relevant family history. Studies now indicate lipid deposits can start as early as this age.

Clinical intervention often is more about prevention than treatment. Unless children are homozygous for one of the genetic defects associated with familial hyperlipidemia, they may not have signs or symptoms until they reach their twenties or thirties.

It is appropriate for you to begin lifestyle recommendations with any overweight or obese child. Counsel the patient and family about better diet and exercise regimens. For example, instruct them to avoid fried foods and if they need to cook with oil, to use vegetable oil.

Recommend 60 minutes of moderate exercise daily. This does not have to be an hour all at once—it can be 20 minutes in the morning before the school bus comes, 20 minutes in the afternoon, and another 20 minutes in the evening. The physical activity does not have to be on the soccer field either. The patient can exercise by climbing the stairs or participating in a scavenger hunt at the mall.

The essential thing is getting the child off the couch and away from the computer. This is particularly important because many schools are cutting their physical education programs in this economy.

Emphasize to parents that familial hyperlipidemia is one of the preventable forms of heart disease. Parents have a choice if they want their children to lead long, healthy lives.

Monitor the child's growth. If the child exceeds the 95th percentile on the growth chart, draw cholesterol levels. If the numbers are high, initiate at least a 6-month trial of diet and exercise. If, after this time, the cholesterol levels remain high, consider prescribing a low-dose statin. If medication fails to reduce high cholesterol after 2 months, I recommend these children see a subspecialist like myself.

For the most part, they come to me obese and/or with high cholesterol. I lecture them like you cannot believe, and their weight and cholesterol numbers improve. For this reason, I have very few patients for whom I have to start medication.

The cholesterol assay you do has to be a fasting lipid profile, not a random cholesterol reading. A random test does not provide the most appropriate information. Use common sense regarding when to test kids. In other words, do not test cholesterol levels the day after their birthday, right after Halloween, or anytime between Thanksgiving and Christmas. Testing cholesterol at any time during spring and summer, if possible, is preferable.

You don't need to refer most children with familial hyperlipidemia for cardiac stress testing. Stress testing is generally reserved for treatment-refractory patients with established high cholesterol. This provides useful baseline information for children we cannot control well.

[email protected]

Start with the most important thing—education of the child and the family. This condition is familial, so relatives are more likely to have this form of hyperlipidemia as well.

Ask families about relevant history of early heart disease. “Early familial heart disease” is defined as a father or grandfather younger than age 55 years and/or mother or grandmother younger than 65 years with known heart disease.

We recommend screening all children by the age of 2 years for relevant family history. Studies now indicate lipid deposits can start as early as this age.

Clinical intervention often is more about prevention than treatment. Unless children are homozygous for one of the genetic defects associated with familial hyperlipidemia, they may not have signs or symptoms until they reach their twenties or thirties.

It is appropriate for you to begin lifestyle recommendations with any overweight or obese child. Counsel the patient and family about better diet and exercise regimens. For example, instruct them to avoid fried foods and if they need to cook with oil, to use vegetable oil.

Recommend 60 minutes of moderate exercise daily. This does not have to be an hour all at once—it can be 20 minutes in the morning before the school bus comes, 20 minutes in the afternoon, and another 20 minutes in the evening. The physical activity does not have to be on the soccer field either. The patient can exercise by climbing the stairs or participating in a scavenger hunt at the mall.

The essential thing is getting the child off the couch and away from the computer. This is particularly important because many schools are cutting their physical education programs in this economy.

Emphasize to parents that familial hyperlipidemia is one of the preventable forms of heart disease. Parents have a choice if they want their children to lead long, healthy lives.

Monitor the child's growth. If the child exceeds the 95th percentile on the growth chart, draw cholesterol levels. If the numbers are high, initiate at least a 6-month trial of diet and exercise. If, after this time, the cholesterol levels remain high, consider prescribing a low-dose statin. If medication fails to reduce high cholesterol after 2 months, I recommend these children see a subspecialist like myself.

For the most part, they come to me obese and/or with high cholesterol. I lecture them like you cannot believe, and their weight and cholesterol numbers improve. For this reason, I have very few patients for whom I have to start medication.

The cholesterol assay you do has to be a fasting lipid profile, not a random cholesterol reading. A random test does not provide the most appropriate information. Use common sense regarding when to test kids. In other words, do not test cholesterol levels the day after their birthday, right after Halloween, or anytime between Thanksgiving and Christmas. Testing cholesterol at any time during spring and summer, if possible, is preferable.

You don't need to refer most children with familial hyperlipidemia for cardiac stress testing. Stress testing is generally reserved for treatment-refractory patients with established high cholesterol. This provides useful baseline information for children we cannot control well.

[email protected]

Start with the most important thing—education of the child and the family. This condition is familial, so relatives are more likely to have this form of hyperlipidemia as well.

Ask families about relevant history of early heart disease. “Early familial heart disease” is defined as a father or grandfather younger than age 55 years and/or mother or grandmother younger than 65 years with known heart disease.

We recommend screening all children by the age of 2 years for relevant family history. Studies now indicate lipid deposits can start as early as this age.

Clinical intervention often is more about prevention than treatment. Unless children are homozygous for one of the genetic defects associated with familial hyperlipidemia, they may not have signs or symptoms until they reach their twenties or thirties.

It is appropriate for you to begin lifestyle recommendations with any overweight or obese child. Counsel the patient and family about better diet and exercise regimens. For example, instruct them to avoid fried foods and if they need to cook with oil, to use vegetable oil.

Recommend 60 minutes of moderate exercise daily. This does not have to be an hour all at once—it can be 20 minutes in the morning before the school bus comes, 20 minutes in the afternoon, and another 20 minutes in the evening. The physical activity does not have to be on the soccer field either. The patient can exercise by climbing the stairs or participating in a scavenger hunt at the mall.

The essential thing is getting the child off the couch and away from the computer. This is particularly important because many schools are cutting their physical education programs in this economy.

Emphasize to parents that familial hyperlipidemia is one of the preventable forms of heart disease. Parents have a choice if they want their children to lead long, healthy lives.

Monitor the child's growth. If the child exceeds the 95th percentile on the growth chart, draw cholesterol levels. If the numbers are high, initiate at least a 6-month trial of diet and exercise. If, after this time, the cholesterol levels remain high, consider prescribing a low-dose statin. If medication fails to reduce high cholesterol after 2 months, I recommend these children see a subspecialist like myself.

For the most part, they come to me obese and/or with high cholesterol. I lecture them like you cannot believe, and their weight and cholesterol numbers improve. For this reason, I have very few patients for whom I have to start medication.

The cholesterol assay you do has to be a fasting lipid profile, not a random cholesterol reading. A random test does not provide the most appropriate information. Use common sense regarding when to test kids. In other words, do not test cholesterol levels the day after their birthday, right after Halloween, or anytime between Thanksgiving and Christmas. Testing cholesterol at any time during spring and summer, if possible, is preferable.

You don't need to refer most children with familial hyperlipidemia for cardiac stress testing. Stress testing is generally reserved for treatment-refractory patients with established high cholesterol. This provides useful baseline information for children we cannot control well.

[email protected]

When presented with an overweight child who has hypertension, collect a detailed history, including a 24-hour food-intake history.

Also assess the child's nutritional habits, such as number of fast-food items typically eaten per week and number of family dinners.

Ask about the fluids these children generally consume. For instance, do they drink any caloric beverages other than low-fat milk?

Take an exercise history. Inquire how many hours per day the child is exposed to television, video games, and other media.

Social interaction can be particularly important with an overweight child. Ask if the child has been teased or bullied at home, in school, or elsewhere in the community.

Next ask the parent(s) and patient what they know about high blood pressure. Also inquire about a family history of hypertension.

Confirm any elevation in the child's blood pressure during a physical examination. If the patient has severe hypertension, it is usually time to refer the child to a specialist.

If the child has hypertension for three consecutive monthly visits, further evaluation with blood work is appropriate. Order a complete metabolic panel, urinalysis, and fasting lipid panel. Urinalysis, for example, is useful as a screen for type 2 diabetes.

On a full review of systems, identify other morbidities associated with obesity and perform appropriate tests.

For instance, the child with daytime sleepiness and snoring may require a sleep study to identify obstructive sleep apnea.

In addition, if liver function tests are elevated, a pediatric ultrasound exam can identify a fatty liver.

You can also order an electrocardiogram to identify heart pathology and refer the child if the findings are abnormal.

Many families request thyroid testing for an overweight child. Full thyroid function tests are not cost effective and need not be done. A thyroid-stimulating hormone test should suffice.

As for behavioral counseling, at the Cleveland Clinic Children's Hospital, we recommend our “5 to GO!” messaging, in which children are told to eat 5-a-day fruits and veggies; give 4 compliments a day to anyone they encounter, including other kids, and get 4 compliments a day from anyone; consume 3 dairy products a day; engage in no more than 2 hours of media/TV time a day; drink 0 sugar-sweetened beverages, and go!

For teenagers, we aim for 4 dairy/calcium servings and 3 compliments a day (not that they need fewer compliments, but they do need more calcium than the under age 10 crowd).

The key is to follow patients monthly. Slow, steady change—with positive motivation tailored to each family—works better than trying to do everything at once.

Follow up, follow up, and follow up—with a lot of cheerleading!

Patient education is also essential. Help patients and their families figure out how to cook a no-added-salt diet, how to shop the periphery of a grocery store where the fresh produce is located, and how to build physical activity and exercise into the family's daily plan.

Consider a weight management program such as our Fit Youth Program. Patients and families who participate in this 12-week program at the Cleveland Clinic receive group counseling sessions led by a psychologist in combination with a pediatrician, a dietitian, and an exercise physiologist.

Multidisciplinary interventions such as this one can accomplish modest weight loss versus progression toward 30 pounds of weight gain per year, as occurs in many of our children who do not receive effective treatment.

[email protected]

When presented with an overweight child who has hypertension, collect a detailed history, including a 24-hour food-intake history.

Also assess the child's nutritional habits, such as number of fast-food items typically eaten per week and number of family dinners.

Ask about the fluids these children generally consume. For instance, do they drink any caloric beverages other than low-fat milk?

Take an exercise history. Inquire how many hours per day the child is exposed to television, video games, and other media.

Social interaction can be particularly important with an overweight child. Ask if the child has been teased or bullied at home, in school, or elsewhere in the community.

Next ask the parent(s) and patient what they know about high blood pressure. Also inquire about a family history of hypertension.

Confirm any elevation in the child's blood pressure during a physical examination. If the patient has severe hypertension, it is usually time to refer the child to a specialist.

If the child has hypertension for three consecutive monthly visits, further evaluation with blood work is appropriate. Order a complete metabolic panel, urinalysis, and fasting lipid panel. Urinalysis, for example, is useful as a screen for type 2 diabetes.

On a full review of systems, identify other morbidities associated with obesity and perform appropriate tests.

For instance, the child with daytime sleepiness and snoring may require a sleep study to identify obstructive sleep apnea.

In addition, if liver function tests are elevated, a pediatric ultrasound exam can identify a fatty liver.

You can also order an electrocardiogram to identify heart pathology and refer the child if the findings are abnormal.

Many families request thyroid testing for an overweight child. Full thyroid function tests are not cost effective and need not be done. A thyroid-stimulating hormone test should suffice.

As for behavioral counseling, at the Cleveland Clinic Children's Hospital, we recommend our “5 to GO!” messaging, in which children are told to eat 5-a-day fruits and veggies; give 4 compliments a day to anyone they encounter, including other kids, and get 4 compliments a day from anyone; consume 3 dairy products a day; engage in no more than 2 hours of media/TV time a day; drink 0 sugar-sweetened beverages, and go!

For teenagers, we aim for 4 dairy/calcium servings and 3 compliments a day (not that they need fewer compliments, but they do need more calcium than the under age 10 crowd).

The key is to follow patients monthly. Slow, steady change—with positive motivation tailored to each family—works better than trying to do everything at once.

Follow up, follow up, and follow up—with a lot of cheerleading!

Patient education is also essential. Help patients and their families figure out how to cook a no-added-salt diet, how to shop the periphery of a grocery store where the fresh produce is located, and how to build physical activity and exercise into the family's daily plan.

Consider a weight management program such as our Fit Youth Program. Patients and families who participate in this 12-week program at the Cleveland Clinic receive group counseling sessions led by a psychologist in combination with a pediatrician, a dietitian, and an exercise physiologist.

Multidisciplinary interventions such as this one can accomplish modest weight loss versus progression toward 30 pounds of weight gain per year, as occurs in many of our children who do not receive effective treatment.

[email protected]

When presented with an overweight child who has hypertension, collect a detailed history, including a 24-hour food-intake history.

Also assess the child's nutritional habits, such as number of fast-food items typically eaten per week and number of family dinners.

Ask about the fluids these children generally consume. For instance, do they drink any caloric beverages other than low-fat milk?

Take an exercise history. Inquire how many hours per day the child is exposed to television, video games, and other media.

Social interaction can be particularly important with an overweight child. Ask if the child has been teased or bullied at home, in school, or elsewhere in the community.

Next ask the parent(s) and patient what they know about high blood pressure. Also inquire about a family history of hypertension.

Confirm any elevation in the child's blood pressure during a physical examination. If the patient has severe hypertension, it is usually time to refer the child to a specialist.

If the child has hypertension for three consecutive monthly visits, further evaluation with blood work is appropriate. Order a complete metabolic panel, urinalysis, and fasting lipid panel. Urinalysis, for example, is useful as a screen for type 2 diabetes.

On a full review of systems, identify other morbidities associated with obesity and perform appropriate tests.

For instance, the child with daytime sleepiness and snoring may require a sleep study to identify obstructive sleep apnea.

In addition, if liver function tests are elevated, a pediatric ultrasound exam can identify a fatty liver.

You can also order an electrocardiogram to identify heart pathology and refer the child if the findings are abnormal.

Many families request thyroid testing for an overweight child. Full thyroid function tests are not cost effective and need not be done. A thyroid-stimulating hormone test should suffice.

As for behavioral counseling, at the Cleveland Clinic Children's Hospital, we recommend our “5 to GO!” messaging, in which children are told to eat 5-a-day fruits and veggies; give 4 compliments a day to anyone they encounter, including other kids, and get 4 compliments a day from anyone; consume 3 dairy products a day; engage in no more than 2 hours of media/TV time a day; drink 0 sugar-sweetened beverages, and go!

For teenagers, we aim for 4 dairy/calcium servings and 3 compliments a day (not that they need fewer compliments, but they do need more calcium than the under age 10 crowd).

The key is to follow patients monthly. Slow, steady change—with positive motivation tailored to each family—works better than trying to do everything at once.

Follow up, follow up, and follow up—with a lot of cheerleading!

Patient education is also essential. Help patients and their families figure out how to cook a no-added-salt diet, how to shop the periphery of a grocery store where the fresh produce is located, and how to build physical activity and exercise into the family's daily plan.

Consider a weight management program such as our Fit Youth Program. Patients and families who participate in this 12-week program at the Cleveland Clinic receive group counseling sessions led by a psychologist in combination with a pediatrician, a dietitian, and an exercise physiologist.

Multidisciplinary interventions such as this one can accomplish modest weight loss versus progression toward 30 pounds of weight gain per year, as occurs in many of our children who do not receive effective treatment.

[email protected]

The general pediatrician's role in managing an adolescent with an autism spectrum disorder depends largely on his or her comfort with doing counseling, testing, and medication management.

Most adolescents with an autism spectrum disorder already have a pretty thick chart from a history of pediatrician and pediatric subspecialist consultations, but the etiology question may remain. If a child's intelligence is within the normal range, a lot of elaborate medical testing generally is not necessary. If the child has cognitive dysfunction, such as an IQ below 70, there is a greater probability of finding an underlying cause for the disorder.

Consider separate counseling and procedural visits. Like many pediatric patients, one with an autism spectrum disorder can be anxious about vaccinations, needles, or any other unpleasant procedure. So if they know a particular visit is limited to a discussion of concerns, they are more likely to relax and be more communicative.

Counseling will depend on the cognitive and language abilities of the patient. Discussions will have to be tailored to the level of understanding of the teen with autism spectrum disorder.

Counseling can include addressing sexuality issues. Discuss physical and emotional changes associated with adolescence and the effects they can have on the patient and the family. Teenagers in general are often confused about these changes, and those with autism spectrum disorder are no exception.

Discussions of the sort of sexual interest the patient has or does not have will depend on the patient's expressive capacity. Ask open-ended questions about any situations that may have arisen or about any concerns the patient may have about the future.

Also, educate the teen about the prevention of unwanted pregnancy and sexually transmitted infections.

Medication management is important in this population. Many adolescents on the autism spectrum already take psychopharmacologic agents. There is a wide range of comfort levels among pediatricians regarding prescription of psychopharmacologic agents and management of behavioral challenges. Refer the patient to a specialist if you are not at ease in these situations.

Similarly, some pediatricians will be more comfortable than others in ordering and evaluating genetic testing.

Technology has advanced from general karyotype testing a decade ago to more accurate molecular fragile X assays and chromosome microarray analyses that are available today.

If you feel up to date based on your training and experience, go ahead and order initial testing or updated testing as indicated.

General pediatricians are well equipped to manage any underlying medical issues. For example, if a patient has spells that might suggest seizures, an EEG might be in order, especially in this higher-risk population.

Start a transition plan once the adolescent is in high school. Pediatricians are integral in creating this plan, along with family physicians, internists, and/or other adult care providers.

Also work with school personnel to ensure an optimal outcome. Specific goals can include preparing the patient for postsecondary education or having the patient get necessary vocational skills as he or she becomes more independent and joins the workforce.

Work with parents to clarify goals for future living arrangements. Also suggest that parents establish a special needs trust to protect assets designated for the adolescent while still maintaining eligibility for government benefit programs.

[email protected]

The general pediatrician's role in managing an adolescent with an autism spectrum disorder depends largely on his or her comfort with doing counseling, testing, and medication management.

Most adolescents with an autism spectrum disorder already have a pretty thick chart from a history of pediatrician and pediatric subspecialist consultations, but the etiology question may remain. If a child's intelligence is within the normal range, a lot of elaborate medical testing generally is not necessary. If the child has cognitive dysfunction, such as an IQ below 70, there is a greater probability of finding an underlying cause for the disorder.

Consider separate counseling and procedural visits. Like many pediatric patients, one with an autism spectrum disorder can be anxious about vaccinations, needles, or any other unpleasant procedure. So if they know a particular visit is limited to a discussion of concerns, they are more likely to relax and be more communicative.

Counseling will depend on the cognitive and language abilities of the patient. Discussions will have to be tailored to the level of understanding of the teen with autism spectrum disorder.

Counseling can include addressing sexuality issues. Discuss physical and emotional changes associated with adolescence and the effects they can have on the patient and the family. Teenagers in general are often confused about these changes, and those with autism spectrum disorder are no exception.

Discussions of the sort of sexual interest the patient has or does not have will depend on the patient's expressive capacity. Ask open-ended questions about any situations that may have arisen or about any concerns the patient may have about the future.

Also, educate the teen about the prevention of unwanted pregnancy and sexually transmitted infections.

Medication management is important in this population. Many adolescents on the autism spectrum already take psychopharmacologic agents. There is a wide range of comfort levels among pediatricians regarding prescription of psychopharmacologic agents and management of behavioral challenges. Refer the patient to a specialist if you are not at ease in these situations.

Similarly, some pediatricians will be more comfortable than others in ordering and evaluating genetic testing.

Technology has advanced from general karyotype testing a decade ago to more accurate molecular fragile X assays and chromosome microarray analyses that are available today.

If you feel up to date based on your training and experience, go ahead and order initial testing or updated testing as indicated.

General pediatricians are well equipped to manage any underlying medical issues. For example, if a patient has spells that might suggest seizures, an EEG might be in order, especially in this higher-risk population.

Start a transition plan once the adolescent is in high school. Pediatricians are integral in creating this plan, along with family physicians, internists, and/or other adult care providers.

Also work with school personnel to ensure an optimal outcome. Specific goals can include preparing the patient for postsecondary education or having the patient get necessary vocational skills as he or she becomes more independent and joins the workforce.

Work with parents to clarify goals for future living arrangements. Also suggest that parents establish a special needs trust to protect assets designated for the adolescent while still maintaining eligibility for government benefit programs.

[email protected]

The general pediatrician's role in managing an adolescent with an autism spectrum disorder depends largely on his or her comfort with doing counseling, testing, and medication management.

Most adolescents with an autism spectrum disorder already have a pretty thick chart from a history of pediatrician and pediatric subspecialist consultations, but the etiology question may remain. If a child's intelligence is within the normal range, a lot of elaborate medical testing generally is not necessary. If the child has cognitive dysfunction, such as an IQ below 70, there is a greater probability of finding an underlying cause for the disorder.

Consider separate counseling and procedural visits. Like many pediatric patients, one with an autism spectrum disorder can be anxious about vaccinations, needles, or any other unpleasant procedure. So if they know a particular visit is limited to a discussion of concerns, they are more likely to relax and be more communicative.

Counseling will depend on the cognitive and language abilities of the patient. Discussions will have to be tailored to the level of understanding of the teen with autism spectrum disorder.

Counseling can include addressing sexuality issues. Discuss physical and emotional changes associated with adolescence and the effects they can have on the patient and the family. Teenagers in general are often confused about these changes, and those with autism spectrum disorder are no exception.

Discussions of the sort of sexual interest the patient has or does not have will depend on the patient's expressive capacity. Ask open-ended questions about any situations that may have arisen or about any concerns the patient may have about the future.

Also, educate the teen about the prevention of unwanted pregnancy and sexually transmitted infections.

Medication management is important in this population. Many adolescents on the autism spectrum already take psychopharmacologic agents. There is a wide range of comfort levels among pediatricians regarding prescription of psychopharmacologic agents and management of behavioral challenges. Refer the patient to a specialist if you are not at ease in these situations.

Similarly, some pediatricians will be more comfortable than others in ordering and evaluating genetic testing.

Technology has advanced from general karyotype testing a decade ago to more accurate molecular fragile X assays and chromosome microarray analyses that are available today.

If you feel up to date based on your training and experience, go ahead and order initial testing or updated testing as indicated.

General pediatricians are well equipped to manage any underlying medical issues. For example, if a patient has spells that might suggest seizures, an EEG might be in order, especially in this higher-risk population.

Start a transition plan once the adolescent is in high school. Pediatricians are integral in creating this plan, along with family physicians, internists, and/or other adult care providers.

Also work with school personnel to ensure an optimal outcome. Specific goals can include preparing the patient for postsecondary education or having the patient get necessary vocational skills as he or she becomes more independent and joins the workforce.

Work with parents to clarify goals for future living arrangements. Also suggest that parents establish a special needs trust to protect assets designated for the adolescent while still maintaining eligibility for government benefit programs.

[email protected]

General pediatricians can take care of a great number of children with reflux disease. I recommend a step-up approach employing lifestyle modifications and/or medication prior to specialist referral in most cases. When symptoms become more troublesome or there is no response to therapeutic interventions, consultation with a pediatric gastroenterologist may be appropriate.

Begin with a thorough patient history, which is instrumental to distinguishing gastroesophageal reflux disease (GERD) from other conditions. Family medical and medication history also are important because of compelling evidence demonstrating a family link with GERD.

Advise school-age children with GERD to eat smaller meals throughout the day and not to eat too close to bedtime. Tomato-containing products, caffeine-containing products, citrus, and—believe it or not—chocolate are commonly implicated as evoking or exacerbating symptoms of GERD. Foods with high-fat content also are associated with the disorder, as they delay the ability of the stomach to empty quickly, thus potentially worsening GERD.

Sleep disturbances may be the sole symptom for a lot of older children with reflux. Microburps or microaspirations that occur when children are supine at night wake some; they do not wake others, so keep in mind that some children might be unaware of their GERD. A good question to ask is how many pillows they sleep on at night; some children already self-manage their symptoms by elevating their upper torso at night without realizing why.

Early morning nausea also can occur after a night of continuous reflux. Therefore, the presentation of a child who says he or she routinely does not want to eat in the morning, particularly if he or she complains of nausea, raises clinical suspicion for GERD. Also, some children can report regurgitating and re-swallowing all day as they sit in class.

In addition to lifestyle changes, a trial of acid-suppressing medication, such as an H₂ blocker or a proton pump inhibitor, can be tried. Limit initial treatment to 6-8 weeks for most children. If a child reports respiratory symptoms associated with GERD, consider a longer course of acid suppression therapy. It is important to discuss the specific GERD-related symptoms you expect the medication to resolve prior to initiation of therapy.

A referral to a pediatric gastroenterologist is warranted after lifestyle modifications and pharmacotherapy fail, or if symptoms return after therapy is discontinued. Sometimes patients do not improve with these interventions or they get better but you cannot get patients off the medication without symptoms returning. Also, other warning signs or symptoms such as anemia or occult blood in the stool or vomit require a referral.

Frequently, children, particularly those of school age, with GERD complain of a stomachache. However, GERD is more of a burning pain versus a cramping pain. Pain that is associated with GERD or due to another “organic” cause tends to be pain that localizes away from the belly button and is more epigastric, versus periumbilical pain, which tends to be more functional. In addition, abdominal pain that awakens children at night tends to be more organic in nature. Some children with GERD are misdiagnosed and actually have a functional GI disorder or vice versa. Definitions of pediatric functional GI disorders can aid in the differential diagnosis; these are outlined in Rome III criteria (www.romecriteria.org

There is no diagnostic test that is 100% accurate for the diagnosis of GERD. Thus, it is important to avoid too much testing or inappropriate treatment. For example, pediatricians tend to do an upper gastrointestinal series using barium and x-ray fluoroscopy, which is not good for ruling GERD in or out, but can be beneficial in identifying upper GI anatomic abnormalities. Nuclear scintigraphy can be employed to assess gastric emptying and aspiration of reflux contents.

Pediatricians can order a pH probe to ascertain the degree of acid exposure to the esophagus, although some centers require a GI consultation first. Endoscopic studies require a referral to a specialist. Specialists also may perform a newer modality called multichannel intraluminal impedance, which, when combined with the pH probe, can measure both acid reflux and nonacid or weakly acid reflux.

In a survey of 6,000 American Academy of Pediatrics members, 82% of the 1,245 responding pediatricians and pediatric specialists said they treat GERD based on clinical suspicion (J. Pediatr. Gastroenterol. Nutr. 2007;45:56-64). Such empiric therapy is still appropriate in the pediatric patient. However, there is a need for future research on the optimal therapy type, dose, and duration in these patients with clinically suspected GERD.

To promote a more standardized approach to pediatric GERD, I participated on an international committee that released an evidence-based set of definitions for reflux and GERD in the pediatric population (Am. J. Gastroenterol. 2009;104:1278-95). Additional guidance on GERD is available from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (www.naspghan.orgwww.cdhnf.org

[email protected]

General pediatricians can take care of a great number of children with reflux disease. I recommend a step-up approach employing lifestyle modifications and/or medication prior to specialist referral in most cases. When symptoms become more troublesome or there is no response to therapeutic interventions, consultation with a pediatric gastroenterologist may be appropriate.

Begin with a thorough patient history, which is instrumental to distinguishing gastroesophageal reflux disease (GERD) from other conditions. Family medical and medication history also are important because of compelling evidence demonstrating a family link with GERD.

Advise school-age children with GERD to eat smaller meals throughout the day and not to eat too close to bedtime. Tomato-containing products, caffeine-containing products, citrus, and—believe it or not—chocolate are commonly implicated as evoking or exacerbating symptoms of GERD. Foods with high-fat content also are associated with the disorder, as they delay the ability of the stomach to empty quickly, thus potentially worsening GERD.

Sleep disturbances may be the sole symptom for a lot of older children with reflux. Microburps or microaspirations that occur when children are supine at night wake some; they do not wake others, so keep in mind that some children might be unaware of their GERD. A good question to ask is how many pillows they sleep on at night; some children already self-manage their symptoms by elevating their upper torso at night without realizing why.

Early morning nausea also can occur after a night of continuous reflux. Therefore, the presentation of a child who says he or she routinely does not want to eat in the morning, particularly if he or she complains of nausea, raises clinical suspicion for GERD. Also, some children can report regurgitating and re-swallowing all day as they sit in class.

In addition to lifestyle changes, a trial of acid-suppressing medication, such as an H₂ blocker or a proton pump inhibitor, can be tried. Limit initial treatment to 6-8 weeks for most children. If a child reports respiratory symptoms associated with GERD, consider a longer course of acid suppression therapy. It is important to discuss the specific GERD-related symptoms you expect the medication to resolve prior to initiation of therapy.

A referral to a pediatric gastroenterologist is warranted after lifestyle modifications and pharmacotherapy fail, or if symptoms return after therapy is discontinued. Sometimes patients do not improve with these interventions or they get better but you cannot get patients off the medication without symptoms returning. Also, other warning signs or symptoms such as anemia or occult blood in the stool or vomit require a referral.

Frequently, children, particularly those of school age, with GERD complain of a stomachache. However, GERD is more of a burning pain versus a cramping pain. Pain that is associated with GERD or due to another “organic” cause tends to be pain that localizes away from the belly button and is more epigastric, versus periumbilical pain, which tends to be more functional. In addition, abdominal pain that awakens children at night tends to be more organic in nature. Some children with GERD are misdiagnosed and actually have a functional GI disorder or vice versa. Definitions of pediatric functional GI disorders can aid in the differential diagnosis; these are outlined in Rome III criteria (www.romecriteria.org

There is no diagnostic test that is 100% accurate for the diagnosis of GERD. Thus, it is important to avoid too much testing or inappropriate treatment. For example, pediatricians tend to do an upper gastrointestinal series using barium and x-ray fluoroscopy, which is not good for ruling GERD in or out, but can be beneficial in identifying upper GI anatomic abnormalities. Nuclear scintigraphy can be employed to assess gastric emptying and aspiration of reflux contents.

Pediatricians can order a pH probe to ascertain the degree of acid exposure to the esophagus, although some centers require a GI consultation first. Endoscopic studies require a referral to a specialist. Specialists also may perform a newer modality called multichannel intraluminal impedance, which, when combined with the pH probe, can measure both acid reflux and nonacid or weakly acid reflux.

In a survey of 6,000 American Academy of Pediatrics members, 82% of the 1,245 responding pediatricians and pediatric specialists said they treat GERD based on clinical suspicion (J. Pediatr. Gastroenterol. Nutr. 2007;45:56-64). Such empiric therapy is still appropriate in the pediatric patient. However, there is a need for future research on the optimal therapy type, dose, and duration in these patients with clinically suspected GERD.

To promote a more standardized approach to pediatric GERD, I participated on an international committee that released an evidence-based set of definitions for reflux and GERD in the pediatric population (Am. J. Gastroenterol. 2009;104:1278-95). Additional guidance on GERD is available from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (www.naspghan.orgwww.cdhnf.org

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General pediatricians can take care of a great number of children with reflux disease. I recommend a step-up approach employing lifestyle modifications and/or medication prior to specialist referral in most cases. When symptoms become more troublesome or there is no response to therapeutic interventions, consultation with a pediatric gastroenterologist may be appropriate.

Begin with a thorough patient history, which is instrumental to distinguishing gastroesophageal reflux disease (GERD) from other conditions. Family medical and medication history also are important because of compelling evidence demonstrating a family link with GERD.

Advise school-age children with GERD to eat smaller meals throughout the day and not to eat too close to bedtime. Tomato-containing products, caffeine-containing products, citrus, and—believe it or not—chocolate are commonly implicated as evoking or exacerbating symptoms of GERD. Foods with high-fat content also are associated with the disorder, as they delay the ability of the stomach to empty quickly, thus potentially worsening GERD.

Sleep disturbances may be the sole symptom for a lot of older children with reflux. Microburps or microaspirations that occur when children are supine at night wake some; they do not wake others, so keep in mind that some children might be unaware of their GERD. A good question to ask is how many pillows they sleep on at night; some children already self-manage their symptoms by elevating their upper torso at night without realizing why.

Early morning nausea also can occur after a night of continuous reflux. Therefore, the presentation of a child who says he or she routinely does not want to eat in the morning, particularly if he or she complains of nausea, raises clinical suspicion for GERD. Also, some children can report regurgitating and re-swallowing all day as they sit in class.

In addition to lifestyle changes, a trial of acid-suppressing medication, such as an H₂ blocker or a proton pump inhibitor, can be tried. Limit initial treatment to 6-8 weeks for most children. If a child reports respiratory symptoms associated with GERD, consider a longer course of acid suppression therapy. It is important to discuss the specific GERD-related symptoms you expect the medication to resolve prior to initiation of therapy.

A referral to a pediatric gastroenterologist is warranted after lifestyle modifications and pharmacotherapy fail, or if symptoms return after therapy is discontinued. Sometimes patients do not improve with these interventions or they get better but you cannot get patients off the medication without symptoms returning. Also, other warning signs or symptoms such as anemia or occult blood in the stool or vomit require a referral.

Frequently, children, particularly those of school age, with GERD complain of a stomachache. However, GERD is more of a burning pain versus a cramping pain. Pain that is associated with GERD or due to another “organic” cause tends to be pain that localizes away from the belly button and is more epigastric, versus periumbilical pain, which tends to be more functional. In addition, abdominal pain that awakens children at night tends to be more organic in nature. Some children with GERD are misdiagnosed and actually have a functional GI disorder or vice versa. Definitions of pediatric functional GI disorders can aid in the differential diagnosis; these are outlined in Rome III criteria (www.romecriteria.org

There is no diagnostic test that is 100% accurate for the diagnosis of GERD. Thus, it is important to avoid too much testing or inappropriate treatment. For example, pediatricians tend to do an upper gastrointestinal series using barium and x-ray fluoroscopy, which is not good for ruling GERD in or out, but can be beneficial in identifying upper GI anatomic abnormalities. Nuclear scintigraphy can be employed to assess gastric emptying and aspiration of reflux contents.

Pediatricians can order a pH probe to ascertain the degree of acid exposure to the esophagus, although some centers require a GI consultation first. Endoscopic studies require a referral to a specialist. Specialists also may perform a newer modality called multichannel intraluminal impedance, which, when combined with the pH probe, can measure both acid reflux and nonacid or weakly acid reflux.

In a survey of 6,000 American Academy of Pediatrics members, 82% of the 1,245 responding pediatricians and pediatric specialists said they treat GERD based on clinical suspicion (J. Pediatr. Gastroenterol. Nutr. 2007;45:56-64). Such empiric therapy is still appropriate in the pediatric patient. However, there is a need for future research on the optimal therapy type, dose, and duration in these patients with clinically suspected GERD.

To promote a more standardized approach to pediatric GERD, I participated on an international committee that released an evidence-based set of definitions for reflux and GERD in the pediatric population (Am. J. Gastroenterol. 2009;104:1278-95). Additional guidance on GERD is available from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (www.naspghan.orgwww.cdhnf.org

[email protected]

Chest pain is extremely common in children and adolescents—as many as 70% of healthy children experience chest pain. In most instances, following a thorough history and physical examination, no intervention is required.

The incidence of chest pain with a cardiac etiology is extraordinarily low, less than 1%. Patient and family histories and physical examination dictate when management by a general pediatrician is appropriate. First, determine through history if the child has exercise-induced pain. Patients with noncardiac chest pain often have sharp stabbing pain that lasts a few seconds to 1-2 minutes, and the pain is not associated with exercise.

Exercise-induced chest pain is concerning, but the most common cause is exercise-induced bronchospasm. Ask the child or adolescent to describe the painful episodes. If the patient says: “I run, and then I feel like there is an elephant sitting on my chest,” that should prompt referral to a cardiologist. In contrast, if the patient says: “I run, and I feel like I cannot breathe and/or I cough,” that is more likely exercise-induced asthma.

There are red flags in the history and physical examination that prompt referral of the child to a specialist. But keep in mind that overreferral is a concern. Many general pediatricians understandably are scared when a patient presents with chest pain, but most communities do not have the resources to support widespread referral nor is it warranted in most cases.

Anticipatory guidance is critical for pediatricians managing most children and adolescents with chest pain. Inform the typical patient with sharp, stabbing pain and the family members that such episodes are likely to continue in the future. The patient does not necessarily need to return or go to the emergency department every time the pain recurs.

In contrast, a patient with a history of exercise-induced chest pain or who reports passing out during exercise is more of a concern. Ask patients about any extreme fatigue associated with exercise that is different from what their peers experience. Also, children with an unexplained seizure disorder or a history of passing out after an emotional startle (from a loud noise) might have long QT syndrome. Referral to a specialist is warranted. Although Kawasaki disease is rare, consider it in your differential diagnosis; keep in mind that some patients might experience chest pain associated with Marfan syndrome.

In terms of family history, ask if any relatives were diagnosed with long QT syndrome or hypertrophic cardiomyopathy. Family history also is relevant if there were any unexpected or unexplained deaths before age 50 years. A family member who died of cardiac causes before age 50, especially in the absence of typical risk factors, is also a concern. Listen for a murmur, especially a murmur that gets louder when the patient stands. This feature could be consistent with hypertrophic cardiomyopathy.

I do not recommend an electrocardiogram for most patients with a history of sedentary chest pain because there is a high false-positive rate with this test. Also, I generally do not recommend exercise stress tests because they are not helpful in the setting of routine chest pain. For the minority of patients with true exercise-induced chest pain, however, these tests can be useful, but they should be ordered by a cardiologist.

Children's Healthcare of Atlanta provides a Pediatric Sudden Cardiac Death Risk Assessment Form online for any health care provider. This tool can be accessed at www.choa.org/default.aspx?id=7317

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Chest pain is extremely common in children and adolescents—as many as 70% of healthy children experience chest pain. In most instances, following a thorough history and physical examination, no intervention is required.

The incidence of chest pain with a cardiac etiology is extraordinarily low, less than 1%. Patient and family histories and physical examination dictate when management by a general pediatrician is appropriate. First, determine through history if the child has exercise-induced pain. Patients with noncardiac chest pain often have sharp stabbing pain that lasts a few seconds to 1-2 minutes, and the pain is not associated with exercise.

Exercise-induced chest pain is concerning, but the most common cause is exercise-induced bronchospasm. Ask the child or adolescent to describe the painful episodes. If the patient says: “I run, and then I feel like there is an elephant sitting on my chest,” that should prompt referral to a cardiologist. In contrast, if the patient says: “I run, and I feel like I cannot breathe and/or I cough,” that is more likely exercise-induced asthma.

There are red flags in the history and physical examination that prompt referral of the child to a specialist. But keep in mind that overreferral is a concern. Many general pediatricians understandably are scared when a patient presents with chest pain, but most communities do not have the resources to support widespread referral nor is it warranted in most cases.

Anticipatory guidance is critical for pediatricians managing most children and adolescents with chest pain. Inform the typical patient with sharp, stabbing pain and the family members that such episodes are likely to continue in the future. The patient does not necessarily need to return or go to the emergency department every time the pain recurs.

In contrast, a patient with a history of exercise-induced chest pain or who reports passing out during exercise is more of a concern. Ask patients about any extreme fatigue associated with exercise that is different from what their peers experience. Also, children with an unexplained seizure disorder or a history of passing out after an emotional startle (from a loud noise) might have long QT syndrome. Referral to a specialist is warranted. Although Kawasaki disease is rare, consider it in your differential diagnosis; keep in mind that some patients might experience chest pain associated with Marfan syndrome.

In terms of family history, ask if any relatives were diagnosed with long QT syndrome or hypertrophic cardiomyopathy. Family history also is relevant if there were any unexpected or unexplained deaths before age 50 years. A family member who died of cardiac causes before age 50, especially in the absence of typical risk factors, is also a concern. Listen for a murmur, especially a murmur that gets louder when the patient stands. This feature could be consistent with hypertrophic cardiomyopathy.

I do not recommend an electrocardiogram for most patients with a history of sedentary chest pain because there is a high false-positive rate with this test. Also, I generally do not recommend exercise stress tests because they are not helpful in the setting of routine chest pain. For the minority of patients with true exercise-induced chest pain, however, these tests can be useful, but they should be ordered by a cardiologist.

Children's Healthcare of Atlanta provides a Pediatric Sudden Cardiac Death Risk Assessment Form online for any health care provider. This tool can be accessed at www.choa.org/default.aspx?id=7317

[email protected]

Chest pain is extremely common in children and adolescents—as many as 70% of healthy children experience chest pain. In most instances, following a thorough history and physical examination, no intervention is required.

The incidence of chest pain with a cardiac etiology is extraordinarily low, less than 1%. Patient and family histories and physical examination dictate when management by a general pediatrician is appropriate. First, determine through history if the child has exercise-induced pain. Patients with noncardiac chest pain often have sharp stabbing pain that lasts a few seconds to 1-2 minutes, and the pain is not associated with exercise.

Exercise-induced chest pain is concerning, but the most common cause is exercise-induced bronchospasm. Ask the child or adolescent to describe the painful episodes. If the patient says: “I run, and then I feel like there is an elephant sitting on my chest,” that should prompt referral to a cardiologist. In contrast, if the patient says: “I run, and I feel like I cannot breathe and/or I cough,” that is more likely exercise-induced asthma.

There are red flags in the history and physical examination that prompt referral of the child to a specialist. But keep in mind that overreferral is a concern. Many general pediatricians understandably are scared when a patient presents with chest pain, but most communities do not have the resources to support widespread referral nor is it warranted in most cases.

Anticipatory guidance is critical for pediatricians managing most children and adolescents with chest pain. Inform the typical patient with sharp, stabbing pain and the family members that such episodes are likely to continue in the future. The patient does not necessarily need to return or go to the emergency department every time the pain recurs.

In contrast, a patient with a history of exercise-induced chest pain or who reports passing out during exercise is more of a concern. Ask patients about any extreme fatigue associated with exercise that is different from what their peers experience. Also, children with an unexplained seizure disorder or a history of passing out after an emotional startle (from a loud noise) might have long QT syndrome. Referral to a specialist is warranted. Although Kawasaki disease is rare, consider it in your differential diagnosis; keep in mind that some patients might experience chest pain associated with Marfan syndrome.

In terms of family history, ask if any relatives were diagnosed with long QT syndrome or hypertrophic cardiomyopathy. Family history also is relevant if there were any unexpected or unexplained deaths before age 50 years. A family member who died of cardiac causes before age 50, especially in the absence of typical risk factors, is also a concern. Listen for a murmur, especially a murmur that gets louder when the patient stands. This feature could be consistent with hypertrophic cardiomyopathy.

I do not recommend an electrocardiogram for most patients with a history of sedentary chest pain because there is a high false-positive rate with this test. Also, I generally do not recommend exercise stress tests because they are not helpful in the setting of routine chest pain. For the minority of patients with true exercise-induced chest pain, however, these tests can be useful, but they should be ordered by a cardiologist.

Children's Healthcare of Atlanta provides a Pediatric Sudden Cardiac Death Risk Assessment Form online for any health care provider. This tool can be accessed at www.choa.org/default.aspx?id=7317

A thorough differential diagnosis, primarily based on history and physical examination, is essential when a child presents with a suspicious cough. Certain imaging modalities are also useful for diagnosis.

Identification of an underlying cause is crucial. When doing your history and physical exam, look for something that does not fit a routine presentation. For example, a cough in the presence of a constitutional change, such as weight loss, can indicate a more serious problem. In addition, a cough with a relatively sudden onset or one associated with labored breathing can be worrisome. Also, a choking episode followed by sudden cough, for example, can indicate the presence of a foreign body.

Asthma is the most common cause of chronic cough in the pediatric population, but also consider less common etiologies such as tracheoesophageal fistula, cystic fibrosis (CF), and bronchopulmonary dysplasia. Failure to thrive, clubbing, cardiac signs, and persistent stridor suggest alternative diagnoses.

Patient age offers some guidance in your differential diagnosis. In a neonate (younger than 28 days), persistent cough might suggest an infection or a congenital anomaly such as compression of the esophagus and trachea by a vascular ring. Infectious etiologies include rhinovirus, adenovirus, respiratory syncytial virus, and pertussis.

In preschool children, think upper or lower respiratory tract infection, rhinitis, postnasal drip syndrome, gastroesophageal reflux, an irritant source (such as passive smoking or air pollution), and, of course, asthma.

Among school-age children and adolescents, consider the same possibilities, but add inhalant or other substance abuse to your list of possible irritant causes. In addition, these older children can develop psychogenic or “habit” cough, one that is absent during sleep, distraction, or periods of concentration. Vocal cord dysfunction, also known as laryngeal wheeze, is another possibility in this group.

General pediatricians commonly treat children with a cough that lasts 5-10 days in the context of an upper respiratory tract illness, such as a cold. If a child still coughs incessantly after other cold symptoms have resolved, I would be concerned. This is not necessarily a call to refer the patient to a specialist, but this scenario is a call to do further diagnostic evaluation.

If the child already is diagnosed with asthma and develops a cough, determine whether the patient is taking the appropriate medication and/or is compliant with therapy. Also, ask about the child's environment, particularly the presence of passive smoking, dust, and pets.

In terms of allergy testing, I recommend a radioallergosorbent allergen-specific IgE antibody assay. This is indicated if a child has other lateral symptoms, such as eczema, and/or during peak times for seasonal allergies.

It is helpful when pediatricians do spirometry for a child with a suspicious cough. Nationwide, about 20%-25% of general pediatricians do pulmonary function testing. Pediatric pulmonologists like me would like to see more pediatricians perform these tests. Sinus x-rays also can be helpful, and are within the purview of the general pediatrician. Some might consider this an unnecessary test, however, or one for which you need a high index of suspicion before ordering.

A test that is generally unnecessary is a sweat test for cystic fibrosis. A lot of pediatricians get this test, and I would not tell them not to because often the child with CF has other symptoms that are more diagnostic.

A thorough differential diagnosis, primarily based on history and physical examination, is essential when a child presents with a suspicious cough. Certain imaging modalities are also useful for diagnosis.

Identification of an underlying cause is crucial. When doing your history and physical exam, look for something that does not fit a routine presentation. For example, a cough in the presence of a constitutional change, such as weight loss, can indicate a more serious problem. In addition, a cough with a relatively sudden onset or one associated with labored breathing can be worrisome. Also, a choking episode followed by sudden cough, for example, can indicate the presence of a foreign body.

Asthma is the most common cause of chronic cough in the pediatric population, but also consider less common etiologies such as tracheoesophageal fistula, cystic fibrosis (CF), and bronchopulmonary dysplasia. Failure to thrive, clubbing, cardiac signs, and persistent stridor suggest alternative diagnoses.

Patient age offers some guidance in your differential diagnosis. In a neonate (younger than 28 days), persistent cough might suggest an infection or a congenital anomaly such as compression of the esophagus and trachea by a vascular ring. Infectious etiologies include rhinovirus, adenovirus, respiratory syncytial virus, and pertussis.

In preschool children, think upper or lower respiratory tract infection, rhinitis, postnasal drip syndrome, gastroesophageal reflux, an irritant source (such as passive smoking or air pollution), and, of course, asthma.

Among school-age children and adolescents, consider the same possibilities, but add inhalant or other substance abuse to your list of possible irritant causes. In addition, these older children can develop psychogenic or “habit” cough, one that is absent during sleep, distraction, or periods of concentration. Vocal cord dysfunction, also known as laryngeal wheeze, is another possibility in this group.

General pediatricians commonly treat children with a cough that lasts 5-10 days in the context of an upper respiratory tract illness, such as a cold. If a child still coughs incessantly after other cold symptoms have resolved, I would be concerned. This is not necessarily a call to refer the patient to a specialist, but this scenario is a call to do further diagnostic evaluation.

If the child already is diagnosed with asthma and develops a cough, determine whether the patient is taking the appropriate medication and/or is compliant with therapy. Also, ask about the child's environment, particularly the presence of passive smoking, dust, and pets.

In terms of allergy testing, I recommend a radioallergosorbent allergen-specific IgE antibody assay. This is indicated if a child has other lateral symptoms, such as eczema, and/or during peak times for seasonal allergies.

It is helpful when pediatricians do spirometry for a child with a suspicious cough. Nationwide, about 20%-25% of general pediatricians do pulmonary function testing. Pediatric pulmonologists like me would like to see more pediatricians perform these tests. Sinus x-rays also can be helpful, and are within the purview of the general pediatrician. Some might consider this an unnecessary test, however, or one for which you need a high index of suspicion before ordering.

A test that is generally unnecessary is a sweat test for cystic fibrosis. A lot of pediatricians get this test, and I would not tell them not to because often the child with CF has other symptoms that are more diagnostic.

A thorough differential diagnosis, primarily based on history and physical examination, is essential when a child presents with a suspicious cough. Certain imaging modalities are also useful for diagnosis.

Identification of an underlying cause is crucial. When doing your history and physical exam, look for something that does not fit a routine presentation. For example, a cough in the presence of a constitutional change, such as weight loss, can indicate a more serious problem. In addition, a cough with a relatively sudden onset or one associated with labored breathing can be worrisome. Also, a choking episode followed by sudden cough, for example, can indicate the presence of a foreign body.

Asthma is the most common cause of chronic cough in the pediatric population, but also consider less common etiologies such as tracheoesophageal fistula, cystic fibrosis (CF), and bronchopulmonary dysplasia. Failure to thrive, clubbing, cardiac signs, and persistent stridor suggest alternative diagnoses.

Patient age offers some guidance in your differential diagnosis. In a neonate (younger than 28 days), persistent cough might suggest an infection or a congenital anomaly such as compression of the esophagus and trachea by a vascular ring. Infectious etiologies include rhinovirus, adenovirus, respiratory syncytial virus, and pertussis.

In preschool children, think upper or lower respiratory tract infection, rhinitis, postnasal drip syndrome, gastroesophageal reflux, an irritant source (such as passive smoking or air pollution), and, of course, asthma.

Among school-age children and adolescents, consider the same possibilities, but add inhalant or other substance abuse to your list of possible irritant causes. In addition, these older children can develop psychogenic or “habit” cough, one that is absent during sleep, distraction, or periods of concentration. Vocal cord dysfunction, also known as laryngeal wheeze, is another possibility in this group.

General pediatricians commonly treat children with a cough that lasts 5-10 days in the context of an upper respiratory tract illness, such as a cold. If a child still coughs incessantly after other cold symptoms have resolved, I would be concerned. This is not necessarily a call to refer the patient to a specialist, but this scenario is a call to do further diagnostic evaluation.

If the child already is diagnosed with asthma and develops a cough, determine whether the patient is taking the appropriate medication and/or is compliant with therapy. Also, ask about the child's environment, particularly the presence of passive smoking, dust, and pets.

In terms of allergy testing, I recommend a radioallergosorbent allergen-specific IgE antibody assay. This is indicated if a child has other lateral symptoms, such as eczema, and/or during peak times for seasonal allergies.

It is helpful when pediatricians do spirometry for a child with a suspicious cough. Nationwide, about 20%-25% of general pediatricians do pulmonary function testing. Pediatric pulmonologists like me would like to see more pediatricians perform these tests. Sinus x-rays also can be helpful, and are within the purview of the general pediatrician. Some might consider this an unnecessary test, however, or one for which you need a high index of suspicion before ordering.

A test that is generally unnecessary is a sweat test for cystic fibrosis. A lot of pediatricians get this test, and I would not tell them not to because often the child with CF has other symptoms that are more diagnostic.

[email protected]

More often than not the child who presents with recurrent or chronic headaches will be experiencing migraines. Pediatric migraine is very common; in fact, it is one of the top five health problems for children. General pediatricians treat the majority of these children, up to 90%. There are not enough pediatric neurologists in the United States to take care of all of these children. For example, given the prevalence rate of 10%, an estimated 60,000 children and adolescents experience migraine out of the 2.4 million people in the Cincinnati draw area for my institution. Obviously, they cannot all be referred to a specialist.

The most important thing for you to do is to rule out secondary headaches. Differentiate primary headaches (such as migraine and tension headaches) from secondary ones, being skeptical of the secondary presentations. If a secondary etiology is suspected and the headaches do not resolve, then reassess, but the headaches may be primary ones.

Ask patients and parents about headache symptoms because often the symptoms are initially missed. Standardized criteria such as the American Academy of Neurology practice parameters on the treatment of migraine headache in children and adolescents can guide your diagnosis and management (Neurology 2004;63:2215–24). If the clinical picture does not fit these criteria, consider further evaluation of the child.

After your differential diagnosis, perform a complete neurologic examination. If findings are abnormal on the neurologic exam, consider an MRI. Such imaging also may be warranted for children with exclusively occipital headaches, if they experience a crescendo or abrupt change in headaches, or if they lack a relevant family history.

Almost all other tests are less useful and do not help prior to referral to a pediatric neurologist. We do not need EEGs, sinus x-rays, or CT exams, which have lots of unnecessary radiation. We routinely check riboflavin and coenzyme Q10 levels, but this may be beyond the level of general pediatricians.

Referral to a specialist is appropriate when the above strategies are not working and if the headaches do not improve. Also refer if a child has chronic daily headaches (defined as 15 or more days per month), if a child is missing a lot of school or other activities of daily living, and/or if the history and diagnosis do not seem to fit the presentation.

Optimal treatment is a standardized strategy that incorporates acute and preventive pharmacologic strategies, as well as biobehavioral treatments.

Appropriate NSAID use, for example, can aid a child with an acute presentation. For example, prescribe 10 mg/kg of ibuprofen at onset, and do not exceed three dosages per week. In addition, be familiar with at least one triptan at appropriate dosing (an adult dose for teenagers).

Also be comfortable with at least one age-appropriate, preventive agent. Amitriptyline is the easiest to use. The recommended dosage regimen is 1 mg/kg titrated up slowly (over a period of 8–10 weeks) for about 2–3 months at full dose to allow sufficient time for clinical effect. I also advise against the use of cyproheptadine for teenagers with migraines because of the appetite effect.

Adequate fluid intake without caffeine, exercise at least three to four times per week, and sufficient regular sleep (8–9 hours, for example) are important components of biobehavioral treatment. In addition, educate patients and parents about the importance of a healthy, balanced diet. Instruct patients not to skip meals. We do not recommend avoidance of particular foods, and the evidence supports this stance. It is more important to make healthy food choices.

[email protected]

More often than not the child who presents with recurrent or chronic headaches will be experiencing migraines. Pediatric migraine is very common; in fact, it is one of the top five health problems for children. General pediatricians treat the majority of these children, up to 90%. There are not enough pediatric neurologists in the United States to take care of all of these children. For example, given the prevalence rate of 10%, an estimated 60,000 children and adolescents experience migraine out of the 2.4 million people in the Cincinnati draw area for my institution. Obviously, they cannot all be referred to a specialist.

The most important thing for you to do is to rule out secondary headaches. Differentiate primary headaches (such as migraine and tension headaches) from secondary ones, being skeptical of the secondary presentations. If a secondary etiology is suspected and the headaches do not resolve, then reassess, but the headaches may be primary ones.

Ask patients and parents about headache symptoms because often the symptoms are initially missed. Standardized criteria such as the American Academy of Neurology practice parameters on the treatment of migraine headache in children and adolescents can guide your diagnosis and management (Neurology 2004;63:2215–24). If the clinical picture does not fit these criteria, consider further evaluation of the child.

After your differential diagnosis, perform a complete neurologic examination. If findings are abnormal on the neurologic exam, consider an MRI. Such imaging also may be warranted for children with exclusively occipital headaches, if they experience a crescendo or abrupt change in headaches, or if they lack a relevant family history.

Almost all other tests are less useful and do not help prior to referral to a pediatric neurologist. We do not need EEGs, sinus x-rays, or CT exams, which have lots of unnecessary radiation. We routinely check riboflavin and coenzyme Q10 levels, but this may be beyond the level of general pediatricians.

Referral to a specialist is appropriate when the above strategies are not working and if the headaches do not improve. Also refer if a child has chronic daily headaches (defined as 15 or more days per month), if a child is missing a lot of school or other activities of daily living, and/or if the history and diagnosis do not seem to fit the presentation.

Optimal treatment is a standardized strategy that incorporates acute and preventive pharmacologic strategies, as well as biobehavioral treatments.

Appropriate NSAID use, for example, can aid a child with an acute presentation. For example, prescribe 10 mg/kg of ibuprofen at onset, and do not exceed three dosages per week. In addition, be familiar with at least one triptan at appropriate dosing (an adult dose for teenagers).

Also be comfortable with at least one age-appropriate, preventive agent. Amitriptyline is the easiest to use. The recommended dosage regimen is 1 mg/kg titrated up slowly (over a period of 8–10 weeks) for about 2–3 months at full dose to allow sufficient time for clinical effect. I also advise against the use of cyproheptadine for teenagers with migraines because of the appetite effect.

Adequate fluid intake without caffeine, exercise at least three to four times per week, and sufficient regular sleep (8–9 hours, for example) are important components of biobehavioral treatment. In addition, educate patients and parents about the importance of a healthy, balanced diet. Instruct patients not to skip meals. We do not recommend avoidance of particular foods, and the evidence supports this stance. It is more important to make healthy food choices.

[email protected]

More often than not the child who presents with recurrent or chronic headaches will be experiencing migraines. Pediatric migraine is very common; in fact, it is one of the top five health problems for children. General pediatricians treat the majority of these children, up to 90%. There are not enough pediatric neurologists in the United States to take care of all of these children. For example, given the prevalence rate of 10%, an estimated 60,000 children and adolescents experience migraine out of the 2.4 million people in the Cincinnati draw area for my institution. Obviously, they cannot all be referred to a specialist.

The most important thing for you to do is to rule out secondary headaches. Differentiate primary headaches (such as migraine and tension headaches) from secondary ones, being skeptical of the secondary presentations. If a secondary etiology is suspected and the headaches do not resolve, then reassess, but the headaches may be primary ones.

Ask patients and parents about headache symptoms because often the symptoms are initially missed. Standardized criteria such as the American Academy of Neurology practice parameters on the treatment of migraine headache in children and adolescents can guide your diagnosis and management (Neurology 2004;63:2215–24). If the clinical picture does not fit these criteria, consider further evaluation of the child.

After your differential diagnosis, perform a complete neurologic examination. If findings are abnormal on the neurologic exam, consider an MRI. Such imaging also may be warranted for children with exclusively occipital headaches, if they experience a crescendo or abrupt change in headaches, or if they lack a relevant family history.

Almost all other tests are less useful and do not help prior to referral to a pediatric neurologist. We do not need EEGs, sinus x-rays, or CT exams, which have lots of unnecessary radiation. We routinely check riboflavin and coenzyme Q10 levels, but this may be beyond the level of general pediatricians.

Referral to a specialist is appropriate when the above strategies are not working and if the headaches do not improve. Also refer if a child has chronic daily headaches (defined as 15 or more days per month), if a child is missing a lot of school or other activities of daily living, and/or if the history and diagnosis do not seem to fit the presentation.

Optimal treatment is a standardized strategy that incorporates acute and preventive pharmacologic strategies, as well as biobehavioral treatments.

Appropriate NSAID use, for example, can aid a child with an acute presentation. For example, prescribe 10 mg/kg of ibuprofen at onset, and do not exceed three dosages per week. In addition, be familiar with at least one triptan at appropriate dosing (an adult dose for teenagers).

Also be comfortable with at least one age-appropriate, preventive agent. Amitriptyline is the easiest to use. The recommended dosage regimen is 1 mg/kg titrated up slowly (over a period of 8–10 weeks) for about 2–3 months at full dose to allow sufficient time for clinical effect. I also advise against the use of cyproheptadine for teenagers with migraines because of the appetite effect.

Adequate fluid intake without caffeine, exercise at least three to four times per week, and sufficient regular sleep (8–9 hours, for example) are important components of biobehavioral treatment. In addition, educate patients and parents about the importance of a healthy, balanced diet. Instruct patients not to skip meals. We do not recommend avoidance of particular foods, and the evidence supports this stance. It is more important to make healthy food choices.