pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

New Guidelines: Autism, Flu and ACL Tears

February 15, 2015

We’ve been reviewing all the new pediatric health-care guidelines published last year in the past two articles. So far we’ve found that new research prompted governing groups to release care-guidelines for Congenital Dislocated Hips, Calcium supplementation, Fluoride supplementation, Respiratory Syncytial Virus and drug testing.
Boy with knee injury during soccer game
Today, we’ll finish the set by examining the new recommendations for physicians treating: Anterior Cruciate Ligament (ACL) Tears, Influenza Vaccination and Autism Spectrum Disorders (ASD).

The American Academy of Pediatrics convened a fairly large group of specialists in the area who reviewed the latest research to create and publish the latest evidence-based guidelines for pediatricians and other care-givers for children: Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention.

Perhaps it occurs less often and doesn’t receive the “press” of sports-related concussions but a tear of the Anterior Cruciate Ligament is none-the-less a substantial impact to the child who receives one.

Slightly more frequent in girls than boys, 300% more frequent in college than high-school and more frequent in girls soccer and boys football (US) than other sports, a tear of the ACL may take months to resolve and increase the likelihood of developing degenerative arthritis of the knee up to 10 times.

Surgical procedures will continue to evolve because it involves working on a skeletally immature knee across growth lines but the most current evidence and guidelines include:

Anterior Cruciate Ligament Tears

• Of the several theorized possible rationals for the difference, neuromuscular control may be the most important factor in non-contact ACL injury rates in males and females.
• Surgery and many months of rehab are often needed for treatment of ACL injuries.
• The Lachman test is the best physical examination to detect an ACL tear.
• An MRI may be needed in young patients where pain, swelling and lack of cooperation in the exam are issues.
• An ACL tear is not a surgical emergency in pediatric patients. There must be clear and adequate discussions with the patient and parents covering: Goals, expectations and treatment options.
• In skeletally immature patients, measurement of skeletal age with an anteroposterior radiograph of the left hand and wrist and Tanner staging may help determine optimal treatment.
• There is an increased risk of early-onset osteoarthritis in young knees so injured.
• In adolescent female athletes, neuromuscular training may reduce risk of injury by 72%.

[ Pediatrics 2014;133:e1437–e1450 ]

Influenza Vaccination

The poor response to this years (2015) “flu shots,” and the surge in children’s admissions to the hospital with the disease, serves to underscore just how difficult it is to “guess” at which influenza virus will “hit” in any given year AND to proclaim just how little else we can do to prevent it.

Influenza is still very much present in the environment and still very much the deadly culprit plaguing the world’s children. The American Academy of Pediatrics, Centers for Disease Control, American Academy of Family Practice and American Congress of Obstetricians and Gynecologists all published the latest version of the immunization schedule for children and adults.

There were some clarifications this year, based on new research findings, about giving the influenza vaccine to very young children; namely, how young can the vaccine be given and still have them work?

• The minimum age for receiving inactivated influenza vaccine is 6 months
• The minimum age for receiving live, attenuated influenza vaccine (LAIV) is 2 years.
• Children aged 6 mo to 8 yr who are receiving influenza vaccine for the first time should receive 2 doses at least 4 weeks apart; some previously vaccinated children will also need 2 doses.
• Contraindications to the use of LAIV include asthma, wheezing during the past 12 mo in children 2-4 yr of age, or any other underlying medical conditions that predispose to influenza complications.

I hope you can comprehend just how difficult it is to create consensus between large groups of professionals. These guidelines being published by four different (and major) healthcare entities should convince you just how important childhood immunizations are not only to the continued improvement in world health BUT literally to just maintaining the health level that we now take for granted.

[ Pediatrics Feb 1, 2014 133(2):357 ]

Autism Spectrum Disorders (ASD)

If vaccination takes the award for the most widely accepted guidelines, new guidelines covering the Autism Spectrum Disorder (ASD) must surely take it in the category of: “well, it’s about time!”

Despite the fact that you can’t read nearly any medical journal these days without seeing at least one article about autism, there hasn’t been published, updated guidelines on the issue for 15 years – since 1999.

Part of that is due, I’m sure, to the fact that the topic is so dynamic it has become intolerably confusing; and I just need to say it… a bit of a mess. Much of it due to all the extra money being tossed around by the government solely based on its diagnosis, the as-expected influx of children with “different diagnoses” being lumped in nearly every year, and the resulting loss of any ability to compare the diagnosis THIS YEAR with the diagnosis LAST YEAR.

However, accepting that there can be little in the way of specific guidelines, some very generalized guidelines can be made – if only to acknowledge the state of flux and confusion that we now exist in. Several such were compiled and published by the American Academy of Child and Adolescent Psychiatry last year.

• Questions about the core symptoms of autism spectrum disorder (ASD) should be a routine part of the developmental assessment of young children.
• If screening dictates a more thorough evaluation, the clinician should also consider and evaluate any comorbid diagnoses.
• The ASD evaluation includes a multidisciplinary assessment including: thorough physical examination, hearing screen, communication and psychological test appropriate for age and genetic testing as warranted.
• Clinicians should help families obtain education and behavioral interventions, such as applied behavioral analysis (ABA) programs.
• Pharmacotherapy should be offered for specific target symptoms or comorbid conditions.
• Clinicians should maintain an active role in the planning of long-term treatment. Families should be asked about the use of alternative/complimentary treatments.

[ J Am Acad Child Adolesc Psychiatry. 2014;53:237-257 ]