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2 episodes with references american academy
2 episodes with references american academy
2 episodes with references american academy
Did you know that congenital cytomegalovirus (cCMV) is the most common congenital viral infection in newborns and a leading cause of non-genetic hearing loss? Despite its prevalence, awareness and screening for cCMV remain inconsistent across healthcare systems. In this episode, we dive into the critical importance of cCMV screening, early diagnosis, and intervention. Join our expert guests Dr. Ingrid Camelo and Dr. John Noel as they discuss: The impact of cCMV on neonatal and long-term health outcomes Best practices for screening and diagnostic methods The role of early intervention, including antiviral therapy How advocacy efforts are shaping the future of universal screening policies Tune in to stay informed on how pediatricians and healthcare providers can play a vital role in improving outcomes for infants affected by cCMV. Special thanks to Dr. James Grubbs for peer reviewing this episode. CME Credit (requires free sign up): Link Coming Soon! References: American Academy of Pediatrics. A targeted approach for congenital cytomegalovirus. Available at: https://publications.aap.org/pediatrics/article/139/2/e20162128/60211/A-Targeted-Approach-for-Congenital-Cytomegalovirus. Accessed August 13, 2024. Chiopris G, Veronese P, Cusenza F, Procaccianti M, Perrone S, Daccò V, Colombo C, Esposito S. Congenital cytomegalovirus infection: update on diagnosis and treatment. Microorganisms. 2020 Oct 1;8(10):1516. doi: 10.3390/microorganisms8101516. PMID: 33019752; PMCID: PMC7599523. Gantt S. Newborn cytomegalovirus screening: is this the new standard? Curr Opin Otolaryngol Head Neck Surg. 2023 Dec 1;31(6):382-387. doi: 10.1097/MOO.0000000000000925. Epub 2023 Oct 11. PMID: 37820202. Minnesota Department of Health. Minnesota implements universal newborn screening for cytomegalovirus. Available at: https://www.health.state.mn.us/news/pressrel/2023/ccmv020823.html. Accessed August 13, 2024. National CMV Foundation. Advocacy: universal newborn CMV screening. Available at: https://www.nationalcmv.org/about-us/advocacy#:~:text=Minnesota%20was%20the%20first%20state%20to%20enact%20universal%20newborn%20CMV%20screening. Accessed August 13, 2024. New York State Department of Health. Newborn screening for cytomegalovirus. Available at: https://www.health.ny.gov/press/releases/2023/2023-09-29_newborn_screening.htm#:~:text=ALBANY%2C%20N.Y.,all%20babies%20for%20the%20virus. Accessed August 13, 2024. UpToDate. Congenital cytomegalovirus (CMV) infection: clinical features and diagnosis. Available at: https://www.uptodate.com/contents/congenital-cytomegalovirus-ccmv-infection-clinical-features-and-diagnosis?search=cmv%20screening&source=search_result&selectedTitle=1%7E28&usage_type=default&display_rank=1#H92269684. Accessed August 13, 2024. UpToDate. Congenital cytomegalovirus (CMV) infection: management and outcome. Available at: https://www.uptodate.com/contents/congenital-cytomegalovirus-ccmv-infection-management-and-outcome?search=congenital%20cmv&source=search_result&selectedTitle=2%7E66&usage_type=default&display_rank=2. Accessed August 13, 2024. UpToDate. Ganciclovir and valganciclovir: an overview. Available at: https://www.uptodate.com/contents/ganciclovir-and-valganciclovir-an-overview?search=ganciclovir&source=search_result&selectedTitle=2%7E80&usage_type=default&display_rank=1#H6. Accessed August 13, 2024. University of Texas Medical Branch. Neonatology manual: infectious diseases. Available at: https://www.utmb.edu/pedi_ed/NeonatologyManual/InfectiousDiseases/InfectiousDiseases3.html#:~:text=may%20be%20required.-,Cytomegalovirus,Clinical%20findings. Accessed August 13, 2024. National Center for Biotechnology Information. Cytomegalovirus (CMV) infection. Available at: https://www.ncbi.nlm.nih.gov/books/NBK541003/. Accessed August 13, 2024.
Episode 189: Intermittent Fasting (Religious and Sports)Future Doctors Carlisle and Kim give recommendations about patients who are fasting for religious reasons, such as Ramadan. They also explain the benefits and risks of fasting for athletes and also debunked some myths about fasting. Dr. Arreaza add input about the side effects of fasting and ways to address them. Written by Cameron Carlisle, MSIV (RUSM) and Kyung Kim, MSIV (AUC). Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: In the last episode on fasting (#179), we explored how intermittent fasting (IF) can help manage type 2 diabetes by improving insulin sensitivity, promoting weight loss, and lowering inflammation. We discussed the benefits of methods like 16:8 time-restricted eating and the 5:2 meal plan, and even compared IF to medications like metformin. Today, we're bringing that science into real life. We'll talk about how people fast for religious reasons, like during Ramadan, how athletes use IF to stay in shape, and how we can use IF as a tool in family medicine to support community health and A1c control.Intermittent Fasting in Religious PracticeRamadan just ended on 3/30/25, but this is a great time to talk about the broader role of fasting in religion and health. Many faiths incorporate fasting into spiritual practice and understanding this can help us better support our patients.Islam (Ramadan): Ramadan is a month where Muslims fast from dawn to sunset, focusing on spiritual reflection and self-control. No food or drink is consumed during daylight hours. Despite this, studies have shown that with good planning, fasting during Ramadan does not significantly impair physical performance or metabolic health.Key health tips for patients observing Ramadan:Hydrate well between iftar (sunset) and suhoor (pre-dawn).Break the fast with dates and water to gently replenish energy and electrolytes.Eat balanced meals with complex carbs, protein, and healthy fatsAvoid greasy, heavy foods right after fastingLight exercise (such as a walk) after iftar is beneficialReview medications with a healthcare provider, especially for those on insulin or sulfonylureas.For example: Metformin should be taken when you break your fast and then again before dawn. If its an extended-release metformin, take it at night. Metformin does not cause significant hypoglycemia and can be continued during Ramadan. Basal insulin is advised to be given at Iftar, and the dose should be reduced by 25-35% if the patient is not well managed. And regarding the fast-acting insulin, it requires a little more reading, so you can look it up and learn about it. Judaism: In Judaism, fasting is practiced on days like Yom Kippur and Tisha B'Av, typically lasting 25 hours without food or water. These fasts are spiritual and reflective, and patients with medical conditions may seek guidance on how to participate safely.Christianity: Many Christians fast during Lent, either by abstaining from certain foods or limiting meal frequency. Some practice partial-day fasts or water-only fasts for spiritual renewal.A branch of Christianity known as The Church of Jesus Christ of Latter-day Saintsoften observe a 24-hour fast on the first Sunday of each month, known as Fast Sunday, where they abstain from food and drink and donate the cost of meals to charity. This practice is both spiritual and communal.Cameron: Fasting for religious reasons, when done safely, can align with IF protocols and be culturally sensitive for diverse patients in family medicine.IF in Athletes and PerformanceIntermittent fasting is gaining popularity in the sports world. Athletes are using IF to improve body composition, increase fat oxidation, and enhance metabolic flexibility. A recent study, known as the DRIFT trial and published in Annals of Internal Medicine, found that fasting three non-consecutive days a week led to more weight loss than daily calorie restriction. Participants lost an average of 6.37 pounds more over 12 months.Why? Better adherence. People found the 3-day fasting schedule easier to stick to than counting calories every day.Benefits of IF for athletes:Encourages fat burning (via AMPK activation and GLUT4 upregulation, listen to ep. 179).Helps maintain lean muscle while reducing fat.No major drop in performance when meals and workouts are timed properly.What are some practical tips?Schedule workouts during or just before eating windows.Eat protein-rich meals post-workout.Avoid intense training during long fasts unless adapted.Stay hydrated, especially in hot environments or endurance sports.Broader Applications and Myths Around IFHormonal Effects of IF: In addition to improving insulin sensitivity, IF also affects hormones such as ghrelin (which stimulates hunger, remember it as growling) and leptin (which signals fullness). Over time, IF may help the body regulate appetite better and reduce cravings. IF can also decrease morning cortisol levels, the stress hormone. That's why it's important to monitor sleep, hydration, and stress levels when recommending IF.Circadian Rhythm Alignment: Emerging research shows that aligning eating times with natural light/dark cycles—eating during the day and fasting at night—can improve metabolic outcomes. This practice, known as early time-restricted eating (eTRE), has been shown to lower blood glucose, reduce insulin levels, and improve energy use. Patients who eat earlier in the day tend to have better results than those who eat late at night.Myths and Clarifications on IF:-“Fasting slows metabolism” In fact, short-term fasting may boost metabolism slightly due to increased norepinephrine. -“You can't exercise while fasting.” Many people can safely train during fasted states, especially for moderate cardio or strength training. -“Skipping breakfast is bad.” For some, skipping breakfast is a useful IF strategy—as long as total nutrition is maintained. You can break your fast at 2:00 pm, it does have to be at 7:00 AM.What to Eat When Breaking a FastBreaking a fast properly is just as important as fasting itself. Whether it's after a Ramadan fast or a 16-hour fast, the goal is to replenish energy gently and restore nutrients.Ideal foods to break a fast:Dates and water: provide quick energy, potassium, and fiberSoups: lentil or broth-based soups are gentle on digestionComplex carbs: whole grains like brown rice or oatsLean proteins: chicken, fish, eggs, legumesFruits and vegetables: hydrate and provide fiberHealthy fats: nuts, avocado, olive oilProbiotics: yogurt or kefir for gut supportBalanced meals with carbs, protein, and healthy fats help the body transition smoothly back to a fed state.Using IF in Family Medicine and Community HealthIntermittent fasting can be a practical, cost-effective strategy in family medicine. In areas with high rates of obesity and diabetes, like Kern County, IF offers a lifestyle-based tool to improve metabolic health, especially in underserved populations. IF is free!How IF can help in family medicine:Lower A1c levels: improves insulin sensitivity and glucose controlPromote weight loss: decreases insulin resistance and inflammationReduce medication dependence: fewer meds needed over time for some patientsEncourage patient engagement: flexible and easier to follow than strict calorie countingFit diverse lifestyles: aligns with religious and cultural practicesAddress food insecurity: structured eating windows can help patients stretch limited food resourcesHow to apply IF in clinic:Start the conversation by asking if the patient has heard of IFRecommend simple starting points: 12:12 or 14:10Emphasize hydration and nutrient-dense mealsMonitor labs and symptoms, especially in diabetic patientsAdjust medications to avoid hypoglycemiaProvide follow-up and patient education handouts if possibleWhat if a patient isn't ready to try fasting?For those not ready to commit to intermittent fasting, one effective alternative is walking after meals. A simple 10–20 minute walk post-meal can help stimulate GLUT4 receptors in skeletal muscle, promoting glucose uptake independent of insulin. This reduces the demand on pancreatic beta cells and may help improve blood sugar control over time. This strategy is particularly useful for patients with insulin resistance or early-stage type 2 diabetes.Conclusion: Intermittent fasting is not one-size-fits-all, but it can be a powerful tool for both individual and community health. From Ramadan to race day, IF has a place in family medicine when used thoughtfully. Encourage patients to work with their healthcare providers to find an approach that fits their lifestyle, medical needs, and personal values. IF is a cost-effective toolEven without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Academy of Family Physicians. (2022). "Intermittent Fasting: A Promising Treatment for Diabetes." AAFP Community Blog. https://www.aafp.org/pubs/afp/afp-community-blog/entry/intermittent-fasting-a-promising-treatment-for-diabetes.htmlHealthline. (2023). "What Breaks a Fast? Foods, Drinks, and Supplements." https://www.healthline.com/nutrition/what-breaks-a-fast.Sarri KO, Tzanakis NE, Linardakis MK, Mamalakis GD, Kafatos AG. Effects of Greek Orthodox Christian Church fasting on serum lipids and obesity. BMC Public Health. 2003 May 16;3:16. doi: 10.1186/1471-2458-3-16. PMID: 12753698; PMCID: PMC156653. https://pmc.ncbi.nlm.nih.gov/articles/PMC156653/.Shang, Y., et al. (2024). "Effects of Intermittent Fasting on Obesity-Related Health Outcomes: An Umbrella Review." eClinicalMedicine.https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00098-1.Abaïdia AE, Daab W, Bouzid MA. Effects of Ramadan Fasting on Physical Performance: A Systematic Review with Meta-analysis. Sports Med. 2020 May;50(5):1009-1026. doi: 10.1007/s40279-020-01257-0. PMID: 31960369. https://pubmed.ncbi.nlm.nih.gov/31960369/.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.
How often should our patients present for their perio maintenance recall? Is it okay to graduate them from 3 mos to 4 mos recalls? How do we evaluate this? Check out this 5 minute episode with Katrina Sanders to learn more! References: American Academy of Periodontology. Acquired from: https://www.ada.org/~/media/JCNDE/pdfs/Perio_Disease_Classification_FAQ.pdf?la=en. Accessed on: September 21, 2021. Magnusson, I., Lindhe, J., Yoneyama, T., & Liljenberg, B. (1984). Recolonization of a subgingival microbiota following scaling in deep pockets. Journal of clinical periodontology, 11(3), 193-207. Greenstein, G., Periodontal response to mechanical non-surgical therapy: a review. J Periodontol, 1992. 63(2): p. 118-30.
How often should our patients present for their perio maintenance recall? Is it okay to graduate them from 3 mos to 4 mos recalls? How do we evaluate this? Check out this 5 minute episode with Katrina Sanders to learn more! References: American Academy of Periodontology. Acquired from: https://www.ada.org/~/media/JCNDE/pdfs/Perio_Disease_Classification_FAQ.pdf?la=en. Accessed on: September 21, 2021. Magnusson, I., Lindhe, J., Yoneyama, T., & Liljenberg, B. (1984). Recolonization of a subgingival microbiota following scaling in deep pockets. Journal of clinical periodontology, 11(3), 193-207. Greenstein, G., Periodontal response to mechanical non-surgical therapy: a review. J Periodontol, 1992. 63(2): p. 118-30.
*In this episode we touch on some adult topics. Listener discretion is advised. Smart phones and social media are a part of our everyday lives, that's just the society we live in. Your adolescents have grown and learned so much since the early says of screen time, and yet they are still kids and still learning. As your kids grow older, it might feel like all the rules go out the window. They're more independent and often push back, making it challenging to manage their screen time effectively. In this episode, we discuss the unique aspects of managing electronics with adolescents. Their phones are not just for calls; they encompass their social lives, homework, and more. We explore the importance of setting clear guidelines and expectations, treating their phone as a privilege rather than a right. We'll share tips on creating a phone contract to establish rules and consequences, and emphasize the significance of modeling responsible phone use ourselves. Join us as we navigate this new age of technology with our teens, aiming to foster healthy habits and open communication. References: American Academy of Pediatrics. (n.d.). The 5 C's of Media Use: Young Teen. American Academy of Pediatrics. https://downloads.aap.org/AAP/PDF/CoE_5Cs_Young_Teens_Final.pdf American Academy of Pediatrics. (n.d.). The 5 C's of Media Use: Older Teen. American Academy of Pediatrics. https://downloads.aap.org/AAP/PDF/CoE_5Cs_Older_Teens_Final.pdf DIGCIT curriculum. Common Sense Education. (n.d.). https://www.commonsense.org/education/digital-citizenship/curriculum Vogels, E. A. (2023, April 24). Teens and social media: Key findings from Pew Research Center Surveys. Pew Research Center. https://www.pewresearch.org/short-reads/2023/04/24/teens-and-social-media-key-findings-from-pew-research-center-surveys/ Disclaimer: This podcast represents the opinions of the hosts and their guests. Views and opinions expressed in the podcast are our own and do not necessarily represent that of our employers or Momentum Parenting, LLC. The content discussed by the hosts or their guests should not be taken as mental health or medical advice and is for informational and educational purposes only. In no way does listening, contacting our hosts, or engaging with our content establish a doctor-patient relationship. Please consult your or your child's healthcare professional for any mental health or medical questions. Strategies discussed in this podcast are backed by peer-reviewed literature. Please see show notes for references. All examples mentioned in the podcast have been modified to protect patient confidentiality.
We know you hear about this everywhere, and most of the time it's guilt inducing. But fear not, in Part I of the screen time series your hosts, Dr. Roseanne Lesack and Dr. Jill Wilson, will discuss what the recommendations say and what's realistic. By mixing personal stories with professional advice, the hosts aim to help you tackle this modern parenting challenge with confidence and ease. Managing screen time is complex as there are academic, social, and interpersonal components involved. We aim to highlight the importance of balance, boundaries, and open family communication when discussing screen content and screen time. The goal is for parents to use screen time to their advantage, and for kids to get the most out of screen time while balancing the need for other activities to foster development. References: American Academy of Pediatrics. (n.d.). Where we stand: Screen time. HealthyChildren.org. https://www.healthychildren.org/English/family-life/Media/Pages/Where-We-Stand-TV-Viewing-Time.aspx Disclaimer: This podcast represents the opinions of the hosts and their guests. Views and opinions expressed in the podcast are our own and do not necessarily represent that of our employers or Momentum Parenting, LLC. The content discussed by the hosts or their guests should not be taken as mental health or medical advice and is for informational and educational purposes only. In no way does listening, contacting our hosts, or engaging with our content establish a doctor-patient relationship. Please consult your or your child's healthcare professional for any mental health or medical questions. Strategies discussed in this podcast are backed by peer-reviewed literature. Please see show notes for references. All examples mentioned in the podcast have been modified to protect patient confidentiality.
Over the past two decades the number of children with obesity has continued to rise. Obesity in childhood predisposes children to both immediate and future health risk. Dr. Rebecca Yang, a general pediatrician, joins community pediatrician Dr. Ashley Miller to discuss nutrition and physical activity recommendations throughout childhood. Specifically, they will: Discuss the role nutrition and physical activity plays in pediatric obesity Educate on nutritional requirements for healthy growth and development Determine on how food insecurity plays a role in obesity Inform about recommendations for physical activity and age-appropriate guidelines Understand the barriers to physical activity Special thanks to Dr. Shreeti Kapoor who peer reviewed today's episode. FREE CME Credit (requires free sign-up): Link Coming Soon! References: • American Academy of Pediatrics. (2022, May 13). Recommended Drinks for Children Age 5 & Younger. Retrieved from Healthy Children: https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Recommended-Drinks-for-Young-Children-Ages-0-5.aspx • COUNCIL ON COMMUNITY PEDIATRICS, C. O. (2015). Promoting Food Security for All Children. Pediatrics , 136(5), e1431-e1438. doi:10.1542/peds.2015-3301 • Felipe Lobelo, Natalie D. Muth, Sara Hanson, Blaise A. Nemeth, COUNCIL ON SPORTS MEDICINE AND FITNESS, SECTION ON OBESITY, Cynthia R. LaBella, M. Alison Brooks, Greg Canty, Alex B. Diamond, William Hennrikus, Kelsey Logan, Kody Moffatt, K. Brooke Pengel, Andrew R. Peterson, Paul R. Stricker, Christopher F. Bolling, Sarah Armstrong, Matthew Allen Haemer, John Rausch, Victoria Rogers, Stephanie Moore Walsh; Physical Activity Assessment and Counseling in Pediatric Clinical Settings. Pediatrics March 2020; 145 (3): e20193992. 10.1542/peds.2019-3992 • Hemmingsson E. Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication. Curr Obes Rep. 2018 Jun;7(2):204-209. doi: 10.1007/s13679-018-0310-2. PMID: 29704182; PMCID: PMC5958160. • Lee JW, Lee M, Lee J, Kim YJ, Ha E, Kim HS. The Protective Effect of Exclusive Breastfeeding on Overweight/Obesity in Children with High Birth Weight. J Korean Med Sci. 2019 Mar 8;34(10):e85. doi: 10.3346/jkms.2019.34.e85. PMID: 30886551; PMCID: PMC6417996. • Maternal Diet. (2022, May 17). Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html • Lobelo F, Muth ND, Hanson S, Nemeth BA; COUNCIL ON SPORTS MEDICINE AND FITNESS; SECTION ON OBESITY. Physical Activity Assessment and Counseling in Pediatric Clinical Settings. Pediatrics. 2020 Mar;145(3):e20193992. doi: 10.1542/peds.2019-3992. Epub 2020 Feb 24. PMID: 32094289. • USDA . (2022, April 22). Definitions of Food Security. Retrieved from USDA Econimic Reserach Service: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security/
Lead toxicity continues to be a major public health concern in the United States. Children are particularly vulnerable to the potential toxicity of lead. Nicole Bisel, a medical student at the Medical College of Georgia is joined by pediatricians Dr. Tyrone Bristol and Dr. Rebecca Yang to to discuss the risk, evaluation and management of lead toxicity in children. Specifically, they will: Why lead toxicity continues to be an issue today Discuss sources of how humans are exposed to lead Review Risk Factors & Consequences of lead toxicity And finally discuss screening, management, and treatment for children with lead toxicity FREE CME Credit (requires sign-in): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=9855 Thank you for listening to this episode from the Department of Pediatrics at the Medical College of Georgia. If you have any comments, suggestions, or feedback- you can email us at mcgpediatricpodcast@augusta.edu Remember that all content during this episode is intended for educational purposes only. It should not be used as medical advice to diagnose or treat any particular patient. Clinical vignette cases presented are based on hypothetical patient scenarios. Thank you for your support! References: American Academy of Pediatrics. Council of Environmental Health. Prevention of Childhood Lead Toxicity. Pediatrics. 2016;38(1)e20161493 – August 01, 2017 https://pediatrics.aappublications.org/content/138/1/e20161493 American Academy of Pediatrics. Childhood Lead Exposure Infographic. In: American Academy of Pediatrics Health Initiatives Lead Exposure and Lead Poisoning. American Academy of Pediatrics Website. https://www.aap.org/en-us/ImagesGen/Lead_infographic.jpg. Accessed February 6, 2021. PEHSU: Pediatric Environmental Health Specialty Units. Lead and Drinking Water: Information for Health Professionals Across the United States. American Academy of Pediatrics Website. https://www.pehsu.net/_Library/facts/LeadandDrinkingWater_62116_final.pdf. Accessed February 6, 2021. American Academy of Pediatrics. Lead Exposure in Children. American Academy of Pediatrics Website. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-exposure/Pages/Lead-Exposure-in-Children.aspx. Accessed February 6, 2021. Centers for Disease Control and Prevention. Childhood Lead Poisoning Prevention. Childhood Lead Poisoning Prevention Program Website. https://www.cdc.gov/nceh/lead/. Accessed February 6, 2021. Mayans L. Lead Poisoning in Children. American Family Physician. 2019; 100(1):24-30. https://www.aafp.org/afp/2019/0701/p24.html. Accessed February 13, 2021. Hanna-Attisha M, LaChance J, Sadler RC, Schnepp AC. Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. American Journal of Public Health. 2016; 106(2): 283-290. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4985856/#__ffn_sectitle. Accessed February 13, 2021. Council on Environmental Health. Prevention of Childhood Lead Toxicity. Pediatrics. 2016; 138(1):e20161493. https://pediatrics.aappublications.org/content/138/1/e20161493%20. Accessed February 13, 2021. Sanders T, Liu Y, Buchner V, Tchounwou PB. Neurotoxic Effects and Biomarkers of Lead Exposure: A Review. Rev Environ Health. 2009; 24(1): 15-45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858639/#__ffn_sectitle. Accessed February 13, 2021. American Academy of Pediatrics. Detection of Lead Poisoning. American Academy of Pediatrics Website. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-exposure/Pages/Detection-of-Lead-Poisoning.aspx. Accessed March 7, 2021 American Academy of Pediatrics. Treatment of Lead Poisoning. American Academy of Pediatrics Website. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-exposure/Pages/Treatment-of-Lead-Poisoning.aspx. Accessed March 7, 2021. Zahran S, McElmurry SP, Sadler RC. Four Phases of Flint Water Crisis: Evidence from Blood Lead Levels in Children. Environ Res. 2017; 157: 160-172. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5538017/. Accessed February 13, 2021. https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm. Accessed March 14, 2021. https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm. . Accessed Nov 14, 2021.
References: American Academy of Clinical Endocrinologists' Guidelines: https://www.aace.com/pdfs/diabetes/algorithm-exec-summary.pdf https://www.aace.com/pdfs/diabetes/AACE_2019_Diabetes_Algorithm_FINAL_ES.pdf https://journals.aace.com/doi/pdf/10.4158/EP15672.GLSUPPL History of Diabetes https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749019/ Hypoglycemia https://ihsgonline.com/wp-content/uploads/2017/05/Jan_2017-Diabetes_Care-Glucose_Concentrations.pdf Sleep Podcast: https://podcasts.apple.com/us/podcast/episode-93-sleep/id1199780143 For more of our stuff: Podcasts: goo.gl/X4H4z8 Website: www.barbellmedicine.com Instagram: @austin_barbellmedicine @jordan_barbellmedicine @leah_barbellmedicine @vaness_barbellmedicine @untamedstrength @michael_barbellmedicine @derek_barbellmedicine @hassan_barbellmedicine @michael_amato_barbellmedicine @charlie_barbellmedicine @alex_barbellmedicine @tomcampitelli Email: info@barbellmedicine.com Supplements/Templates/Seminars: www.barbellmedicine.com/shop/ Forum: forum.barbellmedicine.com/
This episode of Part 2 of the conversation about discipline our children. Our guests are pediatricians, Dr. Michelle Collins Ogle and Dr. Shontae Buffington. During the conversation we'll discuss the American Academy of Pediatrics policy on Effective Discipline, the policy's impact on African-American families and cultural influences of parenting recommendations.Guest Bios:Dr. Shontae Buffington is a pediatrician and an active American Academy of Pediatrics member practicing in southeast Georgia. She earned a Bachelors of Arts in Human Biology from Stanford University in Palo Alto, California and her medical degree from Howard University College of Medicine. Dr. Buffington completed her residency at the University of California Davis in Sacramento, California where she developed a keen interest in adolescent medicine, ADHD, and child behavioral disorders. In her free time, she designs, sews, and blogs about creating her own clothing.Dr. Michelle Collins Ogle is a Clinical Infectious Disease Specialist who has dedicated most of her career to providing comprehensive medical care to infants, children, adolescents and adults living with HIV / AIDS. She also has a special interest in assuring equal access for the treatment of HIV as well as other infections in young gay men and transgender youth. Dr. Collins Ogle received her training in Infectious Diseases at Childrens Hospital in Detroit, Michigan. She is currently the Medical Director at Warren-Vance Community Health Center, Inc., which provides comprehensive medical care for adolescents and adults living with HIV/AIDS in the most rural, isolated communities in the state.Dr. Ogle passionately advocates for patients living in rural, indigent isolated areas of North Carolina because she holds the belief that these patients deserve the same access to quality medical care as those living in urban areas. She expanded the HIV practice to provide a warm, non-judgmental and welcoming environment for transgender people living with HIV in rural NC. Providing hormone therapy and coordinated HIV care for the transgender population has been a welcomed service.Dr. Collins Ogle currently serves as the Pediatric liaison for the Pediatric Infectious Disease Society and the HIV Medicine Association, past Co-Chairman of the Steering Committee for the Ryan White Medical Providers Coalition which advocates and Lobbies legislators on the state and federal level to protect funding for HIV/AIDS medical care programs. She also proudly served as a member of the Presidential Advisory Council on HIV/AIDS; Inducted Sept 4, 2014 resigned along with 5 other members in 2017 in protest of this administrations attempt to cut Medicaid and RW funding.References:American Academy of Pediatrics Effective Discipline Policyhttp://pediatrics.aappublications.org/content/142/6/e20183112American Academy of Pediatrics, HealthyChildren.org: What's the Best Way to Discipline My Child?https://www.healthychildren.org/English/family-life/family-dynamics/communication-discipline/Pages/Disciplining-Your-Child.aspx
This episode of Part 2 of the conversation about discipline our children. Our guests are pediatricians, Dr. Michelle Collins Ogle and Dr. Shontae Buffington. During the conversation we'll discuss the American Academy of Pediatrics policy on Effective Discipline, the policy's impact on African-American families and cultural influences of parenting recommendations. Guest Bios: Dr. Shontae Buffington is a pediatrician and an active American Academy of Pediatrics member practicing in southeast Georgia. She earned a Bachelors of Arts in Human Biology from Stanford University in Palo Alto, California and her medical degree from Howard University College of Medicine. Dr. Buffington completed her residency at the University of California Davis in Sacramento, California where she developed a keen interest in adolescent medicine, ADHD, and child behavioral disorders. In her free time, she designs, sews, and blogs about creating her own clothing. Dr. Michelle Collins Ogle is a Clinical Infectious Disease Specialist who has dedicated most of her career to providing comprehensive medical care to infants, children, adolescents and adults living with HIV / AIDS. She also has a special interest in assuring equal access for the treatment of HIV as well as other infections in young gay men and transgender youth. Dr. Collins Ogle received her training in Infectious Diseases at Children’s Hospital in Detroit, Michigan. She is currently the Medical Director at Warren-Vance Community Health Center, Inc., which provides comprehensive medical care for adolescents and adults living with HIV/AIDS in the most rural, isolated communities in the state. Dr. Ogle passionately advocates for patients living in rural, indigent isolated areas of North Carolina because she holds the belief that these patients deserve the same access to quality medical care as those living in urban areas. She expanded the HIV practice to provide a warm, non-judgmental and welcoming environment for transgender people living with HIV in rural NC. Providing hormone therapy and coordinated HIV care for the transgender population has been a welcomed service. Dr. Collins Ogle currently serves as the Pediatric liaison for the Pediatric Infectious Disease Society and the HIV Medicine Association, past Co-Chairman of the Steering Committee for the Ryan White Medical Provider’s Coalition which advocates and Lobbies legislators on the state and federal level to protect funding for HIV/AIDS medical care programs. She also proudly served as a member of the Presidential Advisory Council on HIV/AIDS; Inducted Sept 4, 2014 resigned along with 5 other members in 2017 in protest of this administration’s attempt to cut Medicaid and RW funding. References: American Academy of Pediatrics Effective Discipline Policy http://pediatrics.aappublications.org/content/142/6/e20183112 American Academy of Pediatrics, HealthyChildren.org: What's the Best Way to Discipline My Child? https://www.healthychildren.org/English/family-life/family-dynamics/communication-discipline/Pages/Disciplining-Your-Child.aspx
Dr. Jerry Snow, a medical toxicologist and emergency medicine physician from Phoenix joins the show for an interesting discussion about the opiate crisis facing America today, with a specific emphasis on fentanyl and its derivatives. We discuss EMS/first responder exposure risks and preventative measures along with patient care pearls when treating patients with fentanyl overdose. References: American Academy of Clinical Toxicology Statement on Fentanyl Exposure Risks - https://www.acmt.net/_Library/Fentanyl_Position/Fentanyl_PPE_Emergency_Responders_.pdf https://www.whitehouse.gov/ondcp/key-issues/fentanyl/
Text ‘bulletproof’ to 345345 to stay in the know about our upcoming book release and the Bulletproof Summit on October 12-13th 2018 in Atlanta! Bulletproof Dental Practice Podcast Episode 60 Hosts: Dr. Peter Boulden & Dr. Craig Spodak Guest: Debra Englehardt-Nash Watch full video of the interview by clicking here! Key Takeaways: Private practice dentistry is NOT going to go away. We must learn how to stop commoditizing our patients. Instead we should learn to value appreciation of our patients. Passionate dentists make great leaders. They create the vision and enlist the help of a supportive team to put that vision in action. When a new patient calls start out asking “inspirational” questions, instead of asking about insurance first. Listen to what the patient wants. Help your team and patients understand how fees are based: Skill required to do it right Time it takes to do it well Materials used so treatment endures Dentistry used to be all about efficiency, now it’s all about experience. Thoughtful approaches take longer, but you end up with a better result. Pre-collect for appointments. It takes the stress off collecting at the end of the appointment and eliminates no-shows. There’s room for all kinds of dentistry, you just have to decide where you want to be. Success is a meandering stream, it’s not a direct line. The business of dentistry is hard work. Consultants are facilitators to help the leader be the difference in the practice. Listening to webinars and podcasts is important, but they can’t replace in-person trainings and meetings. Toil is good for you. Successful people don’t act as victims, they address their own actions that led to where they are. Catastrophes give perspective and help you redirect. You don’t have a lot of time to establish trust, so you better do it quickly. Ask for your patient’s permission before you start offering treatment options. 70% of the reason why patients don’t follow through with treatment is because the treatment wasn’t explained well enough and they were released too soon to talk about money and they weren’t ready to commit. Dentists often settle for way too little when choosing members of their team. Olympics are won by 1/10th of a second. That extra 10th of a second could be that one thing that moves you forward faster. References: American Academy of Dental Practice Extreme Ownership by Jocko Willink Tweetables: It’s the head of the fish that always smells first. – Benjamin Franklin People who get frozen in fear will never get a win. – Debra Englehardt-Nash You have to believe to be believed. – Debra Englehardt-Nash Whether you’ve spent $400 or $4000, if you’re not happy you’ve spent too much. – Debra Englehardt-Nash Change your modalities and you might get a different result. – Debra Englehardt-Nash The dentist’s fear is holding back dentistry. – Debra Englehardt-Nash Life’s too short to be unhappy. – Debra Englehardt-Nash Happiness is in the solving of problems, not in the absence of them. – Dr. Craig Spodak If you’re going to ask your team to be a cheerleader, you better give them something to cheer about. – Debra Englehardt-Nash The chokehold on any business is always the psychology and skill set of the owner. – Dr. Craig Spodak The culmination of many small successes is a massive win. – Dr. Craig Spodak
N.B.: This month's show notes are a departure from the usual summary. Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017. Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features. In children often the predominant feature may not be initially apparent. Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach. What is the age and developmental stage of the child? How is the child reacting to his condition? What are the circumstances? What is the family or caregiver dynamic? We rely much on how patients and families interact with us to gauge pain. Assessing and managing children’s pain can be challenging, because they may not exhibit typically recognized signs and symptoms (Srouji 2010). Further, children participate in and absorb their family’s culture and specific personality from a very young age (Finley 2009). Knowing the context of the episode may help. For example, a very anxious caregiver can easily transmit his or her anxiety to the child, which may either inhibit or amplify presentation of symptoms (Bearden 2012). The guiding principles in pediatric pain assessment and management are: know the child; know the family; and know the physiology. Children have long suffered from an under-treatment of their pain, due both to our incomplete acknowledgement of their pain and our fear of treatment (Howard 2003). As the pendulum on pain management swings one way or the other, do not let your pediatric patient get knocked by the wayside. Take a thoughtful approach: know the signs and symptoms, and aggressively treat and reassess. ASSESSMENT Each stage of development offers a unique framework to the child’s signs and symptoms of pain. In pre-verbal children, use your observational skills in addition to the parent’s report of behavior. Verbal children can self-report; younger children require pictorial descriptions, while older children and adolescents may use standard adult scales. In all ages, ask open-ended questions and allow the child to report and speak for himself whenever possible. Neonates Neonates are a unique group in pain assessment. The neonate (birth to one month of age) has not yet acquired social expression of pain, and his nascent nervous system is only now learning to process it. Do not expect typical pain behaviors in neonates. Facial grimacing is a weak indicator of pain in neonates (Liebelt 2000). When this behavior is present, look for a furrowed brow, eyes squeezed shut, and a vertically open mouth. Tachycardia, tachypnea, and a change in behavior can be indicators not only to the presence of pain, but possibly to its etiology as well. Neonatal observational scales have been validated in the intensive care and post-operative settings; ED-specific quantitative scales are lacking. CRIES is a 10-point scale, using a physiologic basis similar to APGAR: Crying; Requires increased oxygen administration (distress and breath-holding); Increased vital signs; Expression; and Sleeplessness (Krechel 1995). CRIES (Table 1) was validated for post-operative patients; to adapt its use for the ED, the most conservative approach is to substitute “preoperative baseline” with normal range for age. Although the numerical values of CRIES have not been validated to date in the ED, the clinician may find the domains included in CRIES to be a useful cognitive construct in assessing neonatal pain. Neonatal pain pathways are particularly plastic; prompt assessment of and increased alertness to neonatal pain may help to mitigate long-lived pain sensitivity and hyperalgesia (Taddio 2002). In other words, treat the neonate’s pain seriously, as you may save him long-term pain sequelae in the future. Infants and Toddlers This group will begin to exhibit more reproducible, reliable signs and symptoms of pain. For infants of less than one year of age, the Neonatal Infant Pain Scale (NIPS) uses observational and physiologic parameters to detect pain (Table 2). A score of 0-2 indicates no pain present. A score of 3-4 indicates mild to moderate pain; non-pharmacologic techniques may be tried first. A score of 5 or greater indicates severe pain; some pharmacologic intervention is indicated (Lawrence 1993). For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability (Table 3). Contextual and caregiver features predominate in this group. Frequent reassessments are helpful, as the initial trepidation and fright in triage may not accurately reflect the child’s overall pain status. Preschool and School-age children Increasing language development offers the hope of more information to the clinician, but be careful not to ask leading questions. Do not jump directly to “does this hurt?”. Preschoolers will say ‘yes’ to anything, in an attempt to please you. School-age children may passively affirm your “statement”, if only to validate their human need for care or attention. Start with some ice-breaking banter, lay down the foundations for rapport, and then ask open-ended questions. Be careful not to allow the caregiver to “instruct” the child to tell you where it hurts, how much, how often, etc. Rather, engage the parents by asking them what behavior they have noticed. Eliciting history from both the child and the parent will go a long way in constructing a richer picture of the etiology and severity of the pain, and will help to build rapport and trust. The Baker-Wong FACES Pain Rating scale (Figure 1) was developed with feedback from children and has been validated for use in those 3 years of age and older (Keck 1996, Tomlinson 2010). Adolescents Adolescents vary in their development, maturity, and coping mechanisms. You may see a mixture of childhood and adult behaviors in the same patient; e.g. he may be initially stoic or evades questioning, then later exhibits pseudo-inconsolability. Do what you can to see the visit from the adolescent’s perspective, and actively transmit your concern and intention to help – many will respond to a warm, open, non-judgemental, and helpful attitude. The overly “tough” adolescent is likely secretly fearful, and the “dramatic” adolescent may simply be very anxious. Take a moment to gauge the background behind the presentation. You may use the typical adult scale of 0 (no pain) to 10 (worst pain), or the Faces Pain Scale–Revised (FPS-R). The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain (Tsze 2013). PAIN PHYSIOLOGY Pain includes two major components: generation and perception. Generation of pain involves the actual propagation of painful stimuli, either through nociceptive pain or neuropathic pain. Nociceptive pain arises from free nerve endings responding to tissue damage or inflammation. Nociceptive pain follows a specific sequence: transduction (an action potential triggered by chemical mediators in the tissue, such as prostaglandins, histamine, bradykinin, and substance P); transmission (the movement of the action potential signal along the nerve fibers to the spinal cord); perception (the impulse travels up the spinothalamic tract to the thalamus and midbrain, where input is splayed out to the limbic system, somatosensory cortex, and parietal and frontal lobes); and modulation (the midbrain enlists endorphins, enkephalins, dynorphin, and serotonin to mitigate pain) (Pasero 2011). As clinicians we can target specific “stations” along the pain route to target the signal more effectively. Simple actions such as ice, elevation, local anesthetics, or splinting help in pain transduction. Various standard oral, intranasal, or IV analgesics may help with pain’s transmission. Non-pharmacologic techniques such as distraction, re-framing, and others can help with pain perception. The sum of these efforts encourage pain modulation. A phenomenon separate from nociceptive pain is neuropathic pain, the abnormal processing of pain stimuli. It is a dysregulated, chaotic process that is difficult to manage in any setting. Separating nociceptive from neuropathic symptoms may help to select specific pain treatments and to clarify treatment goals and expectations. Neonates Neonates are exquisitely sensitive to many analgesics. Hepatic enzymes are immature and exhibit decreased clearance and prolonged circulating levels of the drug administered. Once the pain is controlled, less frequent administration of medications, with frequent reassessments, are indicated. The neonate’s vital organs (brain, heart, viscera) make up a larger proportion of his body mass than do muscle and fat. That is to say, the volume of distribution is unique in a neonate. Water-soluble drugs (e.g. morphine) reach these highly perfused vital organs quickly; relatively small overdosing will have rapid and exaggerated central nervous system and cardiac effects. The neonate’s small fat stores and muscle mass limit the volume of distribution of lipophilic medications (e.g. fentanyl, meperidine), also making them more available to the central nervous system, and therefore more potent. Other factors that predispose neonates to accidental analgesic overdose are their decreased concentrations of albumin and other plasma proteins, causing a higher proportion of unbound drug. Renal clearance is also decreased in the first few months of life. Clinical note: in the ED, neonates often require analgesia for procedures more than for injury. Non-pharmacologic techniques predominate (see below). Make liberal use of local anesthetics such as eutectic mixture of local anesthetics (EMLA; for intact skin, e.g. IV access, lumbar puncture) and lidocaine-epinephrine-tetracaine gel (LET; for superficial open skin and soft tissue application). Oral sucrose (30%) solutions (administered either with a small-volume syringe or pacifier frequently dipped in solution) are effective for minor procedures (Harrison 2010, Stevens 2013) via the release of dopamine and through distraction by mechanical means. Neonates with severe pain may be managed with parenteral analgesics, on a monitor, and with caution. Infants and Toddlers With increasing body mass comprised of fat stores in conjunction with an increase in metabolism, this group will require a different approach than the neonate. For many medications, these children will have a greater weight-normalized clearance than adults (Berde 2002). They will often require more frequent dosing. Infants and toddlers have a larger functioning liver mass per kilogram of body weight, with implications for medications cleared by cytochrome p-450. Clinical note: some drugs, such as benzodiazepines, will have both a per-kilogram dosing as well as an age-specific modification. When giving analgesics or anxiolytics to young children, always consult a reference for proper dosing and frequency. School-age children and Adolescents This group retains some hyper-metabolic features of younger children, but the dose-effect relationship is more linear and transparent. Physiologic clearance is improved, and from a physical standpoint, these are typically lower-risk children. From a psychological standpoint, this group may need more non-pharmacologic consideration and support to modulate pain optimally. NON-PHARMACOLOGIC TREATMENT The first line of treatment in all pain management is non-pharmacopeia (Horeczko 2016). Not only is this the safest of all techniques, but often the most effective. Some are simple comfort measures such as splinting (fracture or sprain), applying cold (acute soft tissue injury) or heat (non-traumatic, non-specific pain), or other targeted non-pharmacology. Many a pain control regimen is sabotaged without consideration of non-pharmacologic techniques, which may augment, or at times replace, analgesics. Think of non-pharmacopoeia as your “base coat” or “primer” before applying additional coats of analgesic treatment. With the right base coat foundation, you have a better chance of painting a patient’s symptoms a more tolerable and long-lasting new color. A tailored approach based on age will allow the practitioner to employ a child’s developmental strengths and avoid the frustration that results in asking the child to do what he is not capable of doing. A brief review of Piaget’s stages of development will help to meet the child at his developmental stage for best effect (Piaget 1928, Sheppard 1977) during acute painful presentations and minor procedures. Sensorimotor stage (from birth to age 2): Children use the five senses and movement to explore the world. They are egocentric: they cannot see the world from another’s viewpoint. At 6 to 9 months, object permanence is established: understanding that objects (or people) exist even without seeing them. Preoperational stage (from ages 2 to 7): Children learn to use language. Magical thinking predominates. They do not understand rational or logical thinking. Concrete operational stage (from age 7 to early adolescence): Children can use logic, but in a very straightforward, concrete manner (they do well with simple examples). By this stage, they move from egocentrism to understanding another point of view. N.B. Some children (and adults) never completely clear this stage. Formal operational stage (early adolescence to adult): children are capable of abstract thinking, rationalizing, and logical thinking. It is important to assess the child’s general level of development when preparing and guiding him through the minor procedure or distracting him until his pain is controlled. It is not uncommon for acutely ill or injured to regress temporarily in their behavior (not their development) as a coping mechanism. Neonate and Infant (0-12 months) Involve the parent, and have the parent visible to the child at all times if possible. Make advances slowly, in a non-threatening manner; limit the number of staff in the room. Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly. Swaddle the infant and encourage the parent to comfort him during and after the procedure. Engage their developing sensorimotor skills to distract them. Toddler to Preschooler (1-5 years) Use the same techniques as for the infant, and add descriptions of what he will see, hear, and feel; you can use a doll or toy to demonstrate the procedure. Use simple, direct language, and give calm, firm directions, one at a time. Explain what you are doing just before doing it (do not allow too much time for fear or anxiety to take root). Offer choices when appropriate; ignore temper tantrums. Distraction techniques include storytelling, bright and flashy toys, blowing bubbles, pinwheels, or having another staff member play peek-a-boo across the room. The ubiquitous smart phone with videos or games can be mesmerizing at this age. School age (6-12 years) Explain procedures using simple language and (briefly) the reason (understanding of bodily functions is vague in this age group). Allow the child to ask questions, and involve him when possible or appropriate. Distraction techniques may include electronic games, videos, guided imagery, and participation in the minor procedure as appropriate. Adolescent (13 and up) Use the same techniques for the school age child, but can add detail. Encourage questioning. Impose as few restrictions as possible – be flexible. Expect more regression to childish coping mechanisms in this age group. Distraction techniques include electronic games, video, guided imagery, muscle relaxation-meditation, and music (especially the adolescent’s own music, if available). APPLIED PHARMACOLOGY No amount of knowledge of the above physiology, pharmacology, or developmental theory will help your little patient in pain without a well constructed and enacted plan. Aggressively search out and treat your pediatric patient’s presence and source of pain. Frequent reassessments are important to ensure that breakthrough pain treatment is achieved, when re-administration is indicated, or when a change of plan is necessary. This is the time to involve the parents or caregivers to let them know what the next steps are, and what to expect. Start with the least invasive modality and progress as needed. After non-pharmacologic treatments such as splinting, ice, elevation, distraction, and guided imagery, have an escalation of care in mind (Figure 2). From a pharmacologic perspective, various options are available. Your pain management plan will differ depending on whether a painful procedure is performed in the ED (Table 4). Once pain is addressed, create a plan to keep it managed. Consider the trajectory of illness and the expected time frame of the painful episode. Include practicalities such as how well the pain may be controlled as an outpatient. Poorly controlled pediatric pain is more often managed as an inpatient than the same condition in an adult. Speak frankly with the parents about what drug is indicated for what type of pain and that treatment goals typically do not include absence of all pain, but function in face of the pain, in anticipation for clinical improvement. A special note on codeine: Tylenol with codeine (“T3”) has never been a very effective pain medication, as up to 10% of patients lack enzymatic activity to metabolize it into morphine, its active form (Crews 2014). New evidence is emerging on the erratic and unpredictable individual metabolism of codeine. Some children are ultra-rapid-metabolizers of codeine to morphine, causing a rapid “bolus” of the available drug, with respiratory depression and death in some cases (Ciszkowski 2009, Racoosin 2013). Author’s advice: take codeine off your formulary. COMMON SCENARIOS Head and neck pain Most common non-traumatic head and neck complaints can be managed non-pharmacologically (e.g. headache: improved hydration, sleep, stress, nutrition) or with PO medications, such as NSAIDs. The anti-inflammatory nature of ibuprofen (10 mg/kg PO q 4-6 h prn, up to adult dose) for example, will treat the cause as well as the symptoms of ear pain, sore throat, and muscular pain. Ibuprofen may be more effective than acetaminophen (paracetamol) for odontogenic pain (Bailey 2013). For most applications, acetaminophen may be as effective; however, the combination of both NSAIDs is not likely to be more effective than either agent individually (Merry 2013). True migraine headache may be treated with all of the above, and rescue therapy may include prochlorperamide (0.15 mg/kg IV, up to 10 mg ) (Brousseau 2004), often given with diphenhydramine (1 mg/kg PO or IV, up to 50 mg) and IV fluids. Ketoralac (0.5 mg/kg IV, up to 10 mg) may be substituted for ibuprofen (Paniyot 2016). Other specific therapies may be considered, although evidence for them varies. Chest pain After ruling out important pulmonary (e.g. the under-recognized spontaneous pneumothorax) and cardiac (e.g. pericarditis, myocarditis) etiologies, many chest complaints are amenable to NSAIDs. There is often a large component of anxiety in the child and/or parents in chest pain; no amount of medication will assuage them without addressing their concerns as well. Abdominal pain Abdominal pain in children is challenging, as it is common, often benign, but may be disastrous if the etiology is missed. For mild pain, consider acetaminophen as indicated (15 mg/kg/dose q 4-6 h prn, up to 650 mg). The oral route is preferred, but intravenous acetaminophen is an option for patients unable to tolerate PO, or for those in whom the per rectum (PR) route is contraindicated (e.g. neutropenia) (Babl 2011, Dokko 2014). For children with moderate to severe abdominal pain in whom a nil per os (NPO) status is ideal, consider rehydration/volume repletion, and small, frequent aliquots of a narcotic agent. Surgical pain is not “erased” by opioids (Thomas 2003, Poonai 2014); treating pain improves specificity to certain surgical emergencies with retained diagnostic accuracy (Manterola 2007). If there is inter-departmental concern about prolonged effects, sedation, limitation in the physical exam, or there is a need to “see if the pain will come back”, you may opt to use fentanyl initially for its shorter half-life. More frequent re-assessments may help the surgical team in its deliberations. Transition quickly to a longer-acting opioid as soon as possible. Long-bone injuries Fracture pain should be addressed immediately with splinting and analgesia. Oral, intranasal, and intravenous routes are all acceptable, depending on the severity of the injury and symptoms. Intranasal (IN) medications offer the advantage of a fast onset for moderate-to-severe pain (Graudins 2015), either as monotherapy or as a bridge to parenteral treatment (Table 4). The ideal volume of IN medication is 0.25 mL/naris, with a maximum of 1 mL/naris. Common concentrations of fentanyl limit its mg/kg use to the school-aged child; intranasal ketamine may be used for pain (i.e. sub-dissociative dose) up to adult weight. Long-bone injuries are a good opportunity to employ a speedy modality that requires little technical skill in administration: nebulized fentanyl. Clinically significant improvement in pain scales are achieved with 3 mcg/kg/dose of fentanyl administered via standard nebulizer in children 3 years of age or older (Miner 2007, Furyk 2009). Nebulized fentanyl is a rapid, non-invasive alternative to the IN route for older children, adolescents, or adults, in whom the volume of IN medication would exceed the recommended per naris volume (Deaton 2015). Consider an aggressive, multi-modal approach to control symptom up front. For example, for a simple forearm fracture, you may opt to give an oral opioid, perform a hematoma block, and offer inhaled nitrous oxide for reduction, rather than a formal intravenous procedural sedation (Luhmann 2006). Ultrasound-guided peripheral nerve blocks are a good pain control adjunct, after initial treatment, and in communication with referring consultants (Ganesh 2009, Suresh 2014). Skin and Soft tissue Skin and soft tissue injuries or abscesses often require solid non-pharmacopoeia in addition to local anesthetics. For IV cannulation, consider EMLA if the patient is stable and a minor delay is acceptable. Topical ethyl chloride vapo-coolant offers transient pain relief due to rapid cooling and may be used just prior to an IV start (Farion 2008). Try this: engage your young child’s imagination to distract him and say, “have you ever held a snow ball? You are in luck – it’s just like that – here, do you feel it?”. Vibratory adjuncts such as the “BUZZY” bee can be placed near the IV cannulation site to provide mechanical and cognitive distraction (Moadad 2016). Needleless lidocaine injectors may facilitate IV placement without obscuring the target vein (Spanos 2008, Lunoe 2015). The medication is propelled into the dermis by a CO2 cartridge that makes a loud popping sound; try this to alleviate anxiety, just before using it: “your skin looks thirsty – it needs a drink – there you are!”. As with any minor procedure, when you tell the child what you are doing, be sure to do it right away. Do not delay or build suspense. Lidocaine-epinephrine-tetracaine gel (LET) is used for open or mucosal wounds. Apply as soon as possible in the visit. The goal of LET is to pretreat the wound to allow for a painless administration of injectable anesthetic. A common practice to apply LET two or three times at 15-minute intervals for deeper anesthesia, in an attempt to avoid injection altogether. Researchers are currently working to offer an evidence base to this anecdotal practice. Pediatric burns should be assessed carefully and treated aggressively. Submersion of the affected extremity in room-temperature water (if possible) or applying room-temperature saline-soaked gauze will both thwart ongoing thermal damage, soothe the wound, and provide foundational first-aid. Minor burns can be treated topically and with oral medications. Major burns require IN, IM, or IV analgesics with morphine. Treatment may escalate to ketamine (Gandhi 2010), in analgesic or dissociative dosing, depending on the context. Post-traumatic disorders are common in burns; effective pain management is ever-more important in these cases. SPECIFIC SCENARIOS The child with chronic medical problems Children with acute exacerbations of their chronic pain or episodic painful crises require special attention. Some examples of children with recurring pain are those suffering from sickle cell disease, juvenile idiopathic arthritis, complex regional pain syndrome, and cancer. Find out whether these symptoms and circumstances are typical for them, and what regimen has helped in the past. Previous unpleasant experiences may prime these children with amplified anxiety and perception of pain (Cornelissen 2014). Target the disease process and do your best to show the patient and his family you understand his condition and needs. An equally challenging scenario is the child with chronic pain. Treat the entire patient with a multimodal approach. Limit opioids as possible. As an opioid-sparing strategy or as rescue therapy, consider sub-dissociative ketamine, especially for conditions such as sickle cell crisis, complex regional pain syndrome, autoimmune disorders, or chronic pain due to sub-acute trauma (Sheehy 2015). Intranasal ketamine may be used for sub-dissociative pain control at 0.5 – 1 mg/kg (Andolfatto 2013, Yeaman 2013). Intravenous infusions of ketamine at 0.1 – 0.3 mg/kg/h may be initiated in the ED and continued 4 – 8 h/d, up to a maximum of 16 h total in 3 consecutive days (Sheehy 2015). In vaso-occlusive episodes, dexmedetomidine has been shown to be an effective adjunct for severe pain poorly responsive to opioids and/or ketamine (Sheehy 2015b). The child with cognitive impairment Children with cognitive impairment such as those with various genetic or metabolic syndromes, or primary neurologic conditions such as some with cerebral palsy are a challenge to assess and treat properly. These children not only cannot explain their symptoms, but they also have atypical expressions of pain. Pain responses in severely intellectually disabled children include a full-blown smile (which may or may not accompany inappropriate laughter), stiffening, and non-cooperation (Hadden 2002). Other observed behaviors include the freezing phenomenon, in which the child acutely feels the pain, and he abruptly pauses without moving his face for several seconds. Look also for episodes of unexplained pallor, diaphoresis, breath-holding, and shrill vocalizations. The FLACC has been revised (r-FLACC) for children with cognitive impairment and appears to be reliable for acute care (Malviya 2006). The most distressing and perplexing presentation is the parent who brings his or her child with cognitive impairment for “fussiness”, “irritability”, or “I think he’s in pain”. Often, this is after significant investigations have been performed, sometimes repeatedly. Poorly controlled spasticity is an often under-appreciated cause of unexplained pain; treat not with opioids, but with GABA-receptor agonists, such as baclofen or benzodiazepines. Take special precautions in the administration of opioids or benzodiazepines in children with metabolic disorders (e.g. mitochondrial disease) or various syndromes (e.g. Trisomy 21). They may have a disproportionate reaction to the medication. Start with a low dose in these children and reassess frequently, titrating in small aliquots as needed. After careful, meticulous investigation in the ED to rule out occult infection, trauma, electrolyte imbalance, or surgical causes, the child with cognitive impairment who continues to be symptomatic despite ED treatment may be admitted for observation. However, in some cases, the addition of gabapentin to the typical regimen has been shown to manage unexplained irritability in these children (Hauer 2007) by treating visceral hyperalgesia. Multi-trauma The child with multi-trauma is in need of meticulous critical care. Frequent assessments of pain analgesic response (typically via the intravenous route) are necessary to gauge the child’s trajectory. Unexplained tachycardia may be the early signs of shock. Without controlling the child’s pain, it is difficult to distinguish the extreme tachycardia from pain or from blood loss. If intubated, control the pain first with a fentanyl drip, then use a sedative in addition as needed to keep him comfortable. The child under palliative care Children undergoing palliative care require a multidisciplinary approach. This includes engaging the patient’s car team as well as “treating” members of the patient’s family. Examples include the natural course of devastating chromosomal, neurologic, and other congenital conditions; terminal cancer; and trauma, among others (Michelson 2007). Family dynamics and family members’ needs are often overlooked; the family as a whole must be considered. Focus on the productive and beneficial treatments that can be offered. Treat pain promptly, but speak with the parents about end-of-life goals as early as possible, as any analgesic or sedative may have an untoward effect. You do not want to be caught in the position of potentially precipitously providing cardiopulmonary resuscitation in a child undergoing palliative care, because of a lack of understanding of how increasingly large doses of pain medications can affect breathing and circulation (AAP 2000). Children with ongoing opioid requirements may present not so much with an exacerbation of their chronic pain, but a complication of its treatment. Identify, assess and aggressively treat constipation, nausea and vomiting, pruritus, and urinary retention (Friedrichsdorf 2007); treating side-effects of pain management may be just as important for quality of life as treating the pain itself. PEARLS AND PITFALLS IN PEDIATRIC PAIN Allow the child to speak for himself whenever possible. After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you. Tell me more.” Engage parents and communicate the plan to them. Elicit their expectations, and give them of preview of what to expect in the ED. Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible. Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction. Premature infants present a challenge in pain control. Their pain is under-recognized, as they often display atypical responses to painful stimuli. Treatment is equally difficult, as they are particularly sensitive to analgesia-sedation. This is important, as this group is even more likely to undergo painful procedures due to their higher-risk status. Give detailed advice on how to manage pain at home. Set expectations. Let them know you understand and will help them through your good advice that will carry them through this difficult time. Patients and families often just need a plan. Map it out clearly. SUMMARY In pediatric acute pain, know the child; know the family; and know the physiology. Use your observational skills enhanced with collateral information to assess and reassess for pain in children. Treat pediatric pain well and often. Failure to address the child’s pain has long-lasting consequences. Non-pharmacologic treatments for all, pharmacologic treatments for many. A multi-modal approach is the most effective. 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Validation of Self-Report Pain Scales in Children. Pediatrics. 2013 Oct; 132(4): e971–e979. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013 Apr;25(2):161-7 This post and podcast are dedicated to Sergey M. Motov, MD, FAAEM, for his integrity, hard-won expertise, humility, and innovation. Thank you for making us better doctors, Sergey, and for getting us ever closer to a pain-free ED. Pediatric Pain Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP
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