All posts by Richa

Breastfeeding Resource

Breastfeeding was not a focus during my training, so I have been doing a lot of self-study on the topic, and do not have personal experience in this area.

The Toronto Public Health Website has great resources for healthcare providers and patients (https://www.toronto.ca/community-people/children-parenting/pregnancy-and-parenting/breastfeeding/breastfeeding-your-baby/learning-to-breastfeed/)

I have been working through the E-Modules and they have been great and informative!

https://www.toronto.ca/community-people/health-wellness-care/information-for-healthcare-professionals/maternal-child-health-info-for-doctors/breastfeeding/breastfeeding-e-learning-modules/

Would definitely recommend!

Culture Negative Sepsis

Interesting article: “Ending the Culture of Culture-Negative Sepsis in the Neonatal ICU” in the October 2017 edition of Pediatrics (Volume 140, Number 4). Antibiotics are not without side effects, and we always think about them causing short term side effects, but according to this article, there is evidence that prolonged exposure can result in diseases such as obesity and atopy.

When there are short AND long term consequences at play, it gives more power to the antimicrobial stewardship viewpoint. Certainly antibiotic resistance is a major concern, especially on a population-level.

I remember when I worked in the UK, the lab would reject any blood culture that had insufficient quantity of blood in it. At the time, I would be drawing the blood culture samples myself, so I know it can sometimes be quite challenging to get the right amount.

This article highlights the importance of drawing 1mL of blood at minimum, and that they have excellent sensitivity and are the gold standard for diagnosing neonatal sepsis. We should learn to trust a negative blood culture, and treat no longer than 36-48h if culture returns negative and patient is clinically well.

Essentially, all efforts must be put forth in obtaining the correct amount of blood, which will also reduce the number of times repeated blood sampling is required (which is quite important in premature babies/LBW babies).

Great article, has impacted my practice!

 

 

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.

 

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).

RSV Prophylaxis – Canadian Paediatric Society

RSV – virus causing significant respiratory distress, oxygen requirements in high risk children. Can become complicated by respiratory failure, requiring ICU admission.

Season starts Nov-Dec and goes for another 4-5 months

Risk factors:
Aboriginal populations in northern communities

Palivizumab (monoclonal antibody) for RSV prophylaxis (not treatment):
5 doses 30 days apart
or
4 doses 38 days apart

reduced rate of hospitalizations

Little evidence to require it after the 1st year unless treatment still required three months before RSV season the second year of life.

Other preventative measures:
hand hygiene
breastfeeding
no exposure to cigarette smoke

Recommendations regarding RSV prophylaxis:

Provide to eligible infants prior to discharge from hospital if within RSV season.

CLD/Hemodynamically significant CHD – if treatment required within the last 12 months

Not recommended to continue monthly RSV doses if breakthrough RSV infection occurs.

Not recommended for: children with immunodeficiencies, Down syndrome, cystic fibrosis, upper airway obstruction or a chronic pulmonary disease other than CLD. However, may be considered for children <2 years of age who are on home oxygen, have had a prolonged hospitalization for severe pulmonary disease or are severely immunocompromised.

 

Rotavirus Vaccine – Canadian Paediatric Society

 

http://www.cps.ca/en/documents/position/rotavirus-vaccines

screen-shot-2016-10-10-at-12-37-10-am Rotavirus is a double stranded RNA. 2 outer capsid proteins, VP7, the glycoprotein (G protein), and VP4 (P protein, which refers to virus serotype). Genotypes commonly affecting humans: G1P, G2P, G3P, G4P, with G1P being the commonest in Canada.

screen-shot-2016-10-10-at-12-44-46-am

Transmission: feco-oral, fomites (remain on objects for months)

Incubation period: 48h

Presentation: vomiting and fever may precede diarrhea.

  • First 3 months: mild presentation due to maternal
  • 3 months to 5 years: variable, mild to severe diarrhea, +/- vomiting.

Course: Resolves in 3-7 days

When is it Rotavirus Season?

Starts in November to December.

Peaks in February to March (Western Canada), March to April (Eastern Canada).

Why is prophylaxis important?

Rotavirus gastroenteritis can lead to significant dehydration, shock, death if not managed appropriately. Most severe manifestations occur with the first episode and get milder with subsequent episodes.

Mortality is rare, but morbidity and healthcare costs, are similar to AOM, uncomplicated pneumonia.

Although, only a minority require hospitalization (median of 3 days in one study), since the introduction of rotavirus immunization programs, numerous studies have demonstrated a substantial decline in rotavirus disease, rotavirus related hospitalizations particularly <1 year of age, and shortened or eliminated peak seasons.

Herd immunity was demonstrated, with significant decreases in RV gastroenteritis hospitalizations for all age groups ≤19 years and significant decreases in acute gastroenteritis hospitalizations for all age groups, including those ≥65 years of age.

Evidence for rotavirus vaccination decreasing seizure- related hospitalizations in childhood, most marked in children <2 years of age. 1) Due to reduced febrile seizures, 2) limiting direct neurologic effects of systemic rotavirus infection.

Risk Factors for Severe Illness:

  • Prematurity (possibly due to lack of maternal antibodies)
  • immunocompromised state (severe, prolonged and fatal illness)

Not risk factors for rates of hospitalizations due to rotavirus:

  • socio-economic status
  • parental marital status
  • child care attendance
  • ethnicity

Breastfeeding may be protective against symptomatic rotavirus infection.

Rotavirus gastroenteritis is considered to be more severe than gastrointestinal illness, for several reasons: 1) association with vomiting, 2) gut epithelial damage leading to significant diarrhea, 3) can be associated with viremia, leading to more severe presentations, particularly in young infants.

Diagnosis: non specific clinical features, limiting clinical diagnosis. Stool enzyme immunoassay to detect antigen. Some labs offer molecular based testing.

Rotavirus Vaccine

Two types:

  1. RotaTeq (RV5), a live, oral, pentavalent bovine human reassortant vaccine composed of five strains.
    • RotaTeq is supplied in single prefilled 2 mL tubes and given as three oral doses.
  2. Rotarix (RV1), A live-attenuated monovalent G1P1 vaccine derived from a single human strain, RIX4414.
    • Rotarix is supplied in single prefilled 1.5mL tubes and given as two oral doses.

Both vaccines are latex-free. Since both are live virus vaccines, they should be stored in a refrigerator at 2°C to 8°C, and they do not require reconstitution before administration.

No data on whether they are interchangeable or not, so it is recommended to stick to the same type. Moreover, if RV5 is given, remember to give three, rather than two, doses.

When to vaccinate: Can be started at 6 weeks. Given at same time as regularly scheduled immunizations. 2 and 4 months. A minimal interval between doses of four weeks.

However, if any dose in the series was the RV5 vaccine, a total of three doses of vaccine should be administered.

The last dose must be given before eight months, 0 days of age because of concern about intussusception when given later.

The Public Health Agency of Canada’s National Advisory Committee on Immunization (NACI) indicates that the first dose should be given before a child is 14 weeks, six days of age. However, if this first dose of RV1 was not administered before that point, a catch-up first dose can be administered up to 20 weeks of age. This does not apply to RV5.

Because Rotavirus vaccines contain sucrose, it may be helpful to administer the oral rotavirus vaccine before injectable vaccines to aid in pain reduction.

Duration of protection unknown.

Some evidence to suggest that the circulating wild-type genotypes of rotavirus may shift after universal vaccination. Vaccine efficacy has not changed substantially with shifts in wild-type genotypes.

Intussussception:

RV1 and RV5: mall increased risk of intussusception among infants 1-7 days after receiving their 1st and 2nd Rotavirus vaccine doses. These risks were in the order of 1 to 3 excess cases for every 100,000 infants vaccinated,

In Canada, 19 case reports of intussusception following rotavirus vaccine were reported between 2011 and 2014. Fifteen of these cases occurred within 21 days of immunization, representing a rate of 0.74 cases per 100,000 doses distributed during that time period.

Advice for Parents:

Benefits of disease prevention, which are substantial, relative to the very small increased risk of intussusception. Particularly in the first week following rotavirus vaccine.

Health Care Providers:

Follow-up for all infants who have persistent vomiting, or appear to have severe abdominal pain, bloody stools and/or a high fever or who have a documented intussusception. Inquire specifically about recent Rotavirus vaccination.

Report all cases of intussusception occurring within 21 days of receiving rotavirus vaccine to local public health authorities, using the adverse event reporting system administered by the Public Health Agency of Canada (http://www.phac-aspc.gc.ca/im/aefi-essi-form-eng.php).

Fecal shedding of Rotavirus vaccine virus is common (50% to 80%) in the first week following vaccination. Falls to <24% at 30 days. Shedding becomes less common with subsequent doses. The clinical significance of viral shedding and the potential for horizontal transmission are unknown, but to date there has been no reported adverse clinical effect on household members or contacts.

If there is a pregnant or immunocompromised person in the household: vaccinate infant as per the routine schedule because the indirect protection provided by preventing wild-type rotavirus infection outweighs the risk of transmitting vaccine virus.

Good hygiene practices, including the cleaning of surfaces and hand hygiene after diapering, should be emphasized.

Contraindications:

  1. A history of intussusception/greater susceptibility to intussusception (eg, uncorrected Meckel’s diverticulum)
  2. Hypersensitivity to any of the ingredients in rotavirus vaccines
  3. Known or suspected SCID/immunocompromised state

Other important tips:

Mild illness with or without fever ==> like other vaccines, give.

If spits/regurgitates a dose = do not repeat.

If previously documented rotavirus infection: should still receive rotavirus vaccination

Preterm infants (6 weeks to 8 months) should receive rotavirus vaccine at/following discharge. Schedule is the same as for term infants.

Infants who are HIV-exposed should receive vaccine according to chronological age.

 

CPS Summary of Recommendations

  • Recommended for all infants except those who are immunocompromised or have a history of or a known condition that predisposes them to intussusception. Premature and immunocompromised hosts are at highest risk of severe infection.
  • Both licensed rotavirus vaccines are efficacious, but stick to the same one.
  • 2 doses, unless RV5 was used, in which case, a total of 3 doses should be administered
  • Started as early as six weeks, but usually given at 2 months
    • Usually given at two and four months of age if using RV1, with a third dose at six months if using RV5.
    • If a first dose of RV1 (Rotarix) has been delayed beyond 15 weeks, NACI recommends catch-up first dose up to 20 weeks chronological age. **does not apply to RV5.
  • Inform caregivers of slightly higher temporal risk for intussusception, especially in the week after receiving rotavirus vaccine.

 

 

Acute Otitis Media – Canadian Paediatric Society Recommendations

Acute Otitis Media (AOM) can have viral or bacterial origin. The commonest bacterial causes include: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Group A streptococcus (strep.pyogenes or GAS).

Co-infection is possible.

Who do you treat with antibiotics?

High grade fever (>/= 39 degrees Celcius)
Severe otalgia
Moderately to severely unwell child
No improvement within 48h (as with viral AOM, we usually see improvement within this time frame)

Those who have bulging tympanic membrane (TM)
Middle ear effusion (MEE) – reduced mobility of tympanic membrane has high sensitivity an specificity for MEE.
Perforated tympanic membrane with purulent drainage (otorrhea) – commonly caused by GAS
Erythematous or yellow tympanic membrane
Of note: air fluid level visible on TM without erythematous TM is not consistent with AOM.

Why do you treat?
Bacteria such as strep. pneumoniae can become invasive and there can be complications.

Complications include (although, rarely at presentation):
1) Acute mastoiditis (commonest complication) – clinically, this may manifest as pain or swelling over the mastoid bone. Ensure IV antibiotics, imaging to delineate extent of infection, and surgical consultation for potential intervention.

2) less common:

acute facial (CN VII) nerve palsy – associated with temporal bone inflammation

abducens (VI) nerve palsy – associated with petrous bone inflammation or infection (Gradenigo’s syndrome)

labyrinthitis- associated with cochlear space spread

venous sinus thrombosis of transverse, lateral or sigmoid venous sinuses

meningitis.

If infection is in keeping with viral:
Do not treat with antibiotics due to increased rates of resistant bacterial infections.

Which Antibiotics?
Amoxicillin cover strep. pneumonia and GAS, and has good middle ear penetration. It does not have good cover for H.influenzae or M.catarrhalis, but these infections tend to self-resolve within a few hours. Amoxicillin also has good middle ear penetration.

Doses:

Amoxicillin 75-90 mg/kg/day divided twice per day (capsules/suspension)

Amoxicillin 45- 60 mg/kg/day divided there times per day (capsules/suspension)

For clinical cure: amoxicillin should be adequate for over 50% o the day, therefore twice per day regimens require higher dosing.

 

If penicillin allergic:
second generation cephalosporin such as cefuroxime, cefprozil, or third generation cephalosporin such as ceftriaxone.

cefuroxime axetil – 30mg/kg/day divided twice or three times/day (tablet/suspension)

ceftriaxone – 50mg/kg IM/IV daily for three days

What if the patient does not entirely appear to have bacterial features, as above, and it has only been one day since symptoms started, and they appear mild to moderately affected, but are eating/drinking well, no otalgia, and have lower grade temps?

One option is to “watch and wait”, and have the patient return the following day to be re-assessed.

Another option is to provide a prescription for antibiotics, so if the child becomes more febrile, more ill, or increasingly impacted by otalgia or other symptoms. It is always important to counsel on signs and symptoms to return to seek medical attention, however.

Other conditions to consider:
H. influenzae and M. catarrhalis if there is otitis conjunctivitis syndrome. In this case, a macrolide/azalide should be administered, although they are bacteriostatic, and as such, have less bactericidal activity than B-lactams (penicillins/cephalosporins). In this case, amoxicillin/clavulin or cefuroxime should be administered.

If treated with amoxicillin in the last thirty days, there is relapse or no response –> start amoxiclav.

If the child is 2 years of age or older, with uncomplicated AOM:

5 days of antibiotics

If the child is under 2 years of age (i.e., 6 months to 23 months):

10 days of antibiotics

Over 6 months, with perforated TM or recurrent AOM:

10 days

 

This is a brief summary of the CPS Statement, which can be found below:

http://www.cps.ca/documents/position/acute-otitis-media