Your Options for Contraception

Below is a great video outlining the various options for contraception.

There are three categories of reversible methods:
Barrier
Intrauterine (hormonal IUD, copper IUD)
Hormonal (pills, patch, depot injection; nuvaring, we do not offer the implant in Canada)

Irreversible methods – vasectomy, tubal ligation.

Of note the IUD is just as effective, and reversible.

Pediatrician:
HEADSS history – identifying risk factors.
Provide counselling and advice around the most appropriate method for the adolescent, with regard to the specific indications and contraindications. Adolescent should provide input.

Benefits:
contraception
acne
prevention of teratogenicity when starting medication such as accutaine

Side effects:
weight gain
may experience irregular bleeding particularly in the first three to six months, and ultimately may have minimal to no bleeding.

Caution with CYP inducers, rendering OCP ineffective

Absolute contraindications to combined oral contraceptives

(estrogen component, hypercoagulability):
Acute or recent (within last three months) history of DVT/PE
Liver disease/hepatocellular carcinoma/cirrhosis
Hypertension with BP >160/100
Migraine with aura
Diabetes mellitus with complications (ie.nephropathy, neuropathy, retinopathy)

Provide counselling and advice on safe sexual practices – including utilizing barrier methods, such as condoms to help prevent against STIs.

Cervical cancer screening to start at 21years of age, or after onset of sexual activity, whichever is first.

Legal age for consent is 16 years and older, non-exploitative in nature.
If 14-15 years of age, </= 5 years older, non exploitative
if 12-13 years of age, </=2 years older, non exploitative

Emergency contraception:

Yuzpe method (depending on the type of contraceptive pills the patient is on)

Levonogestrel emergency (ideally within 72h, but up to 120h), if within 60 minutes of taking the tablet, vomiting occurs (as this is a side effect), the dose needs to be repeated.

The IUD method can also be utilized as emergency contraception within 5 days/120h.

The adolescent:
Here are some options, speak to your doctor about your options.

 

CMPA, Soy and CPS Statement about concerns around Soy

 

This is intended for assistance in counseling around soy and CMPA

Concerns around using soy based formulas arose due to phytoestrogens and the findings in in vitro animal studies. They have not been substantiated in humans as yet, but there have been some findings that raise concern in some groups. Studies have mostly been performed in children 6 months or older, decreasing the applicability in non IgE mediated CMPA which also tends to present younger than this.

Contraindications:

  1. Congenital hypothyroidism, as animal studies suggest phytoestrogens can inhibit thyroid peroxidase, potentially lowering free thyroxine concentrations, which could lead to abormal thyroid function (not a concern if normal thyroid function). Therefore, infants with congenital hypothyroidism who are fed soy-based infant formulas should have their thyroxine levels monitored.
  2. Prematurity: inadequate growth promotion
  3. non IgE mediated CMPA – due to cross reactivity between soy bean protein and bovine casein

So when can we recommend it?

  1. Galactosemia
  2. Cultural or religious practices restrict dairy-based products (veganism)
  3. IgE mediated CMPA

Animal studies have shown that consumption of phytoestrogens can result in infertility.

Exposure of neonatal animals to the isoflavones present in soy-based formula can cause subtle alterations in sex organ development, brain maturation and immune system function, and can also stimulate cancer development.

Currently available soy-based formulas support normal growth and nutritional status for the first year of life, with no overt toxicities observed in normal infants.

Limited long term safety data. Over 40 years of use support the safety of currently available formulations. The Committee on Toxicity (United Kingdom) released a report in 2003 titled “Phytoestrogens and Health”, which identified infants who were fed soy-based formulas as the population subgroup with exposure to the highest concentrations of isoflavones. Although this committee did not identify definitive evidence of adverse health effects in their review, they believed that the potential risks were a concern. The Committee on Toxicity also sought consultation with the United Kingdom’s Scientific Advisory Committee on Nutrition, who suggested that there was no substantive medical need for, nor health benefit arising from, the use of soy-based infant formulas.

CMPA

  • the commonest food allergy in infants with incidence of approximately 2.5% among infants <1year
  • IgE mediated vs. non IgE mediated is difficult to distinguish but most commonly it is done based on signs/symptoms and confirmed with SPT and specific/nonspecific serum IgE. Some signs have been used to differentiate between the two but they lack sensitivity and specificity.

screen-shot-2016-11-12-at-12-08-52-pmAbove figure taken from: https://www.inmo.ie/MagazineArticle/PrintArticle/10953

screen-shot-2016-11-12-at-2-31-09-pmTable above taken from: Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. JPGN Volume 55, Number 2, Aug 2012.

To differentiate between IgE mediated and non IgE mediated:

History should include symptoms particularly related to skin and gut with some respiratory consideration, and family atopic history.

“acute onset” IgE mediated (traditionally, anaphylaxis type symptoms):

  • urticaria+/- pruritis
  • angioedema
  • respiratory symtpoms
  • GI symptoms
  • eczema may be present

“delayed onset” non IgE mediated (which usually presents under six months of age):

  • gastrointestinal symptoms, and most commonly blood +/- mucus in stool, in the event of colitis
  • colic, reflux, loose/frequent stools, food aversion.

Why do we recommend soy-based formula?

  • cost (reduced compared to hydrolyzed formulas)
  • comparative palatability

However, there is cross-reactivity with cows milk protein, and therefore the use of soy-based formulas is only contraindicated for non IgE-mediated CMPA

NASPAGHAN Recommendation:

  1. hydrolyzed protein formula (HPF) as first line –> Nutramigen
  2. amino acid formula (AAF) if hydrolyzed formula not tolerated–> Neocate

ESPGHAN Recommendation:

  1. soy based formulas should not be used in infants under 6 months due to higher reported rate of adverse reactions to soy protein in the population.

Before soy based formulas are started – tolerance to soy protein should first be established by clinical challenge.

screen-shot-2016-11-12-at-1-58-10-pmFigure above taken from: Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. JPGN Volume 55, Number 2, Aug 2012.

DIAGNOSIS:

The gold standard is the double-blind, placebo-controlled food challenge, which, if the patient is clinically stable, with no concern with possible anaphylaxis, can be done in the community setting, but personally, I would leave that to an allergy expert.

If non IgE mediated is suspected, elimination diet ideally recommended for 2-4 weeks with planned slow re- introduction.

If IgE mediated suspected – SPT, specific IgE assay, consideration of food challenge in a hospital/controlled (non community) setting.

screen-shot-2016-11-12-at-3-06-41-pmDiagnosis and management of non-IgE-mediated cow’s milk allergy in infancy – a UK primary care practical guide. Clinical and translational Allergy. Vater et al. 2013.

If there are ongoing difficulties in differentiating the two types, consider consult with Allergist, although not always practical.

MANAGEMENT once CMPA is diagnosed:

  1. Firstly, breast is best.
  2. If this is not tolerated, treat with HPF which is the safest and most appropriate from a public health standpoint
  3. Soy is acceptable in IgE mediated (in non IgE mediated, there is cross reactivity with soy)
  4. Our job is then to: To counsel families about the importance of breastfeeding; to inform families about alternative formulas and to advocate on the behalf of families to the government for assisted coverage of HPF for CMPA.

When to consider re-introduction?

No ideal time. If proven CMPA, keep off at least until 6 months and up to 9-12 months of age.
screen-shot-2016-11-12-at-3-18-26-pm screen-shot-2016-11-12-at-3-18-36-pm

The above advice and flowcharts are from: Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy – A UK primary care practical guide. Available from: https://www.researchgate.net/publication/247771645_Diagnosis_and_management_of_non-IgE-mediated_cow’s_milk_allergy_in_infancy_-_A_UK_primary_care_practical_guide [accessed Nov 12, 2016].

Here is a link to the CPS statement used: http://www.cps.ca/documents/position/use-soy-based-formulas

CPS Statement – ED use of oral ondansetron for acute gastroenteritis related vomiting in infants and children

Ondansetron oral (weight based dosing) to be considered in:

  • 6months to `12 years
  • mild to moderate dehydration
  • or who have failed a trial of ORT
  • DOSING recommendations are for oral and a single dose:
    • 8-15kg: 2mg
    • 15-30kg: 4mg
    • >30kg: 6-8mg

Key facts for counselling:

  • works within 1-2h
  • oral rehydration should be started 15-30 minutes after the dose is given
  • Benefits:
    • reduced risk of further emesis, and reduced frequency of emesis
    • reduced risk of IV rehydration and admission
  • Adverse event:
    • the most significant adverse event is increased risk of diarrhea up to 48 h after administration of dose. Self-limited and lasts <48h.
    • Therefore, it is not recommended for those who have gastroenteritis with a predominant symptom of diarrhea.
  • the studies reviewed were mainly with oral but IV ondansetron studies appear to have the same conclusions
  • only studied for in hospital, not out of hospital setting.

APGAR – by Dr. Virginia Apgar 1952

 

What is the purpose?

Reports status of newborn immediately after birth and the response to resuscitation

Keeps a record of fetal to neonatal transition

Does not provide evidence of asphyxia

Cannot predict mortality, morbidity or prognosis

Taken at 1,5,10,15 minutes, until 20 minutes in infants who score <7.

if it remains 0 beyond 10 minutes –> consider discontinuation of resuscitative efforts, due to mortality and poor neurologic outcomes.

Keep in mind, an APGAR score is a snapshot and has subjective components (tone, colour, reflex irritability). It can also be influenced by maternal sedation/anesthesia, congenital malformations (cardiopulmonary/neurologic), gestational age, resuscitation, trauma.

What score is reassuring?

5 minutes –>  7 to 10, as this makes it unlikely to have an intrapartum HIE.

At 5+ minutes, a score of 0-3 may indicate early signs of encephalopathy, but cannot predict outcome of neurologic function.

Poor neurologic outcome if apgar is 0-3 at 10, 15 and 20 minutes.

If apgar of 0-5 at 5 minutes –> obtain UA gas (from a clamped section of umbilical cord) + send placenta for pathology.

Population studies: most infants with low apgars will not develop CP, but low apgar <5 at 5 minutes confers risk of CP as high as 20-200 fold over infants whose apgar at 5 minutes is 7-10.

Most with low apgars will not go on to develop CP.

A – appearance/colour – pink, screen-shot-2016-11-11-at-7-14-28-pm

P – pulse

G – grimace

A – activity (muscular/vigorous)

R – respirations

Remember to start resuscitation immediately, and not to wait until the 1 minute score, should there be concerns with the baby’s colour, tone, heart rate, breathing, cry.

Apgar alone does not rule in or out “Asphyxia” which is a marked impairment of gas exchange, that can lead to progressive hypoxemia, hypercapnia, and significant metabolic acidosis. Asphyxia describes a process of varying severity and duration, rather than an end point. Should only be applied if specific evidence of “markedly impaired intrapartum or immediate postnatal gas exchange can be documented on the basis of laboratory tests results”

In order to document an intrapartum hypoxic event, many factors including NRFHR, abnormal UA gas, EEG, neuroimaging studies, cerebral function, placental pathology, hematologic studies and multisystem organ dysfunction need to be considered in diagnosing an intrapartum HIE.

Normal or indeterminate FHR + Apgar 7 or higher at 5 minutes a normal umbilical artery gas is not consistent with HIE.

Reference: PEDIATRICS Volume 136, number 4, October 2015 http://pediatrics.aappublications.org/content/pediatrics/136/4/819.full.pdf

screen-shot-2016-11-11-at-7-06-22-pmThe expanded version is more useful as it can take into account resuscitative interventions. Documentation in the comments section can include delayed cord clamping (1) time of birth, (2) clamping (3) initiation of resuscitation.

WHO Growth Charts- Boys and Girls

Ages 2-20 (Start using a stadiometer for height. Assess weight, height and BMI):

BOYS

  1. Weight and Height: 2-19-weight-and-height-boys
  2. BMI: bmi-boys-2-20

GIRLS

  1. Weight and Height:girls-2-19-height-and-weight
  2. BMI: girls-bmi-2-19

 

Birth to 24 months (weight, length, HC, weight for length):

BOYS:

  1. Weight and Length boys-0-24-months
  2. HC and Weight for Length boys 0-24m HC and Wt for Lt

GIRLS:

  1. Weight and Length: girls-0-24months-weight-and-length
  2. HC and Weight for Length: girls-0-24m-hc-and-weight-for-length

 

  • Overweight: 85-95th percentile
  • Obesity: >97th percentile of weight for height or >95th percentile for BMI
  • Underweight: <3rd weight for length, <90th IBW, <5th BMI for age
  • Stunting: <3rd length/height for age
  • HC: <3rd ( 2SD below) or >97th (2SD above)

Breastfeeding – Strong Evidence Supporting “Breast is Best”

 

There are several advantages of breastfeeding, and fortunately, it is available worldwide!

Here are some advantages:

1) Nutrition: optimal for the needs of the baby in terms of nutrients, vitamins and minerals

2) Immunity: provides passive immunity, particularly in colostrum within the first few days.

3) Reduced incidence of infectious diseases such as bacterial meningitis, bacteremia, diarrhea, UTI, OM and respiratory illnesses, thereby reducing hospitalizations.

4) Reduction in incidence of NEC in preterm babies
5) Possible reduction in risk of SIDS (sudden infant death syndrome)

6) Increase in IQ possible

7) Protection from allergen exposure

8) Reduction in obesity possible

9) Bonding between mother and infant, which can have developmental implications (emotional and cognitive) for baby

10) Convenient, accessible and affordable, no sterilization required

Benefits to mother:

1) post partum ovulation suppression and weight loss
2) decrease in breast and ovarian cancer

Barriers to breastfeeding include:

1) Cultural/social limitations. Mothers may feel conscious, and therefore early designated rooms should be made available, and there are also nursing scarves feeding for public use. Early education regarding the importance of breastfeeding is also important to promote societal acceptance.

screen-shot-2016-10-29-at-3-46-04-pm

2) Maternal breast milk let down – can try several measures, including herbal: Blessed Thistle + Fenugreek (should be taken together), and prescription (domperidone). Remember, the more frequently the baby breastfeeds and mother pumps, the increase in the milk production due to signals sent to the brain. Think of it like, “if you don’t use it, you lose it”

3) Technique – there may be benefit from involving a lactation consultant. The baby should be making swallowing sounds. The following website is a great resource, providing tips for optimization of breastfeeding:
http://www.nbci.ca/index.php?option=com_content&view=frontpage&Itemid=1

4) Anatomical causes, such as tongue tie (anterior and/or posterior tongue tie, which can inhibit the infant’s ability to create adequate seal and sucking ability. In this case, they may need to be reviewed by a doctor to assess for the benefit of releasing the tongue tie. There is a Canadian Paediatric Society statement on ankyloglossia.

There are also some circumstances where it is not recommended, for example in developed countries, when the mother has a communicable infection such as HIV, as there are are alternatives. In the developing nations, given inaccessibility to alternative methods of providing nutrition, breastfeeding may still be encouraged.

Contraindications in Canada include (CPS Statement):

1) HIV positive (recommended to formula feed)
2) Cytotoxic chemotherapy in mothers
3) Radioactive isotopes or radiation therapy
4) Galactosemia – no breastmilk! Indication for soy based milk
5) PKU: breastfeed to supplement low phenylalanine formula + strict monitoring of levels
6) Limit alcoholic beverages as they pass into breast milk. Motherisk and LactMed for further information regarding drug safety and breastfeeding.
7) Limit and quit smoking – but continue breastfeeding as it may mitigate the negative effects of smoking
8) Continue breastfeeding even in physiologic jaundice and breast milk jaundice. Assess latch, teach appropriate skills and monitor feeding closely. May need to refer to lactation consultant.

The Canadian Paediatric Society has a policy statement on Breastfeeding also, promoting the Baby Friendly Initiative started by WHO and UNICEF in 1991. The goal is to improve breastfeeding initiation and adherence.

Recommendation: Breastfeed for the first 6 months of life, and then supplement accordingly following this, up to 2 years of life and beyond. Of note, breastfeeding can be tapered at 4 months (subsequent CPS statement), with early introduction of complementary foods.

TEN STEPS TO SUCCESSFUL BREASTFEEDING (the Innocenti Declaration and the WHO International Code of Marketing of Breastmilk Substitutes):

1) Have a written breastfeeding policy that is routinely communicated to all healthcare providers and volunteers

2) Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy

3) Inform pregnant women and their families about the importance and process of breastfeeding

4) Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: encourage mothers to recognize when their baby is ready to feed, offering help as needed.

5) Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants

6) Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated

7) Facilitate 24h rooming in for all mother-infant-dyads: mothers and infants remain together.

8) Encourage baby led or cue based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods

9) Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

10) Provide seamless transition among the services provided by the hospital, community health services and peer support programs. Apply principles of primary health care and population health to support the continuum of care, and implement strategies that affect the broad determinations that will improve breastfeeding outcomes.

Introducing any food or drink before it is nutritionally required can interfere with breastfeeding!

Also, although pacifiers may reduce risk of SIDS, consider introducing them after successful breastfeeding is established to prevent “nipple confusion”. In the NICU, they may use it as suck training and for soothing/pain relief.

Skin-to-skin (kangaroo care) within the first half hour of life is recommended, even if not expected to breastfeed.

http://www.cps.ca/documents/position/baby-friendly-initiative-breastfeeding

ADHD

 

According to the DSM V

Attention Deficit Hyperactivity Disorder – the diagnosis requires symptoms to be:

  • present for 6+ months,
  • in 2+ different settings,
  • show negative impact on the child’s functioning (in academic/occupational or social realms) and development, and
  • not caused by another mental disorder.
  • Remember this assessment should be made according to the developmental level of the child.
  • Of note, 6+ is for those up to age 16, and 5+ for 17y+ and adults.
  • Symptoms must have been present before 12 years of age.

What are the types?

Inattentive (6+ required up to 16, 5+ for 17 and older)

  • little or no attention to detail, careless mistakes: schoolwork/work/other activities
  • difficulty holding attention on tasks or play activities (must differentiate between something they may find boring and something interesting)
  • doesn’t seem to listen when spoken to directly
  • does not follow through: schoolwork, chores, work duties
  • difficulty organizing tasks and activities
  • avoids/dislikes/reluctant to do tasks that require mental effort over long period of time
  • loses things necessary for tasks and activities
  • easily distracted
  • forgetful in daily activities

Hyperactive/Impulsive (6+ if 16 and under, and 5+ of 17 and over)

  • fidgeting/tapping hands or feet, squirming in seat
  • leave seat in situations where remaining seated is expected
  • runs about or climbs in situations where it is not appropriate
  • unable to play or take part in leisure activities quietly
  • “on the go”, “driven by a motor”
  • talks excessively
  • blurts out answers before question is completed
  • trouble waiting their turn
  • interrupts or intrudes on others

Combined: 

  • 6+ of both types

Severity

They can be graded as mild/moderate/severe, based on the number of symptoms in excess of the ones required to make a diagnosis, and functional impairment within the social or academic/occupational realms.

Scoring

SNAP IV questionnaire:

http://www.myadhd.com/snap-iv-6160-18sampl.html

http://www.crfht.ca/files/8913/7597/8069/SNAPIV_000.pdf

Used at the initial visit and also to gauge effectiveness of medication, once started. This is filled out by both the school and the home.

Other things to think about:

  1. are there comorbidities (i.e., anxiety, depression, learning disability, ASD, other mental health disorder)
  2. social environment
  3. suspect in those who are older and depressed, as this may have been an undiagnosed ADHD and compensation with depression, anxiety and low self esteem may result.
  4. girls tend to be missed more than boys as they tend to have more outbursts at younger ages

MEDICATIONS:

http://www.caddra.ca/pdfs/Medication_Chart_English_CANADA.pdf

caddra-adhd-medications

 

Simply Explaining, Explaining Simply: Autism Spectrum Disorder

Autism Spectrum Disorder

DSM V Diagnostic Criteria

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history:

  1. Deficits in social-emotional reciprocity.
  2. Deficits in nonverbal communicative behaviours used for social interaction
  3. Deficits in developing, maintaining, and understanding relationships.

B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history:

  1. Stereotyped or repetitive motor movements, use of objects, or speech.
  2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour.
  3. Highly restricted, fixated interests that are abnormal in intensity or focus.
  4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

C. Symptoms must be present in the early developmental period (may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies later in life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

Epidemiology:

  • prevalence in the U.S is 11.3/1,000
  • male:female ratio is 4:1
  • immigrants may be more affected

Risk Factors:

  • high recurrence risk for siblings: 2-19%
  • closer spacing of pregnancies
  • advanced maternal or paternal age
  • extreme prematurity (<26weeks)
  • family members with learning problems, social disability, psychiatric disorders

In the Community Setting, once there is reason for concern particularly >18 months of age, use MCHAT (individual and parents) from 6-30 months (2.5years) of age.

https://www.m-chat.org/mchat.php

Also use the infant-toddler scale for 6-24 months (2 years) of age.

http://www.autismalert.org/uploads/PDF/SCREENING–DEVELOPMENTAL%20DELAY%20&%20AUTISM–CCBS%20DP%20Infant-Toddler%20Checklist.pdf

An official diagnosis is often not made until 2-3 years of age.

Keep in mind delayed developmental milestones or regression of developmental milestones.

If deemed to be at high risk, referral to a developmental pediatrician is made where an official diagnosis would be made following an assessment with a multidisciplinary team (i.e., Developmental Paediatrician, Speech and Language Pathologist). An ADOS is used for this assessment, following a series of interview questions and observation of the child’s behaviours and interactions.

There may also be other concerning features, for example, focal neurological signs, seizures, dysmorphic features. Particularly, a family history of developmental concerns or genetic conditions as well as consanguinity become important to consider.

In these situations, consider chromosomal microarray (with appropriate counselling provided), referral to neurologist (with possible EEG and MRI ordered), and consider referral to geneticist.

The earlier the diagnosis is made, the earlier the ABA treatment can be started. In the interim, there are services the child can start going to available in the community for those with developmental concerns (i.e., delayed speech or motor milestones).

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