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

2014 New Children’s Health Guidelines

February 7, 2015

Eight major sets of published guidelines for children’s health care were developed in 2014. We are discussing them (in lay terms) and how they affect the way we help children stay healthy.
Child with RSV on top of asthma in the ICU
We’ve covered those developed for Congenital Dislocated Hips, Calcium supplementation and bone density and Fluoride supplementation and tooth development in the previous article.

Today we’ll cover new guidelines for the prophylaxis against Respiratory Syncytial Virus (RSV) as well as how we now think best to handle drug testing in children and teens.

In the next article we’ll cover Anterior Cruciate Ligaments, Influenza Immunizations and Autism Spectrum Disorder.

Respiratory Syncytial Virus (RSV) Prophylaxis

The Respiratory Syncytial Virus (RSV) is a for-sure, gosh-awful problem for us all. It’s a virus – so there is no cure. It’s everywhere – so literally everyone gets it before they’re two. It’s spread in the air, and on everything we touch. It “lives” for 8 hours on clean, dry, hard surfaces. AND, it can attack deep in the lungs – which are things that count! Especially in infants.

It attacks at any age, sometimes more than once, with cold, asthma-like and pneumonia-like symptoms. Adults get runny noses, infants and children wheeze and newborns, prematures, asthmatic’s and others at risk end up in the intensive care units.

The issue has been/is that we’ve developed a medication which we use to “help prevent development of serious RSV disease” if the child contracts it. But, it doesn’t prevent it or cure it or treat it once you’ve contracted it, just makes the disease a little easier IF it’s taken monthly BEFORE the child is infected. And, of course, the drug company has designed the price to wipe out your kid’s college funds!

Therefore it isn’t useful on every child, just those destined for the ICU if they catch it: immuno- and respiratory-compromised infants, especially prematures. Obviously, we’re still working for something better; but, here is the best research we’ve got as of 2014.

• Palivixumab prophylaxis is limited to infants born before 29 weeks’ gestation and to infants with chronic illnesses like heart and lung disease.
• Give 5 or less monthly doses during the RSV season
• Qualifying infants born during the RSV season may require fewer doses
• Prophylaxis is given in the second year of life only to children who needed supplemental oxygen for over 27 days after birth AND who continue to need medical intervention (oxygen, steroids, diuretics)
• Monthly prophylaxis is discontinued if child is hospitalized for RSV
• Prophylaxis can be considered between 1 and 2 years of age if a child will be severely immunocompromised during the RSV season

There are other considerations which also need to be made based upon location, remoteness of the area and disease burden (i.e. cost of transportation from remote locations.)

• Broader use of prophylaxis may be appropriate for Alaska natives (and possibly other Native American populations) based on remoteness and transportation availability.
• The AAP does NOT recommend prophylaxis to prevent healthcare-associated RSV disease

And, lastly, there are other common-sense preventive things parents can do which need to be listed in any guidelines. For example, because nearly every mother has already had an RSV infection, breast milk can likely provide some protection.

• All infants, especially preterm infants, should be offered breast milk.
• All infants, especially those in the qualifying group, should avoid smoke exposure of any kind (cigarette, fires), attendance in large-group child-care settings during the first winter season and contact with ill-people.
• Household members should be immunized against influenza and practice good hand and cough hygiene

[ http://pediatrics.aappublications.org/content/134/2/415.full ]

Drug Testing In Children and Teens

Drug testing children and teens is, as you would expect, a fairly “charged” issue with several diverse opinions; and, also as expected, a plethora of internet/spam scammers making huge profits from the confusion. The actual testing is becoming less burdensome, more accurate and less costly all the time; but, it’s the WHEN, WHO and HOW that is the rubbing-point.

Who can disagree that, if it’s done, it’s best if it’s a “we do it on everybody” “no big deal” type of thing rather than a highly personal “I don’t trust you” kind of attack. I know several parents who were silently relieved when their high-school sports program began mandatory drug testing.

The American Academy of Pediatrics has opinions toward full and up-front disclosure based on the substantial potential that involuntary testing can damage the parent-teen relationship permanently. The most recent guidelines, issued in 2014, tend to “err on the side of caution” and give options based on the latest research and understanding.

• Test in emergent situations like after an accident, suicide attempt, or unexplained seizure that renders the patient incapable of informed consent.
• To asses behavioral problems such as fatigue, excessive moodiness, failure in school, or when a parent or other adult suspects drug use may be a factor.
• As part of a therapy program for substance abuse with rewards and consequences based on the test outcome.
• The AAP does NOT endorse HOME drug testing largely due to the strong potential for damage to the parent-child relationship; but also because there is strong potential for parents to misinterpret as well as little statistical evidence that it reduces drug use.

When testing is performed, there are several methods of doing it – all with their strong and weak points. Urine testing was the first widely used method and probably still is.

• Urine tests are: the most common and well standardized. However they are susceptible to tampering and (in some eyes) invasive (perhaps either in the sense that the urine originally came from the patient or possibly that a witness in the room might be considered by some ‘invasive’).
• If urine testing is used, it is best if it’s witnessed. If not witnessed, all coats, packages and bags must be banned from the collection room – a room without running water, soap or other chemicals and with the toilet water tinted.
• Color, temperature and appearance must be recorded within 4 minutes. Temp should range from 90°-100°F.

Effective testing for drug usage can also be performed on blood, saliva, sweat and hair samples. Obviously some are more “invasive” than others as well as differing on when the drug(s) it reveals were taken.

• Saliva and sweat are similar to blood tests; but less invasive and easier to obtain. Saliva can detect drug use before a urine test may detect it with less chance of contamination.
• Blood tests are more useful detecting alcohol and other drug use within 2 – 12 hrs but should be correlated with patient symptoms and are more expensive.
• Hair testing (first 3 centimeters near roots) detects extended used (after 7 – 10 days) and is easily observed.

Finally, the guidelines for physicians and other professionals include administrative and clinical procedures. Keeping in mind always that the whole point of a physician’s involvement in this activity is for the health, well being and success of a child – and not to help the police in doing their job – the child must be treated fairly; and, hopefully, have someone he sees an an advocate in his corner.

While one may argue that the parent-child relationship is already broken when a teen uses drugs, strong-arming submission to a drug test when other possible rationale for behavior/school failure are left unexplored may drive needless “wedges” between the teen and his only source of people who care. Not all emotional turmoil and bad behavior is due to the use of illicit drugs – especially through puberty.

“Blindsiding” the child will only teach distrust and damage any future hope that the physician will be confided in for help; whereas, even if the outcome is troublesome for the teen, they will recognize the openness and truthfulness of the physician in the matter, which may leave them still as a source to use for help.

To accomplish this the APP advises pediatricians to:

• Discuss who will receive results with child and parents BEFORE ordering a drug test.
• Reach a consensus with a responsible adult for the action plan covering both positive and negative results BEFORE conducting testing
• Balance the need for the information the test will give with protecting dignity. Alternatives to testing are to base decisions on behavior and symptom history plus complete physical examination findings alone.
• Test results absolutely MUST be correlated with medication history – like treatment for ADHK disorder which will test positive for amphetamines.

This is an issue where we can most certainly look forward to further guidelines again next year. It just doesn’t “feel” like we’ve got the whole answer yet.

[ Pediatrics. Published online May 26, 2014 ]