'Pediatric Potpourri': Care of children calls for a mixed-bag approach
Family physicians exited the "Pediatric Potpourri" course Sept. 18 with the latest updates on treating and preventing childhood disease and discomforts. A panel of three experts discussed issues such as immunizations, common childhood maladies and breast feeding.
Immunization update
Worldwide, the two vaccine-preventable diseases responsible for the greatest childhood mortality are measles and neonatal tetanus, according to Donald Middleton, M.D. Annually, measles causes 1 million deaths, and neonatal tetanus causes 500,000.
Middleton, professor and interim chairman of the family medicine and clinical epidemiology department at the University of Pittsburgh, urged FPs and nurses to determine whether patients recently had immunoglobulin (Ig) therapy prior to giving the measles vaccine. Patients who have had Ig therapy may have to wait up to nine months before receiving the measles vaccine. Pregnancy is still a contraindication for measles vaccine, although egg allergy is not.
Other diseases of recent concern include pertussis and diphtheria, primarily due to a declining immunogenicity in adult populations. "Adults are not very immune to pertussis and in epidemics are usually the carriers," Middleton said.
He added that diphtheria, which has a high carriage rate in immunized populations, is linked with poor economic conditions. The former Soviet Union, for example, has been hit particularly hard by a deadly diphtheria epidemic in recent years. Although the diphtheria epidemic is slowly declining, adult travelers from the United States still face a significant risk from the disease. Persons 15 years and older account for 70 percent of diphtheria cases.
Common maladies
"Some things in life will stand up and bite your patients," Thomas Irons, M.D., told physicians. Among those things is a prolonged Q-T interval.
Irons, professor of pediatrics at East Carolina University School of Medicine, Greenville, N.C., warned that it is crucial to look at the Q-T interval in children suffering from syncope. Family physicians can calculate the correct Q-T interval by measuring from the beginning of the Q wave to the end of the T wave, then dividing it by the square root of the preceding R-R interval. The upper limit of normal is 0.44 seconds.
In addition to arrhythmias, asthma may pose a challenge to pediatric patients.
"Children have strong hearts," Irons said. "Children who die from asthma either are not getting adequate medical care, or the parents or children do not recognize when the child is acutely ill."
He suggested that family physicians prescribe three units of albuterol inhalers for children -- one for the child's bedroom, one for the family car and one for the child.
FPs will also likely encounter dehydration in children, only to be daunted by the placing of an IV in the vein of a 2-year-old. In such a case, according to Irons, a nasogastric tube will usually work fine instead.
However, according to some studies, children given fluids directly to the stomach may vomit an average of 60 percent of a liquid bolus. In that case, Irons said, you simply replace the regurgitated fluid with 60 percent of what the child just received.
"There is one caveat," Irons said. "Patients who have lost 15 percent or more of their body fluid need rapid rehydration via an IV."
'Breast is best'
Maryellen Schroeder, M.D., M.P.H., told FPs unequivocally: "Breast is best" when feeding infants. But it's not an instinctual process, said Schroeder, who is assistant director of the family practice residency at the University of Pittsburgh Medical Center in Pennsylvania.
She told family physicians to counsel patients about breast-feeding in advance of delivery. However, get your facts straight and be careful: You don't want to inhibit an opportunity for a mother to breast-feed by offering clumsy advice.
"Also encourage breast-feeding when your patient is returning to school or work," Schroeder suggested. "Have breast-feeding well established during their first four to six weeks postpartum." It normally takes five weeks to fully establish the pituitary/oxytocin/prolactin loop.
Using illness as a cost indicator, if full breast-feeding were practiced for 12 weeks in the United States, $2.16 billion would be saved annually through a reduction in infant ear and respiratory infections and diarrheal afflictions, Schroeder said.
