APRIL 2011, VOL 2, NO 2 by Sean Walsh

What’s this? See page 5.

APRIL 2011

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VOL 2, NO 2

PROFILE

2011 NAPNAP CONFERENCE COVERAGE

Monroe Carell Jr. Children’s Hospital at Vanderbilt

Pediatric Nurse Practitioners Inspired to THINK BIG! Jim Hoyt

orld-renowned pediatric neurosurgeon and Presidential Medal of Freedom recipient Benjamin S. Carson Sr, MD, delivered the keynote address entitled “THINK BIG! Creating Healthy Minds in Children” at the 32nd annual conference of the National Association of Pediatric Nurse Practitioners. The conference, entitled “Charting the Course for Advocacy and Innovation,” took place in Baltimore, MD, on March 23-26, 2011. As the director of pediatric neurosurgery at the prestigious Johns Hopkins

Children’s Center for over 25 years, Dr Carson has long cared about the health and well-being of children. During this time, not only has Dr Carson cared for countless children medically, but he has also become an advocate to help children reach their potential academically, emotionally, and spiritually. Dr Carson’s hour-long presentation was based on his book entitled THINK BIG: Unleashing Your Potential For Excellence. THINK BIG is an acronym that explains Dr Carson’s philosophy on promoting academic achievement, phiContinued on page 12

Jessica Marshall, MSN, CPNP, and Alison Grisso, PharmD, working in a new program in the cardiac critical care unit at Children’s Hospital in which the responsibilities formerly performed by residents are now fulfilled by pediatric acute care nurse practitioners. Photo by Susan Urmy.

he Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tennessee, is recognized nationally as a leader in pediatric healthcare services by U.S. News & World Report and Parents magazine. The hospital features Centers of Excellence for the treatment of congenital heart disorders and for diabetes, which is highlighted in this issue. For this interview we spoke with Pediatric NP/PA board member Alison Grisso, PharmD, about her experience at Children’s Hospital. In addition, Adelaide Vienneau, the manager of the Junior League Family Resource Center at the hospital, was available to field a question. PNPPA: Alison, as a pediatric pharmacist, can you describe your interaction with the nursing staff at Children’s and how it relates to patient outcomes? Dr Grisso: We are fortunate at Children’s to have a great team approach when treating our patients. As a pediatric clinical pharmacist in the pediatric critical care unit, I make rounds that cover our post-op cardiac patients with Continued on page 28

SPECIAL ENDOCRINOLOGY ISSUE DIABETES

Overview of Diabetes in Children for Primary Healthcare Providers Leslie K. Scott, PhD, PNP-BC, CDE Assistant Professor and Coordinator, Pediatric Nurse Practitioner, Doctorate of Nursing Practice Program, University of Kentucky, College of Nursing Pediatric Endocrinology, University of Kentucky, Lexington, Kentucky Leigh Small, PhD, CPNP-PC, FNAP Associate Professor and Coordinator, Pediatric Nurse Practitioner, Doctorate of Nursing Practice Program, Arizona State University, College of Nursing & Health Innovation, Phoenix, Arizona

iabetes, or elevated blood glucose that is unopposed by insulin, is one of the most common chronic diseases in children, currently affecting 215,000 American youth.1 Recent estimates are that 1 in 3 children born in the

year 2000 will develop diabetes in his or her lifetime.2 Annually, approximately 15,000 children and adolescents are diagnosed with type 1 diabetes mellitus (T1DM) and 3700 are diagnosed with type 2 diabetes mellitus (T2DM).2 Due to Continued on page 20

INSIDE

IN HEALTH LAW, RX FOR TROUBLE ..........................................7

LORETTA C. FORD TO BE INDUCTED INTO HALL OF FAME......................10

COMPLIMENTARY CE CREDIT

THE GROWTH CHART

Pharmacologic Considerations for Diabetic Ketoacidosis..............14

News for the Ages ......................31

Recognizing those providing bright futures for kids

! "! # " $$$% &! " ! % ' $ &# Nurse Practitioner of the Year Physician Assistant of the Year

Pediatric Institution of the Year Treatment Advance of the Year

All awardees will be nominated and voted on by you, our reading community, and will receive the distinct recognition for making a bright future for a child. You will have the opportunity to make nominations in each category and provide a description of how the nominee helped to spread a little sunshine.

Editorial Board Patti Batchelder, RN, MSN, PNPBC

Somer DelSignore, RN, BSN, MSN, C-PNP

Susana P. JuarezLeal, PNP-BC, PhD

Sharon SablesBaus, PhD, RN, PCNS-BC

The Children’s Hospital University of Colorado at Denver Aurora, CO

Maria Fareri Children’s Hospital at Westchester Medical Center Valhalla, NY

Martin’s Pediatrics and Counseling Jacksonville, NC

University of Colorado Denver Aurora, CO

Cris Ann Bowman-Harvey, RN, MSN, CPNP

Shannon Fitzgerald, MSN, ARNP

Nancy R. Kloha, FN, FNP-BC, DNP

Sue Shepard, RN, BSN

Advanced Pediatric Associates Aurora, CO

Seattle Children’s Hospital Seattle, WA

University of Kentucky College of Nursing Lexington, KY

Michelle Brei, CPNP, APRN

Sara Gerrie, RN, MSN, CPNP

Bernadette McCormick, RN, BSN

Rady Children’s Hospital San Diego, CA

Jacqueline Marie Toia, RN, MS, DNP

Yale Health New Haven, CT

Center for Cancer and Blood Disorders Littleton, CO

Karyn Brundige, MSN, CPNP

Scott W. Governo, MSN, FNP/PNP, BC

Shirley Becton McKenzie, MS, PNP-BC, AE-C

Olson Huff Center of Child Development Asheville, NC

The Children’s Hospital Aurora, CO

The Children’s Hospital University of Colorado Denver Aurora, CO

Alison G. Grisso, PharmD

Katherine Michalek, PA-C, MS

Deborah Walter, BSN, MSN, ACNP

Seattle Children’s Hospital Seattle, WA

Maria E. Bullock, APRN, MSN, CPNP-AC/PC Vanderbilt University School of Nursing Nashville, TN Children’s Memorial Hospital, Chicago, IL

Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, TN

Nathalie Cleveland, MSN, RN, CPNP

Maureen S. Haugen, RN, MS, CPNP, CPON

The Children’s Hospital Aurora, CO

Children’s Memorial Hospital Chicago, IL

Rady Children’s Hospital San Diego, CA

The Children’s Hospital, Denver, CO

Erica Monasterio, RN, MN, FNP University of California, San Francisco San Francisco, CA

Children’s Memorial Hospital Chicago, IL

Scott B. Turner, MSN, APRN-BC

Rady Children’s Hospital San Diego, CA

Ruth S. DeVoogd, MSN, RN, PNP-AC/PC The Children’s Hospital, Aurora, CO

Kathleen Ryan, MSN, FNP San Diego Unified School District San Diego, CA

Alison Moriarty Daley, MSN, APRN, PNP-BC

Susan Hines, RN, BSN, MSN, CPNP

Janette H. Prokop, MSN, APRN-C, CPEN

Yale University School of Nursing New Haven, CT

The Children’s Hospital Aurora, CO

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APRIL 2011 I VOL 2, NO 2

IN THE SPOTLIGHT PUBLISHING STAFF Publisher Russell Hennessy russell@novellushc.com 732-992-1888 Director, Client Services Jack Iannaccone jack@novellushc.com Editorial Director Kristin Lee Siyahian kristin@novellushc.com Copy Editor Bjarne Hansen Contributing Editors Rosemary Hansen Jim Hoyt Production Manager Marie R.S. Borrelli Director of Quality Control Barbara M. Marino Business Manager Blanche Marchitto blanche@greenhillhc.com Executive Administrator Andrea Boylston Circulation Department circulation@novellushc.com Editorial Contact: Telephone: 732-656-7935 Fax: 732-656-7938

Pediatric NP/PA presents… Endocrinology Pharmacologic Considerations for Diabetic Ketoacidosis Preventing Negative Psychosocial Outcomes in Girls With Early Pubertal Onset Overview of Diabetes in Children for Primary Healthcare Providers

Pulmonology Cystic Fibrosis–Related Diabetes

Dermatology Fun in the Sun

241 Forsgate Drive, Suite 205D Monroe Twp, NJ 08831

BPA Worldwide membership applied for July 2010. EDITORIAL CORRESPONDENCE should be addressed to EDITORIAL DIRECTOR, Pediatric NP/PA™, 241 Forsgate Drive, Suite 205D, Monroe Township, NJ 08831. E-mail: kristin@novellushc.com. YEARLY SUBSCRIPTION RATES: United States and possessions: one year: $29.00; two years: $39.00; single issues: $17.00. Orders will be billed at individual rate until proof of status is confirmed. Prices are subject to change without notice. Correspondence regarding permission to reprint all or part of any article published in this journal should be addressed to REPRINT PERMISSIONS DEPARTMENT, Novellus Healthcare Communications, LLC, 241 Forsgate Drive, Suite 205D, Monroe Township, NJ 08831. The ideas and opinions expressed in Pediatric NP/PA™ do not necessarily reflect those of the editorial board, the Editorial Director, or the Publisher. Publication of an advertisement or other product mention in Pediatric NP/PA™ should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturer with questions about the features or limitations of the products mentioned. Neither the Editorial Board nor the Publisher assumes any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material contained in the periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosage, the method and duration of administration, or contraindications. It is the responsibility of the treating physician or other healthcare professional, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Every effort has been made to check generic and trade names, and to verify dosages. The ultimate responsibility, however, lies with the prescribing physician or healthcare provider. Please convey any errors to the Editorial Director. ISSN 2155-1529 (print); ISSN 2155-1553 (online).

Profile Monroe Carell Jr. Children’s Hospital at Vanderbilt

Conference Coverage From NAPNAP

Pediatric NP/PA™ is published 6 times a year by Novellus Healthcare Communications, LLC, 241 Forsgate Drive, Suite 205D, Monroe Township, NJ 08831. Telephone: 732.656.7935. Fax: 732.656.7938. Copyright ©2011 by Novellus Healthcare Communications, LLC. All rights reserved. Pediatric NP/PA™ logo is a trademark of Novellus Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the Publisher. Printed in the United States of America.

APRIL 2011 I VOL 2, NO 2

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Letter to Our Readers

Turn a Page, Click a Mouse, or Scan a Bar Code… Dear Colleague,

t is my pleasure to present this issue of Pediatric NP/PA with a special section focusing on pediatric endocrinology. You will find several articles about pediatric diabetes and a contribution on early maturing girls. You will also read about Sun Safety and several other noteworthy topics.

In each issue, we strive to present articles that directly impact your practice and enable you to provide better care. However, as healthcare providers, we are faced with an abundance of information critical to our professional performance and to our personal satisfaction as well as more and more ways to acquire that information. Internet connectivity allows a convenient method to access the information we need immediately. Yet, there is an irreplaceable connection we have to the printed word – the unparalleled experience of holding a journal in our hands and feeling a connection with the author of that work. Now there is a way to link the finite scope of a printed work with the infinite capacity of the Internet through scanning a bar code with your smartphone.

Alison G. Grisso, PharmD

In this issue, you will find 2D bar codes that you can scan with a smartphone that will connect you to further information. We are proud to bring you the ability to connect to the information you need through our written pages, our Web site, and now through a scanning application. On behalf of all of us at Pediatric NP/PA, it is my pleasure to bring this innovative and convenient way to connect to the information you need. Happy scanning! With best regards,

Alison G. Grisso, PharmD Guest Editor in Chief, Endocrinology Edition Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, Tennessee To enable your smartphone to scan a 2D code, you will need to download the ScanLife application in one of the following ways: • Text “scan” to 43588 • Go to www.getscanlife.com on your smartphone’s Web browser and select “download” • Visit the app store for your smartphone

Look for these bar codes throughout this issue to connect to more information.

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APRIL 2011 I VOL 2, NO 2

Reader Response

Nurse Practitioner vs Mid-Level Provider Dear Pediatric NP/PA, As a life and career coach who works with a lot of NPs, I found Alison Moriarty Daley’s article entitled “I Am a Nurse Practitioner, NOT a Mid-Level Provider” powerful and highly representative of the views of many NPs I talk to. As her references and many other studies have shown, the quality, personalization, and continuity of care they provide is on average as good or better than that of many physicians, both in the eyes of their patients and based on outcomes. Given that NPs are the primary providers of healthcare to many, are playing a key role in filling the gap left by a growing shortage of general practice physicians, and play key roles in nearly every branch of healthcare, the “Mid-Level” name is simply wrong factually and insulting. NPs shouldn’t be held at arm’s length with such patronizing language. Instead, they should be embraced and celebrated for the excellent care, attention, and education they provide their patients with. Sincerely, Pratt Bennet NP Coach Scan here to view Ms Moriarty Daley’s editorial and participate in a poll (see instructions to download the ScanLife application in the Letter to Our Readers on page 5).

Artwork Month OF THE

Leanna, age 9

Scott, age 5

Submit your patients’ artwork by visiting us at www.pediatricnppa.com or e-mailing kristin@novellushc.com.

APRIL 2011 I VOL 2, NO 2

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The OTC Dilemma

In Health Law, Rx for Trouble Janet Adamy

andy Chung is grappling with a new kind of request at her pediatrics office in Fairfax, VA: prescriptions for aspirin and diaper-rash cream. Patients are demanding doctors’ orders for over-the-counter products because of a provision in the healthcare overhaul that slipped past nearly everyone’s radar. It says people who want a tax break to buy such items with what’s known as flexible-spending accounts need to get a prescription first. The result is that Americans are visiting their doctors before making a trip to the drugstore, hoping their physician will help them out by writing the prescription. The new requirements create not only an added burden for doctors, but also new complications for retailers and pharmacies. “It drives up the cost of healthcare as opposed to reducing it,” says Dr Chung, who rejected much of a 10-item request from a mother of four that included pain relievers and children’s cold medicine. Though the new rules on over-thecounter drugs amount to a small part of the massive overhaul of the healthcare system, the unintended side effects show how difficult it can be to predict how such game-changing legislation will play out in the real world. Some doctors, irked by the paperwork and worried about lawsuits, are balking at writing the new prescriptions. Pharmacists and retailers say the changes mean they have to apply a personalized label on some 15,000 different everyday products for customers paying with certain debit cards. The over-the-counter provision isn’t the only part of the healthcare law that has defied expectations. Health-policy experts predicted that new insurance pools for high-risk patients would attract so many expensive enrollees that funding would be quickly exhausted. In fact, enrollment is running at just 6% of expectations, partly because of high premiums. A provision preventing insurers from denying coverage to children with preexisting health conditions prompted insurers in dozens of states to stop selling child-only policies altogether. And a piece of the law designed to centralize patient care by encouraging healthcare providers to collaborate is running into antitrust concerns from regulators. To the handful of congressional aides who came up with the idea to limit tax breaks on over-the-counter drugs, it was supposed to be a minor tweak to raise revenue and to discourage wasteful spending on health products.

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Some 33 million Americans are in families that have flexible-spending accounts, which are funded through payroll deductions and allow consumers to pay for health expenses with tax-free dollars. The change also applies to health savings accounts designed for consumers in insurance plans with high deductibles. If fewer people use these accounts to buy drugs, the government gets more tax revenue. Retail sales of over-the-counter medicines amounted to about $17 billion in 2010, not counting sales at Wal-Mart Stores Inc, according to Nielsen Co. What the law’s writers didn’t anticipate was the determination of some people to squeeze every last drop of tax savings from their accounts. When Dianna Greer of San Diego and her son came down with a cold, she wanted a $13 bottle of NyQuil and daytime cold medicine – and she wanted to pay for it by tapping the $5000 in her flexible-spending account. Ms Greer says her doctor wouldn’t write prescriptions without an office visit, so she went without the drugs. Later, she got the prescriptions from a doctor at the emergency room, where she was diagnosed with pneumonia.

Pharmacists and retailers say the changes mean they have to apply a personalized label on some 15,000 different everyday products... “It feels like you’re begging for something when it’s your money,” she says. Much of the health law, which passed last year despite overwhelming opposition by Republicans, doesn’t take effect until 2014. The nonpartisan Congressional Budget Office has projected that an additional 32 million Americans will get insurance, and the law has already extended tax credits to small businesses for buying insurance and allowed many parents to keep their children on their health plan until their 26th birthday. But opponents say it costs too much and gives the federal government too much control over healthcare. Republicans in the House voted this year to repeal the law, though the measure died in the Senate. Opponents are trying to get it struck down in the courts, a fight that is likely to last until at least next year. As that larger battle plays out, the

over-the-counter provision is emerging as a top target for change. Republicans in both the House and Senate have introduced legislation to repeal it and return to the old system. The largest chain drugstore lobbying group is backing the effort, arguing that the new rules are inefficient and limit access to the medicines. Asked whether she would support such legislation, Kathleen Sebelius, secretary of Health and Human Services, said: “I’d take a look at it.” A spokeswoman for the Treasury Department, which oversees tax policy, says the provision “enjoyed bipartisan support in Congress, but, as the president said, anything can be improved, and we are always willing to listen to ideas about how to make healthcare better and more affordable.” Tax breaks for over-the-counter drugs date to 2003, as popular drugs like the allergy medicine Claritin began switching to over-the-counter status. The Internal Revenue Service loosened the rules on flexible-spending accounts so consumers could use them to buy thousands of nonprescription medications. The tax-free dollars can also go for insurance co-payments, eyeglasses and other out-of-pocket health costs. Critics say the accounts encourage overconsumption of medical services. Since consumers typically must forfeit unused funds by year’s end, they often ended up scrambling in December to drain their funds by loading up on aspirin, antacid and the like. “The entire flexible-spending account thing is a waste of our taxpayer dollars,” says Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology and a former paid consultant on the health law to the Department of Health and Human Services. “If you’re going to scale it back, this is a natural place to start.”

(Another part of the law limits the amount consumers can save in flexiblespending accounts to $2500 a year, starting in 2013.) Peeling back tax breaks for health plans was on the table in 2009 when lawmakers began drafting the health overhaul. Inside the Senate Finance Committee, aides to three Democratic and three Republican senators hashed out the blueprint for what ultimately became the final bill. Some big ideas – like limiting the tax break for employer-sponsored health insurance – lacked support, so committee aides lowered their sights. Making people pay the full price for over-thecounter medicines seemed like a way to reduce wasteful spending and generate money for the law’s main goal: expanding health insurance to nearly every American. An objection came from William Pewen, senior health-policy adviser to Maine Republican Sen. Olympia Snowe. He believed the tax-free treatment could lower health costs and thought everyone should have access to a flexible-spending account. He told the group that he takes over-the-counter Prilosec, a heartburn medication, which meant he didn’t need a more expensive prescription drug. “I didn’t want to see us set up perverse incentives for people to use more costly drugs than they needed,” Mr. Pewen says. He proposed a compromise that he concedes “was not the ideal solution.” People could spend tax-free dollars on over-the-counter drugs, but only if they got a doctor’s prescription. It wasn’t exactly a new idea: Medicaid, the federal-state program for the poor, already covers some over-the-counter drugs if they are prescribed. Continued on page 8

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The OTC Dilemma In Health Law...continued from page 7 Congress’s number-crunchers estimated the change would generate $5 billion over a decade. Hardly anyone noticed it, even as it stayed in the bill through passage in March 2010. Only after the president’s signature was dry did the American Medical Association realize what had happened and send a letter to the government warning of unintended consequences, including more office visits and extra paperwork. Sure enough, when the change took effect Jan. 1, patients began bringing lists of over-the-counter drugs to office visits and also requesting over-the-counter prescriptions by phone, doctors says. While it may not be worth the trouble for some patients, the savings can add up for those with chronic conditions, especially if the doctor writes multiple refills. A survey late last year by Nielsen found that nearly half of consumers with flexible-spending accounts would request the prescriptions as a result of the changes. Among those most upset by the changes are pediatricians, who say that small sizes of children’s medicines and multiple children per family make the requests particularly burdensome. “It’s an amazingly disruptive policy,”

says Jesse Hackell, a Pomona, NY, pediatrician who is charging $5 to fill such requests via phone. “I am now doing the IRS’s work, and that’s what I resent most.” After writing two over-the-counter prescriptions free of charge in January, pediatrician Richard Schwartz of Vienna, VA, says he began imposing a $10 surcharge for each prescription, on top of the office co-payment. That is likely to discourage some patients from asking for a prescription, as the surcharge could outweigh the tax savings from using a flexible-spending account. Doctors are also concerned about malpractice lawsuits, since a prescription potentially puts them on the hook for any problems a patient suffers from over-the-counter drugs. Some malpractice insurers are urging doctors not to write any prescription without seeing the patient in person, says Lawrence Smarr, president of the Physician Insurers Association of America, which represents malpractice insurance providers. Retailers and pharmacies, meanwhile, say another aspect of the change caught them flat-footed. Many flexiblespending accounts come with a debit card, making it easy for consumers to

draw down the money in the accounts when they shop at a pharmacy. But under the original IRS guidance, people couldn’t use those cards for the prescribed over-the-counter medications.

Thousands of over-thecounter products now must pass behind the pharmacist’s counter when the customer pays with the special debit card. An industry group representing WalMart, CVS Caremark Corp, Visa Inc and other large corporations warned that could temporarily halt use of the debit cards for any pharmacy purchase. The IRS eventually decided the cards could be used – as long as the pharmacist labels and processes the over-thecounter item exactly like a prescription. That had another unintended effect. Thousands of over-the-counter products now must pass behind the pharmacist’s counter when the customer pays with the special debit card. “At the moment it’s considered a pre-

scription, it’s subject to all the regulatory requirements,” says Mike DeAngelis, a spokesman for CVS. “It runs through our quality assurance process. We have to generate a label.” The chain also puts each of the prescribed drugs in an individual paper bag. Despite the hopes of Mr Pewen in the Senate, some consumers think they will be better off getting a prescriptiononly drug in place of an over-thecounter medication. In the Nielsen survey, 37% of flexible-spending account users said they would ask their doctor about prescription drugs that could replace their overthe-counter medicines. Dr Chung, the pediatrician in Fairfax, VA, says she recently imposed a policy under which her office writes prescriptions only for chronic conditions, like allergies. That deflects pleas from parents wanting a quick Rx for their child’s cold, but she’s worried about pushback. “It makes us look like the bad guy,” she says. Reprinted by permission of Wall Street Journal, Copyright © 2011. Dow Jones & Company, Inc. All Rights Reserved Worldwide. License number 263436 1340085.

Do You Collaborate or Compete With Physicians?

n the February issue, we published an article entitled “Collaboration Between Physicians and Nurse Practitioners” in which we highlighted the growing sentiment that it is time for the two disciplines to work together for the betterment of public health. We asked our online reading community if they feel they compete or collaborate with physicians.

• 15% reported feeling competition between physicians and nurse practitioners • 85% reported experiencing collaboration

Our sincere thank you to all who participated in this survey. If you would like to be included on future surveys, please register with us at www.pediatricNPPA.com.

APRIL 2011 I VOL 2, NO 2

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Noteworthy

Diabetes by the Numbers hen a diagnosis of diabetes is made during childhood, it is typically assumed to be type 1, or juvenileonset diabetes. However, over the past two decades, type 2 diabetes has been on the rise among children and adolescents in the United States. Let’s take a look at the data from the 2011 National Diabetes Fact Sheet released Janary 26, 2011:

Children and adolescents diagnosed with type 2 diabetes are generally between 10 and 19 years old, obese, have a strong family history for type 2 diabetes, and have insulin resistance.

When oral medication

Approximately 215,000 people younger than 20 years have diabetes. About 1 in every 400 children and adolescents has type 1 diabetes. 25.8 million children and adults in the United States – 8.3% of the population – have diabetes… 18.8 million of those have been diagnosed with diabetes... 7 million are undiagnosed… And it is estimated that 79 million people aged 20 years or older have prediabetes. The total cost of diagnosed diabetes in the United States in 2007 was $174 billion. Source: http://www.cdc.gov/diabetes/pubs/ factsheet1.htm.

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is not an option.

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Noteworthy

Loretta C. Ford to Be Inducted Into the National Women’s Hall of Fame

he National Women’s Hall of Fame recently announced the upcoming induction of Loretta C. Ford along with 10 other American women who have made valuable and enduring contributions to our nation. These women will be formally inducted on September 30 and October 1, 2011, in Seneca Falls, NY, the birthplace of the American Women’s Rights Movement. The National Women’s Hall of Fame is the nation’s oldest membership organization recognizing the achievements of great American women. Inductees are selected every 2 years based on their lasting contributions to society through the arts, athletics, business, education, government, humanities, philanthropy, and science. From a

group of over 200 completed nominations, a national panel of judges conducted a rigorous scoring process and selected 11 women for induction. The National Women’s Hall of Fame 2011 inductees are: Loretta C. Ford (1920 – ). An internationally renowned nursing leader, Dr Loretta C. Ford has devoted her career to practice, education, research, consultation, and the delivery of health services. Dr Ford is best known for cofounding the nurse practitioner model through her studies on the nurse’s expanded scope of practice in public health nursing. In 1972, Dr Ford became the founding dean of the University of Rochester School of Nursing, where she implemented the

unification model. Dr Ford is the author of more than 100 publications and has served as a consultant and lecturer to multiple organizations and universities. St. Katharine Drexel (1858 – 1955). A missionary who dedicated her life and fortune to aid Native Americans and African Americans, Saint Katharine Drexel is only the second recognized American-born saint. Dorothy Harrison Eustis (1886 – 1946). A philanthropist, Dorothy Harrison Eustis combined her love of animals and her passion for helping others to cofound the nation’s first dog guide school, The Seeing Eye. Abby Kelley Foster (1811 – 1887). A major figure in the national antislavery and women’s rights movements,

Abby Kelley Foster is remembered for her roles as a lecturer, fundraiser, recruiter, and organizer. In 1850, Foster helped develop plans for the National Women’s Rights Convention in Massachusetts, and later, in 1868, she was among the organizers of the founding convention of the New England Woman Suffrage Association. Helen Murray Free (1923 – ). A pioneering chemist, Helen Murray Free conducted research that revolutionized diagnostic testing in the laboratory and at home. Free is the codeveloper of Clinistix, the first dip-and-read diagnostic test strips for monitoring glucose in urine. Along with her husband, Alfred Free, she also developed additional strips for testing levels of key

St. Katharine Drexel

Dorothy Harrison Eustis

Abby Kelley Foster

Helen Murray Free

Loretta C. Ford

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Noteworthy

indicators for other diseases. Today, dipand-read strips make testing for diabetes, pregnancy, and other conditions available in underdeveloped regions of the United States and in foreign countries. Free is the recipient of numerous awards, including the National Medal of Technology and Innovation and the American Chemical Society’s 66th National Historic Chemical Landmark designation (2010). Billie Holiday (1915 – 1959). Considered by many to be one of the greatest jazz vocalists of all time, Billie Holiday forever changed the genres of jazz and pop with her unique style. Coretta Scott King (1927 – 2006). One of the most celebrated champions of human and civil rights, Coretta Scott King, in partnership with her husband, Dr Martin Luther King, Jr, ignited democracy movements worldwide. Lilly Ledbetter (1938 – ). For over a

decade, Lilly Ledbetter has fought to achieve equal pay for men and women; her efforts proved successful when President Obama signed the Lilly Ledbetter Fair Pay Act into law in 2009.

The National Women’s Hall of Fame, founded in 1969, has inducted 236 women since its inception.

Barbara Mikulski (1936 – ). The first female Democratic United States senator elected in her own right, Barbara Mikulski has been a political trailblazer for more than 30 years. Donna Shalala (1941 – ). A groundbreaking educator and politician, Dr Donna Shalala has more than 25 years

of experience as an accomplished scholar, teacher, and administrator. Dr Shalala is recognized as the longest serving United States Secretary of Health and Human Services (19932001) and is the current president of the University of Miami. Kathrine Switzer (1947 – ). As the first woman to officially enter the Boston Marathon (1967), Kathrine Switzer broke the gender barrier and paved the way for women in running. “From an early suffragist to a civil rights pioneer; from a university president to trailblazers in health and science; each of these women have demonstrated fortitude, perseverance, intelligence, and hope. Their experiences provide both an example for each of us to emulate and a challenge for each of us to embrace. What began in Seneca Falls comes full circle this October, when this phenomenal group

of inductees convenes in the birthplace of women’s rights,” said Christine Moulton, Executive Director of the National Women’s Hall of Fame. The National Women’s Hall of Fame, founded in 1969, has inducted 236 women since its inception. This year’s inductees will join a notable group that includes Susan B. Anthony, Dr Dorothy Height, Maya Lin, Sandra Day O’Connor, and Rosa Parks. “We congratulate this year’s inductees and are excited to welcome them to Seneca Falls later this year,” said Beverly P. Ryder, the Hall’s President, from Los Angeles. The National Women’s Hall of Fame recently launched its new Web site, www.greatwomen.org. The site allows visitors to read about this year’s inductees, view a complete list of all Hall inductees, and make plans to attend Induction Weekend 2011.

Billie Holiday

Coretta Scott King

Lilly Ledbetter

Barbara Mikulski

Donna Shalala

Kathrine Switzer

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APRIL 2011 I VOL 2, NO 2

NAPNAP Conference Coverage

Helping Families to Make Healthier Decisions Jim Hoyt

here are many factors that contribute to the increased occurrence of childhood obesity. Poor nutritional choices, busy family schedules, and the lack of safe and affordable exercise options are often identified as key contributors to an unhealthy lifestyle. Pediatric healthcare providers have long been faced with the challenge of helping families overcome these obstacles and make healthier choices. Eliza S. McCartney, MS, CNS, CPNP, and Cathi A. Badik, MD, of the University of Toledo, conducted a 3month study to help pediatric healthcare providers combat childhood obesity. They presented the results from the

study at the 32nd annual conference of the National Association of Pediatric Nurse Practitioners in Baltimore, MD.

The families reported that during the study they did make a conscious effort to make better food choices and live a more active lifestyle. The study followed 8 families, each with at least one member who is obese,

over a 3-month period. The goal of the study was to receive feedback from the families at the end of the 3 months to determine what tools were most effective in helping them to adopt healthier lifestyles. A pediatrician and a pediatric nurse practitioner met with each family before, during, and after the study to collect measurements that included height, weight, body mass index, and blood pressure and food and activity logs. Three-month memberships to the YMCA, three $50 gift cards to purchase groceries, and pedometers were provided to the families. To encourage the participants to make healthy choices, points were awarded for healthy food

choices, activities completed, and educational events attended. At the end of the study, the 3 families with the highest point totals received prizes. The families reported that during the study they did make a conscious effort to make better food choices and live a more active lifestyle. It appeared that involving the entire family in the process to live a healthier lifestyle impacted the success of the program. The study provided insight into the effectiveness of relationship-based interventions. The results from this study are being used to design a plan being implemented at a youth weight management clinic.

BIG philosophy and give practical examples of each component. Whether he was telling the story of becoming the

reports per week as a child, even though she could not actually read them (although he did not know it at the

THINK BIG...continued from the cover lanthropy, and inspiring others to lead successful and meaningful lives. THINK BIG stands for: T Talent and Time should be looked upon as gifts H Honesty is the best policy I Insight should be taken from people and books N be Nice to everyone you meet K Knowledge should be seen as the key to living B Books are to be read actively

In-depth learning skills should be developed G God, or whatever belief you choose, is important Dr Carson explained how he has used this philosophy to rise to the top of his field despite being born into poverty to a single mother with a third-grade education. During his talk, Dr Carson shared inspirational anecdotes and stories from his life. The tales, both personal and professional, allowed him to illustrate the meaning of his THINK

Dr Carson explained how he has used this philosophy to rise to the top of his field... first person to successfully separate craniopagnus (Siamese) twins or how his mother made him turn in 2 book

time), Dr Carson stressed the importance of responsibility, faith, and kindness toward others.

Pediatric NP/PA at NAPNAP: Spreading a Little Sunshine

Jenilea Hueftle, PNP; Kelly Gettig, RN; and Jodie Roth, BA NP, at the Pediatric NP/PA booth.

APRIL 2011 I VOL 2, NO 2

The Pediatric NP/PA booth â&#x20AC;&#x201C; a popular stop at NAPNAP.

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Nutrition

Healthy Snacking for Your Patients With Diabetes Kristin Siyahian

ny parent will tell you that kids love snacks – and this fact can pose a challenge for your patients with diabetes. Children and teens are notorious for reaching for high-sugar, high-carb, and high-fat snacks such as potato chips and cookies. But with a little planning, snacks can be fun, delicious, and nutritious too.

Portion size is the key to controlling blood glucose and avoiding weight gain. You can encourage your patients to make healthy snack choices and their parents to stock the pantry and refrigerator with healthy snacks, placing them where they are easily accessible to kids. Placing premeasured snacks, such as plastic bags filled with baby carrots and

airtight containers with hummus, on the bottom shelf of the refrigerator where the children can help themselves is a great strategy. It helps avoid impromptu snacking when poor choices may occur and also gives the children a sense of independence in selecting a snack. Planning snacks is a great opportunity to fit in another serving of whole grains, fruits, or vegetables. Remember that portion size is the key to controlling blood glucose and avoiding weight gain. Scan to view delicious and nutritious recipes (see instructions to download the ScanLife application in the Letter to Our Readers on page 5).

Snack Ideas Suggested by the American Diabetes Association Snacks with less than 5 grams of carbohydrate 3 celery sticks + 1 tbsp of peanut butter 5 baby carrots 5 cherry tomatoes + 1 tbsp ranch dressing 1 hard-boiled egg 1 cup cucumber slices + 1 tbsp ranch dressing 1/4 cup of fresh blueberries 1 cup of salad greens, 1/2 cup of diced cucumber, with vinegar and oil 1 sugar-free Popsicle 1 cup of light popcorn 10 Goldfish crackers 16 green olives 1/2 cup sugar-free gelatin 1 string cheese stick About 10-20 grams of carbohydrate 1/2 cup almonds or other nuts 1/4 cup dried fruit and nut mix 1 cup chicken noodle, tomato (made with water), or vegetable soup 1 small apple or orange 3 cups light popcorn

1/3 cup hummus + 1 cup raw fresh-cut veggies (green peppers, carrots, broccoli, cucumber, celery, cauliflower, or a combination of these) 1/4 cup cottage cheese + 1/2 cup canned or fresh fruit 1 cheese quesadilla (made with one 6-inch corn or whole wheat tortilla + 1 oz shredded cheese) + 1/4 cup salsa 2 rice cakes (with a 4″ diameter) + 1 tbsp peanut butter 5 whole wheat crackers (or 3/4 oz) + 1 piece of string cheese 1/2 turkey sandwich (1 slice whole wheat bread + 2 oz turkey + mustard) 1/2 cup tuna salad + 4 saltines About 30 grams of carbohydrate (good to eat before exercise) 1/2 peanut butter sandwich (1 slice whole wheat bread + 1 tbsp peanut butter) + 1 cup milk 6 oz light yogurt + 3/4 cup berries (blueberries, blackberries, raspberries, or a combination of these) 1 English muffin + 1 tsp low-fat tub margarine 3/4 cup whole grain, ready-to-eat cereal + 1/2 cup fat-free milk 1 medium banana + 1 tbsp peanut butter Source: http://www.diabetes.org/food-and-fitness/food/planning-meals/snacks/.

Now Accepting Nominations for Editorial Board Positions The Editorial Board is instrumental in determining the content and direction of Pediatric NP/PA. If you are interested in serving on the Pediatric NP/PA Editorial Board, or would like to nominate a colleague, please e-mail the candidate’s resume to kristin@novellushc.com.

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APRIL 2011 I VOL 2, NO 2

CONTINUING EDUCATION TO RECEIVE CREDIT, LOG ON TO: WWW.PEDIATRICNPPA.COM/CE13 1. Select “Continuing Education” 2. Click on this article’s title from the list shown 3. Select “Click here to complete the posttest and obtain a CE certificate online”

4. Complete and submit the CE posttest and CE Activity Evaluation 5. Print your Certificate of Completion Release date: APRIL 1, 2011. Expiration date: APRIL 1, 2012. Estimated time to complete: 1.0 hour

Pharmacologic Considerations for Diabetic Ketoacidosis Alison G. Grisso, PharmD Pediatric Clinical Pharmacy Specialist; Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee

iabetic ketoacidosis from insulin deficiency and (DKA) is responsiis characterized by hyperble for over 160,000 glycemia, water and elechospital admissions per trolyte depletion, and aciyear.1 Additionally, 35% to dosis. The lack of insulin, 40% of pediatric patients either from noncompliance, present in DKA correlating lack of diagnosis, inadverwith their initial diagnosis tently missing doses, or failof type 1 diabetes mellitus.1 ure to give adequate insulin As with many other disease to meet the body’s needs states, some of the compli- Alison G. Grisso, PharmD during intercurrent illnesscations of DKA are unique es, causes glucose levels to to pediatric patients, most notably cere- rise. This lack of utilization then sets bral edema. Understanding the patho- the counterregulatory hormones (gluphysiology and proper management can cagon, catecholamines, cortisol, and prevent many of the complications asso- growth hormone) in motion as the body ciated with DKA. In general, managing reacts as if it does not have enough gludiabetes is key to prevention of DKA. cose for energy. Glucose levels begin to rise and create an osmotic gradient due Pathophysiology to the hypertonicity of the extracellular Diabetes occurs when the body is fluid. This fluid shift affects many of the unable to utilize glucose. DKA results electrolyte imbalances seen in DKA.

Table 1

Goals of Fluid and Electrolyte Therapy in DKA2

Volume restoration Replace electrolytes and fluid deficit Enhance glucose and ketone clearance with increased glomerular filtration Avoidance of fluid overload to prevent exacerbation of cerebral edema

CONTINUING MEDICAL EDUCATION ACCREDITATION AND DESIGNATION OF CREDIT STATEMENT LEARNING OBJECTIVES

Upon completion of this activity, participants should be able to: • Understand the pathophysiology of diabetic ketoacidosis (DKA) in the pediatric patient • Describe effective management strategies for DKA in the pediatric patient • Discuss complications associated with DKA TARGET AUDIENCE

Pediatric nurses, physician assistants, and other interested healthcare professionals, especially those caring for pediatric patients with diabetes. FACULTY

Alison G. Grisso, PharmD Pediatric Clinical Pharmacy Specialist Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, Tennessee PROGRAM FORMAT

The learners will participate in this educational activity by reading through the article, answering multiple choice questions on the

APRIL 2011 I VOL 2, NO 2

Additionally, the increase in extracellular glucose tends to exceed the renal threshold, resulting in an osmotic diuresis leading to dehydration and the symptoms of polyuria and polydipsia. Polyphagia is another symptom of DKA as the body act as though it lacks glucose needed for normal function. In addition to glucose and insulin abnormalities, lipolysis occurs, increasing the free fatty acids. The oxidation of these fatty acids results in the production of ketones, which then lead to a metabolic acidosis. Kussmaul respirations are a subsequent symptom of DKA as the body tries to compensate for the increase in partial pressure of carbon dioxide.1,2 Individual institutions may define when DKA exists based on a patient’s level of hyperglycemia, ketonemia, and acidosis (eg, pH <7.3 and serum bicarbonate <15 mEq/L). Management Fluid and Electrolytes Once the necessary arterial blood gasses have been established, fluid and electrolytes are managed because dehydration is usually present in these children. An initial rapid infusion of 10 to 20 mL/kg with isotonic saline or lactat-

ed Ringer’s solution is appropriate when necessary to help with volume expansion and potentially poor perfusion and hypotension, if present. Unless the latter two symptoms are present, additional boluses are usually not required, and a maintenance fluid can be started. Goals of this maintenance fluid are listed in Table 1. Due to the osmotic diuresis and extracellular fluid shifts, a sodium deficit of 5 to 25 mEq/kg can be present.1 Additionally, this fluid shift can cause a dilutional hyponatremia, which dictates the use of isotonic saline (0.9%) as maintenance fluid in these patients. Potassium is also depleted in DKA, usually along the order of 4 to 10 mEq/kg.1 Unless there is no urine output or hyperkalemia exists, potassium is added to the fluids in the salt forms of chloride, phosphate, or acetate or a combination of these. Institutions vary as to which salt forms are used. Phosphate helps with restoration of oxygen delivery to tissues.1 Other electrolytes to monitor in patients with DKA are calcium and magnesium, to prevent them from falling too low. Insulin Insulin is one of the mainstays of

posttest, and completing the evaluation. There is no fee to participate in this CE activity. After reading the article, please log on to www.PediatricNPPA.com/CE13. Select “Continuing Education” and click on this article’s title from the list shown. Then click on “Click here to complete the posttest and obtain a CE certificate online.”

CONTINUING NURSE EDUCATION ACCREDITATION AND CONTACT HOURS STATEMENT

SCIENCE CARE DISCLOSURE POLICY

COMMERCIAL SUPPORT

As a provider accredited by the California Board of Registered Nursing, Science Care must ensure balance, independence, objectivity, and scientific rigor in all its activities. All course directors, faculty, planners, and any other individual in a position to control the content of this educational activity are required to disclose to the audience any relevant financial relationships with any commercial interest. Science Care must determine if the faculty’s relationships may influence the educational content with regard to exposition or conclusion and resolve any conflicts of interest prior to the commencement of the educational activity.

This CE activity is not funded by any commercial supporters.

Disclosures are as follows: • Alison G. Grisso, PharmD, has nothing to disclose

DISCLAIMER

PLANNER DISCLOSURES

No other planners or staff in the position to influence the content of this activity has any relationships with relevant commercial interests to disclose.

Science Care is approved by the California Board of Registered Nursing as a provider of continuing nursing education, Provider number 15559. This program is acceptable for 1.0 contact hour.

UNLABELED OR UNAPPROVED USE OF DRUGS OR DEVICES

It is the policy of Science Care to require the disclosure of all references to unlabeled or unapproved uses of drugs or devices prior to the presentation of educational content. The audience is advised that this CE activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. Please consult the prescribing information for full disclosure of approved uses.

The opinions and recommendations expressed by faculty, authors and other experts whose input is included in this program are their own and do not necessarily represent the viewpoint of Science Care or Novellus Healthcare Communications, LLC. Copyright © 2011 by Science Care.

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CONTINUING EDUCATION

treatment for DKA in conjunction with fluid management. Endogenous insulin is deficient or ineffective in patients with DKA, and therefore supplementation is necessary. Insulin works to utilize glucose and suppress gluconeogenesis as well as to suppress lipolysis, thereby stopping ketone production and acidosis.1 Insulin boluses are not recommended for use in DKA by the American Diabetes Association (ADA).2 Instead, a continuous infusion of insulin is recommended at an initial rate of 0.05 to 0.1 unit/kg/hr. Only regular insulin is permitted in an insulin infusion, never an insulin analog (such as insulin aspart or insulin lispro) or intermediate-acting insulin (such as NPH). Insulin is used to treat acidosis, not hyperglycemia. The insulin infusion should not be stopped if acidosis persists. Therefore, to avoid decreasing the insulin rate to treat falling serum glucoses, dextrose is added to the maintenance fluids (see next section). The insulin infusion is continued until resolution of DKA based on closure of the anion gap, bicarbonate levels, and increasing pH. Transition to subcutaneous insulin occurs once the acidosis has resolved and the patient can tolerate oral intake. Usually the blood glucose has fallen to <200 mg/dL as well. Interestingly, a retrospective cohort study at Monroe Carell Jr. Children’s Hospital at Vanderbilt by Shankar and colleagues found that the addition of subcutaneous insulin glargine (Lantus) within the first 6 hours of treatment actually decreased the length of infusion time for regular insulin and shortened the time to acidosis correction. Additionally, no adverse effects were seen with the addition of insulin glargine to the DKA treatment plan.3 Glucose Because of the addition of insulin to the treatment regimen, blood glucose levels will slowly fall, necessitating the use of additional dextrose to prevent hypoglycemia and to allow for the continuation of an insulin infusion until resolution of the acidosis. This is achieved by adding dextrose to the maintenance fluids in a range from 0% to 10%. To accommodate changes in blood sugars, a “two-bag system” may be used for fluid management. In a prospective study, Poirier and colleagues found this system to be most efficient for making changes to the IV fluid rates in DKA patients presenting to the emergency department.4 An example to illustrate this system is the use of one bag containing 0.9% saline and potassium but no dextrose, and a second bag containing 0.9% saline and potassium plus 10% dextrose. Adjustment of the rates for each bag allows the amount of

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Table 2

Signs and Symptoms of Cerebral Edema6

Decreased or altered mental status Headache Abnormal pupil findings Sudden hypertension or hypotension Seizures Incontinence Bradycardia Respiratory arrest

DKA Algorithm

Start IV insulin infusion 0.05-0.1 units/kg/hr

Avoid adjusting insulin infusion rate unless hyperglycemia despite dextrose infusion

Assess and establish airway, breathing, circulation Establish 2 large-caliber peripheral IV access

Initial Labs Blood glucose, Na, K, HCO3, CI, Mg, Ca, PO4, venous blood gas

If patient in shock, resuscitate with 0.9% saline bolus 20 mL/kg as required

Follow-up Labs Blood glucose q1h, serum electrolytes q4h, venous blood gases q4h

IV Fluids Bag 1: 0.9% saline with 20 mEq/L KCL + 20 mEqL KPO4 Bag 2: D10W + 0.9% saline with 20 mEq/L KCL + 20 mEq/L KPO4 Rate of infusion: 2225-3000 mL/m2/24h Titrate Bag 1 and Bag 2 to maintain a steady decrease in blood glucose, starting Bag 2 after the blood glucose <300 mg/dL Switch to subcutaneous insulin if 1. Alert 2. No vomiting 3. Venous pH >7.30 & base deficit <8

Reprinted with permission from Monroe Carell Jr. Children’s Hospital at Vanderbilt.

glucose being infused to be changed easily instead of mixing a new bag of fluid for each change. Bicarbonate Supplemental bicarbonate is never recommended for correction of the acidosis in patients with DKA as there is no clinical benefit associated with its addition to the treatment. In fact, the adverse effects of bicarbonate therapy, including hypokalemia and paradoxical central nervous system acidosis, preclude its use even more. Rather, the acidosis is corrected using a combination of the aforementioned measures.2 Complications of DKA Cerebral edema, venous thrombosis, hypoglycemia, aspiration, and fluid over-

load leading to congestive heart failure are all complications of DKA. However, with the exception of cerebral edema, complications can be avoided with proper management of the patient. Cerebral edema is a complication seen only in children, occurring at a rate of 1% to 2%.1 Though this rate may appear low, the associated mortality rate ranges from 21% to 90%.5 While there are several proposed mechanisms for this complication, including fluid overload and improper clinical management, it appears that cerebral edema may occur prior to treatment of DKA, thereby lessening these arguments.6 Signs and symptoms of cerebral edema are shown in Table 2. Marcin and colleagues performed a retrospective review of pediatric patients with DKA and cerebral

edema and found that elevated BUN levels, intubation with hyperventilation and hypocapnia, and more profound neurological depression at onset are correlated with poorer outcomes.5 Cerebral edema is usually treated with mannitol, though hypertonic saline may have a role as well.2 DKA in Children vs Adults In its consensus statement on DKA in the pediatric population, the ADA listed four differences of DKA in children vs adults2: • A standard history of polyuria, polydipsia, and polyphagia symptoms as well as weight loss are less likely to be obtained in younger children, resulting in missed or delayed diagnosis • Replacement of fluid and electrolytes requires greater precision in the pediatric population due to differences in body mass • Pediatric patients have a higher risk of cerebral edema due to greater severity at presentation, together with less mature autoregulatory systems • Recurrent DKA is greatest among adolescents due to lack of compliance with their insulin regimen Prevention Is Key For pediatric patients, prevention of DKA is imperative and should be the main goal of diabetic management. With DKA being “10 times as likely to be the cause of death as hypoglycemia,” and cerebral edema from DKA as “the most common cause of death and neurologic sequelae in children younger than 12 years of age,” education of diabetes and its management in this patient population is of the utmost importance.7 In the future, identification of individuals at high risk for developing type 1 diabetes by screening for diabetes-related antibodies in the blood may help reduce the frequency with which diabetes presents as DKA.8 References 1. White NH. Diabetic ketoacidosis in children. Endocrinol Metab Clin North Am. 2000;29:657-682. 2. Wolfsdorf J, Glaser N, Sperling MA; American Diabetes Association. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1150-1159. 3. Shankar V, Haque A, Churchwell K, et al. Insulin glargine supplementation during early management phase of diabetic ketoacidosis in children. Intensive Care Med. 2007;33:1173-1178. 4. Poirier MP, Greer D, Satin-Smith M. A prospective study of the “two-bag system” in diabetic ketoacidosis management. Clin Pediatr (Phila). 2004;43:809-813. 5. Marcin JP, Glaser N, Barnett P, et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002;141: 793-797. 6. Bevacqua JE. Diabetic ketoacidosis in the pediatric ICU. Crit Care Nurs Clin North Am. 2005;17:341-347. 7. Sperling M. No gold at the ends of the glycemic rainbow. J Pediatr. 2002;141:754-756. 8. Type 1 Diabetes TrialNet. http://www2.diabetestrial net.org.

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Pulmonology

Cystic Fibrosis–Related Diabetes Cynthia Y. Driskill, RN, BSN, MSN, CPNP Monroe Carell Jr. Childrenʼs Hospital at Vanderbilt; Pediatric Pulmonary Medicine, Nashville, Tennessee

ystic fibrosis (CF) is ing 20% of adolescents and one of the most com50% of adults with CF.2 mon chronic inherWhat Is CFRD? ited disorders. It affects CFRD is a distinct type of 30,000 children and adults diabetes that shares characin the United States and teristics of both type 1 and 70,000 worldwide. The type 2 diabetes. The pripathophysiologic markers of mary cause is insulin insufficystic fibrosis are as follows: ciency. Thick secretions 1) Pancreatic enzyme defiCynthia Y. Driskill, RN, associated with CF cause ciency; 2) Progressive BSN, MSN, CPNP inflammation, obstruction, obstructive lung disease; and destruction in the panand 3) Sweat gland dysfunction.1 Cystic fibrosis–related dia- creas, thereby affecting insulin producbetes (CFRD) is the most common tion. Studies have shown that CFRD is comorbidity in individuals with CF. The associated with worse nutritional status, incidence of CFRD increases with age. more severe lung disease, and greater Due to advances in pulmonary treat- mortality. The greatest impact is on the ments and improvements in nutrition, patient’s pulmonary function. In a the life expectancy for an individual patient with CF, pulmonary function is with CF has increased to more than 37 directly related to nutritional status. years. Therefore, there are more Hyperglycemia and insulin insufficiency patients diagnosed with CFRD, affect- have a negative impact on the patient’s ability to gain and/or maintain weight, which directly affects the health of the lungs. Studies have also shown that hyperglycemia may contribute to lung disease by creating an environment that promotes inflammation and bacterial growth.3 CF lung disease is caused by thick dehydrated mucus that leads to inflammation, obstruction, and infection. Therefore, hyperglycemia further complicates the lung environment. Macrovascular disease has not been shown to be a problem with CFRD.

Table

ADA Guidelines for Diagnosing CFRD

For healthy outpatients: 1. Fasting blood glucose ≥126 mg/dL 2. 2-Hour OGTT glucose ≥200 mg/dL 3. A1c ≥6.5% 4. Random glucose ≥200 mg/dL plus polyuria, polydipsia If abnormal, all but #4 should be repeated. For patients on continuous tube feedings: 1. Mid- or immediate post-feeding glucose ≥200 mg/dL Confirmed on 2 separate nights. For patients with acute illness and/or on systemic steroids: 1. Fasting glucose ≥126 mg/dL 2. 2-Hour postprandial glucose ≥200 mg/dL Diagnosis based on hyperglycemia that persists for greater than 48 hours. During pregnancy, a diagnosis is made if any of the following glucose levels are present: 1. Fasting glucose ≥92 mg/dL 2. 1-Hour OGTT glucose ≥180 mg/dL 3. 2-Hour OGTT glucose ≥153 mg/dL

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However, microvascular problems do occur, with mild neuropathy being the most common complaint. Not only does CFRD complicate the physical health of the patient, psychosocial challenges may also be faced. The daily care schedule for a patient with CF is demanding. The diagnosis of CFRD adds an additional chronic illness, further burdening the patient’s quality of life. Due to the distinct pathophysiologic differences in CFRD and the negative impact on the health of the patient, clinical care guidelines were published in 2010. This was a joint effort between the Cystic Fibrosis Foundation (CFF), the American Diabetes Association (ADA), and the Pediatric Endocrine Society. The guidelines included recommendations for screening, diagnosis, and treatment of CFRD.4 Screening CF patients are screened for CFRD annually, beginning at 10 years of age. Patients may also be screened at other times due to suspicion of CFRD. For example, a patient with unexplained weight loss may warrant additional screening. The standard screening test is the oral glucose tolerance test (OGTT), which includes a fasting and a 2-hour glucose level. The 2-hour level is obtained after the patient is challenged by drinking a beverage containing 1.75 g/kg of glucose (maximum 75 grams). In addition to the annual screening, there are specific screening guidelines implemented during inpatient treatment. Studies have shown that patients may develop hyperglycemia during times of stress, such as acute illness. This hyperglycemia may be intermittent and resolve when the stressor is not present. Therefore, patients are screened for CFRD by monitoring fasting and 2hour postprandial glucose levels for the first 48 hours of admission. If glucose levels are normal during this time, testing can be discontinued. Many CF patients are on gastrostomy tube feedings due to the high caloric demands associated with the disease. During admission, glucose levels are measured in the middle of the tube feed and immediately after the tube feed ends. Pregnancy is also a time of increased concern in CF. Women with CF are at high risk of developing hyperglycemia during pregnancy. Therefore, an OGTT is performed at the end of both the first and second trimesters. The OGTT during pregnancy includes a 1-hour glucose level in addition to the fasting and 2hour glucose levels. The purpose of the

screening guidelines is early identification of CFRD patients. If the OGTT is found to be within normal limits, the patient then resumes routine annual screening. An abnormal OGTT should be confirmed by repeat testing, unless the patient has classic signs of diabetes in the presence of a random glucose level greater than 200 mg/dL.4 Diagnosis As shown in the Table, a diagnosis of CFRD is made according to the standards outlined by the ADA.4 Once the diagnosis of CFRD is made, diabetes clinicians become part of the patient’s healthcare team. Management of CFRD requires healthcare professionals who are familiar with both CF and diabetes. This team approach demands excellent communication skills between the clinicians in order to provide the patient with the best outcomes. The patient should be the center of the team, with all team members working to meet the patient’s specific needs. All patients will need support, encouragement, and ongoing education. It is important for CF patients to receive care in a center that is accredited by the CFF. Accredited care centers are reviewed by the CFF to ensure that standard CF care is being provided, such as aggressive nutritional therapy, frequent antibiotic treatment for pulmonary exacerbations, and standard CFRD screening. Not only are the care centers dedicated to quality patient care, they also participate in clinical research resulting in up-to-date care of CF and CFRD patients. Treatment Insulin is the only treatment recommended for CFRD. Oral agents have not been shown to be effective. Evidence shows that with good glucose control, the patient’s nutritional status and lung function improve. There is also evidence showing a decrease in the number of pulmonary exacerbations and an increased survival rate once glycemic control is achieved. No specific insulin regimen is recommended to achieve this goal. Clinical judgment based on the patient’s specific needs should guide the treatment plan. There are some patients who require daily insulin and others who only require insulin in times of stress, such as a pulmonary exacerbation. As in any patient on insulin therapy, hypoglycemia can occur. Signs, symptoms, and treatment of hypoglycemia should be included in the patient’s education plan. Nutrition

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Pulmonology

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is also a part of the treatment plan as it is critical to the health of CF patients that they maintain a healthy body mass index. The caloric needs of CF patients are great due to their loss of calories through malabsorption and their highenergy expenditure. Because of this, calories and carbohydrates are not restricted in the CFRD patient. Carbohydrate counting with insulin-to-carbohydrate ratios helps to determine insulin therapy. The goal is a balanced diet that is high in calories and the use of insulin to gain glycemic control. The CF nutritionist is a critical member of the healthcare team because of the guidance he or she provides for the nutrition plan. Exercise is also recommended to aid in the patientâ&#x20AC;&#x2122;s overall health.4

healthcare team is advised to use clinical judgment in deciding the treatment plan based on the patientâ&#x20AC;&#x2122;s individual needs.

Conclusion CFRD is a unique type of diabetes that is primarily caused by insulin insufficiency. CFRD is associated with a decline in nutritional status and pulmonary function, along with increased mortality. The CFRD Guidelines Committee published clinical care guidelines in 2010.4 According to the guidelines, patients are screened annually starting at 10 years of age, and anytime CFRD is suspected. Once diagnosed, the patient requires a multidisciplinary team including clinicians with knowledge of both CF and diabetes. Insulin is the only treatment recommended for CFRD. Glycemic control has been associated with improved nutritional status, improved lung function, and greater survival rate. No specific insulin regimen is recommended. The

Glycemic control has been associated with improved nutritional status, improved lung function, and greater survival rate. The CFRD guidelines have helped to guide the screening, diagnosis, and care of CFRD patients. The guidelines shed light on a distinct type of diabetes, but many issues were also identified that warrant

further investigation, such as obstacles in OGTT screening, risk of insulin therapy, the most effective treatment plan, and the psychosocial impact of CFRD. These issues will guide future research projects, further improving the care of CFRD patients, and may give insight into preventing the onset of CFRD.4 References 1. Jackson PL, Vessey JA. Primary Care of the Child with a Chronic Condition. 3rd ed. St. Louis, MO: Mosby, Inc; 2000. 2. Kirk D, Buse JB. Clinical care guidelines: too much of a good thing? Diabetes Care. 2010;33:2716-2718. 3. Moran A, Becker D, Casella SJ, et al. Epidemiology, pathophysiology, and prognostic implications of cystic fibrosis-related diabetes: a technical review. Diabetes Care. 2010;33:2677-2683. 4. Moran A, Brunzell C, Cohen RC, et al. Clinical care guidelines for cystic fibrosis-related diabetes: a position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society. Diabetes Care. 2010;33:2697-2708.

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APRIL 2011 I VOL 2, NO 2

Overview of Pediatric Diabetes Diabetes...continued from the cover the reported rise in childEpidemiologic Review of Type 1 and Type 2 hood diabetes rates,2 it has Diabetes become more important than ever that primary Type 1 Diabetes healthcare providers be T1DM diabetes accounts able to appropriately screen for 5% to 10% of all diapatients, diagnose the disbetes cases4 and is caused ease, initiate effective therby the immune-mediated apies, and problem-solve destruction of the pancrethe challenges associated Leslie K. Scott, PhD, atic β-cells. This destrucwith this diagnosis. PNP-BC, CDE tion of insulin-producing Of all pediatric diabetes β-cells results in an conditions, T1DM and T2DM occur with the greatest frequen- absolute deficiency of insulin secrecy.2 There are several other types of dia- tion. Currently, it is believed that envibetes affecting children, such as maturi- ronmental triggers such as enteroty-onset of diabetes in youth, neonatal virus,5 measles virus,6 and Coxsackie B diabetes, and cystic fibrosis–related dia- virus,6 to name a few, can initiate the betes,3 but these are extremely rare. In immune-mediated response in genetithis overview, epidemiology and diagno- cally predisposed individuals, the consis of diabetes will be discussed, as well as sequence of which is T1DM. Once initreatment strategies, including pharma- tiated autoantibodies begin to be cologic management and dietary and produced, however, it may be several activity management considerations, months before an individual demonand recommended screening tests for strates overt signs and symptoms the complications of diabetes. of diabetes.

Table 1

Risk Factors Associated With T2DM and AAP/ADA Screening Guidelines for Children11

Beginning at 10 years of age, children meeting the following high-risk criteria should undergo laboratory testing every 3 years: Body mass index (BMI) >95th percentile – Obese or BMI >85th percentile (overweight) with 2 of the following risk factors: • High-risk ethnic groups Native American Latino or Hispanic African-American Asian-American • Family history of T2DM (1st- or 2nd-generation relative) • Evidence of insulin resistance Acanthosis nigricans Hypertension Hyperlipidemia • Maternal diabetes or gestational diabetes (during this child’s gestation) The recommended laboratory testing for at-risk children, 10 years of age, should include: • Fasting plasma glucose and/or 2-hour oral glucose tolerance test (75 g load; 1.75 g/kg up to 75 g [<90 lb/43 kg]) • Hgb A1c Evaluate for comorbidities associated with T2DM by assessment of the following: • Elevated blood pressure • Abnormal lipid profile • Elevated liver function tests

APRIL 2011 I VOL 2, NO 2

ing strategies that will be The Role of Autoantibodies in discussed later in this Diabetes overview. One or more of the diaNote that the presence betes autoantibodies will be of serum antibodies in the present in 95% of individuals absence of signs and sympaffected with T1DM at the toms associated with diatime of initial diagnosis,7 whereas autoantibodies are betes does not assure the typically absent in an individfuture development of ual with T2DM. Given that T1DM. The risk of T1DM Leigh Small, PhD, there appear to be 4 autoantidevelopment is directly CPNP-PC, FNAP bodies that demonstrate the proportional to the numβ-cell autoimmunity of ber and titer of antibodies T1DM7 and thus play a critical role in present.9 As noted above, the presence the identification and accurate diagnosis of GAD antibodies and IA-2 antibodies of diabetes, a more in-depth understand- predict β-cell failure and thus signal the ing regarding these autoantibodies is impending development of T1DM.7,9 The titers or levels of all antibodies necessary. The glutamic acid decarboxylase decrease over time in T1DM10 in (GAD) antibody, detected in 80% of response to the continued autoimmune new-onset T1DM cases, is specific to process, making repeated antibody the β-cell protein7 and is the most com- measurement after the diagnosis of monly detected antibody. Protein tyro- T1DM of little use for providers. sine phosphatase–like antibodies (IA-2 antibodies) also are antigen-specific Type 2 Diabetes islet antibodies. The IA-2 antibodies T2DM accounts for 90% to 95% of are frequently detected in children who all diabetes cases4 and is believed to be have been newly diagnosed with the result of a complex combination of T1DM.7,8 More specifically, IA-2 anti- metabolic disorders that include cellular bodies are present in 60% of all children insulin resistance, increased hepatic diagnosed with T1DM.7,8 glucose production, and relative The islet cell antibody (ICA) serum decreased pancreatic insulin secretion. test is elevated or positive in 70% to Findings from recent reports indicate 80% of new-onset cases of T1DM8; that up to 45% of newly diagnosed cases however, this antibody is not specific to of diabetes among children and adolesthe pancreatic β-cell. Similarly, insulin cents in the United States are classified autoantibodies (IAAs), different from as T2DM. The prevalence of T2DM IA-2 antibodies, are not islet cell specif- among American children is expected ic and thus do not distinguish between to continue to increase and exceed that endogenously produced and exogenous- of T1DM over the next 10 years.4 As a brief review, the oral intake of ly produced insulin. The detection of increased IAA levels is thought by carbohydrates (CHO) normally results many to signal T1DM, but this test is in elevated blood glucose and the connot sensitive for those individuals being sequential increase in the glucagon-like treated with exogenous insulin. Of peptide (GLP-1). Some of the many note, both individuals with T1DM and responses to GLP-1 production are the those with T2DM who have received stimulation of insulin production, supexogenous insulin therapy lasting pression of glucagon secretion, and longer than 2 to 3 weeks may have pos- the hepatic production of glucose. itive IAAs upon analysis.7 These obser- However, in the case of T2DM there is vations suggest specific diagnostic test- a blunted effect following an oral

Table 2

Differentiation in Diagnostic Criteria for Diabetes and Prediabetes2,11,12

Laboratory Study

Diabetes

Prediabetes

Random plasma glucose (with diabetes symptoms of weight loss, polydipsia, polyphagia, and polyuria)

>200 mg/dL

N/A

Fasting plasma glucose

>126 mg/dL

100-126 mg/dL

2-Hour OGTT results (75 g CHO load*)

>200 mg/dL

140-200 mg/dL

Hgb A1c

>6.5%

5.7%-6.5%

*If child <43 kg, the CHO load should be 1.75 g/kg/dose.

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Overview of Pediatric Diabetes

CHO/glucose load, and thus normal amounts of insulin are inadequate to produce a normal insulin response in cells (ie, body fat, liver, and muscle cells). In the early stages of the T2DM disease process, there may be an increase of blood glucose following an oral CHO load but a disproportionately low production of insulin. Because the body requires glucose for glucose metabolism and energy production to survive, there is further stimulation of insulin production that leads to the state of hyperinsulinemia. As the disease progresses, the chronic state of insulin resistance and hyperinsulinemia causes the inadequate secretion of insulin and resultant high blood glucose. These changes occur over time, making the onset of T2DM insidious, much more so than T1DM. Additionally, there appears to be strong genetic predisposition among family members toward the development of T2DM, although T2DM development in children younger than 10 years of age is relatively rare.2 Due to the gradual nature of the onset of diabetes symptoms, the American Academy of Pediatrics (AAP) and the American Diabetes Association (ADA) recommend screening for the known risk factors associated with T2DM with children every 3 years (Table 1).11 Upon the identification of an at-risk child as defined in Table 1, who is 10 years of age or older, laboratory screening should ensue. Recommended laboratory testing should include a fasting plasma glucose (FPG) and/or an oral glucose tolerance test (OGTT).11 Experts consider that the 2-hour OGTT is a gold standard screening tool.12 The administration of the oral CHO load during an OGTT is weight dependent when testing children (1.75 g/kg body weight, up to a 75 g CHO load).11 Resultant serum glucose values are only diagnostic at the 0- and 120-minute post-CHO load time points. The glycosylated hemoglobin (or hemoglobin [Hgb] A1c) is a serum test that serves as a marker for average blood glucose levels over the previous several months. This serum measure has become accepted as a criterion upon which to establish a T2DM diagnosis in adult patients.12 This, however, is not the case in children as the Hgb A1c may not be a reliable indicator of T2DM.13 Diagnosing Diabetes In 1993, the diagnostic criteria for diabetes were significantly changed. Since that time there have been additional alterations in the criteria, with the most recent occurring in 2010 as Hgb A1c values were added.2 Table 2 shows the most current criteria to diag-

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Table 3

Laboratory Differentiation Between T1DM and T2DM

Laboratory Studies

T1DM

T2DM

Urinary ketones

Positive (may be negative depending on degree of insulin insufficiency)

Negative (may be positive if fasting or illness present)

CO2 (assesses acid-base balance)

Normal (may be low if acidosis/DKA)

Normal

Fasting C-peptide (assesses pancreatic insulin secretion)

Low to normal (may be low if FPG is low or normal)

Typically elevated

GAD autoantibody

Positive

Negative

IA-2 antibody

Positive

Negative

Islet cell antibody

Positive

Negative

Insulin autoantibody

Positive (may be negative if never taken exogenous insulin)

Negative (may be positive if exogenous insulin has been initiated)

nose a child with diabetes and compares those criteria with those of prediabetes. Prediabetes occurs when blood glucose levels are higher than normal yet not high enough for the diagnosis of diabetes and presents diagnostically as either impaired fasting glucose or impaired glucose tolerance.12 Pathophysiologically, prediabetes usually occurs prior to the development of classic signs and symptoms of T2DM (eg, polydipsia, polyphagia, polyuria) but may be undetected; therefore, prediabetes potentially heralds the future onset of T2DM and thus providers should give diet and nutrition guidance similar to that associated with T2DM discussed later in this overview. Prediabetes should not be confused with metabolic syndrome,14 which is a cluster of risk factors associated with cardiovascular disease such as obesity, abdominal obesity, insulin resistance, increased blood pressure, elevated triglycerides, decreased high-density lipoproteins, and hyperglycemia. Patients presenting with this clustering of risk factors (metabolic syndrome) should undergo testing for diabetes. With the continued high prevalence of obesity in children of all ages as well as the number of children with clinical features of T2DM (eg, obesity, acanthosis nigricans, polydipsia, polyuria, polyphagia) presenting with ketosis and autoantigens (ie, GAD, IA-2, IAA, and ICA) at diagnosis,10 it is becoming more difficult to differentiate between T1DM and T2DM in children.2 Making the diagnosis of T1DM or T2DM is critical given the differences in recommended treatment regimens, educational content, and approaches needed, as well as specific dietary counseling strategies.15 Providers can use laboratory analyses to differentiate between T1DM and T2DM as it presents in children (Table 3). Because only 1 in 4 children who are later identified to have new-onset dia-

Table 4

Glycemic Goals for Children With Diabetes15

Age of Child

Glycemic Goal

Preprandial Glucose

Bedtime Glucose

<6 years

7.5%-8.5%

100-180 mg/dL

110-200 mg/dL

6-12 years

<8%

90-180 mg/dL

100-180 mg/dL

13-19 years

<7.5%*

90-130 mg/dL

100-150 mg/dL

*The American Academy of Clinical Endocrinologists guidelines alternatively recommend Hgb A1c <6.5%.

betes presents in diabetic ketoacidosis (DKA),16 specific laboratory testing should be used in conjunction with blood glucose and Hgb A1c levels to accurately diagnose patients with suspected diabetes. Treatment Strategies Treatment strategies for T1DM or T2DM are based on achieving optimal glycemic goals for the individual, otherwise known as blood glucose goals (optimal adult blood glucose goals range from <110 mg/dL fasting to 130 mg/dL preprandially).4 Appropriate glycemic goals for children (those with T1DM, specifically) are less stringent than for adults (Table 4) and should take into consideration a childâ&#x20AC;&#x2122;s age and cognitive development or ability to recognize early symptoms of hypoglycemia or hyperglycemia (ie, hunger, shakiness, sweating).15 Blood glucose goals for children are more flexible than those for adults because of the detrimental effects of intermittent or repeated severe hypoglycemia that may occur during young childhood as a result of exogenous insulin administration. These effects, such as ataxia, paralysis, and seizures, may lead to permanent neuropsychologic or intellectual impairments in young children.15 To achieve the identified glycemic goals, the majority of treatment strate-

gies are similar for a child who has either T1DM or T2DM.4 One example may be that of blood glucose monitoring, one of the basic cornerstones of diabetes care. Providers should develop a schedule for blood glucose monitoring based on a childâ&#x20AC;&#x2122;s glycemic goals and cognitive ability to recognize symptoms associated with hyperglycemia and hypoglycemia. The ability to self-reflect and appraise a personal state of wellness and/or signs and symptoms of abnormal glucose levels is necessary because early clinical symptoms may indicate the need for CHO or insulin to attain better glycemic control and avert a hyperglycemic or hypoglycemic crisis. Children with diabetes, type 1 or type 2, who are prescribed insulin therapy are traditionally scheduled to monitor blood glucose levels a minimum of 4 times daily to evaluate insulin dose requirements throughout a day.15 Children with diabetes who are not prescribed insulin therapy are able to monitor blood glucose less frequently due to the reduced risk of hypoglycemia, whereas exogenous insulin administration is more likely to produce intermittent episodes of unmatched insulin and resultant hypoglycemia. Additional management strategies for children diagnosed with any type of diabetes should include referral to a Continued on page 22

APRIL 2011 I VOL 2, NO 2

Overview of Pediatric Diabetes Diabetes...continued from page 21 Table 5

Insulin Preparations: Onset, Peak, and Duration of Action4

Insulin Preparation

Onset of Action

Peak Action

Duration of Action

Rapid-acting (Humalog/NovoLog)

5-20 minutes

2-3 hours

3-5 hours

Short-acting regular insulin (Humulin R, Novolin R)

0.5-1 hour

2-4 hours

6-8 hours

Intermediate-acting NPH insulin (Humulin N, Novolin N)

1-3 hours

8 hours

20 hours

1-2.5 hours 1 hour

7-15 hours None

18-24 hours 22-24 hours

Long-acting detemir (Levemir)* glargine (Lantus)*

*Detemir and glargine cannot be mixed with any other insulin.

Table 6

Medical Management Considerations for Children With T2DM4

Hgb A1c Level

Pharmacologic Therapy

6%-7%

Monotherapy with a type of metformin – Metformin (approved for children ≥10 years) – Metformin XR (not approved for children or adolescents <17 years)

7%-8%

Metformin + secretagogue or insulin analog

8%-10%

Aggressively initiate combination therapies (see above) to improve fasting and postprandial glucose levels (many patients require the initiation of insulin therapy)

>10%

Initiate intensive insulin therapy

pediatric endocrinologist/multidisciplinary diabetes team for comprehensive education, including age-appropriate self-care/parent-care and management skills, pharmacologic treatment management, and nutrition therapy.4,15 Referral to such specialist healthcare teams is particularly important for children diagnosed with T1DM and for those children diagnosed with T2DM who are not achieving optimal glycemic goals.15 Pharmacologic Management The pharmacologic management of T1DM includes the initiation of subcutaneous (SC) exogenous insulin, otherwise referred to as intensive insulin therapy. The multiple administration times and dosages of the various types of exogenous insulin are usually prescribed in what is described as a basal-bolus pattern, a pattern that is thought to have an effect similar to the physiologic responses to glucose intake and metabolism patterns (ie, 3 meals and 2 snacks per day) that occur in children who do not have diabetes.4 Many children initially require 0.5-1.0 insulin units per/kg/day.15,17 This insulin dose repre-

APRIL 2011 I VOL 2, NO 2

sents the total daily insulin requirement, inclusive of both the basal or long-acting insulin dose and the shortacting insulin bolus doses. Frequently, these insulin administration schedules need individual adjustment at various time points according to insulin sensitivity, dietary intake, and physical activity. There are many types of insulin preparations (ie, rapid-, intermediate-, and long-acting insulin; Table 5) and administration methods (eg, the insulin pen, SC insulin pumps) appropriate for use with children.4 Diabetes management decisions regarding insulin preparation, use, and means of administration should take into account a child’s schedule, glucose intake, activity level, and self-management support (ie, parent/family/school personnel support).15 Recently, the American Academy of Clinical Endocrinologists (AACE) released diabetes management guidelines/strategies for individuals diagnosed with T2DM based on Hgb A1c levels and clinical symptoms (Table 6).4 These recommendations call for providers to prescribe an insulin sensitizer, such as metformin, at the same time lifestyle

changes are recommended as a first step in effective treatment. The use of metformin, however, has demonstrated a limited reduction of approximately 1% to 2% in Hgb A1c levels to date.4 This reduction may not be adequate to assure that patients achieve their optimal glycemic goal. According to AACE guidelines, insulin therapy should be initiated for an individual with serum Hgb A1c levels greater than 10% to gain control of the patient’s hyperglycemia and reverse glucose toxicity.4 Insulin treatment may subsequently be modified as glucose toxicity resolves and the patient experiences improvement in his or her clinical condition. Dietary and Activity Management Considerations One foundational component in the treatment of T1DM and T2DM in children is dietary management.15 Effective dietary plans should be individualized in a way that meets a child’s nutritional needs while being respectful of food preferences, activity levels, cultural influences, and current eating schedule.15,17 The dietary planning and associated education may be best accomplished by a registered dietician or a trained diabetes educator. The dietary goals of overweight children not prescribed insulin therapy should target weight loss or weight maintenance. Specifically, individualized strategies that vary in aggressiveness are necessary, with strategies based upon the degree of obesity (ie, body mass index percentile) and child’s age.18 Children receiving a consistent insulin dose at mealtimes should have a consistent CHO intake15 so that the exogenous insulin has a target for its action and the child does not experience hypoglycemia or hyperglycemia as a result of mismatched insulin and dietary CHO.4,15 Some children and their parents desire more flexibility in CHO dietary intake, and as a result, the insulin in prescribed insulin-to-CHO ratios can vary in response to changing amounts of CHO dietary intake.15 Insulin-to-CHO ratios may vary from meal to meal dependent on varying degrees of individual insulin resistance/insulin sensitivity and diurnal patterns. For example, many children experience a greater degree of insulin resistance in the morning than at other times of the day.17 Therefore, the insulin-to-CHO ratio would be different at breakfast than at the other meals/snacks. Providers should always encourage routine physical activity be incorporated into the daily schedule of children diagnosed with diabetes.4 Prior to a child receiving insulin therapy, a

provider should consider the child’s level of physical activity because activity results in energy expenditure and increases the need for glucose metabolism. Furthermore, before beginning any form of regular physical activity or engaging in a concerted amount of planned activity, reflexive insulin dose regulation should be considered by the child’s healthcare providers, and the child and parents should be educated regarding the potential need to call the healthcare provider for insulin dose adjustments.15 In such a situation, glucose monitoring by parents and/or children to evaluate the effect of a change in physical activity on blood glucose levels should be strongly encouraged by healthcare providers so that subsequent adjustments can be made to the exogenous insulin therapy.4 Troubleshooting Diabetes Management Tips Blood glucose pattern management is the evaluation of the effectiveness of therapeutic insulin regimens19 (ie, morning long-acting insulin and intermittent doses of regular insulin at 3 or more time points throughout the day) prescribed to a child with diabetes. This management strategy is an important component of diabetes care and is related to a child’s blood glucose monitoring results, medication use, dietary intake, and physical activity. The overall assessment and corresponding blood glucose pattern management result in the child’s degree of diabetes control. An assessment of blood glucose patterns over a number of days results in the ability of healthcare providers to make necessary adjustments in overall treatment regimens4 (eg, medication dosage changes, alterations in dietary intake, modifications in physical activity patterns). Children diagnosed with diabetes and their parents will often need primary healthcare providers to intervene to match glucose/CHO intake and utilization with exogenous insulin. These episodes may arise as a result of alterations in a prescribed therapeutic regimen and/or acute illness. For example, in the case of children with T1DM, hypoglycemia can occur as a result of decreased dietary intake, inadequate digestion/absorption of glucose, or increased levels of physical activity in relation to a consistent exogenous insulin dose.15 Children with T2DM also are at risk of developing hypoglycemia if they are being treated with exogenous insulin or oral antidiabetes agents (eg, secretagogues). Children and their caregivers should be provided with guidance regarding events that may trigger a hypoglycemic Continued on page 24

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Overview of Pediatric Diabetes Diabetes...continued from page 22 response, possible prevention strategies that they can implement, and treatment during episodes of severe hypoglycemia (eg, administration of glucagon) or when oral treatment is impaired (ie, illnesses accompanied by vomiting). The recommended glucagon dose is 0.5 mg SC for preschool children and 1 mg SC for school-agers and teens.15 Children on insulin therapy whose blood glucose is <70 mg/dL should be treated with CHO administration. One method of remembering this treatment protocol is to remember the acronym, “the rule of 15.”17 Simply stated, a child should receive 15 g of dietary CHO (ie, 4 oz juice) every 15 minutes until she/he has a blood glucose level >70 mg/dL. Families should be cautioned by healthcare providers regarding the overtreatment of hypoglycemia because subsequent hyperglycemia can be a result. As soon as a hypoglycemic event resolves, the provider should evaluate the episode with the child and parents to determine why it occurred and adjust the child’s medications or contributing behaviors (ie, physical activity, diet) to prevent future episodes. For example, if a child develops hypoglycemia as a result of increased physical activity (eg, involvement in a new school sport), the child or parent can either decrease the insulin dose scheduled or increase the CHO dietary intake before the activity to lessen the risk of another event. The child or parent can be educated to handle such schedule alterations and notify the healthcare provider when appropriate. A severe hypoglycemic event in which glucagon use is required, however, should signal parents to contact their child’s healthcare provider.15 Additionally, situations requiring a significant change in CHO consumption or availability (eg, fever, vomiting, diarrhea) should signal the child or caregiver to seek medical advice from a healthcare provider regarding necessary changes in the insulin treatment plan. It is crucial that children with T1DM be assessed for the development of urinary ketones during episodes of hyperglycemia or illness.17 During these conditions, insulin needs often increase, leading to a relative insulin deficiency. Left untreated, insulin deficiency may result in ketogenesis and require additional adjustments in dosing. Children with T2DM who do not usually require insulin to manage their condition may require a brief supplementation with

Table 7

Screening Guidelines for Children With Diabetes15,17

Screening Tests/Examinations

T1DM

T2DM

Ophthalmologic examination

10 years of age and 3-5 years following diagnosis

Annually following diagnosis

Thyroid (TSH)

Every 1-2 years following diagnosis if TSH and growth normal

N/A

Foot examination

Annually following puberty

Celiac disease

At diagnosis and periodically with growth failure or if gastroenterologic symptoms develop

N/A

Hypertension

Blood pressure check at each visit

Nephropathy (albumin:creatinine ratio)

Annually, beginning at 10 years and 5 years following diabetes diagnosis

Annually

Lipid profile examination

Child older than 2 years, following diagnosis and achievement of glycemic control; if normal, rescreen every 5 years

insulin during acute illnesses.17 Healthcare providers should emphasize the importance of vigilant blood glucose monitoring during high-risk events such as illness or fever as one strategy necessary to assess the health status of a child. If ketosis develops, the child’s healthcare provider should be contacted as soon as possible for assistance with therapy adjustments. Early intervention (ie, increased CHO intake) should be stressed to avoid the development of DKA. Recommended Screening Tests for the Complications of Diabetes Due to the risk of complications (eg, retinal disease, neuropathy) associated with diabetes, the ADA and AACE recommend periodic screening in children4,15 (Table 7). Children diagnosed with T1DM, an autoimmune disease, are at an increased risk for the development of other autoimmune disorders such as thyroid disease or celiac disease. Children with T2DM are at risk for the development of associated comorbid complications (eg, dyslipidemia, cardiovascular disease, hypertension, and retinal and kidney disease), which are the result of prolonged and undetected hyperglycemia, estimated by some to exist up to 10 years prior to the diagnosis of diabetes.4 Conclusion The medical management of diabetes in children has changed radically in the past two decades. Some of these changes are reflective of advances

regarding medication or medication administration options. Other changes may be a result of the growing epidemic of childhood overweight/obesity and the consequent increase in rates of childhood diabetes. Many of the medical management decisions regarding children with diabetes are dependent upon an accurate initial diagnosis, although diabetes is most often a chronic condition. The medical management of these patients requires meticulous follow-up and is often complex, requiring care by professionals from multiple disciplines (eg, primary care, nutrition, endocrinology). Given the rapid development of the science of pediatric diabetes, healthcare providers are called on to be vigilant and stay abreast of changes in the research and evidencebased guidelines to provide best practices to their patients. References 1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011. 2. Centers for Disease Control and Prevention. Children and diabetes: SEARCH for diabetes in youth. http://www.cdc.gov/diabetes/projects/diab_children.ht m. Accessed March 3, 2011. 3. National Institute of Diabetes and Digestive and Kidney Diseases. Monogenic forms of diabetes: neonatal diabetes mellitus and maturity-onset diabetes of the young. http://diabetes.niddk.nih.gov/dm/pubs/mody/. Accessed March 22, 2011. 4. Rodbard HW, Blonde L, Braithwaite SS, et al; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(suppl 1):1-68.

5. Craig M, Hober D, Zonszein J. Cold viruses appear linked to type 1 diabetes. http://www.diabetesincon trol.com/index.php?option=com_content&task=view &id=10487&Itemid=8. Accessed March 17, 2011. 6. Centre for Genetics Education. Diabetes types 1 and 2 and inherited predisposition. http://www.genetics. com.au/pdf/factsheets/fs57.pdf. Accessed March 15, 2011. 7. Champaneri S, Saudek C. Autoantibodies in type 1 diabetes. http://hopkins-diabetesguide.org/clinical_ tests/immunology/autoantibodies_in_type_1_dia betes.html?contentInstanceId=528535. Accessed March 18, 2011. 8. American Association of Clinical Chemistry. Diabetes-related autoantibodies. http://www.labtestson line.org/understanding/analytes/diabetes_auto/test.html. Accessed March 22, 2011. 9. Borg H, Gottsäter A, Fernlund P, et al. A 12-year prospective study of the relationship between islet antibodies and beta-cell function at and after the diagnosis in patients with adult-onset diabetes. Diabetes. 2002; 51:1754-1762. 10. Winter WE, Schatz DA. Autoimmune markers in diabetes. Clin Chem. 2011;57:168-175. 11. Falik H. Begin diabetes screening at age 10 for highrisk patients: AAP, ADA. AAP News. 2000;16:16. 12. National Institute of Diabetes, Digestive and Kidney Diseases. Diagnosis of diabetes. http://dia betes.niddk.nih.gov/dm/pubs/diagnosis/. Accessed March 17, 2011. 13. Lee JM, Wu EL, Tarini B, et al. Diagnosis of diabetes using A1c: should recommendations in adults be extrapolated to adolescents? [published online ahead of print December 30, 2010]. J Pediatr. 14. Grundy SM, Brewer HB Jr, Cleeman JI, et al. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109:433-438. 15. Silverstein J, Klingensmith G, Copeland K, et al. Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care. 2005;28:186-212. 16. Rewers A, Klingensmith G, Davis C, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics. 2008;121:e1258-e1266. 17. American Diabetes Association. Standards of medical care in diabetes – 2011. Diabetes Care. 2011;34 (suppl 1):S11-S61. 18. Hannon TS, Rao G, Arlanian SA. Childhood obesity and type 2 diabetes mellitus. Pediatrics. 2005;116:473-480. 19. Linekin PL. Diabetes pattern management: the key to diabetes self-management and glycemic control. Home Healthc Nurse. 2002;20:168-177.

Visit www.pediatricNPPA.com to connect with us! In addition to Web-only exclusives, news coverage, and journal articles, you’ll have the opportunity to submit patient quotes and artwork and to make nominations for the Sunshine Awards.

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Endocrinology

Preventing Negative Psychosocial Outcomes in Girls With Early Pubertal Onset Linda A. Lawson, MSN, APRN, CPNP lindaannlawson@gmail.com Alison Moriarty Daley, MSN, APRN, PNP-BC Pediatric Nurse Practitioner and Associate Professor; Yale University School of Nursing, New Haven, Connecticut

Theories Regarding Negative Psychosocial Outcomes There are few theories regarding the reasons girls who experience early puberty have higher risks of many negative behaviors and pathologies. One theory is a psychosocial model that suggests that if a girl looks older than she is, she will be treated as being that older

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age, although she does not necessarily have the cognitive or emotional skills to deal with this increased responsibility.5 This unwarranted perception of maturity may place girls in situations for which they are not developmentally ready, which can cause increased feelings of confusion, fear, and negative emotions.5 Both Inhelder and colleagues13 and Erikson14 stress the importance of identity development during this crucial pubertal transition. Additional stress and role confusion may lead to further negative thoughts and behaviors in the future. Furthermore, these girls look different than their peers, and peer relationships become ever more important as a child moves from childhood into adolescence. Adolescents who mature early may also be unable to receive the peer support that is essential to healthy development.6 With the majority of peers in a different developmental stage, an “early bloomer” may be the victim of teasing and feel isolated, different, and confused. Finally, the biological model suggests that the increased risks associated with early puberty are due to hormone levels different than those in their peers (similar to the psychosocial model). Some suggest that pubertal steroid hormones remodel a younger, less developed brain differently than they would the brain of an older child.12 Primary care providers must consider the enormous social and emotional changes that occur during puberty while keeping in mind the additional stressors to early developing girls. Depression and Early Pubertal Onset Depression affects teenage girls twice as often as it affects teenage boys, whereas the depression rates are similar among prepubertal children.15 Furthermore, depression for girls may correlate more with pubertal status and pubertal timing than with chronological age.15 For girls experiencing a more advanced sexual maturity rating at an earlier chronological age, many studies have shown that the risks of developing major depressive disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)16 is increased even further.4,10,11,17 In a large cross-sectional, population-based Norwegian study, Lien

and colleagues10 looked at menarcheal timing of nearly 4000 10th-grade girls in relation to mental distress. The study showed that there was a direct inverse linear relationship between age at menarche and increased mental distress. In a 2001 American study of nearly 500

Depression affects teenage girls twice as often as it affects teenage boys, whereas the depression rates are similar among prepubertal children. adolescent girls aged 11 to 15 years, Stice and colleagues17 found that girls who experienced early menarche, defined as reaching menarche in the first 33% of the sample, were twice as likely to meet the DSM-IV criteria for major depressive

disorder. Furthermore, using data from the Family and Community Health Study, a study of African-American girls aged 11 to 13 years from Georgia and Iowa (n=472) showed that those who began puberty in the first 20% of the population were more likely to have depressive symptoms in the 5th grade and more likely to have continuing depressive symptoms in the 7th grade, even when almost 90% of their peers were then in middle or late puberty.4 This study suggests not only that girls with early pubertal onset have depressive symptoms when they represent the minority of their peers with regard to pubertal status but also that these depressive symptoms continue even after the girls are no longer different from their peers with regard to pubertal status. Although the exact relationship between early puberty and depression is not yet known, providers must be aware of the possible increased risk of depression when caring for a girl with advanced pubertal timing. Continued on page 26

Average (Caucasian)

Early Normal* (Caucasian)

Pubertal Timing

uberty is a time of cognitive change and physical growth. For American girls, thelarche, usually the first sign of puberty, begins on average at 10.5 years of age, with menarche following about 2 years later at age 12.5.1 However, there is a broad range, and for some normal puberty can begin at 8 years of age.2 An estimated 1 in 5000 children experience pubertal onset before age 8 years, an endocrine disorder known as precocious puberty.3 While true precocious puberty is a medical condition with specific treatments, early-onset puberty is clinically and statistically normal and is defined as the first 20% of a population to reach menarche4,5 (Figure). For girls who begin puberty at an early age but are not considered to have precocious puberty, there are limited options for treatment and intervention. It has been well documented that girls who have early, yet normal, pubertal onset are at risk for numerous and profound negative sequelae. These include higher rates of depression and suicidal ideation, increased incidence of self-mutilating behaviors, increased psychosomatic symptoms such as headaches and heart palpitations, increased risk for bulimia and disordered eating, poorer academic achievement, increased risk of substance abuse and delinquency, earlier age of sexual debut, and higher incidences of teenage pregnancy.4,9-12 The purpose of this paper is to provide an overview of the potential depressive symptoms associated with early menarche and to provide suggestions for pediatric primary care providers. It is imperative for those young girls who begin puberty before their peers to be identified by their providers, screened for possible negative psychosocial outcomes, and provided with tools and guidance to successfully transition through puberty into healthy adolescents and young adults.

Precocious Puberty (Caucasian)

Average (AA)

Early Normal* (AA)

Precocious Puberty (AA) 5

Age (years)

Prepubertal

Tanner Stage 2 of Menarche

Menarche to Tanner Stage 5

Note: Caucasian refers to non-Hispanic Caucasians and AA refers to non-Hispanic African-Americans. *For the purposes of this graph, “early normal” puberty is defined as the first 10% of a population to reach each pubertal stage.

Figure. Pubertal Timing: Normal, Early Normal, and Precocious Puberty1,6-8

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Endocrinology Early Development...continued from page 25 Table 1

Pubertal Anticipatory Guidance for Early Maturing Girl and Her Parent18

AAP Recommended Anticipatory Guidance for the 9- and 10-Year Examinations

Suggested Additional Anticipatory Guidance for Younger Populations Questions for Parents

How well do you and your partner agree on how to talk with your child about sexual development?

I understand that it may seem too soon for your daughter to begin puberty, so please tell me your concerns. It is always OK to bring your daughter into the office if you have questions about her physical or emotional development.

Advice for Children: Pubertal Changes You will notice that your breasts will start to get bigger, and it’s normal for one side to be a little bigger than the other. You may start to wear a bra.

You may notice that your body will start to look different than your friends’. This is normal because everyone’s body is different.

Hair will grow in your underarms and pubic area.

All of these changes are a normal part of growing up. In a few years, all of your friends will have hair in those places too.

Girls can have their first period as early as 10, but every girl is different. A small amount of brownish-red blood will come from your vagina about once a month. You will use pads in your underwear to catch the blood.

We can talk to the school nurse for help with this if you’d like.

Additional Guidance for Parents and Children It is never OK for an older child or adult to show you his or her private parts, touch you there, scare you, or ask you not to tell your parents. Always get away from that person and tell an adult you trust right away.

You may notice that you start to look more like the girls in the grades above you, but that does not mean you have to act like an older girl. It’s OK to play with your friends in your grade, even though you may look different. For parents: Try to remember that your daughter is still only 9, 10, or 11 years old. Try not to put increased demands on your daughter because she looks older.

What questions do you have about your body?

For parents: Because your daughter is developing early and may look different than her peers, it is important to help her develop self-esteem and confidence. I’d be happy to talk further about this with you and give you some resources.

Table 2

Mental Health Screening Tools and Resources for Primary Care Providers20-26 Screening Tools

Strengths and Difficulties Questionnaire. Recommended for use by the AAP Steering Committee for depression screening; available in a parent or teacher version for use with children as young as 3 years. Available free of charge at www.sdqinfo.org. Reynolds Child Depression Scale. Specifically designed for younger children; written at a 2nd-grade reading level. Available at www3.parinc.com. Children’s Depression Inventory Manual. Specifically designed for younger children; written at a 2nd-grade reading level. Available at www.pearsonassessments.com. Guidelines for Adolescent Preventive Services (GAPS). Developed by the American Medical Association; appropriate for children aged 11 years and older. Available from the American Medical Association at www.ama-assn.org. Resources Guidelines for Adolescent Depression in Primary Care Toolkit. A free resource for primary care providers developed by the AAP; includes screening instruments, depression information sheets, assessment algorithms, flow sheets, and patient education materials. Available free of charge from www.glad-pc.org. The KySS Guide to Child and Adolescent Mental Health Screening, Early Intervention and Health Promotion. Includes screening tools and guidelines for providers. Available from the NAPNAP at www.napnap.org.

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Discussion Primary Prevention of Depression Bright Futures is a national health promotion and disease prevention initiative of the American Academy of Pediatrics (AAP).18 Bright Futures recommends starting to talk about puberty with patients at the age of 10 years, although the first pubertal changes can begin years earlier. The AAP also recommends health supervision visits every 2 years for children between the ages of 6 and 10 years; therefore, if breast development is apparent at an 8year-old well-child examination, she may very well reach menarche before her next well-child visit. At well-child visits, providers need to palpate for breast tissue to assess thelarche and assess for pubarche rather than rely on self-reporting, as there are only a few large studies regarding the accuracy of children’s self-reporting of pubertal status. Unless pubertal development is accurately assessed at each well-child visit, the opportunity for appropriate anticipatory guidance may be missed. Providers can also encourage yearly well-child examinations and more frequent follow-up visits for children aged 7, 8, and 9 years who are transitioning into puberty. Providers can take the anticipatory guidance suggestions for 10-year-old patients, adapt them for a younger population and begin the discussion about pubertal progression with parents and children at the first sign of puberty (Table 1).

Screening for Depression Most clinicians believe it is their responsibility to identify depression yet tend to rely on patient complaints rather than routinely using screening tools to identify depression.19 The AAP recommends that patients with risk factors for depression should be identified and assessed with standardized tools and monitored over time. Although the AAP lists several risk factors such as a family history of mental illness or personal trauma, early pubertal development is a significant risk factor for depression as well. Using age-appropriate screening tools in conjunction with a strong health and social history may be the best practice when trying to identify girls with depressive symptoms. It is also important to remember that depressive symptoms can persist throughout adolescence, and a child with known risk factors should be monitored over time. Table 2 lists screening tools and provider references for use in primary care practice. Summary While there is more research to be done to tease out the mechanisms by

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Endocrinology

which early pubertal onset increases the risks of many negative psychosocial outcomes, pediatric providers are currently caring for patients who are experiencing early pubertal onset. This safe and constant relationship is a reason why pediatric care providers are in an ideal position to recognize and follow girls with early onset puberty. Pediatric providers who have been evaluating the growth and development of their patients year after year can: 1. Accurately assess pubertal timing in all girls by palpating breasts and performing external genital exams at each well-child visit; 2. Encourage more frequent visits and follow-ups for girls with early development; 3. Provide age-appropriate anticipatory guidance regarding puberty at the first signs of pubertal development; 4. Screen early for depressive symptoms in girls with early development; and 5. Provide education and resources

for parents and children to encourage self-esteem and self-worth. Every clinician has the opportunity to help ease the pubertal transition for all children and to assist early maturing girls with the negative psychological sequelae that are associated with early onset puberty. References 1. Chumlea WC, Schubert CM, Roche AF, et al. Age at menarche and racial comparisons in US girls. Pediatrics. 2003;111:110-113. 2. American Academy of Pediatrics. What’s Happening to my Body? Healthy Children. www.healthychildren. org/English/ages-stages/gradeschool/puberty/ pages/Whats-Happening-to-my-Body.aspx?nfsta tus=401&nftoken=00000000-0000-0000-0000000000000000&nfstatusdescription=ERROR%3a+No +local+token. Accessed March 7, 2011. 3. Cesario SK, Hughes LA. Precocious puberty: a comprehensive review of literature. J Obstet Gynecol Neonatal Nurs. 2007;36:263-274. 4. Ge X, Kim IJ, Brody GH, et al. It’s about timing and change: pubertal transition effects on symptoms of major depression among African American youths. Dev Psychol. 2003;39:430-439. 5. Mendle J, Turkheimer E, Emery RE. Detrimental psychological outcomes associated with early pubertal timing in adolescent girls. Dev Rev. 2007;27:151-171. 6. Kaltiala-Heino R, Rimpela M, Rissanen A, et al. Early puberty and early sexual activity are associated with bulimic-type eating pathology in middle

adolescence. J Adolesc Health. 2001;28:346-352. 7. Sun SS, Schubert CM, Chumlea WC, et al. National estimates of the timing of sexual maturation and racial differences among US children. Pediatrics. 2002;110: 911-919. 8. Wu T, Mendola P, Buck GM. Ethnic differences in the presence of secondary sex characteristics and menarche among US girls: the Third National Health and Nutrition Examination Survey 1988-1994. Pediatrics. 2002;110:752-757. 9. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network. Pediatrics. 1997;99:505-512. 10. Lien L, Dalgard F, Heyerdahl S, et al. The relationship between age of menarche and mental distress in Norwegian adolescent girls and girls from different immigrant groups in Norway: results from an urban city cross-sectional survey. Soc Sci Med. 2006;63:285-295. 11. Ruuska J, Kaltiala-Heino R, Koivisto A, et al. Puberty, sexual development and eating disorders in adolescent outpatients. Eur Child Adolesc Psychiatry. 2003;12:214-220. 12. Zehr JL, Culbert KM, Sisk CL, et al. An association of early puberty with disordered eating and anxiety in a population of undergraduate women and men. Horm Behav. 2007;52:427-435. 13. Inhelder B, Piaget J. Adolescent thinking. In: Inhelder B, Piaget J, Parsons A, Milgram S, eds. The Growth of Logical Thinking: From Childhood to Adolescence. New York, NY: Basic Books; 1958:334-350. 14. Erikson EH. Identity and the Life Cycle. New York, NY: WW Norton & Co; 1980. 15. Angold A, Costello EJ. Puberty and depression. Child Adolesc Psychiatr Clin N Am. 2006;15:919-937. 16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

Washington, DC: American Psychiatric Association; 2000. 17. Stice E, Presnell K, Bearman SK. Relation of early menarche to depression, eating disorders, substance abuse, and comorbid psychopathology among adolescent girls. Dev Psychol. 2001;37:608-619. 18. Hagan JF Jr, Shaw JS, Duncan PM. Bright Futures. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. 19. Olson AL, Kelleher KJ, Kemper KJ, et al. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambul Pediatr. 2001;1:91-98. 20. Goodman R. The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry. 1997;38:581-586. 21. Reynolds WM. Reynolds Child Depression Scale. Lutz, FL: Psychological Assessment Resources, Inc; 1994. 22. Kovacs M. Children’s Depression Inventory Manual. North Tonawanda, NY: Multi-Health Systems; 1992. 23. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS). Chicago, IL: American Medical Association; 2007. 24. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120:e1299-e1312. 25. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313-e1326. 26. Melnyk B, Moldenhauer Z. The KySS (Keep Your Children/Yourself Safe and Secure) Guide to Child and Adolescent Mental Health Screening, Early Intervention and Health Promotion. Cherry Hill, NJ: National Association of Pediatric Nurse Practitioners (NAPNAP) and NAPNAP Foundation; 2006.

Out Mouths of Babes OF THE

As a tribute to your relationship with your patients, we will feature the special moments and comical quotes you share with us. Enjoy this month’s gems! I was with a patient when I was called out to take a call. I excused myself, most apologetically. When I returned, I thanked my patient (and her parent) for her understanding. I followed by saying, “Thanks for not being a noodge about it.” My patient said, “What’s a noodgeaboutit?” -Matt Tyburski, Denver At a well-check, my 9-year-old patient weighed in at 50 pounds, and she was also 50 inches tall. When I informed her of this coincidence, she thought for a minute and said, “I’m a square!” -Stephani Smith, San Diego I was performing a hearing test on a 4-year-old patient and asked her to raise her hand when she heard a “beep” through the headphones. She never raised her hand. I removed her headphones and asked her if she heard anything, she replied, “yes.” So I reminded her to raise her hand at each “beep.” I replaced the headphones and started the test again. Still she never raised her hand. When I asked her again, she said, “I’m waiting for the ‘beep’ – I only heard a ‘buzz’!” -Karen DiDonato, RN, Mechanicsville Submit your patients’ quotes by visiting us at www.pediatricnppa.com or e-mailing kristin@novellushc.com.

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APRIL 2011 I VOL 2, NO 2

Profile Monroe Carell Jr. Children’s Hospital...continued from the cover

Monroe Carell Jr. Children’s Hospital at Vanderbilt.

the other team members, including our nurse practitioner (NP) team as well as the patients’ bedside nurse and charge nurse. This approach is so helpful to ensuring the best care possible for our patients in that we each look at the patient from a different point of view. My role is to help optimize pharmacotherapy for the patient, which usually requires adjustments of doses and schedules, or lab work. The nursing team and I work together to figure out what will work best for the patient as well as

accommodating the patients’ demanding nursing care. As a pediatric clinical pharmacist for our cystic fibrosis outpatient center, I again get to work closely with the NPs caring for these patients as well as the nurses in clinic. My primary role in clinic is to counsel these patients on their medications and also to serve as a medication information resource to our cystic fibrosis team. If patients make their nurses aware of a problem with a medication, the nurses are quick to defer to me to answer their questions or help find a resolution to the problem. In both of these situations, the team approach to patient care improves our outcomes as we pool our expertise for the good of the patient. PNPPA: Can you explain how the pediatric pharmacist’s role has changed over the past 5 years? Dr Grisso: Pediatric pharmacy in general is ever evolving. When I first graduated pharmacy school, I would never have thought that I would be so intimately involved in managing computer systems and the drug information provided through them. As medication safety has come to the forefront of everyone’s mind in the past 5 or more years, this is just one of the ways to curb the number of medication errors seen.

Comments From Vanderbilt Medical Students Participating in the FACT and FAM Programs “Useful just to see the daily routine with a child with chronic illness (child getting home from school; afterschool activity, etc).” “It helped me understand the many ways that a child’s chronic health condition can impact a family (financial, emotional health, parents as a couple, church, community, etc) as well as to identify ways primary care givers can help navigate these hurdles.” “It helped me to identify ways that I as a physician can help families with children with disabilities cope better with their diagnosis. It also got me thinking about what the best way to deliver the news of a diagnosis of a disability might be.”

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Medication safety and pharintimate setting. Can you macy informatics are two tell us how this program is areas in which the pharmaperceived by participants – cist’s role has expanded. meaning patients, their Additionally, the job defamilies, and the students? scriptions of pediatric pharMs Vienneau: On an macists have changed such annual basis, we have that there are different levels approximately 150 students at which a pharmacist can and/or residents participate practice based on experience in this program that further and training. Currently at Alison G. Grisso, PharmD enhances their understandChildren’s, we have a cening of patient and familytralized pharmacy model, which means centered care. We have approximately that our staff pharmacists are located in 40 families that are trained to share the pharmacy. We are expanding to a their experiences with students and also decentralized model to get the pharma- welcome students and residents into cists out on the floor to have a closer their homes for them to see the joys and working relationship with the bedside challenges of caring for a child with spenurses – hopefully improving communi- cial needs. The program has been very cations and patient care. Pediatric clini- well received by both the students/resical pharmacists generally are already out dents and the families. We send an evalon the floors making rounds with their uation to both sets of participants, specialty teams. Additionally, pharma- meaning the families and students, and cists’ involvement in code response has routinely receive positive feedback. increased, as we now have a pharmacist Families have repeatedly shared with us responding to all codes and traumas any- that this program empowers them and is time there are 2 pharmacists working. a very rewarding experience (see sidebar for comments received back from stuPNPPA: In your opinion, what has dents on these questionnaires). been the greatest treatment advance in pediatrics over your career? PNPPA: Children’s Hospital has a Dr Grisso: I would be hard pressed to well-established and strong relationship single out the greatest treatment with the Nashville community as eviadvance over my career. Overall, so denced by your long-standing partnermany disease states that 10 years ago ship with the Junior League of would have carried a high risk of mor- Nashville, a local women’s organization bidity and mortality are becoming less that has provided thousands of volunand less of a risk. When I think of our teer hours and fundraising efforts for the neonatal population and the ex 24- hospital. Do you sense this connection week preemies who are surviving, and with the community in your daily work? thriving in some cases, it is amazing that Dr Grisso: As a native Nashvillian, I 10 years ago this would not have been know that the Children’s Hospital has the scenario. The same could be said for always been a pivotal point in our comcongenital heart disease and some of the munity. The 2004 move into our freebirth defects that carried the same high standing facility was made possible in morbidity and mortality that are now large part by the generous support of our more survivable, with better outcomes community. Since we are in the heart of overall. In my area of interest, cystic the country music industry, we are forfibrosis, I have seen the lifespan increase tunate to have the support of many of by almost 10 years in that 10 years’ time. the superstars, such as Rascal Flatts. Even more exciting are the therapies in Additionally, members of our National the pipeline that could greatly enhance Hockey League team, the Predators, the average life expectancy of these and our National Football League team, patients. It’s so humbling and rewarding the Tennessee Titans, routinely visit our to be a part of improving the lives of our patients and help in fundraising pediatric patients. I couldn’t imagine endeavors. Every day there are countless being anywhere else. volunteers who help bring smiles to our patients’ faces as well as provide serPNPPA: Adelaide, Children’s Hos- vices such as free meals and entertainpital has instituted two innovative pro- ment. As evidenced by the recent outgrams called “Families As Classroom pouring of volunteerism after the Teachers” (FACT) and “Families As Nashville flood, Nashvillians and Mentors” (FAM). FACT families are Tennesseans alike are known for their invited to the classroom to “teach” med- “volunteer spirit.” They help make ical students about their experience Children’s Hospital what it is today. with chronic illness and its effect on family life, while FAM families welcome PNPPA: Thanks so much for sharing medical students and residents into their your thoughts on the rich traditions homes to share their stories in a more from Children’s Hospital.

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Dermatology

Fun in the Sun Susan Boiko, MD Pediatric Dermatology, Kaiser Permanente, San Marcos, California

ith the rates of skin cancers climbing, pediatricians are at the forefront of the “Safe Sun” campaign, as lifelong sun protection starts in infancy. Certainly, sun exposure has benefits; vitamin D is synthesized in the skin, and many people feel that the rays of the sun are relaxing and that a tan is beautiful. However, according to the American Academy of Dermatology, there is no scientifically validated level of ultraviolet (UV) light exposure from the sun that allows for maximal vitamin D synthesis without increasing the risk of skin cancer. I have seen first-hand in my practice, and as a volunteer with a local high school marching band and flag corps, that teens of all colors and ethnic backgrounds seek a tan as a way to look attractive. “Sun-safe” clothing and sunscreen application are considered in this population to be “not cool” or inconvenient, as sunscreen application “takes too long.” The ramifications of ignoring sun safety at this age are far-reaching, as exemplified by one of my 80-year-old patients. He brought in a black and white photo of himself as a young adult on the beach with a notable tan contrasting with his white bathing trunks. He has now had 4 nonmelanoma skin cancers.

Photodermatitis, sometimes seen as blistering rashes in sun-exposed skin, can occur when UV light strikes skin that a medicine such as oral naproxen or tetracycline has made more sensitive to damage. Common contactants, such as furocoumarins in the peels of limes and other citrus, cause phytophotodermatitis, a streaky often bizarrely angulated tan or brown patch that won’t wash off.

UV Light Exposure Skin cancer caused by UV light exposure can be fatal to children and teens having the rare genetic mutation xeroderma pigmentosum. Even if an adult never has a skin cancer, a lifetime of skin weathering from UV light exposure leads to photoaging and photodermatitis and can aggravate systemic and discoid lupus erythematosus and cause polymorphous light eruption. Skin weathering such as poikiloderma (red and brown lacy pigment and vascular networks) on the neck and upper chest, solar purpura or bruising, and avulsion of the skin (where the fragile skin literally tears) is common starting in people in their 60s but begins in infancy with repeated unprotected sun exposure. Immune suppression from UV light exposure and mutations in skin DNA exposed to UV light lead to skin cancer. Eyes develop cataracts and pterygia. Hyperpigmentation with freckling, melasma, and liver spots (so called because the spot color is similar to that of raw liver, not because liver disease is associated with them) are common cosmetic concerns with aging skin. Again, these changes are a result of lifelong UV light exposure.

Vitamin D Of surfers, who are in the sun so much that their skin darkens and becomes leathery, 51% have low vitamin D levels, indicating that even sun worshippers are at risk for vitamin D insufficiency, as are inner city darkskinned adults, the frail homebound elderly, and some burka wearers. Considering children, how much vitamin D is recommended? For preschoolers, for example, 400 IU per day, two to three 8 oz glasses of milk a day, or a multivitamin is recommended. Because there are so many foods and nutritional supplements rich in vitamin D, exposure to sun for vitamin D synthesis in the skin is not necessary. There is no safe human threshold for sun exposure. Remember, UV light is a human carcinogen.

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UV Light Abuse Nicknamed “Tanorexia,” UV light abuse is on the rise in teens. UV light abuse is a substance-related disorder. Indoor or outdoor tanning addiction or both may be noted; indoor tanning is associated with cigarette smoking, anxiety, alcohol, and marijuana use. The FDA regulates indoor tanning beds as medical devices. Recently, the American Academy of Pediatrics boldly recommended to make it illegal for those younger than 18 years to use tanning beds. Tanning bed use, especially on a daily basis, is associated with wrinkling, accelerated skin aging, and freckling. Tanning bed use before age 35 increases the risk of melanoma, potentially the most deadly skin cancer, by 75%. The risk of melanoma is increased by sunburns during childhood and adolescence, making it the deadliest cancer in young adult women.

Skin Cancers Although red-haired freckled children who burn easily are at the highest risk of melanoma, no one is immune. African-Americans, men over 60 years, and Hispanics have all seen a recent rise in the incidence of melanoma. Therefore, patients and parents should be asked about their history of sunburns

and outdoor activities, use of tanning beds, and medical history. Is the child immunosuppressed or in need of, or has had, an organ transplantation? Is there a family history of skin cancer? Are there multiple moles on a 5-year-old, or more than 50 moles on a person of any age? Basal cell cancer is the most common cancer in the United States. Seen in childhood in the rare genodermatosis xeroderma pigmentosum and in the familial basal cell nevus (Gorlin) syndrome, basal cell carcinoma usually has its onset when the patient is in the 30s, with its roots in childhood UV light exposure, whether from sun, tanning beds, or a combination of both. Because basal cell carcinoma and squamous cell carcinoma, the second most common skin cancer, both affect the face, including eyelids, nose, and ears, they can be disfiguring. Simple things, such as SLIP, SLOP, SLAP, and WRAP (Box); encouraging hair styles that cover ears, back of neck and forehead; hats with broad brims and sunglasses at an early age; and routine use of sunscreen and protective clothing started in infancy and modeled by parental behavior, yield benefits that last a lifetime. It is important to note that sunscreen does not block UV light

completely, so skin should be covered with clothing, sunglasses worn as much as possible, and sunscreen applied generously. Sunscreens intended for babies won’t sting if they get in their eyes – a plus at any age! Parents may worry about nanoparticles, but the most common ones, zinc oxide and titanium dioxide, do not penetrate the surface of the skin, and there is no evidence of human toxicity. Self-Tanners A reasonable alternative for those who enjoy a tanned appearance is to use self-tanners, with the motto “fake it, don’t bake it.” The self-tanner chemical reaction in the skin producing dihydroxyacetone is the same chemical reaction that takes place when white bread sugars brown when toasted. Conclusion Model sun-safe behaviors yourself for your patients, your staff, and your family. Throw on that hat and sunglasses when running errands at noon. Sponsor a sun-safe poster contest at your local school. Look at your own “birthday suit” and report any skin change to your own healthcare provider. Be sun safe and sun smart!

SLIP, SLOP, SLAP, WRAP – a Guide to Sun Safety SLIP SLOP

on a long-sleeved shirt to protect arms and trunk. on sunscreen SPF 30 or higher; apply generously, reapply every 2 hours. SLAP on a hat that covers the ears. Choose wide brims, tight weaves; consider a neck drape or bandana to shade ears and neck. WRAP on sunglasses. “UV protective, blocks 100% of UV rays” is the tag to look for. Besides skin cancers on the eyelids, sunglasses protect against cataracts and pterygia for all skin colors.

APRIL 2011 I VOL 2, NO 2

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Coming in June 2011 Pediatric NP/PA is proud to present the next topic in our focus series

Pediatric Urgent Care We’ve asked nursing leaders to weigh in on topics ranging from fevers to head injuries. Look in the June issue for our section dedicated to urgent care. Rely on us to bring you information that directly impacts your practice.

APRIL 2011 I VOL 2, NO 2

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The Gr wth Chart NEWS FOR THE AGES

Babies

Toddlers

Milestones in Language Development

Decrease in Pediatric Ear Infections

Parents should encourage language development by talking, reading, and singing with the child, but each child learns to speak at his or her own pace. Some general milestones can indicate whether a child’s development is on track, but speech delays occur for many reasons, including hearing loss. If a child hasn’t mastered most of the development milestones for his or her age, it may be necessary to consult an audiologist or a speech and language specialist. • End of 3 months: makes cooing sounds, cries differently for different needs, startles at loud noises, becomes quiet or smiles when spoken to • End of 6 months: makes gurgling sounds, either alone or when playing with others; babbles repetitive syllables such as “ba, ba, ba”; uses voice to express pleasure and displeasure; looks in the direction of sounds; pays attention to music • End of 12 months: tries to imitate words; says a few words, such as “dada,” “mama,” and “uh-oh”; understands simple instructions, such as “Please drink your milk”; understands “no” • End of 18 months: points to an object or picture when it’s named; recognizes names of familiar people, objects, and body parts; follows simple directions accompanied by gestures; says up to 8 to 10 words • End of 24 months: asks for common foods; uses simple phrases, such as “more milk”; begins to use pronouns, such as “mine”; asks 1- to 2-word questions, such as “Go bye-bye?”; follows simple commands without the help of gestures; says more words every month; speaks 50 words and understands more

Ear infections have long been the most common reason parents bring young children to a doctor. Between 1975 and 1990, the visit rate for children aged 5 and younger more than doubled. Dr Richard Rosenfeld, speaking for the American Academy of Pediatrics (AAP), believes the increase was due, at least in part, to exposure to more germs by a greater number of children who were enrolled in day care as more mothers began working outside the home. Then, according to a recent CDC report, from 1993 to 2008 the number of visits for children aged 6 and younger in which the main diagnosis was otitis media dropped by nearly 30%. Harvard researchers suggest that secondhand smoke may have been a major contributor to otitis media and that a reduction in smoking in American homes is associated with fewer cases. Hillel Alpert, lead author of the Harvard study, said, “If parents avoid smoking at home, they can protect their children from the disease that is the most common cause of visits to physicians and hospitals for medical care.” Other theories for the declining numbers have been reported. A vaccine that protects against strep bacteria that can cause ear infections was licensed in 2000, and although it could not have contributed to the decline of cases in the 1990s, some doctors believe the vaccine has contributed to the decrease in cases since its use began. Some studies have credited antibody-rich breast milk with lowering infants’ risk for respiratory and middle ear infections. About 77% of new mothers now breast-feed, at least briefly, up from fewer than 66% in the early 1990s. Although the downward trend seems to have leveled off in the last few years, the decrease in the number of ear infections through 2008 was significant.

Source: http://www.mayoclinic.com/health/infant-development/AN01026.

Sources: http://www.hsph.harvard.edu/news/press-releases/2011-releases/secondhand-smoke-ear-infections-otitismedia.html. http://hosted2.ap.org/APDefault/*/Article_2011-03-04-Ear%20Infections/id-c62d899eb41641d9b3cfea9 383fe7b5d.

School-Age Kids

Teens

Childhood Exercise Sustains Bone Mass

Tanning Is Not for Teens

Although genetics is a major influence on skeletal condition, skeletal health is also affected by physical activity during growth. Two recent studies of young gymnasts indicate that high-impact physical exercise during childhood and early adolescence results in longterm improvement in bone mass and support the idea that exercise in childhood and early adolescence can result in sustained skeletal benefit. In one study, Canadian researchers compared young recreational and precompetitive gymnasts with competitive gymnasts, who are known to have greater bone mass, density, and estimated strength. Their data suggest that recreational and precompetitive gymnastics participation is associated with greater bone strength. They evaluated 120 children (29 gymnasts, 46 ex-gymnasts, and 45 nongymnasts) between the ages of 4 and 9 years (mean = 6.8 ± 1.3) and found that gymnasts and ex-gymnasts had 5% greater adjusted total body bone mineral content and 6% to 25% greater adjusted total bone content, density, and estimated strength compared with non-gymnasts. The researchers suggest that recreational gymnastics can easily be implemented into school physical education programs, which could favorably impact children’s skeletal health. In a second study, Tamara Scerpella, MD, and colleagues evaluated 14 female non-gymnasts and 6 ex-gymnasts from 4 years prior to menarche to 9 years after menarche. They found that when compared with non-gymnasts, ex-gymnasts had greater radius bone mass, size, and areal bone mineral density, benefits that persisted for more than 4 years after discontinuation of the sport.

New guidelines from the AAP urge pediatricians and governments to create bans to keep children younger than 18 years out of tanning salons. The guidelines, which appear in the March 3 issue of Pediatrics, urge experts to strike a balance between ensuring that children get adequate vitamin D and protecting them from ultraviolet (UV) radiation. “In previous guidelines, we really haven’t gotten as specific about the tanning salon issue,” said Sophie Balk, MD, of Children’s Hospital at Montefiore in New York City, a coauthor. The AAP now joins organizations such as the American Medical Association and the World Health Organization in urging that minors be prevented from using sunlamps and tanning beds, the main sources of artificial UV exposure. More than 30 states now regulate use of tanning facilities by minors, and the AAP urged pediatric health professionals to work actively for the passage of such legislation. Because sun exposure and vitamin D status are intertwined, UV exposure for children and teens is a balancing act. The AAP recommends reevaluating dietary and supplemental vitamin D intake vs how much, if any, unprotected sun exposure is beneficial. About 30% of teens and young adults have a vitamin D deficiency. Despite public health campaigns explaining the risks of too much sun exposure, skin cancer rates continue to rise in all age groups, including the younger population. As many as 35% of 17-year-old girls use a tanning bed, where the intensity of UV radiation can be 10 to 15 times higher than that of the midday sun. The AAP guidelines offer many recommendations for sun protection methods and skin cancer prevention that can be shared with patients and their families.

Sources: http://www.ncbi.nlm.nih.gov/pubmed/20458575. http://www.niams.nih.gov/News_and_Events/Spotlight_on _Research/2011/child_exercise_bone.asp.

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Sources: http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/25085. Balk SJ, et al. Ultraviolet radiation: a hazard to children and adolescents. Pediatrics. 2011;127:e791-e817.

APRIL 2011 I VOL 2, NO 2

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