Pediatric NP/PA - December 2010, Vol 1, No 2 by Sean Walsh

DECEMBER 2010

WWW.PEDIATRICNPPA.COM

VOL 1, NO 2

THE OFFICAL NEWSPAPER FOR THE PEDIATRIC/ADOLESCENT NURSE AND ADVANCED PRACTITIONER CONFERENCE COVERAGE

PROFILE

The Children’s Hospital, Denver, Colorado Tia Brayman, lead photographer, The Children's Hospital.

News from the American Academy of Pediatrics National Conference and Exhibition, San Francisco, California, October 2-5, 2010.

Keynote Address: Focus on the Nature Prescription

n 2005, Richard Louv published Last Child in the Woods, in which he coined the term nature-deficit disorder. Updated in 2008, Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder, has been published in 13 countries in 9 languages. Mr Louv’s keynote address, The Impact of Society’s NatureDeficit Disorder on the Health and Well-

Being of Children, explored this issue and the role the pediatric community can play in the movement to reconnect children to the natural world. Although he emphasized that naturedeficit disorder is not itself a medical diagnosis, Mr Louv quoted Dr Mary Brown, a member of the AAP board of directors, who wrote that the disconnect with the Continued on page 9

VACCINES Neurology nurses at The Children's Hospital in Denver. Dee Daniels, CPNP, Mary Ann Maddox, CPNP, Jennifer Flack, CPNP, Editorial Board Member Scott Turner, MSN, APRN-BC, Chelsey Stillman PA-C, and Stephanie Shea, PA-C.

hen The Children’s Hospital (TCH) of Denver was established in 1908, the founders’ goal was for TCH to be a leader in providing the best healthcare outcomes for children. Its modern-day mission is to improve the health of children through the provision of high-quality coordinated programs of patient care, education, research, and advocacy. This calling has consistently made TCH one of the top children’s hospitals in the nation and a place parents across the Rocky Mountain region have come to trust. This institution has a particular appeal to us at Pediatric NP/PA as its academic partner, the University of Colorado, was the first institution to offer a nurse practitioner credentialing program, and ironically, that program was in pediatrics. One of our contributors and an editorial board member, Scott Turner, MSN, APRN-BC, is Senior Instructor of Pediatrics and Neurology in the Pediatric Neurology and Movement Disorders Department at the University of Colorado, Denver/TCH. Scott was kind enough to answer our questions Continued on page 15

HPV Vaccine for Adolescents: An Important Tool in Disease Prevention Nancy R. Kloha, FNP, MSN, DNP Student Clinical Instructor, University of Kentucky College of Nursing Lexington, Kentucky Rose M. Mays, PhD, RN, FAAN Professor Emeritus, Indiana University School of Nursing; Indianapolis, Indiana

HPV Disease Burden The human papillomavirus (HPV) causes cancer and genital warts. There are over 100 types of HPV affecting humans, with 40 of those types affecting the genital area. Each year almost 7600 HPV cancers occur in males and more than 17,300 occur in females. Nearly 100% of cancer of the cervix in women is caused by HPV. In men, cancers of the penis and anal canal are caused by HPV. Many cancers of the oropharynx are also

caused by HPV in both sexes. Human respiratory papillomatosis caused by HPV affects infants and children as well as adults. Genital warts caused by HPV are frequently found in men and women but can also affect children.1 Worldwide, cervical cancer is responsible for 288,000 deaths annually and is the second most commonly diagnosed cancer in women. Developing countries are disproportionally affected, accounting for nearly 80% of the 510,000 new cases of Continued on page 24

Inside From Loretta C. Ford

Conference Coverage

Complimentary CE Credit

Many Reasons to Celebrate

First Lady Michelle Obama and Let’s Move

Pulmonary Hypertension in Infants and Children

Recognizing those providing bright futures for kids To honor the noble profession of pediatric advanced practice, Pediatric NP/PA will recognize the people and practices that have made a difference in the care of children.

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

Nathalie Cleveland, MSN, RN, CPNP

Bernadette McCormick, RN, BSN

Sue Shepard, RN, BSN

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

The Children's Hospital Aurora, CO

Rady Children’s Hospital San Diego, CA

Cris Ann Bowman-Harvey, RN, MSN, CPNP

Shannon Fitzgerald, MSN, ARNP

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

Jacqueline Marie Toia, RN, MS, DNP

Advanced Pediatric Associates Aurora, CO

Seattle Children's Hospital Seattle, WA

The Children's Hospital Aurora, CO

Children's Memorial Hospital Chicago, IL

Michelle Brei, CPNP, APRN

Sara Gerrie, RN, MSN, CPNP

Erica Monasterio, RN, MN, FNP

Scott B. Turner, MSN, APRN-BC

Yale Health New Haven, CT

Center for Cancer and Blood Disorders Littleton, CO

University of California, San Francisco San Francisco, CA

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

Karyn Brundige, MSN, CPNP

Alison G. Grisso, PharmD

Seattle Children’s Hospital Seattle, WA

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

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

Deborah Walter, BSN, MSN, ACNP

The Children’s Hospital Aurora, CO

Rady Children’s Hospital San Diego, CA

Maria E. Bullock, APRN, MSN, CPNP-AC/PC

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

Sharon SablesBaus, PhD, RN, PCNS-BC

Vanderbilt University School of Nursing Nashville, TN Children's Memorial Hospital, Chicago, IL

Children’s Memorial Hospital Chicago, IL

University of Colorado, Denver Aurora, CO

Rady Children’s Hospital San Diego, CA

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

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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CONTENTS december 2010 • VOL 1, NO 2

THE OFFICAL NEWSPAPER FOR THE PEDIATRIC/ADOLESCENT NURSE AND ADVANCED PRACTITIONER

PUBLISHING STAFF Publisher Russell Hennessy russell@novellushc.com Directors, Client Services Mark Timko mark@novellushc.com Jack Iannaccone jack@novellushc.com Editorial Director Kristin Lee Siyahian Copy Editor Bjarne Hansen Contributing Editor Rosemary Hansen Production Manager Marie R.S. Borrelli 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

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: individuals, $105.00; institutions, $135.00; 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 21551553 (online) 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 ©2010 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.

december 2010 I VOL 1, NO 2

FEATURES 10 Conference Coverage: American Academy of Pediatrics • The Mediatrician Is In • A Perspective on the Antivaccine Movement • Diagnosis and Prevention of Iron Deficiency • First Lady Michelle Obama and Let’s Move Pulmonology 12 Identification and Treatment of Pediatric Obstructive Sleep Apnea Susan Hines, RN, BSN, MSN, CPNP Susan C. M. Crane, BA, MS, PsyD 27 Bronchiolitis: What’s the Big Deal Anyway? Janette H. Prokop, MSN, APRN-C Continuing Education 18 Pulmonary Hypertension in Infants and Children: Therapeutic Management Deborah Walter, BSN, MSN, ACNP Cardiology 21 Congestive Heart Failure in the Pediatric Patient Leigh Christopher Reardon, MD Juan Carlos Alejos, MD DEPARTMENTS Editorial 6 I am a Nurse Practitioner, NOT a Mid-Level Provider Alison Moriarty Daley, MSN, APRN, PNP-BS Reader Survey 30 What Inspired You to Become a Pediatric Healthcare Professional? The Growth Chart 31 News for the Ages

WANT TO HEAR FROM YOU!

Out Mouths of Babes page 11 of the

Artwork Month of the

page 14

As a tribute to your relationship with patients, we will feature special moments, comical quotes, and artwork from your patients. Submit your stories, patient quotes, and artwork by visiting www.pediatricNPPA.com or e-mailing kristin@novellushc.com.

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From Loretta C. Ford

Many Reasons to Celebrate Dear Colleague,

am writing to you in recognition of the birth of pediatric nurse practitioners 45 years ago and the birth of Pediatric NP/PA this year. Congratulations on these momentous occasions to you both!

Since the PNP’s birth at the University of Colorado, School of Nursing, children and families in this nation have benefited greatly from the expertise of PNPs. We have been successful in increasing access, availability, and affordability of healthcare to millions of children. At the same time, we have found within ourselves a greater measure of intelligence, confidence, value, and self-worth. While some of the struggles of earlier years are behind us, there are still challenges ahead. But there are great opportunities as well – it’s worth noting that the Chinese symbols for crisis and opportunity are one and the same. Two of the most exciting opportunities are found within the Nursing Profession’s Consensus Model of Regulatory Reform and the Affordable Care Act (ACA). Our profession has opened the door to uniting their missions and goals. The ACA promises to pave the way to our long-sought goal of control over our own profession along with the responsibilities and rewards. PNPs and all nurses must be a fighting force in implementing the many salutary aspects of this new national legislation for universal healthcare; promotion and prevention in health services, changes in delivery patterns, and recognition of the contributions that PNPs and other advanced practice nurses have to offer in the interest of the public good. Nursing organizations can be at the forefront of bringing together these two major forces. In honor of the PNP’s 45th birthday, I encourage you to give the gift of your time and join the fight! Again, congratulations to you! My best regards,

Loretta C. Ford, RN, PNP, EdD, FAAN, FAANP To Our Reading Community,

would like to offer my sincere gratitude to Ms Ford for contributing to Pediatric NP/PA. I am confident that for the majority of our readers Ms Ford needs no introduction, as her name is practically synonymous with “nurse practitioner.” She, alongside pediatrician Henry Silver, MD, initiated the first nurse practitioner program at the University of Colorado (see Profile article on the cover). Impressively, today there are over 106,000 NPs worldwide.

At the time I approached Ms Ford to contribute to our journal, she was preparing for a trip to Bangkok, Thailand, to receive the 2010 Princess Srinagarindra Award, one of the most prestigious awards given in Thailand, in honor of her exceptional contributions to the nursing profession. And so, on behalf of all of us at Pediatric NP/PA, I would like to congratulate Ms Ford on this award and her many achievements. Wishing you all a wonderful holiday season and all the best in 2011.

Kristin Siyahian Editorial Director www.PediatricNPPa.com

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Editorial

I Am a Nurse Practitioner, NOT a Mid-Level Provider! Alison Moriarty Daley, MSN, APRN, PNP-BS Pediatric Nurse Practitioner and Associate Professor, Yale University School of Nursing, New Haven, Connecticut

vividly remember the first time I saw the term “mid-level provider” prominently displayed in the hallway of the hospital and thought, “Who are they referring to?” Within seconds, I received the answer in smaller script displayed below “(NPs/PAs)” and thought, “Why didn’t they just write NPs/PAs?” My reaction to that poster was visceral then and has remained the same every time I have seen or heard the term since. My most recent encounter with this term was at a meeting where the term was used frequently, along with “physician extender.” As the only nurse practitioner in the room, I reflected on why this term made such a negative impression on me and how it may also serve to

do believe nurse practitioners are central to the care of the children and adolescents who are our patients and their families, as well as to the education of

our nurse practitioner students. We are central in the healthcare system, often as the primary care provider, advocate, and coordinator of care for our patients.

My very visceral reaction to being referred to as a mid-level provider is that it implies (loudly) that the care I provide and the knowledge that I have

With all 4 doses, she’s good to grow Give her proven protection with the only DTaP-IPV/Hiba vaccine.1-4 Keep her growing strong with all the recommended childhood immunizations. Help protect with all 4 doses of Pentacel vaccine and help enhance compliance The 2008 National Immunization Survey shows that by 24 months of age, 1 in every 5 children did not receive all 4 recommended doses of DTaP vaccine.5 According to the AAPb, administering a combination vaccine may enhance timeliness and compliance.6,7

Isn’t there already enough confusion about who nurse practitioners are and what we do?

Pentacel vaccine: • Contains a Hib component, so it fits easily into the primary series at 2, 4, 6, and 15-18 months of age1,8

• Can save a shot at the crowded toddler visit 8

—Alison Moriarty Daley, MSN, APRN, PNP-BS

confuse and offend the many adolescents that I care for as well as the nurse practitioner students I educate. I recalled the other common “mid” words in my vocabulary: midnight, not a bad word unless you are having difficulty sleeping or have missed your curfew; midlife, which is usually accompanied by crisis; midwife, colleague, positive; midst, midair, midcycle, midi, midpoint, midriff, midterm, midway, or midwinter – how one considers these depends on one’s point of view and situation, but none are overwhelmingly positive. So I turned to the dictionary and found a positive definition of mid, “central.” I

december 2010 I VOL 1, NO 2

Four doses of Pentacel vaccine constitute a primary pertussis immunization series.1 Children should receive a fifth dose of DTaP at 4-6 years of age.1

To learn more about the efficacy, convenience, and safety of Pentacel vaccine, please visit pentacel.com. To order Pentacel vaccine, log onto VaccineShoppe.com® or call 1-800-VACCINE (1-800-822-2463).

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Editorial

is in the middle, not the best or the worst, just in the middle, mediocre, okay. I did not receive a mid-level education, and I do not provide mid-level care. I did not choose to be a nurse practitioner because I could not be a doctor. I chose to be a nurse practitioner

because I wanted to be a nurse practitioner. I believe in the philosophy of nursing and the manner in which nurse practitioners provide care. My education, philosophy, and scope of practice are different than those of physicians. That does not make what I do “mid-

level”, mediocre, or less than that of physicians. It is also curious that nurse practitioners have been lumped into the same category as physician assistants. The education and scope of practice of each are similar but not the same. Physical

therapists, occupational therapists, and pharmacists have escaped being put into the same “box.” No one would argue that the roles of each are the same. Even midwives and nurse anesthetists have somehow escaped. If I look Continued on page 25

Indication Pentacel vaccine is indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis, and invasive disease due to Haemophilus influenzae type b. Pentacel vaccine is approved for use as a 4-dose series in children 6 weeks through 4 years of age (prior to fifth birthday).

Safety Information The most common local and systemic adverse reactions to Pentacel vaccine include injection site redness, swelling, and tenderness; fever, fussiness, and crying. Other adverse reactions may occur. Known systemic hypersensitivity reaction to any component of Pentacel vaccine or a life-threatening reaction after previous administration of the vaccine or a vaccine containing the same substances are contraindications to vaccination. The decision to give Pentacel vaccine should be based on the potential benefits and risks; if Guillain-Barré syndrome has occurred within 6 weeks of receipt of a prior vaccine containing tetanus toxoid; or if adverse events have occurred in temporal relation to receipt of pertussis-containing vaccine. Encephalopathy within 7 days of administration of a previous dose of a pertussis-containing vaccine or a progressive neurologic disorder is a contraindication. Vaccination with Pentacel vaccine may not protect all individuals. Before administering Pentacel vaccine, please see accompanying brief summary of full Prescribing Information. CPT®c Code: 90698 a DTaP = Diphtheria, tetanus, and acellular pertussis; IPV = Inactivated poliovirus; Hib = Haemophilus influenzae type b. b AAP = American Academy of Pediatrics. c CPT = Current Procedural Terminology is a registered trademark of the American Medical Association.

Pentacel vaccine is manufactured by Sanofi Pasteur Limited and Sanofi Pasteur SA and distributed by Sanofi Pasteur Inc. References: 1. Pentacel vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2009. 2. Decker MD, Edwards KM, Bradley R, Palmer P. Comparative trial in infants of four conjugate Haemophilus influenzae type b vaccines. J Pediatr. 1992;120:184-189. 3. Granoff DM, Anderson EL, Osterholm MT, et al. Differences in the immunogenicity of three Haemophilus influenzae type b conjugate vaccines in infants. J Pediatr. 1992;121:187-194. 4. Greenberg DP, Lieberman JM, Marcy SM, et al. Enhanced antibody responses in infants given different sequences of heterogeneous Haemophilus influenzae type b conjugate vaccines. J Pediatr. 1995;126:206-211. 5. Centers for Disease Control and Prevention (CDC). Estimated vaccination coverage with individual vaccines and selected vaccination series before 24 months of age by state and local area US, National Immunization Survey, 2008. http://www2a.cdc.gov/nip/coverage/nis/nis_iap2.asp?fmt=v&rpt=tab09_24mo_iap&qtr=Q1/2008-Q4/2008. Accessed April 15, 2010. 6. Food and Drug Administration. Pentacel®: DTaP-IPV/Hib Combined (diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus and Haemophilus b conjugate [tetanus toxoid conjugate] vaccine combined). VRBPAC Briefing Document. http://www.fda.gov/ohrms/dockets/ac/07/briefing/2007-4275B1-01.pdf. Accessed April 8, 2010. 7. American Academy of Pediatrics. Combination vaccines for childhood immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Pediatrics. 1999;103:1064-1077. 8. CDC. Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010. MMWR. 2010;58(51&52):1-4.

sanofi pasteur. Discovery Drive. Swiftwater, Pennsylvania 18370. www.sanofipasteur.us MKT20015-1

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Printed in USA

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Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) Vaccine Pentacel® $ only Brief Summary: Please see package insert for full prescribing information. INDICATIONS AND USAGE Pentacel® is a vaccine indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis and invasive disease due to Haemophilus influenzae type b. Pentacel vaccine is approved for use as a four dose series in children 6 weeks through 4 years of age (prior to fifth birthday). DOSAGE AND ADMINISTRATION Immunization Series Pentacel vaccine is to be administered as a 4 dose series at 2, 4, 6 and 15-18 months of age. The first dose may be given as early as 6 weeks of age. Four doses of Pentacel vaccine constitute a primary immunization course against pertussis. Three doses of Pentacel vaccine constitute a primary immunization course against diphtheria, tetanus, H influenzae type b invasive disease, and poliomyelitis; the fourth dose is a booster for diphtheria, tetanus, H influenzae type b invasive disease, and poliomyelitis immunizations. Mixed Sequences of Pentacel Vaccine and DTaP Vaccine While Pentacel and DAPTACEL (Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed [DTaP], Sanofi Pasteur Limited) vaccines contain the same pertussis antigens, manufactured by the same process, Pentacel vaccine contains twice the amount of detoxified pertussis toxin (PT) and four times the amount of filamentous hemagglutinin (FHA) as DAPTACEL vaccine. Pentacel vaccine may be used to complete the first 4 doses of the 5-dose DTaP series in infants and children who have received 1 or more doses of DAPTACEL vaccine and are also scheduled to receive the other antigens of Pentacel vaccine. Children who have completed a 4-dose series with Pentacel vaccine should receive a fifth dose of DTaP vaccine using DAPTACEL at 4-6 years of age. However, data are not available on the safety and immunogenicity of mixed sequences of Pentacel vaccine and DAPTACEL vaccine for successive doses of the DTaP series. Administration Just before use, thoroughly but gently shake the vial of DTaP-IPV component, withdraw the entire liquid content and inject into the vial of the lyophilized ActHIB vaccine component. Shake the vial now containing Pentacel vaccine thoroughly until a cloudy, uniform, white to off-white (yellow tinge) suspension results. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If these conditions exist, Pentacel vaccine should not be administered. Withdraw and administer a 0.5 mL dose of Pentacel vaccine intramuscularly. Pentacel vaccine should be used immediately after reconstitution. CONTRAINDICATIONS Hypersensitivity A severe allergic reaction (eg, anaphylaxis) after a previous dose of Pentacel vaccine or any other diphtheria toxoid, tetanus toxoid, or pertussis-containing vaccine, inactivated poliovirus vaccine or H influenzae type b vaccine, or any ingredient of this vaccine is a contraindication to administration of Pentacel vaccine. Encephalopathy Encephalopathy (eg, coma, decreased level of consciousness, prolonged seizures) within 7 days of a previous dose of a pertussis-containing vaccine that is not attributable to another identifiable cause is a contraindication to administration of any pertussis-containing vaccine, including Pentacel vaccine. Progressive Neurologic Disorder Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, or progressive encephalopathy is a contraindication to administration of any pertussis-containing vaccine including Pentacel vaccine. Pertussis vaccine should not be administered to individuals with such conditions until a treatment regimen has been established and the condition has stabilized. WARNINGS AND PRECAUTIONS Management of Acute Allergic Reactions Epinephrine hydrochloride solution (1:1,000) and other appropriate agents and equipment must be available for immediate use in case an anaphylactic or acute hypersensitivity reaction occurs. Adverse Reactions Following Prior Pertussis Vaccination If any of the following events occur within the specifi ed period after administration of a pertussis vaccine, the decision to administer Pentacel vaccine should be based on careful consideration of potential benefits and possible risks. • Temperature of ≥40.5°C (≥105°F) within 48 hours, not attributable to another identifiable cause. • Collapse or shock-like state (hypotonic-hyporesponsive episode (HHE)) within 48 hours. • Persistent, inconsolable crying lasting ≥3 hours within 48 hours. • Seizures with or without fever within 3 days. Guillain-Barré Syndrome and Brachial Neuritis A review by the Institute of Medicine (IOM) found evidence for a causal relation between tetanus toxoid and both brachial neuritis and Guillain-Barré syndrome. (1) If Guillain-Barré syndrome occurred within 6 weeks of receipt of prior vaccine containing tetanus toxoid, the decision to give Pentacel vaccine or any vaccine containing tetanus toxoid should be based on careful consideration of the potential benefits and possible risks. Infants and Children with a History of Previous Seizures For infants or children with a history of previous seizures, an appropriate antipyretic may be administered (in the dosage recommended in its prescribing information) at the time of vaccination with a vaccine containing acellular pertussis antigens (including Pentacel vaccine) and for the following 24 hours, to reduce the possibility of post-vaccination fever. Limitations of Vaccine Effectiveness Vaccination with Pentacel vaccine may not protect all individuals. Altered Immunocompetence If Pentacel vaccine is administered to immunocompromised persons, including persons receiving immunosuppressive therapy, the expected immune response may not be obtained. ADVERSE REACTIONS Data from Clinical Studies Rates of adverse reactions varied by dose number. The most frequent (>50% of participants) systemic reactions following any dose were fussiness/irritability and inconsolable crying. The most frequent (>30% of participants) injection site reactions following any dose were tenderness and increased circumference of the injected arm. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a vaccine cannot be directly compared to rates in the clinical trials of another vaccine and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to vaccine use and for approximating rates of those events. The safety of Pentacel vaccine was evaluated in four clinical studies in which a total of 5,980 participants received at least one dose of Pentacel vaccine. In three of the studies, conducted in the US, a total of 4,198 participants were enrolled to receive four consecutive doses of Pentacel vaccine. In the fourth study, conducted in Canada, 1,782 participants previously vaccinated with three doses of Pentacel vaccine received a fourth dose. The vaccination schedules of Pentacel vaccine, Control vaccines, and concomitantly administered vaccines used in these studies are provided in Table 1. Across the four studies, 50.8% of participants were female. Among participants in the three US studies, 64.5% were Caucasian, 9.2% were Black, 12.9% were Hispanic, 3.9% were Asian, and 9.5% were of other racial/ethnic groups. In the two controlled studies, the racial/ethnic distribution of participants who received Pentacel and Control vaccines was similar. In the Canadian fourth dose study, 86.0% of participants were Caucasian, 1.9% were Black, 0.8% were Hispanic, 4.3% were Asian, 2.0% were East Indian, 0.5% were Native Indian, and 4.5% were of other racial/ethnic groups. Table 1: Clinical Safety Studies of Pentacel Vaccine: Vaccination Schedules Study 494-01

P3T06 494-03

Pentacel 2, 4, 6, and 15 months

Control Vaccines HCPDT + POLIOVAX + ActHIB at 2, 4, 6, and 15 months

Concomitantly Administered Vaccines 7-valent pneumococcal conjugate vaccine* (PCV7) at 2, 4, and 6 months in a subset of participants†

Hepatitis B vaccine at 2 and 6 months‡ 2, 4, 6, and 15-16 months DAPTACEL + IPOL + ActHIB at 2, 4, and 6 PCV7* at 2, 4, and 6 months months; and DAPTACEL + ActHIB at Hepatitis B vaccine at 2 and 6 months‡ 15-16 months 2, 4, 6, and 15-16 months None PCV7* at 2, 4, and 6 months in all participants; and at 15 months in a random subset of participants Hepatitis B vaccine at 2 and 6 months (if a dose was previously administered)‡ or at 2, 4, and 6 months (if no previous dose) Measles, mumps, rubella vaccine§ (MMR) and varicella§ vaccine at 12 or 15 months in random subsets of participants None

None

5A9908 15-18 months**

HCPDT: non-US licensed DTaP vaccine that is identical to the DTaP component of Pentacel vaccine. POLIOVAX: US licensed Poliovirus Vaccine Inactivated, Sanofi Pasteur Limited. IPOL: US licensed Poliovirus Vaccine Inactivated, Sanofi Pasteur SA. * PCV7 manufactured by Wyeth Laboratories. † PCV7 was introduced after the study was initiated, and thus, administered concomitantly with Pentacel vaccine in a subset of participants. ‡ The first dose of hepatitis B vaccine (manufacturer not specified) was administered prior to study initiation, from birth to 21 days of age. Subsequent doses were with hepatitis B vaccine manufactured by Merck and Co. § MMR and varicella vaccines were both manufactured by Merck and Co. ** Study participants previously had received three doses of Pentacel vaccine by 8 months of age. Solicited Adverse Reactions The incidence and severity of selected solicited injection site and systemic adverse reactions that occurred within 3 days following each dose of Pentacel or Control vaccines in Study P3T06 is shown in Table 2. Information on these reactions was recorded daily by parents or guardians on diary cards. In Table 2, injection site reactions are reported for the Pentacel vaccine and DAPTACEL vaccine injection sites. Table 2: Number (Percentage) of Children with Selected Solicited Adverse Reactions by Severity Occurring within 0-3 days of Pentacel Vaccine or Control Vaccines in Study P3T06

Injection Site Reactions Redness >5 mm >25 mm >50 mm Swelling >5 mm >25 mm >50 mm Tenderness* Any Moderate or Severe Severe Increase in Arm Circumference >5 mm >20 mm >40 mm

Dose 1 N=465-467 %

Pentacel Vaccine Dose 2 Dose 3 N=451 N=438-440 % %

DAPTACEL Vaccine Dose 4 Dose 1 Dose 2 Dose 3 Dose 4 N=387-396 N=1,400-1,404 N=1,358-1,359 N=1,311-1,312 N=376-380 % % % % %

7.1 2.8 0.6

8.4 1.8 0.2

8.7 1.8 0.0

17.3 9.2 2.3

6.2 1.0 0.4

7.1 0.6 0.1

9.6 1.9 0.0

16.4 7.9 2.4

7.5 3.0 0.9

7.3 2.0 0.0

5.0 1.6 0.0

9.7 3.8 0.8

4.0 1.6 0.4

4.0 0.7 0.1

6.5 1.1 0.1

10.3 4.0 1.3

47.5 19.6 5.4

39.2 10.6 1.6

42.7 11.6 1.4

56.1 16.7 3.3

48.8 20.7 4.1

38.2 12.2 2.3

40.9 12.3 1.7

51.1 15.8 2.4

—

33.6 4.7 0.5

—

30.6 6.9 0.8

Pentacel Vaccine Systemic Reactions

DAPTACEL + ActHIB Vaccines Dose 1 Dose 2 Dose 3 Dose 4 N=1,390-1,406 N=1,346-1,360 N=1,301-1,312 N=379-381 % % % % DAPTACEL + IPOL + ActHIB Vaccines

Dose 1 N=466-467 %

Dose 2 N=451-452 %

Dose 3 N=435-440 %

Dose 4 N=389-398 %

Fever†‡ ≥38.0˚ C >38.5˚ C >39.5˚ C

5.8 1.3 0.4

10.9 2.4 0.0

16.3 4.4 0.7

13.4 5.1 0.3

9.3 1.6 0.1

16.1 4.3 0.4

15.8 5.1 0.3

8.7 3.2 0.8

Decreased Activity/ Lethargy§ Any Moderate or Severe Severe

45.8 22.9 2.1

32.7 12.4 0.7

32.5 12.7 0.2

24.1 9.8 2.5

51.1 24.3 1.2

37.4 15.8 1.4

33.2 12.7 0.6

24.1 9.2 0.3

Inconsolable Crying Any ≥1 hour >3 hours

59.3 19.7 1.9

49.8 10.6 0.9

47.3 13.6 1.1

35.9 11.8 2.3

58.5 16.4 2.2

51.4 16.0 3.4

47.9 12.2 1.4

36.2 10.5 1.8

Fussiness/Irritability Any ≥1 hour >3 hours

76.9 34.5 4.3

71.2 27.0 4.0

68.0 26.4 5.0

53.5 23.6 5.3

75.8 33.3 5.6

70.7 30.5 5.5

67.1 26.2 4.3

53.8 19.4 4.5

* Any: Mild, Moderate or Severe; Mild: subject whimpers when site is touched; Moderate: subject cries when site is touched; Severe: subject cries when leg or arm is moved. † Fever is based upon actual temperatures recorded with no adjustments to the measurement route. ‡ Following Doses 1-3 combined, the proportion of temperature measurements that were taken by axillary, rectal or other routes, or not recorded were 46.0%, 53.0%, 1.0%, and 0% respectively, for Pentacel vaccine and 44.8%, 54.0%, 1.0%, and 0.1%, respectively, for DAPTACEL + IPOL + ActHIB vaccines. Following Dose 4, the proportion of temperature measurements that were taken by axillary, rectal or other routes, or not recorded were 62.7%, 34.4%, 2.4% and 0.5%, respectively, for Pentacel vaccine, and 61.1%, 36.6%, 1.7% and 0.5%, respectively, for DAPTACEL + ActHIB vaccines. § Moderate: interferes with or limits usual daily activity; Severe: disabling, not interested in usual daily activity. Hypotonic Hyporesponsive Episodes In Study P3T06, the diary cards included questions pertaining to HHEs. In Studies 494-01, 494-03, and 5A9908, a question about the occurrence of fainting or change in mental status was asked during post-vaccination phone calls. Across these 4 studies, no HHEs, as defined in a report of a US Public Health Service workshop (2) were reported among participants who received Pentacel vaccine (N = 5,979), separately administered HCPDT + POLIOVAX + ActHIB vaccines (N = 1,032) or separately administered DAPTACEL + IPOL + ActHIB vaccines (N = 1,455). Hypotonia not fulfilling HHE criteria within 7 days following vaccination was reported in 4 participants after the administration of Pentacel vaccine (1 on the same day as the 1st dose; 3 on the same day as the 3rd dose) and in 1 participant after the administration of DAPTACEL + IPOL + ActHIB vaccines (4 days following the 1st dose). Seizures Across Studies 494-01, 494-03, 5A9908 and P3T06, a total of 8 participants experienced a seizure within 7 days following either Pentacel vaccine (4 participants; N = 4,197 for at least one of Doses 1-3; N = 5,033 for Dose 4), separately administered HCPDT + POLIOVAX + ActHIB vaccines (3 participants; N = 1,032 for at least one of Doses 1-3, N = 739 for Dose 4), separately administered DAPTACEL + IPOL + ActHIB vaccines (1 participant; N = 1,455 for at least one of Doses 1-3), or separately administered DAPTACEL + ActHIB vaccines (0 participants; N = 418 for Dose 4). Among the four participants who experienced a seizure within 7 days following Pentacel vaccine, one participant in Study 494-01 had an afebrile seizure 6 days after the first dose, one participant in Study 494-01 had a possible seizure the same day as the third dose, and two participants in Study 5A9908 had a febrile seizure 2 and 4 days, respectively, after the fourth dose. Among the four participants who experienced a seizure within 7 days following Control vaccines, one participant had an afebrile seizure the same day as the first dose of DAPTACEL + IPOL + ActHIB vaccines, one participant had an afebrile seizure the same day as the second dose of HCPDT + POLIOVAX + ActHIB vaccines, and two participants had a febrile seizure 6 and 7 days, respectively, after the fourth dose of HCPDT + POLIOVAX + ActHIB vaccines. Serious Adverse Events In Study P3T06, within 30 days following any of Doses 1-3 of Pentacel or Control vaccines, 19 of 484 (3.9%) participants who received Pentacel vaccine and 50 of 1,455 (3.4%) participants who received DAPTACEL + IPOL + ActHIB vaccines experienced a serious adverse event. Within 30 days following Dose 4 of Pentacel or Control vaccines, 5 of 431 (1.2%) participants who received Pentacel vaccine and 4 of 418 (1.0%) participants who received DAPTACEL + ActHIB vaccines experienced a serious adverse event. In Study 494-01, within 30 days following any of Doses 1-3 of Pentacel or Control vaccines, 23 of 2,506 (0.9%) participants who received Pentacel vaccine and 11 of 1,032 (1.1%) participants who received HCPDT + POLIOVAX + ActHIB vaccines experienced a serious adverse event. Within 30 days following Dose 4 of Pentacel or Control vaccines, 6 of 1,862 (0.3%) participants who received Pentacel vaccine and 2 of 739 (0.3%) participants who received HCPDT + POLIOVAX + ActHIB vaccines experienced a serious adverse event. Across Studies 494-01, 494-03 and P3T06, within 30 days following any of Doses 1-3 of Pentacel or Control vaccines, overall, the most frequently reported serious adverse events were bronchiolitis, dehydration, pneumonia and gastroenteritis. Across Studies 494-01, 494-03, 5A9908 and P3T06, within 30 days following Dose 4 of Pentacel or Control vaccines, overall, the most frequently reported serious adverse events were dehydration, gastroenteritis, asthma, and pneumonia. Across Studies 494-01, 49403, 5A9908 and P3T06, two cases of encephalopathy were reported, both in participants who had received Pentacel vaccine (N = 5,979). One case occurred 30 days post-vaccination and was secondary to cardiac arrest following cardiac surgery. One infant who had onset of neurologic symptoms 8 days post-vaccination was subsequently found to have structural cerebral abnormalities and was diagnosed with congenital encephalopathy. A total of 5 deaths occurred during Studies 494-01, 494-03, 5A9908 and P3T06: 4 in children who had received Pentacel vaccine (N = 5,979) and one in a participant who had received DAPTACEL + IPOL + ActHIB vaccines (N = 1,455). There were no deaths reported in children who received HCPDT + POLIOVAX + ActHIB vaccines (N = 1,032). Causes of death among children who received Pentacel vaccine were asphyxia due to suffocation, head trauma, Sudden Infant Death syndrome, and neuroblastoma (8, 23, 52 and 256 days post-vaccination, respectively). One participant with ependymoma died secondary to aspiration 222 days following DAPTACEL + IPOL + ActHIB vaccines. Data from Post-Marketing Experience The following additional adverse events have been spontaneously reported during the post marketing use of Pentacel vaccine worldwide, since 1997. Between 1997 and 2007, Pentacel vaccine was primarily used in Canada. Because these events are reported voluntarily from a population of uncertain size, it may not be possible to reliably estimate their frequency or establish a causal relationship to vaccine exposure. The following adverse events were included based on one or more of the following factors: severity, frequency of reporting, or strength of evidence for a causal relationship to Pentacel vaccine. Cardiac disorders (cyanosis); gastrointestinal disorders (vomiting, diarrhea); general disorders and administration site conditions (injection site reactions [including inflammation, mass, abscess and sterile abscess], extensive swelling of the injected limb [including swelling that involved adjacent joints], vaccination failure/therapeutic response decreased (invasive H influenzae type b disease); immune system disorders (hypersensitivity, such as rash and urticaria); infections and infestations (meningitis, rhinitis, viral infection); metabolism and nutrition disorders (decreased appetite); nervous system disorders (somnolence, HHE, depressed level of consciousness); psychiatric disorders (screaming); respiratory, thoracic and mediastinal disorders (apnea, cough); skin and subcutaneous tissue disorders (erythema, skin discoloration); vascular disorders (pallor). DRUG INTERACTIONS Concomitant Administration with Other Vaccines In clinical trials, Pentacel vaccine was administered concomitantly with one or more of the following US licensed vaccines: hepatitis B vaccine, 7-valent pneumococcal conjugate vaccine, MMR and varicella vaccines. When Pentacel vaccine is given at the same time as another injectable vaccine(s), the vaccine(s) should be administered with different syringes and at different injection sites. STORAGE AND HANDLING Pentacel vaccine should be stored at 2° to 8°C (35° to 46°F). Do not freeze. Product which has been exposed to freezing should not be used. Do not use after expiration date shown on the label. PATIENT COUNSELING INFORMATION Before administration of Pentacel vaccine, health-care personnel should inform the parent or guardian of the benefits and risks of the vaccine and the importance of completing the immunization series unless a contraindication to further immunization exists. The health-care provider should inform the parent or guardian about the potential for adverse reactions that have been temporally associated with Pentacel vaccine or other vaccines containing similar ingredients. The health-care provider should provide the Vaccine Information Statements (VIS) which are required by the National Childhood Vaccine Injury Act of 1986 to be given with each immunization. The parent or guardian should be instructed to report adverse reactions to their health-care provider. REFERENCES 1. Stratton KR, et al. editors. Adverse events associated with childhood vaccines; evidence bearing on causality. Washington, DC: National Academy Press; 1994. p. 67-117. 2. Braun MM. Report of a US Public Health Service workshop on hypotonic-hyporesponsive episode (HHE) after pertussis immunization. Pediatrics 1998;102(5)1-5.

Product information as of December 2009. Manufactured by: Sanofi Pasteur Limited Toronto Ontario Canada and Sanofi Pasteur SA Lyon France Distributed by: Sanofi Pasteur Inc. Swiftwater PA 18370 USA

Pentacel® is a registered trademark of the sanofi pasteur group, and its subsidiaries. MKT20183

R1-1209 USA 2027314-242

Conference Coverage Keynote Address...continued from the cover natural world is “one of the core reasons for so many of the physical and mental problems that have changed the practice of pediatrics over the last 20 years.” Mr Louv cited the increase among children of depression, asthma, vitamin D deficiency, obesity, and type 2 diabetes as symptoms of nature-deficit disorder. The Grow Outside! campaign described by Mr Louv was based on the belief that pediatric healthcare professionals could use their “special, trusted voice” to encourage the reconnection with nature by offering “prescriptions” to go outside. Mr Louv clearly stated

that the “educators, conservationists, business people and many others” supporting the nature prescription do not view it as a replacement for evidencebased medical treatment. They do believe that the nature prescription can complement traditional therapies. Sufficient longitudinal research supporting nature-based therapy is lacking, but Mr Louv said “the correlative evidence does tend to point in a single, common-sense direction: Getting children outside can be good for their health, and getting them outside in nature may well offer special benefits.”

Table 1 What Does Preliminary Research Suggest? • Contact with the natural world appears to significantly reduce symptoms of attention deficit disorder in children as young as 5 years • Natural settings, even a view of nature from a bedroom window, can reduce stress in children • Older children who spent more time outside were generally more physically active and had a lower prevalence of overweight than children who spent less time outside • Children in greener neighborhoods appear to have lower body weight changes • Spending time outdoors may help prevent myopia • Play in natural environments is associated with improved motor abilities and increased creativity in young children • Access to nature nurtures self-discipline and self-confidence among children, including children with disabilities • Natural environments, such as parks, foster recovery from mental fatigue and may help children learn

To help children reconnect with nature, Mr Louv recommended learning more about the research on the restorative power of nature, passing this information on to parents, and encouraging parents to have their children play in nature. He also suggested a personally restorative hike for healthcare professionals. Mr Louv supplied several sources for additional information and examples of successful programs. Information about Grow Outside! is available at the Children & Nature Network (C&NN). Mr Louv is a founder and the chairman of C&NN, a Web site providing the Grow Outside! Start Guide, links to research, information about local campaigns, and family nature club tool kits (in English and Spanish). The National Environmental Education Foundation (NEEF), chartered by Congress in 1990, provides regional “train the trainer” programs and the Children and Nature Initiative. Its Web site (www.neefusa. org/) offers adaptable nature prescription pads, patient brochures, and other documents to download. Programs singled out for praise included Mrs Obama’s efforts to fight child obesity, Let’s Move and Let’s Move Outside; the Prescription Trails program in Santa Fe, New Mexico, which addresses the local high rate of diabetes; and the Leave No Child Inside Central Ohio collaborative. Mr Louv said, “The nature prescrip-

Nature Play Prescription Dr.

Rx R Name:

Date:

Your Healthcare Provider encourages you to:

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Nature prescription.

tion isn’t for everyone, and it’s no panacea.” But in the context of healthy relationships, diet, and environment, experiencing nature can help many children. In closing, he asked that the pediatric community help in the movement to reconnect children to the natural world.

An adapted version of Mr Louv’s speech is available at http://www.childrenandna ture.org/blog/2010/10/04/grow-outside keynote-address-to-the-american-acade my-of-pediatrics-national-conference/#mor Provider: e-1170. Parent/Child:

Pediatric NP/PA Debuts at the American Academy of Pediatrics!

• Green exercise may offer added benefits when compared to equal exertion in indoor gyms • The concept of “play,” including play in nature, is more compelling and inviting to most adult caregivers, parents, and guardians than “exercise”

Table 2 What Can Pediatric Health Providers Do to Encourage Nature Connection? • Learn more about the research on the restorative power of nature and pass this information on to parents and other caregivers • Informally recommend green exercise in nearby nature to your patients and their families • Educate families about the powers of nature for stress reduction for children and parents • Recommend nature time for parent-child family bonding, including infants • Provide information on where parents, grandparents, and other caregivers can get outdoors • Attend one of the Nature Champion training sessions offered by the National Environmental Education Foundation (NEEF) • Take a hike yourself; be restored in nature

www.PediatricNPPa.com

Thanks to all who stopped by our booth at the AAP for our official debut on the pediatric scene and for the positive feedback about our journal. We are honored to be serving the pediatric healthcare community.

december 2010 I VOL 1, NO 2

Conference Coverage

The Mediatrician Is In

ollowing Richard Louv’s keynote address advocating connecting with nature, Michael Rich, MD, MPH, presented Finding Huck Finn: Reclaiming the Primary Experience of Childhood From the Electronic River, which examined the effects of media on child development and offered a rationale for limiting its use. Dr Rich is director of the Center on Media and Child Health and last year launched Ask the Mediatrician, the Web site through which he provides information and advice to parents on questions related to media. Dr Rich’s interest in media is longstanding – before becoming a physician, he spent 12 years in the film industry, where his credits include assistant director to Akira Kurosawa on the award-winning film Kagemusha. He is now associate professor of pediatrics at Harvard Medical School and associate professor of society, human development, and health at Harvard School of Public Health. Recognizing that some media can be beneficial, Dr Rich noted that Sesame

Street remains the gold standard in educational television and continues having a positive influence on former viewers into their teen years. However, his concern over the media exposure to children under the age of 2 years was

time was spent using multiple media. Dr Rich reported significant differences between the 17% of children who use media less than 3 hours daily (light users) and the 21% who use more than 16 hours daily (heavy users). Among

Dr Rich recommended that pediatric healthcare professionals ask patients about media use and that they provide anticipatory guidance. apparent in the statistics he provided: 79% watch television, and 61% watch for more than an hour on a typical day; 26% have a TV set in their bedroom. Based on Kaiser Family Foundation data from 2009, Dr Rich reported that among children 8 to 18 years of age, 99% live in homes that have television, and 45% have TV on “most of the time.” Children in this age group used media for 7 hours and 38 minutes per day; in addition, they spent more than 2 hours talking and texting on mobile phones. One-quarter of their media

light users, 23% had “fair or poor grades,” 16% “got in trouble a lot,” and 10% experienced “low personal contentment.” These figures actually doubled for children who were heavy users: 47%, 33%, and 20%, respectively, for the same categories. Viewing media violence has been shown to contribute to anxiety, fears, nightmares, and even posttraumatic stress disorder. There is an exceptionally strong correlation between media exposure and aggressive behavior. Obesity, risky sexual behavior, and use of tobacco and alcohol are also

associated with excessive use of media. Dr Rich recommended that pediatric healthcare professionals ask patients about media use and that they provide anticipatory guidance. He suggested that parents be counseled to establish ground rules including having open access to the child’s technology and that time spent on media be less than that spent on other activities. Addressing parents, Dr Rich said in an interview, “Media have to be balanced with free play and creative outdoor activities. We may see building forts and ‘capture the flag’ as old-fashioned, too risky, or just much harder than pushing a button on a remote, but they are essential to optimizing your child’s health and learning.” Dr Rich’s conference slides are available at http://www.aapexperience.org/2010/ downloads/plenaryslides/100210b-RichReclaimingChildhoodfromRiverofElectroni cs.pdf. Visit Ask the Mediatrician at http://cmch.typepad.com/mediatrician/.

A Perspective on the Antivaccine Movement

aul Offit, MD, FAAP, the awardwinning expert on vaccines and well-known critic of the antivaccine movement, reviewed the history of vaccine fears in America. Dr Offit said, “Parents are bombarded with false stories about the dangers of vaccines, and the result is that some are backing away from vaccinating their children. This is tragic, because it leaves children vulnerable to deadly diseases, and it lowers the immunity of the entire community.” Dr Offit described events that could have triggered antivaccine movements in the past but did not. In the 1940s, a contaminated yellow fever vaccine infected 330,000 soldiers with hepatitis B, causing 65 deaths. In 1955, polio vaccine produced by Cutter Laboratories mistakenly contained live polio virus. Dr Offit reported that 120,000 children developed abortive polio, 200 children were left permanently paralyzed, and 10 children died as a result of the defective vaccine.

According to Dr Offit, the current antivaccine movement began in 1982, following the television broadcast of the documentary DPT: Vaccine Roulette, which focused on children said to have been harmed by the pertussis vaccine. In response, opponents of the vaccine established Dissatisfied Parents Together. Senate hearings and media coverage ensued. Lawsuits successfully claimed that the pertussis vaccine caused sudden infant death syndrome (SIDS), Reye’s syndrome, coma, mental retardation, epilepsy, and transverse myelitis. Dissatisfied Parents Together later became the National Vaccine Information Center (NVIC), which continues to comment on vaccine safety. Autism is one of the diseases the NVIC and the antivaccine movement have been most vocal about. Alleged connections between autism and the measles, mumps, and rubella (MMR) vaccine were first published in 1998 (in The Lancet, which retracted the report

in 2004). Since then, thimerosal, toxins in vaccines, and the high number of required immunizations have been blamed for the increased incidence of autism.

"If population immunity continues to break down, the door will open wider to diseases that we thought had been vanquished by vaccines.”

In addition to the danger that decreased immunization presents for individual children, Dr Offit discussed the breakdown of the “herd immunity” that protects the general population by having enough people vaccinated

against a disease to keep it in check. Dr Offit pointed to the ongoing pertussis epidemic in California as one example of the resurgence of a disease following decreased immunizations. He said, “We are at a crossroads. If population immunity continues to break down, the door will open wider to diseases that we thought had been vanquished by vaccines.” Dr Offit is a scientist, professor, author, and a co-inventor of RotaTeq, a rotavirus vaccine. Through the years, he has been a zealous advocate for childhood immunizations and a prime target of the antivaccine movement. His latest book, Deadly Choices: How the Anti-Vaccine Movement Threatens Us All, will be published in January. Sources: http://www.aapexperience.org /2010/downloads/plenaryslides/100410eOffit-Anti-VaccinePerspective.pdf; http://www.aap.org/pressroom/Offitfinala ntivaccine.pdf.

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 make nominations for the Sunshine Awards.

december 2010 I VOL 1, NO 2

www.PediatricNPPa.com

Flap Moves

The Flow-Vu F

Inspiratory Flow Indicator • Visual indicator moves when patient inhales, so caregiver can help monitor if the patient is inhaling correctly

Anti-Static Technology

• Improves HFA MDI medication delivery

BPA-Free

ad and PVC

Product is

Bis

MOUTHPIECE

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15-1018981

9/10

MEDIUM MASK CHAMBER

Anti-Static Chamber

SMALL MASK CHAMBER

Backpiece

Alignment Feature

TIPS

This product is intended to be used by patients who are under the care or treatment of a physician or licensed healthcare professional. The device is intended to be used by these patients to administer aerosolized medication from most pressurized Metered Dose Inhalers. The intended environments for use include the home, hospitals and clinics.

INDICATIONS FOR USE

Remove cap from the MDI.

Carefully examine the product for damage, missing parts or foreign objects. Remove any foreign objects prior to use. The product should be replaced IMMEDIATELY if there are any damaged or missing parts. If necessary, use the Metered Dose Inhaler (MDI) alone until a replacement is obtained. If the patient's symptoms worsen, please seek immediate medical attention. Shake the MDI immediately before each use as per the instructions supplied with the MDI.

3 Insert the MDI into the backpiece of the chamber.

Cautions: • To ensure proper performance this product should only be cleaned according to these instructions. • Do not leave the chamber unattended with children. • Federal (USA) law restricts the sale of this device on or by the order of a physician.

Apply mask to face and ensure an effective seal. The Flow-Vu® Inspiratory Flow Indicator only moves if the patient has a good seal.

Medium Mask

Follow instructions supplied with the MDI on how long to wait before repeating steps 3 – 6 as prescribed.

Mouthpiece

Large Mask

Shake out excess water from the parts and allow to air dry in a vertical position. Ensure parts are dry before reassembly.

Breathe out gently and depress the MDI at the beginning of a slow inhalation. Use the Flow-Vu® Indicator to assist in the coordination of this maneuver. Maintain seal for 5 – 6 breaths after the MDI is depressed. Administer one (1) puff at a time.

If possible, give treatments when the child is happy and not crying.

Use teddy bears or dolls to ‘pretend’ to use the chamber to make it look like a game.

Subsidiary of Forest Laboratories, Inc. St. Louis, MO 63045 Monaghan Medical Corporation, 5 Latour Ave., Suite 1600, Plattsburgh, NY 12901

Distributed by:

To reassemble, center the Alignment Feature on the Backpiece with the Flow-Vu® Indicator, as shown. Press firmly to attach the Backpiece.

Give praise and rewards.

© 2009 Monaghan Medical Corporation. ™ and ® are trademarks and registered trademarks used under license by Forest Pharmaceuticals, Inc. Printed in USA. Covered by one or more of the following patents # 5,645,049; 5,848,588; 5,988,160; 6,293, 279; 6,345,617; 6;435,177; 6,904,908 and patents pending. RMC 16417 Revision: 01/10

Small Mask

Rinse parts in clean water.

• Storage and operating range 5° C - 40° C (41° F - 104° F) at 15 to 95% relative humidity. • Product may need to be replaced after 12 months of use. Environmental conditions, storage and proper cleaning can affect product life span. • THIS PRODUCT CONTAINS NO LATEX. • Do not share this medical device. • Clarity of the chamber is a result of the properties of the StatBan ® anti-static material. • If you notice medication build-up in your chamber, wash the inside of the chamber gently with a soft cloth.

Soak the parts for 15 minutes in a mild solution of liquid dish detergent and lukewarm clean water. Agitate gently.

Notes:

Remove the Backpiece only. Do not tamper with valve during cleaning or disassemble the product beyond what is recommended or damage may result.

THIS PRODUCT CAN BE USED RIGHT OUT OF THE PACKAGE AND THEN CLEANED WEEKLY.

CLEANING INSTRUCTIONS

THIS PRODUCT CAN BE USED RIGHT OUT OF PACKAGE. BEFORE USE, ENSURE THESE INSTRUCTIONS AND THE INSTRUCTIONS SUPPLIED WITH THE METERED DOSE INHALER (MDI) HAVE BEEN READ.

INSTRUCTIONS FOR USE

SMALL MASK MEDIUM MASK

ComfortSeal® Mask

Inhalation Valve

Flow-Vu® Inspiratory Flow Indicator

Exhalation Valve

Conference Coverage

Diagnosis and Prevention of Iron Deficiency

ew guidelines to address the diagnosis and prevention of iron deficiency in infants and children under the age of 3 years were presented during the conference. Robert D. Baker, MD, PhD; Frank R. Greer, MD; and the Committee on Nutrition prepared the clinical report containing recommendations for screening methods, appropriate levels of iron intake, proper nutrition, and iron supplementation. Although iron deficiency has decreased among infants in the United States following the introduction of iron-fortified infant formulas and foods in the 1970s, studies indicate 4% of 6month-olds and 12% of 12-month-olds are iron deficient. In children 1 to 3 years old, the rate ranges from 6.6% to 15.2%, with ethnicity and socioeconomic status as determining factors. Recent research also indicates that iron deficiency during infancy and child-

hood, with or without anemia, can have long-lasting adverse effects on neurodevelopment and behavior.

Recent research indicates that iron deficiency during infancy and childhood, with or without anemia, can have long-lasting adverse effects on neurodevelopment and behavior. Because there is still no single accurate test to determine a child’s iron level, the clinical report recommends four screening protocols, including combinations of several tests and follow-up procedures. Recommendations

are given on the prevention of iron deficiency through diet. Dr Baker said, “Ideally, we would prevent iron deficiency and iron-deficiency anemia with a diet consisting of foods that are naturally rich in iron.” For older infants and toddlers the report recommends meat, shellfish, legumes, iron-fortified cereals, and iron-rich vegetables and fruits, especially fruits rich in vitamin C, which help iron absorption. The guidelines specify that all premature infants should have at least 2 mg/kg/day of iron through the first year. Iron-fortified formulas supply this amount, but premature infants given human milk should receive an iron supplement of 2 mg/kg/day by 1 month of age. Full-term formula-fed infants normally receive adequate iron. Breast-fed infants should receive 1 mg/kg/day of supplemental oral iron beginning at 4 months until the introduction of ironfortified foods. Infants 6 to 12 months of

age need 11 mg/day of iron, and complementary foods including red meat and vegetables with high iron content should be introduced early. Toddlers 1 to 3 years of age need 7 mg/day of iron, preferably from food. Either liquid supplements or chewable multivitamins can be used if necessary. Now that more is known about the detrimental effects of iron deficiency, Dr Greer advised, “It’s critical to children’s health that we improve their iron status starting in infancy.” See the AAP press release at http:// www.aap.org/pressroom/Ironfinal.pdf and Clinical Report – Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (03 Years of Age). Pediatrics. 2010; 126:1040-1050. The full article is available free online at the Pediatrics Web site http://pediatrics.aappublications.org /cgi/reprint/peds.2010-2576v1.

First Lady Michelle Obama and Let’s Move

ddressing the Academy via video, Michelle Obama thanked pediatricians and healthcare professionals for the work they have done to fight childhood obesity. As Mrs Obama said when she launched the program in February, the goal of Let’s Move is to solve the problem of childhood obesity in this generation. She also said Let’s Move is a way to offer support to pediatricians and other healthcare providers. Mrs Obama admitted that not long ago she was a busy working mom who

didn’t always make the best decisions for her family. Sometimes at the end of a busy day, she made dinner choices that were convenient and inexpensive but not necessarily the healthiest option. She said her pediatrician suggested that she “might want to think about doing things a little differently.” Mrs Obama said that comment from her pediatrician was a “wake-up call” for her and one example of the impact that pediatricians can have on keeping families healthy. Mrs Obama asked for continued help

with the next steps in the effort to end the childhood obesity epidemic. Goals set by Let’s Move include calculating body mass index (BMI) at every wellchild visit starting at age 2 years, providing that information to parents, and counseling parents and children about eating right and staying active. Mrs Obama also called for a commitment to encourage new mothers to breast-feed their babies and asked that guidance be offered on optimal portion size for older children. Pediatricians have the power to make

a difference, according to Mrs Obama, not just as doctors, but as parents, role models, and community leaders. She suggested that they reach out to schools, faith organizations, community groups, and local officials. Mrs Obama reiterated that solving the problem of childhood obesity will not be easy. She is confident, however, that by working together we can help give all our children the healthy future they deserve. Source:http://www.aap.org/obesity/white house/index.html.

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!

Working in the eR one day, a little 21-month-old girl came in who had fallen and required stitches on her chin. She was scared and didn’t quite know how to articulate her feelings of not wanting us to proceed with the stitches. throughout the process, in such a polite little voice, she kept saying “No, thank you. No, thank you.” -Melissa Alegre, San Diego

A mother brought in her baby for a routine well-baby visit and also brought in her 4-year-old son. I overheard the mother explaining to her son that the baby would have to have “a shot.” When I walked into the room, the 4-yearold asked me, “Are you going to shoot the baby?” the mother was mortified! I explained how the “shot” would protect the baby and he seemed satisfied with that, but more satisfied with the lollipop I gave him! -Andrea O’Connor, Detroit

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

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december 2010 I VOL 1, NO 2

Pulmonology

Identification and Treatment of Pediatric Obstructive Sleep Apnea Susan Hines, RN, BSN, MSN, CPNP Instructor, The Breathing Institute, Pulmonary Department, The Childrenâ&#x20AC;&#x2122;s Hospital, Aurora, Colorado Susan C. M. Crane, BA, MS, PsyD Sleep Psychologist, The Breathing Institute, Pulmonary Department, The Childrenâ&#x20AC;&#x2122;s Hospital, Aurora, Colorado

leep is a necessary Obesity is associated with tion.2 Alternatively, OSA is Children with allergies are process to ensure norcharacterized by obstruction also at risk secondary to higher rates of OSA due to mal physiologic, menin the airway, resulting in nasal turbinate swelling, obstruction, decreased respital, and emotional funccontinued breathing effort secretions, and an often ratory drive, and increased tions during waking hours. but inadequate ventilation. swollen pharynx related to resistance to the hormone Disturbances in sleep in Hypopneas are character- the leptin.4 Leptin, an adipocyteallergy process. derived hormone, suppresses early childhood can predisized by decreased but not Children with craniofacial appetite.5 Ironically, obese pose children to attention, absent airflow, resulting in a abnormalities such as individuals have higher levalertness, and emotional decrease in oxygen satura- Apert-Crouzon syndrome els of leptin, suggesting problems later in life. Retion and/or arousals. Mixed can have difficulties resistance to its metabolic quirements for sleep vary by Susan Hines, RN, BSN, apneas are comprised of breathing at night related Susan C.M. Crane, MSN, CPNP BA, MS, PsyD effects.5 The severity of age and by person, but chilboth central and obstructive to anatomical abnormaliOSA also seems to correlate dren should feel rested breathing patterns. ties. All children with upon awakening if allowed to sleep craniofacial disorders should be with the degree of insulin resistance and enough according to their individual Etiology screened for snoring, as this can indicate has been shown to greatly increase the OSA affects both adults and chil- SDB. Children with Down syndrome risk of diabetes mellitus.4,5 Furthermore, requirements. Sleep-disordered breathing (SDB) is commonly seen in children, but the presentation is often dif- are also at risk for SDB due to smaller ghrelin, a hormone naturally secreted to dren and includes a range of disorders ferent. Adults have more discrete airways, possible large tongues, low increase the appetite, has been found to from primary snoring to obstructive apneic episodes, whereas children expe- tone, and recessed jaws.3 In addition, be secreted in response to lack of sleep. sleep apnea (OSA).1 SDB poses a prob- rience more hypopneas associated with children from lower socioeconomic If sleep is being compromised by frelem by disrupting the normal sleep pat- a reduced amount of air entering the households may be more at risk for quent awakenings associated with SDB, tern, causing frequent awakenings dur- lungs, causing inadequate gas OSA, and it is speculated that this is weight gain may occur.6 In adults and children, increased ing the night. The resulting sleep exchange.1 There are multiple reasons due in part to larger obesity rates in this fragmentation can significantly impact for SDB in children; however, a fre- group. African-Americans children are neck size has been linked to more obstructive events while sleeping due to the health of children and be associated quent association is enlarged tonsils and also at greater risk.4 Restrictive lung disease typically the upper airway narrowing resulting with attention deficit hyperactivity dis- adenoids, which peak in size between 2 order (ADHD), daytime sleepiness, dif- and 6 years of age and can cause partial occurs in children with chest wall defor- from increased neck fat deposit.7 Furthermore, lingual tonsils, which are ficulties concentrating, moodiness, not frequently found in normal chilheadaches, and even weight gain.2 This article will explain the pathophysiology, dren, can be prominent in obese chilIt is well documented that the obesity in children risk factors, diagnoses, treatment, and dren and those with Down syndrome.7 in America is increasing. Furthermore, recent Removal of these tonsils lower in the potential outcomes of SDB. hypopharynx may improve the overall studies are revealing a correlation between sleep Definition respiratory results postoperatively.7 deprivation and difficulty losing weight. SDB is characterized by partial or Symptoms complete airway obstruction during SDB can affect all body systems, and sleep due to collapse or narrowing of the pharynx, which can result in fragmenta- blockage of air flow into the lungs.4 mities, scoliosis, and neuromuscular dis- the presentation varies widely among tion of sleep due to brief arousals during Adenotonsillectomy is beneficial in the ease, but it can also occur in obese chil- children. In younger children, for examthe night as well as cessation of airflow.3 majority of children who suffer from dren secondary to increased intra- ple, snoring is the most common comSDB is considered a spectrum (see SDB related to adenotonsillar hypertro- abdominal pressure. Premature children plaint.1 Additional common nighttime Table), with primary snoring defined as phy, especially in the young and in and those with asthma are at increased symptoms include mouth breathing, snoring without associated oxygen those with a normal body mass index risk due to immature respiratory systems. diaphoresis, restlessness, enuresis, fredesaturations or arousals at the mild (BMI). Many children still have SDB It is well documented that obesity in quent awakenings, witnessed apneas, end, affecting up to 10% to 12% of chil- after surgery, and obesity is perhaps the children in America is increasing. and increased work of breathing. As dren.2 Upper airway resistance syn- most significant reason.5 Restrictive Furthermore, recent studies are reveal- children enter the school environment, drome (UARS) is in the middle of the lung disease, characterized by reduced ing a correlation between sleep depriva- symptoms of ADHD, including hyperspectrum and is characterized by lung volume, can also lead to SDB. tion and difficulty losing weight.6 activity and impulsivity, are commonly increased negative intrathoracic pressure with sleep arousals and sleep fragSleep-Disordered Breathing Spectrum mentation but no oxygen desaturations. OSA is at the severe end of the specType Definition Severity trum and is characterized by repeated Primary snoring Snoring without associated oxygen desaturations or arousals Mild episodes of blockage of the airway with changes in oxygenation, and this affects Upper airway resistance Increased negative intrathoracic pressure with sleep Moderate up to 3% of children.2 Apneas are fursyndrome (UARS) arousals and sleep fragmentation but no oxygen desaturations ther broken down into central sleep Obstructive sleep Repeated episodes of blockage of the airway with changes Severe apnea, characterized by diminished or apnea (OSA) in oxygenation absent respiratory effort due to central nervous system immaturity or dysfunc-

december 2010 I VOL 1, NO 2

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Pulmonology

seen with SDB. Quality of life also appears to suffer in children with SDB. The fatigue associated with SDB may result in increased risk of irritability, depression, and diminished interest in daily activities; in turn, these can affect other aspects of the child’s life, including relationships with family and peers.8 Uncontrolled SDB can also lower the threshold for seizures in children with epilepsy.9 Hypoxemia and sleep fragmentation with resulting sleep deprivation are responsible for these multiple issues. Sleep fragmentation is often difficult to fully appreciate as it is normal to have brief arousals throughout the night. However, many children with SDB have multiple arousals; therefore, consolidated sleep, which is necessary for feeling refreshed, is not achieved. Parents may not be able to recognize this interruption in sleep and may only see the ramifications, such as daytime sleepiness, moodiness, inattention, decreased school performance, difficulty focusing, or hyperactivity. Other symptoms of SDB include weight gain (as described above), morning headaches, parasomnias (sleep walking, sleep terrors, confusional arousal), enuresis (bedwetting), failure to thrive, and, in severe cases, pulmonary hypertension (strain on the heart).8 The physical exam should concentrate on the child’s general appearance, with careful attention to craniofacial characteristics such as midface hypopharynx and micrognathia. The oropharnyx should be evaluated for enlarged tonsils, narrow airway, and high arched palate, and special consideration should be paid to the nasal airway for signs of obstruction.3 The adenoid cannot be visualized directly, but, if warranted, radiographic evaluation of the lateral neck can reveal its size. If there is any concern about obstruction, an ear-nose-throat (ENT) evaluation should be obtained. Treatment SDB treatment depends on the cause and is often complex. Adenotonsillectomy should be considered first-line treatment for SDB in children where there is physical evidence of adenotonsillar hypertrophy.1 Weight loss should be a major goal of therapy in sleep apnea associated with obesity, but this takes time and is typically difficult to achieve. Exercise is essential, and even mild weight loss has been associated with benefits to SDB in obese children.4 For children who have multiple medical comorbidities, craniofacial syndromes, or an unclear etiology (modest physical findings or examination findings inconsistent with severity of

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apnea), a polysomnogram (PSG) is necessary.1 A PSG is a diagnostic sleep study that measures the child’s breathing patterns for abnormalities and the brain waves for sleep staging. The PSG is essential for determining the degree of apnea and differentiating central from obstructive apnea.2 The PSG involves having a patient sleep overnight in a sleep lab monitored by technicians specialized in sleep. The study evaluates sleep and wake stages, gas exchange, airflow and respiratory effort, and limb movement. The test is

ual exposure techniques (systematic desensitization) often seen in phobia treatments. CPAP desensitization involves providing positive experiences while gradually exposing the patient to increasing CPAP sensations. Often desensitization is initiated after a PSG has identified the need for CPAP therapy but before the sleep study with titration is attempted. Due to the demands on the family and financial cost presented by a PSG with titration, it is important to increase the likelihood that the child will be successful in com-

Children can be taught to tolerate a variety of medical procedures through therapy and behavioral interventions. Desensitization is a behavioral process used to increase patients’ comfort in tolerating CPAP sensations to help increase CPAP adherence. expensive and difficult for some children to tolerate, especially the very young and those with developmental delays, but this complication is improved by testing in a pediatric sleep lab with technicians trained to meet the needs of young children through the use of child-sized equipment in a childfriendly environment. Continuous Positive Airway Pressure Continuous positive airway pressure (CPAP) is the treatment of choice for OSA when adenotonsillectomy is contraindicated, unnecessary, or has failed.2 CPAP is a form of noninvasive ventilation (NIV) that works by generating the required air pressure to keep the patient’s airways open during sleep. While some children do very well with NIV therapy, other children have great difficulties tolerating CPAP. Struggles with CPAP adherence often occur with young children and children with developmental delays, trisomy 21, autism, sensory integration issues, or a history of poor response to medical procedures. These children frequently resist using the mask with physical and verbal protests.10 Children can be taught to tolerate a variety of medical procedures through therapy and behavioral interventions.11 Desensitization is a behavioral process used to increase patients’ comfort in tolerating CPAP sensations to help increase CPAP adherence. Desensitization CPAP desensitization is frequently provided by mental health staff trained in cognitive and behavioral interventions in tandem with NIV medical providers. This cognitive behavioral intervention is comparable to the grad-

pleting the study. Desensitization is also initiated after a PSG when the titration was successfully completed but it is learned at follow-up that CPAP adherence is insufficient. Desensitization Procedures There are various ways to accomplish desensitization. One evolving protocol will be described here. Once a patient is identified as needing CPAP desensitization during a sleep clinic visit, he/she is given a “mask desensitization picture book” to read each night at bedtime for improving cognitive associations with masks. This book has photos of mask role models (eg, firefighters, superheroes, doctors), a section about different kinds of masks (eg, masks for work, play, Halloween), and a final series of pictures emphasizing the benefits of CPAP use (eg, improved sleep, weight management, affect regulation). The family also schedules an initial appointment with the sleep psychologist and respiratory therapist, during which the medical need and benefits of CPAP therapy are reviewed and the goals of desensitization are explained. The CPAP desensitization process includes: 1) Increasing positive thoughts and feelings about using the CPAP mask 2) Achieving tolerance of wearing the mask and headgear 3) Developing acceptance of the necessary air pressure 4) Using CPAP all night, every night These objectives are broken down into specific, progressive, achievable goals (“baby steps”). The family’s first goal is to practice with the mask every day at home, usually around bedtime. Depending upon the child’s baseline behaviors, the subgoals of progressive

mask practice may include any of the following: • Continuing to read the mask picture book each night • Playing with the mask (eg, peek-aboo, role playing, putting it on stuffed animals) • Putting the mask on the face/over the nose with no headgear • Holding the mask on the face for a gradually increasing number of seconds or minutes • Putting the mask on the face with the headgear on the head • Wearing the mask and headgear for a gradually increasing number of minutes • Wearing the mask and headgear while lying down for a few minutes at nap time • Wearing the mask and headgear at bedtime • Wearing the mask until the child falls asleep with the mask and headgear on • Falling asleep with the mask on several nights in a row To increase comfort and reduce the possibility of skin breakdown, the caregiver removes the mask each night after the child has fallen asleep. At the first desensitization clinic, the family learns strategies to reach the behavioral “baby step” targets. One strategy involves using enjoyable distractions (eg, watching TV or movies, playing with special toys) while the subgoal is targeted. Selective attention and praise are also employed to encourage goal achievement. General behavioral modification principles are often explained to families. For some patients, a simple rewards plan is developed to encourage progress. Families are given a number of handouts on progressive behavioral goals, effective rewards principles, rewards lists, and tracking charts. Once the child has been wearing the mask and headgear for about 30 minutes a day and has fallen asleep with the mask on for about 7 nights in a row, the child returns to the desensitization clinic with the psychologist and respiratory therapist to begin desensitization to air pressure. A baseline is established according to how the child reacts to the initial air pressure trial. The family uses similar strategies (distraction, selective attention, rewards) to increase the amount of time the child can tolerate the air pressure. If the desensitization is being performed to prepare the child for a sleep study with titration, the home goal is for the child to eventually sleep with air pressure through the night for 7 nights in a row. Then the child will be scheduled to do the PSG with titration. If the child has completed this study, Continued on page 14

december 2010 I VOL 1, NO 2

Pulmonology Sleep Apnea...continued from page 13 the goal is to work up to wearing the mask with the prescribed pressure all night, every night. Desensitization procedures are individualized and modified for each child. For example, very young children, developmentally delayed children, or visually impaired children do not use the mask picture book. Rewards systems are typically not employed for children with very limited development (due to age or delays), and instead, distraction, praise, attention, and/or immediate rewards are used. Further Considerations Additional factors likely to increase challenges to CPAP adherence include: • A chaotic family environment • Caregiver mental health issues (eg, depression, bipolar disorder, personality disorders) • Cultural values that conflict with medical recommendations • Family financial difficulties (eg, lack of insurance, poor transportation, limited funds for basic needs) • Family discord (eg, significant

inconsistencies in parenting styles, divorce, domestic violence) • Long distances between the treatment facility and the family’s home • Pessimistic caregiver attitude (eg, “You’ll never get her to wear this.” “He’s going to hate this mask.” “She’s supposed to wear CPAP, but she just can’t stand it.”) • Poor adherence to previous CPAP attempts • Limited motivation These factors are complicated and can present formidable obstacles. For example, limited motivation for adherence from parents or adolescents can often be a serious challenge.12 In this case, desensitization has limited value, and other interventions must be explored to progress toward adherence. Motivational interviewing (MI) shows promise for increasing adherence in medical situations.13 Specific training is required to provide effective MI interventions. Some complicated family situations (described above) can be mitigated through resources provided by social work staff and through referrals

for individual, couples, and family mental health counseling. Conclusion OSA as well as sleep problems in general are increasingly being recognized as a cause of children’s daytime school and behavioral problems. As described in this article, clinical symptoms and presentations are variable, and children can present to many different disciplines. Therefore, it is important for all care providers to be familiar with symptoms, diagnostic criteria, and treatment strategies, allowing for prompt referral if necessary to a sleep specialist so that proper treatment can be provided. Early detection of symptoms will enhance necessary treatment with the goal of prevention of serious morbidities. References 1. Chan C, Edman JC, Koltai, PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004;69:11471155. 2. Halbower AC, Ishman SL, McGinley BM. Childhood obstructive sleep-disordered breathing: diagnostic and therapeutic technology innovations and challenges. Chest. 2007;132:2030-2041. 3. Guilleminault C, Huang YS, Glamann C, Li K, Chan A. Adenotonsillectomy and obstructive sleep apnea in

children: a prospective survey. Otolaryng Head Neck Surg. 2007;136:169-175. 4. Halbower AC, Sundaram SS, Polotsky V, Smith PL. Management of obesity and childhood obstructive sleep apnea: the dangerous combination. Obes Manag. 2008;4:338-343. 5. Spiegel K, Leproult R, L’Hermite-Balériaux M, et al. Leptin levels are dependent on sleep duration: relationships with sympathovagal balance, carbohydrate regulation, cortisol, and thyrotropin. J Clin Endocrinol Metab. 2004;89:5762-5771. 6. Lumeng JC, Somashekar D, Appugliese D, et al. Shorter sleep duration is associated with increased risk for being overweight at ages 9 to 12 years. Pediatrics. 2007;120:1020-1029. 7. American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. 8. Guimarães CV, Kalra M, Donnelly LF, et al. The frequency of lingual tonsil enlargement in obese children. AJR Am J Roentgenol. 2008;190:973-975. 9. Chervin RD, Archbold KH, Dillon JE, et al. Inattention, hyperactivity and symptoms of sleep-disordered breathing. Pediatrics. 2002;109:449-456. 10. Slifer KJ, Kruglak D, Benore E, et al. Behavioral training for increasing preschool children’s adherence with positive airway pressure: a preliminary study. Behav Sleep Med. 2007;5:147-175. 11. Koontz KL, Slifer KJ, Cataldo MD, Marcus CL. Improving pediatric compliance with positive airway pressure therapy: the impact of behavioral intervention. Sleep. 2003;26:1010-1015. 12. Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. 13. Rollnick S, Miller W, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2007.

Artwork Month of the

Vincent, age 5 Sienna, age 3

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

december 2010 I VOL 1, NO 2

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Profile

Tia Brayman, lead photographer, The Children's Hospital.

Hospital...continued from cover

The Children’s Hospital, Denver, Colorado.

Scott Turner, MSN, APRN-BC, examines patient at The Children’s Hospital in Denver, Colorado.

PNPPA: Thanks for talking with us, Scott. We were intrigued to learn that the first nurse practitioners were educated at the University of Colorado, and they specialized in pediatrics, no less! Can you speak to us about how the role of the nurse practitioner has evolved since that time at your institution? Mr Turner: Nurse practitioner and physician assistant roles were initiated at The Children’s Hospital in the 1970s. Since that time, these roles have grown dramatically both in number of NP/PA providers and in complexity and scope of the care that they provide. NPs and PAs are integral to the provision of care in primary care as well as almost every pediatric subspecialty. Additionally, many are actively involved in research and educational endeavors. Optimal utilization of these

Children’s has been a leader in encouraging NPs and PAs to be innovative in establishing effective practice models. Currently, these professionals practice in all settings, including inpatient, ambulatory, emergency/urgent care, and surgical areas on our main campus and at multiple Network of Care locations. PNPPA: What is your hospital doing that is different from other children’s hospitals? Mr Turner: There are several unique innovations we are proud of at Children’s. Our neonatal nurse practitioners (NNPs) not only staff our NICU but also contract to provide NNP coverage at multiple community hospitals throughout Colorado. Also, our NPs and PAs provide care at several Children’s Network of Care locations, including emergency/urgent care sites and outpatient services in numerous pediatric sub-

Our NPs and PAs provide care at several Children's Network of Care locations, including emergency/urgent care sites and outpatient services in numerous pediatric subspecialties.

roles has improved patient access, increased productivity for all providers, and most importantly, significantly enhanced the quality of care for our patients. Currently there are over 180 NPs and over 60 PAs practicing at Children’s.

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specialties. I should also mention that NPs are an integral part of our hospitalist program providing inpatient care at Children’s as well as at partner institutions. It’s worth mentioning, too, that similar to our medical staff, the majority of NPs/PAs are part of the faculty of the

Tia Brayman, lead photographer, The Children's Hospital.

about TCH, his career, and the roles of NPs and PAs at his institution.

The atrium at The Children’s Hospital, Denver, Colorado.

University School of Medicine, which allows streamlined professional billing practices and facilitates academic development opportunities. PNPPA: The Children’s Hospital celebrated its 100th anniversary in 2008 and has received numerous awards and honors throughout its history. How does this long-standing tradition of achievement impact your career? Mr Turner: When the neurologist that I started my career with suddenly retired 4 years ago, I sought out an institution that was strong in academics and nationally ranked. I have truly enjoyed the opportunities I have been given at The Children’s Hospital to learn, to teach, and to serve. As a provider at Children’s, I work for the University of Colorado and have nearly endless opportunities to attend world-class lectures and to continue my postgraduate education. I have almost unlimited access to electronic medical journals, a

work atmosphere that encourages evidence-based practice, and a schedule that allows me to delve into the literature to research the fascinating cases that present to this large tertiary care center. I have opportunities to precept the next generation of advanced practitioners, to lecture at the school of nursing, and to serve in leadership roles both within the organization and within the community. But the thing I most enjoy is having the opportunity to care for kids and their parents in a world-class, state-of-the-art facility. PNPPA: What is in the future for The Children’s Hospital? Mr Turner: In addition to providing the best possible care for kids who need it, we also work hard to keep kids out of the hospital. Through medical research and advocacy efforts, we are working toward a world where kids are safer and healthier and will one day have less need for a hospital.

december 2010 I VOL 1, NO 2

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CONTINUING EDUCATION RELEASE DATE: DECEMBER 1, 2010. EXPIRATION DATE: DECEMBER 1, 2011. ESTIMATED TIME TO COMPLETE: 1.0 HOUR

Pulmonary Hypertension in Infants and Children: Therapeutic Management Deborah Walter, BSN, MSN, ACNP, Cardiology/Cardiac Surgery Nurse Practitioner, Heart Institute, Rady Children’s Hospital, San Diego, California

ulmonary arterial hypertension (PAH) in infants and children can be a significant contributor to mortality and morbidity in many different pediatric cardiac, pulmonary, hematologic, rheumatologic, and other diseases. This is the second of a 2-part series; it will focus on management, current treatment options, and options still in Deborah Walter, BSN, the research MSN, ACNP phase. Prior to 1995, there was no treatment available specifically for pulmonary hypertension (PH). Since then, several medications have been approved to treat PH. These medications target several different pathways and come in intravenous, inhaled, oral, and subcutaneous formulations.

General Treatment Considerations Infants and children with PH have a more reactive pulmonary vascular bed than normal healthy children. Any respiratory illness has the potential to cause ventilation/perfusion mismatch with resulting hypoxia. This could lead to a catastrophic event if not treated aggressively. Children with PH should receive pneumococcal and annual influenza immunizations if there are no contraindications. Those infants and toddlers who qualify should also receive Synagis®. To minimize the effects of increased metabolic demands on an already compromised cardiorespiratory system, antipyretics should be used for a temperature greater than 38°C (101°F). A high index of suspicion should be the norm in caring for these patients in the outpatient and inpatient setting. Many of these patients will be under the care of specialists in PH, and the primary care provider should never hesitate to utilize them as resources.

CONTINUING MEDICAL EDUCATION ACCREDITATION AND DESIGNATION OF CREDIT STATEMENT LEARNING OBJECTIVES

Upon completion of this activity, participants should be able to: • Define the pathophysiology of pulmonary arterial hypertension • Describe the clinical classification model for pulmonary hypertension • Summarize the recommended diagnostic workup for patients the pulmonary hypertension TARGET AUDIENCE

Advanced practice nurses, registered nurses, and other interested healthcare professionals, especially those caring for pediatric cardiac patients. FACULTY

Deborah Walter, BSN, MSN, ACNP Cardiology/Cardiac Surgery Nurse Practitioner Heart Institute Rady Children’s Hospital San Diego, CA

Molecular targets for therapy in pulmonary arterial hypertension. Figure 1. Targeted therapy for pulmonary hypertension. Humbert M, Sitbon O, Simonneau G. Treatment of pulmonary arterial hypertension. N Engl J Med. 2004;351:1425-1436. Copyright © 2004 Massachusetts Medical Society. All rights reserved.

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. Disclosures are as follows: • Deborah Walter, BSN, MSN, ACNP has nothing to disclose 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. CONTINUING NURSE EDUCATION ACCREDITATION AND CONTACT HOURS STATEMENT

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. COMMERCIAL SUPPORT

This CE activity is not funded by any commercial supporters. PROGRAM FORMAT

Learners will participate in this educational activity by reading through article, answering multiple choice questions on the 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/pulmonary-hyperten sion-infants-children and click on “Click here to complete the posttest and obtain a CE certificate online.”

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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 © 2010 by Science Care.

december 2010 I VOL 1, NO 2

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.

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CONTINUING EDUCATION

Anticoagulation The use of anticoagulation is based on the rationale that patients with chronic PH undergo occlusion of small pulmonary vessels resulting in reduction of pulmonary vascular bed area. Endothelin cell abnormalities present in many forms of PH favor platelet activation and thrombosis. Several studies have established the use of warfarin in patients with PH.1-4 Appropriate and safe therapy should be discussed with child and family. Recommendations for dosage are aimed at achieving an international normalized ratio (INR) of 1.5 to 2.5 when there are no contraindications.5 In patients with known hypercoagulability the INR may need to be higher, and coordination with hematology is suggested. Antiplatelet agents have rarely been utilized in PH; however, preliminary results in a current trial looking at imatinib mesylate has shown that patients with a pulmonary vascular resistance of ≥12.5 Woods units respond with a marked improvement in exercise capacity and hemodynamics.6 Aspirin or potentially no anticoagulation therapy may be more appropriate for children who routinely participate in activities such as riding bikes, skateboarding, horseback riding, etc.

Recommendations for dosage are aimed at achieving an international normalized ratio (INR) of 1.5 to 2.5 when there are no contraindications.

Oxygen Alveolar hypoxia causes vasoconstriction of the pulmonary vascular bed resulting in increased pressure and resistance. Patients with cardiac malformations, hypoventilation, and/or lung disease may benefit from oxygen therapy.7 Some patients will demonstrate desaturation with activity, and they may benefit from supplemental oxygen. Patients with significant right heart failure and resting hypoxia should be treated with continuous oxygen therapy. Children with nocturnal hypoventilation that demonstrates oxygen desaturation while sleeping (without evidence of obstruction or apnea) would benefit from wearing oxygen when sleeping.8 Diuretics and Cardiac Glycosides Intravascular volume and hepatic congestion seen in patients with right

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heart failure can be decreased with the judicious use of diuretics. However, use with caution in patients with severe PH as the right ventricle is highly preload dependent, and excessive diuresis could result in decreased cardiac output.4 It is also important to monitor electrolytes as imbalances in potassium, magnesium, or phosphorus could contribute to arrhythmias. The use of digitalis for the treatment of isolated right heart failure associated with PH has been controversial; however, certain patients may benefit from it.9

Cronos 5 Infusion Pump

CADD Legacy Pump

Calcium Channel Blockers Calcium channel blockers (CCBs) inhibit calcium influx through slow channel into cardiac and smooth muscle. Their use in patients with PH is based on their ability to cause pulmonary vasodilation. The determination of this response is made during cardiac catheterization with vasoreactivity testing. If no acute response is achieved the patients are not candidates for this therapy. Sitbon and colleagues clarified the role of CCBs in the idiopathic PAH population by showing that only 13% of patients were true responders, and of those only about 7% had a sustained response after 1 year.10 Patients treated with CCBs need close follow-up to evaluate for worsening clinical condition. Prostaglandins The first medication clinically approved for the treatment of PH was intravenous prostacyclin in 1995. It is a potent nonselective vasodilator with platelet antiaggregatory properties. It was shown to improve survival and quality of life with long-term use. The 5-year survival in children with idiopathic PAH was shown to be greater that 80%.11 Epoprostenol is administered by infusion pump 24 hours a day via a central venous catheter. It is chemically unstable at room temperature/neutral ph and has a half-life of ≤6 minutes. It must be mixed daily and kept cold with ice packs around the cassette. Potentially life-threatening pulmonary hypertensive crisis could occur if the infusion is interrupted. Therefore the goal would be to reinitiate the infusion as soon as possible. The average dose in children is 50 to 80 ng/kg/min. There is significant variability of the “optimal dose,” and it usually depends on whether the patient is on combination therapy.8 Treprostinil is an analog of prostacyclin that was initially approved for subcutaneous infusion. In 2004, it was approved for intravenous infusion. It is similar in action to epoprostenol but with important differences. It has a longer half-life, approximately 4 hours,

Figure 2. Home infusion pumps.

I-neb ADD for Iloprost

Tyvaso inhalation system Figure 3. Inhalation devices.

and is stable at room temperature for 48 hours, making mixing less frequent. Dosage comparison to epoprostenol is estimated to be 1.5 to 2 ng/kg/min treprostinil versus 1 ng/kg/min epoprostenol. Severity of the pulmonary hypertension and quality-of-life issues surrounding the administration are the primary determinants of the decision to utilize intravenous prostacyclin. It is considered the gold standard for patients in right heart failure or those who clinically worsen on alternate therapies. The medication and supplies are provided by specialty pharmacies that have pulmonary hypertension specialists to educate patients/families on mixing the medication, working the pumps, and providing 24-hour coverage for troubleshooting and ordering. Intravenous prostacyclin should only be ordered and managed by a medical team that specializes in the treatment of PH. The patient’s insurance company will dictate the specific specialty pharmacy based on the patients benefits. Prostaglandins can also be administered by inhalation route. Iloprost (Ventavis®) was the first inhaled formulation to be approved. It is administered by a special system, the I-neb ADD (Adaptive Aerosol Delivery) system. It

precisely and reproducibly delivers the correct dose. Treprostinil (Tyvaso®) is also available as an inhaled formulation. These medications and nebulizer systems are also provided by specialty pharmacies. Endothelin antagonist In 2001, the first oral medication to treat PH was approved. Bosentan (Tracleer®) is an endothelin A and B receptor blocker that works on vascular endothelin and smooth muscle. Stimulation of endothelin receptors results in vasoconstriction and proliferation. Clinical trials showed that bosentan increased cardiac output and decreased pulmonary artery pressure, pulmonary vascular resistance, and mean right atrial pressure. They also showed increased time to clinical worsening, improved exercise capacity, and improvement of PH symptoms.7,12,13 The FDA requires monthly monitoring of serum transaminases – AST, ALT, and GGT. There are specific guidelines for dosing if elevations occur: • AST/ALT >3 times but ≤5 times upper limits of normal: confirm elevation, then reduce dose or interrupt treatment. Monitor transaminase level every 2 weeks. When levels Continued on page 20

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CONTINUING EDUCATION Pulmonary Hypertension...continued from page 19 Table

Bosentan Dosing

<10 kg 10-20 kg 20-40 kg >40 kg

15.6 mg daily × 4 weeks, then increase to 15.6 mg bid 31.25 mg daily × 4 weeks, then increase to 31.25 mg bid 31.25 mg bid × 4 weeks, then increase to 62.5 mg bid 62.5 mg bid × 4 weeks, then increase to 125 mg bid

return to normal, may reintroduce drug at the initial dose and recheck transaminase levels within 3 days. • AST/ALT >5 times but ≤8 times the upper limit of normal: confirm elevation and stop treatment. Monitor transaminase levels at least every 2 weeks. May consider restarting treatment if levels return to pretreatment values. • AST/ALT >8 times upper limits of normal: stop treatment. Ambrisentan (Letairis®) is an endothelin A receptor antagonist that was approved in June 2007. Dosing is 5 mg daily, increased to 10 mg daily if the initial dose is tolerated. It is approved for patients greater than 40 kg. It also requires monitoring of liver transaminases. Phosphodiesterase Type 5 (PDE5) Inhibitor PDE5 is found in pulmonary smooth muscle. Nitric oxide activates guanylate cyclase, which increases levels of cyclic guanosine monophosphate (cGMP). cGMP produces relaxation of smooth muscle. PDE5 breaks down cGMP. Inhibition of PDE5 increases cGMP levels. Two drugs in this category have been approved for use in treating PH: sildenafil (Revatio®) in June 2005 and tadalafil (Adcirca®) in June 2009. Sildenafil is available as 20 mg tablets. A compounded suspension of

2.5 mg/mL can be used for infants and children. Dosing starts at 0.5 mg/kg/day and can be increased to as high as 4 mg/kg/day in 3 divided doses. Sildenafil has also been approved in an intravenous form for use in the acute care setting. Tadalafil is available in 20 mg tablets and is dosed at 40 mg once a day. It is approved for patients greater that 40 kg. Inhaled Nitric Oxide Nitric Oxide (NO) is a low molecular weight lipophilic molecule in gaseous form. It has a rapid onset of action and short intravascular half-life (seconds). NO increases cGMP, leading to smooth muscle relaxation. It is an effective acute pulmonary vasodilator. In the postoperative cardiac surgery patient with known PH or the potential to have pulmonary vasoreactivity, it is valuable in treating an acute rise in pulmonary vascular resistance.7 Inhaled NO has been the single most important advance in the management of PH in the acute care setting. It is dosed in parts per million (ppm), from 20 ppm up to 80 ppm. It is important to measure methemoglobin levels routinely. Patient and Family Resources The diagnosis of PH can be devastating to families. The severity of the disease has an important impact on the medical regimen selected. It can be as

simple as oral medication several times a day or as complicated as a central line and continuous intravenous infusion. Patients and families require intense education and frequent follow-up. Patients who are started on intravenous therapy will require education on medication mixing, infusion pump management, central line care, and how to fit all this into a daily lifestyle. Medical teams specializing in the care of these patients offer the multidisciplinary approach needed to manage these complex patients. The PH teams rely on the local primary care providers, cardiologists, and pulmonologists to follow these patients between visits to the referral

Nitric Oxide (NO) is a low molecular weight lipophilic molecule in gaseous form. It has a rapid onset of action and short intravascular half-life (seconds).

centers. Many families go long distances to see the specialists at these centers. The Pulmonary Hypertension Association (PHA) is a national organization initially founded in 1985 by 4 PH patients to develop a support group. Since then it has expanded to over 10,000 members, including PH patients, caregivers, family members, and medical professionals. With programs and services expanding to serve the needs of the growing population of patients, families, and PH-focused med-

ical professionals, PHA has also become an international hub for the PH community. They provide online resources for therapies, access to healthcare professionals, educational events, and patient resource books, and every 2 years they sponsor an international conference that hosts patients, families, and healthcare professionals. The Web site is www.phassociation.org. References 1. Rich S, Kaufmann E, Levy PS. The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med. 1992; 327:76-81. 2. Fuster V, Steele PM, Edwards WD, et al. Primary pulmonary hypertension: natural history and importance of thrombosis. Circulation. 1984;70:580-587. 3. Frank H, Mlczoch J, Huber K, et al. The effect of anticoagulant therapy in primary and anorectic druginduced pulmonary hypertension. Chest. 1997;112: 714-721. 4. Barst RJ, Gibbs JS, Ghofrani HA, et al. Updated evidence-based treatment algorithm in pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54(1 suppl):S78S84. 5. Ogawa MT, Albrecht DA, Liu EY. Medical and nonmedical considerations for the outpatient management of children with pulmonary arterial hypertension. Progress in Pediatric Cardiology. 2009;27:57-61. 6. Adatia I, Shekerdemian L. The role of calcium channel blockers, steroids, anticoagulation, antiplatelet drugs, and endothelin receptor antagonists. Pediatr Crit Care Med. 2010;11(2 suppl):S46-S52. 7.Kulik T, Mullen M, Adatia I. Pulmonary arterial hypertension associated with congenital heart disease. Progress in Pediatric Cardiology. 2009;27:25-33. 8. Rosenzweig EB, Widlitz AC, Barst RJ. Pulmonary arterial hypertension in children. Pediatr Pulmonol. 2004;38:2-22. 9. Rich S, Seidlitz M, Dodin E, et al. The short-term effects of digoxin in patients with right ventricular dysfunction from pulmonary hypertension. Chest. 1998; 114:787-792. 10. Sitbon O, Humbert M, Jais X, et al. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension. Circulation. 2005;111: 3105-3111. 11. Rashid A, Ivy D. Severe paediatric pulmonary hypertension: new management strategies. Arch Dis Child. 2005;90:92-98. 12. Barst RJ Ivy D, Dingemanse J, et al. Pharmacokinetics, safety, and efficacy of bosentan in pediatric patients with pulmonary arterial hypertension. Clin Pharmacol Ther. 2003;73:372-382. 13. Adatia I. Improving the outcome of childhood pulmonary arterial hypertension: the effect of bosentan in the setting of a dedicated pulmonary hypertension clinic. J Am Coll Cardiol. 2005;46:705-706.

Coming in February 2011 Pediatric NP/PA is proud to present the next article in our complimentary CE-accredited series

Current State of Asthma: 2011 By Shirley Becton McKenzie, MS, APRN, PNP-BC, AE-C Pediatric Nurse Practitioner, Senior Instructor, Asthma Management Program The Breathing Institute, The Children’s Hospital/University of Colorado Denver Anschutz Medical Campus

We’ve also invited nursing leaders to weigh in on related topics in asthma ranging from allergies to wheezing. Look in the February issue for our special asthma section. Rely on us to bring you information that directly impacts your practice.

december 2010 I VOL 1, NO 2

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Cardiology

Congestive Heart Failure in the Pediatric Patient Leigh Christopher Reardon, MD Fellow, Division of Pediatric Cardiology, Mattel Children’s Hospital UCLA, Los Angeles, California Juan Carlos Alejos, MD Director, Pediatric Heart Failure and Transplant Program, Mattel Children’s Hospital UCLA, Los Angeles, California

ongestive heart failvascular resistance in conure (CHF) is the junction with signaling the inability of the heart kidneys to retain salt and to meet the metabolic fluid. In the short run, these demands of the body. Etiolcompensatory responses ogies for CHF vary widely in often provide adequate carthe pediatric population in diac output but are insufficontrast to adults, who typicient and deleterious in the cally suffer CHF secondary long run. to ischemic disease or from Persistent sympathetic long-standing hypertensive activation and cytokineLeigh Christopher Reardon, MD disease. Approaching the induced inflammation pediatric patient with CHF alters myocardial proteins, requires careful attention to age, cardiac results in proliferation in cardiac cells anatomy, and subtle clinical findings. (hypertrophy), and finally cardiac The heart responds to increased meta- necrosis. Cardiac cell death then stimubolic demands by increasing the heart lates fibroblast proliferation and deposirate, increasing cardiac contractility, and tion of collagen. This process is similar managing cardiac preload and afterload. to scar formation in other tissues. The Contractility is primarily enhanced by resulting cardiac tissue results in subopincreasing circulating catecholamines. timal cardiac substrate and function. On other hand, the body manages carThis article reviews the basic mechadiac preload and afterload by modifying nisms, etiologies, and treatment of CHF.

Table 1 Common Mechanisms for Developing Congestive Heart Failure Cardiac Rhythm Disorders

Volume Overload

• Complete heart block • Supraventricular tachycardia (SVT) • Ventricular tachycardia (VT) • Sinus node dysfunction • Structural heart disease, frequently with a significant shunt 1. Ventricular septal defect (VSD) 2. Patent ductus arteriosis 3. Valvular regurgitation 4. Complex lesions (double outlet right ventricle, atrioventricular [AV] canal, tricuspid atresia) 5. Volume overload secondary to surgical palliation • Anemia • Sepsis

Etiology of CHF Generally, CHF in the pediatric population results from structural heart disease, cardiac dysfunction, and arrhythmias as well as noncardiac causes. Less common, but often devastating CHF occurs secondary to genetic and metabolic abnormalities. The differential diagnosis is guided by patient age and clinical evaluation. General mechanisms of CHF are disorders of rhythm, volume overload, pressure overload, or cardiac muscle dysfunction. Table 1 provides an overview of these mechanisms. Neonates and infants younger than 2 months typically have CHF secondary to structural heart disease. Patients can present with CHF soon after birth or several days to weeks after birth depending on their structural heart defect. Noncardiac causes include genetic disorders, respiratory illness, persistent pulmonary hypertension, anemia, and sepsis. Attention should be paid to common structural causes of CHF in the newborn period and the typical time of CHF onset. Cyanotic congenital heart lesions typically present at birth (tetralogy of Fallot, truncus arteriosus, transposition of the great arteries, tricuspid

atresia, and total anomalous pulmonary venous return). Ductal dependent lesions that are not diagnosed in the newborn period typically present 7 to 10 days after birth; the most notable example is hypoplastic left heart syndrome. These patients present to the emergency department in CHF and shock. Ventricular septal defects (VSDs), atrioventricular (AV) canal defects, and valvular regurgitation tend to present 4 to 6 weeks after birth as pulmonary vascular resistance falls and metabolic demands increase. Routine newborn follow-ups were developed to support new parents, screen for adequate weight gain, and to identify diseases that are difficult to identify in the newborn nursery. Early identification of cardiac disease is a major public health accomplishment. Toddlers and school-age children tend to acquire CHF secondary to myocardial dysfunction due to myocarditis or cardiomyopathy, leftsided obstruction (aortic stenosis or coarctation of the aorta), progression of structural heart disease, hypertension, or renal failure. CHF in adolescents commonly Continued on page 22

Table 2 Laboratory Assessment of Congestive Heart Failure Routine Laboratory

Associated Finding

Electrolytes

• Hyponatremia from water retention • Hyperkalemia from renal compromise due to low cardiac output • Elevated BUN and creatinine from compromised renal blood flow • Depleted serum bicarbonate secondary to acidosis from inadequate tissue perfusion

Hepatic Panel

• Structural heart disease 1. Aortic stenosis 2. Pulmonary stenosis 3. Aortic coarctation • Hypertension

• Liver enzymes may be elevated from poor perfusion and right-sided congestion

Complete Blood Count

• May identify anemia as a cause of CHF or acute decompensation

Systolic Dysfunction – Inability to generate adequate systolic force

• Myocarditis • Dilated cardiomyopathy • Ischemia

Brain Natriuretic Peptide

Diastolic Dysfunction – Inappropriate cardiac filling

• Hypertrophic cardiomyopathy • Restrictive cardiomyopathy • Constrictive pericarditis • Tamponade

• Elevated levels associated with CHF • Can help distinguish respiratory process from CHF

Lactate

• Suggestive of tissue hypoxia

Blood Gas

• Suggestive of tissue hypoxia

Pressure Overload

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• WBC can suggest infectious cause of cardiac compromise and acidosis

BUN: blood urea nitrogen; WBC: white blood cell count; CHF: congestive heart failure.

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Cardiology Congestive Heart Failure...continued from page 21

Figure 1. Chest x-ray of an infant who was admitted for tachycardia, tachypnea, and poor feeding. Notice the enlarged cardiac silhouette.

monary edema demonstrated on chest x-ray. Infants tend to manifest CHF as an inability to gain adequate weight or failure to thrive. The primary energy expenditure in the typical day of infants is during feeding – in essence this is their exercise. Infants with CHF feed for longer periods of time and will frequently sweat with feeds. Parents often note that the back of their baby’s neck is sweaty during or just after feeds. This is related to a catecholamine surge that occurs when the infant is challenged to feed with poor cardiac output. Conversely, right-sided heart failure is associated with signs of systemic venous congestion such as hepatomegaly, jugular venous distention, ascites, and edema. In contrast to adults, children are far less likely to develop capillary leak and thus are less likely to have lower extremity edema and ascites. CHF with normal cardiac output is termed compensated CHF. As cardiac output becomes inadequate, it is termed decompensated CHF. Clinical findings of decompensated heart failure include hypotension, fatigue, altered mental status, cool extremities with poor perfusion, syncope, and decreased urine output. The progression from compensated to decompensated CHF in children is far more rapid than in adults.

Chest x-ray, laboratory studies, and occasionally an echocardiogram will be appropriate for patients presenting with acute or decompensated heart failure.

Figure 2. Echocardiogram of the patient with the enlarged heart on Figure 1 confirms CHF secondary to dilated cardiomyopathy. Note the large thinwalled left ventricle.

result from acquired heart disease such as cardiomyopathy or chronic arrhythmia. Additionally, long-term cardiac stress after surgical repair or palliation of structural heart disease can result in CHF in the adolescent. Illicit drugs such as cocaine and inhaled stimulants are additional etiologies to consider. Clinical Signs and Symptoms The hallmark sign of CHF is tachycardia with the exception of some cardiac rhythm disorders such as complete heart block and bradyarrhythmias. It is important to assess the patient’s heart rate at

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rest, as infants and children are often agitated during physical exams. Trending the heart rate over a 24-hour period in hospitalized children can offer insight into the clinical progression of CHF and effectiveness of therapies. While tachycardia is one of the first manifestations of CHF, continued heart failure is characterized by right- and left-sided congestion. Left-sided heart failure is associated with signs of pulmonary venous congestion. On exam left-sided heart failure is characterized by tachypnea, retractions, nasal flaring and grunting, and rales and by pul-

Clinical evaluation requires a thorough history and physical exam with careful assessment of heart rate, murmurs, respiratory findings, and perfusion. Patients with CHF will frequently have an S3 or S4 gallop. Structural heart disease in the newborn period requires early identification by a pediatric cardiologist and neonatologist. Pulse oximetry on the right upper extremity and on a lower extremity as well as the hyperoxia text may help distinguish cardiac shunts from pulmonary disease. Frequently, patients with structural heart disease will have ongoing management of CHF and will present with a known diagnosis and decompensation. Clinicians should have suspicion of myocarditis and cardiomyopathies in patients presenting with new findings of

CHF and syncope. Attention should be placed on infectious exposures and family history of heart disease in younger individuals as well as unexplained sudden death in the family. Chest x-ray, laboratory studies, and occasionally an echocardiogram will be appropriate for patients presenting with acute or decompensated heart failure. Figure 1 demonstrates the enlarged cardiac silhouette in a newly diagnosed infant with dilated cardiomyopathy. Notice that the cardiac shadow is greater than 1.5 times the chest wall diameter. The patient’s echocardiogram is shown in Figure 2; the dilated left ventricle correlates with her chest x-ray findings. The patient initially presented with poor feeding, tachycardia, and tachypnea. Table 2 lists common laboratory tests and common findings. Brain natriuretic peptide (BNP) levels are elevated as a result of ventricular dilation and volume overload. Serum BNP levels can be very helpful to distinguish a primary cardiac process from a primary respiratory process. A 12-lead EKG can help distinguish an arrhythmia or evidence of structural or coronary artery disease. The chest x-ray in most cases demonstrates an enlarged cardiac silhouette. Echocardiography can help identify previously unidentified structural heart disease and is particularly helpful when assessing patients with cardiac transplant with suspicion of rejection. Treatment Strategies Appropriate treatment is tailored to each patient and the etiology of their CHF. Goals of medical therapy revolve around treating reversible conditions such as anemia and sepsis, preload reduction, afterload reduction, enhancing cardiac contractility, improving oxygen delivery, and managing arrhythmias. Anemia affects the oxygen-carrying capacity of the blood and thereby aggravates CHF by increasing the demand for cardiac output. Patients with mixing anatomic lesions who live at oxygen saturations of 75% to 85% benefit from a hematocrit greater than 40 g/dL. Patients with chronic CHF may require iron supplementation if they are anemic. Judicial blood transfusions on the acute CHF setting can result in significant clinical improvements. Preload reduction refers to reduction of the volume load on cardiac cells and represents the cornerstone of CHF management. Diuretics such as furosemide, thiazides, and metolazone are the common agents. Additionally, in the inpatient setting venous dilators such as nitroglycerine are available but infrequently used. Patients with acute Continued on page 28

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Vaccines HPV Vaccine...continued from the cover cervical cancer reported sexual debut. This recomyearly.2 It is estimated that mendation is intended to 12,200 new cases of cervical eliminate many potentially cancer will be diagnosed in damaging and stressful prothe United States (US), cedures for adolescents, and 4210 women will die of such as colposcopies, biopthe disease in 2010.3 Apsies, and ablative therapies, proximately 90% of genital that were done under previwarts are caused by HPV ous guidelines advocating types 6 and 11, and each cervical screening prior to Nancy R. Kloha, FNP, year 500,000 new cases are age 21.6 4 MSN, DNP Student diagnosed in the US. More HPV Vaccines than $4 billion are spent The first vaccine, GardasilÂŽ, was annually in the US on direct costs related to anogenital warts and cervical licensed for the prevention of HPV infection in females in 2006. Gardasil is HPV-related disease.5 Several types of HPV are most com- approved for females aged 9 to 26 years monly implicated in cervical cancer and and targeted to girls aged 11 to 12 years. genital warts. By far, the largest percent- This vaccine is quadrivalent, protecting age of cancer affecting the cervix is against HPV types 6, 11, 16, and 18, caused by HPV types 16 and 18, where- which cause cervical dysplasia and genas the largest percentage of warts affect- ital warts. For women and girls not ing the anogenital area is caused by receiving the vaccine at the target age, HPV types 6 and 11.4 HPV infections of catch-up immunization is recommendthe cervix, penis, and anogenital areas ed. The second vaccine, CervarixÂŽ, was are caused by direct physical contact licensed in 2009. It is bivalent and probetween skin surfaces during sexual tects against HPV types 16 and 18, activity and are the most common sexu- which cause cervical dysplasia, and is approved for females aged 10 to 25 years.1 Three doses of either vaccine via intramuscular injection are recomInfections with HPV mended, with the second dose given at 1 month (Cervarix) or 2 months are very common in (Gardasil), and the third dose at 6 adolescence and the months after the initial dose. The cost twenties, whereas of vaccination is approximately $130/dose and is covered by the cervical cancer is more Vaccines for Children Program (VCP) prevalent in the third and and most insurance companies. In fourth decades of life. 2009, Gardasil was also approved for use in males to prevent genital warts. At this time, it is available for males aged 9 ally transmitted infections in the US. It to 26 years upon request or at the disis estimated that 6 million people in the cretion of the healthcare provider, but it US alone are newly infected each year.4 is not currently recommended by the Of all people who have had sex, 50% to Advisory Committee on Immunization 75% will at some time in their life have Practice (ACIP) for routine use in been infected with HPV. Over half of males.1 Both HPV vaccines are thought to be the people infected with HPV yearly are very safe and effective. Vaccination between 15 and 25 years of age.4 Most females are infected with HPV prior to first sexual activity has been within the initial year after first sexual shown to produce greater antibody intercourse. Infections with HPV are titers when they are needed.7 Giving very common in adolescence and the either vaccine at catch-up ages is pertwenties, whereas cervical cancer is mitted, but later administration risks more prevalent in the third and fourth missing the initial exposure to HPV as decades of life. Although most HPV well as not allowing optimal time for infections in young girls and women maximal antibody production. Both resolve on their own within 1 to 2 years, vaccines have been shown to be nearly some infections remain in the body and 100% effective at preventing HPV cause changes in the tissue of the cervix infection caused by the types they are that, if left untreated, may progress to designed to prevent. One of the most cervical cancer at a later time. Since frequently reported side effects of most infections clear within a relatively Gardasil is syncope. Therefore, it is recshort time period, the American ommended that those receiving either Congress of Obstetricians and Gyne- vaccine be observed for 15 minutes after cologists (ACOG) recently changed its administration of the injection before recommendation for cervical screening resuming normal activities.8 The to begin at age 21 regardless of age at Vaccine Adverse Event Reporting

december 2010 I VOL 1, NO 2

System (VAERS), a program HPV vaccine might encourrun jointly by the FDA and age sexual promiscuity has the CDC, received >16,000 not been supported in the reports of incidents possibly postvaccine literature.11 In some studies, administrarelated to the safety of the tion of HPV vaccine has HPV vaccine between June met greater acceptance with 2006 and May 2010. The parents of lower socioecoreports were divided into nomic class and less educanonserious events (accounttion.12 Other researchers ing for 92%) and serious Rose M. Mays, PhD, report greater uptake among events (accounting for 8%). RN, FAAN nonwhite adolescents, inExperts have found no comcluding black and Hispanic mon pattern among the serious adverse events that would sug- populations.13 Mothers who have pergest causation by the vaccine. sonally experienced sexually transmitMonitoring of reported adverse events ted infections and treatment for cervical abnormalities are more apt to is ongoing.1 Since the vaccines are relatively new, choose vaccination for their daughit is not known how long protection ters.12 Reasons for lower vaccine uptake will last. Immunogenicity has persisted rate in adolescents whose parents are for at least 5 years in studies to date. white and/or more educated continue Longitudinal studies are ongoing to to be studied. Many parents say that they are not assess the need for future booster doses.5 Because the vaccines do not protect opposed to the HPV vaccine, but that against all HPV types, women should they intend to wait until their girls are receive periodic cervical screening and older. Other parents want their daugheducation on safe sexual practices as ters to understand and participate in the part of routine wellness visits. decision to receive the vaccine. Uncertainty most frequently expressed by parents regarding the vaccine relates to it being too new to have been proven Since the vaccines safe. Concerns include that years down are relatively new, it is the road it will be found to have been not known how long embraced too quickly, with adverse effects occurring as time passes.14 protection will last. Parents place great importance on Immunogenicity has vaccine safety, understanding its purpersisted for at least pose, and advice from respected healthcare providers.14 These parental views 5 years in studies to date. should guide educational efforts to improve vaccine uptake. Also, many adolescents fail to complete the series.15 HPV Uptake in Adolescents This places them at risk of less than Utilization of HPV vaccines in 11- optimal protection and may skew the and 12-year-old girls has not been as ability to evaluate effects of HPV vaccisuccessful as anticipated, despite vac- nation in the future. Therefore, educacine subsidies for girls of this age. The tion needs to focus not only on initiatmost recent national survey of adoles- ing the HPV vaccine but also on cents aged 13 to 17 years reported completing the series of 3 injections. uptake of 1 or more doses to be 44.3% and 3 or more doses, only 26.7%.9 Older Putting Prevention Into Practice To date, the positive improvement in adolescents were more likely to receive the vaccine than those at the ACIP- US cervical cancer mortality has been recommended age of 11 to 12 years. the result of adherence to screening The reasons for this less than optimal guidelines. HPV vaccines have enorresponse are several. Nationally, region- mous potential to greatly accelerate this al variations in funding, policies, and progress. In fact, through vaccination initiatives that promote HPV vaccine and continued screening it may be poshave resulted in vast differences in cov- sible to eventually eliminate all deaths erage across states. Clinical setting and from cervical cancer. Primary healthprovider factors are also implicated. For care providers serving adolescents are example, in one area, pediatricians were uniquely positioned to assist in this premore likely to initiate the series than ventive effort. First and foremost, clinicians must educate patients and their family or womenâ&#x20AC;&#x2122;s health specialists.10 Additionally, negative consumer atti- families about HPV, its relationship to tudes may influence uptake. Some pre- cancer and genital warts, and the risks vaccine concerns have not been found and benefits of HPV vaccination. A to be of consequence in postvaccine vital element of this message is that the studies. One parental fear that giving HPV vaccine, either quadrivalent or

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Vaccines

bivalent, is recommended for all female adolescents. Parents who learn about HPV vaccines from healthcare providers are more likely to begin the series for their daughters,16 and in one study healthcare providers were identified as parents’ preferred source for future HPV vaccine information.17 In addition to notifying females and their parents of the recommendations, providers may also elect to inform adolescent males and their parents of the quadrivalent vaccine’s ability to prevent genital warts. Gardasil for males is covered under the VCP, but since it currently only has a permissive recommendation from ACIP, it may be variably covered by insurance. Parents look to healthcare providers for guidance on keeping their children from harm. Providers have the responsibility to give current, evidence-based advice. Unfortunately, adolescents see their primary healthcare providers less frequently than do younger children. Preventive visits are recommended less often in the teen years, and problemfocused visits are generally few for this relatively healthy age group. Consequently, when they do arrive at the clinic or office, it is essential that they experience an adolescent-friendly service environment. Ensuring confidentiality regarding their concerns, respecting their expanding autonomy, and providing attractive, developmentally appropriate educational materials are important to engaging adolescents in discussions about the HPV vaccine. In addition, affordability may be a consideration. Financial barriers can be addressed with insurance coverage, pharmaceutical patient assistance, and the VCP. Since completing a series of 3 injections can be problematic, a patient

reminder system can be effective in increasing completion rates.18 Whether communicating with parents or adolescents, messages should be very clear and concise. Allow time for questions and actively invite dialog. When met with confusion, skepticism, or even refusal of vaccination, the wise healthcare provider will remain calm and patient. Remember, the seed has been sown. Most will continue to think about your words and may well return later, having changed their minds about the vaccine. Alternate Strategies to Increase HPV Awareness Since its introduction, various approaches have been used to inform stakeholders about the HPV vaccine. For example, private industry has conducted multimedia consumer campaigns, and professional and service organizations have endorsed the vaccine and offered education for members and employees accordingly. Still, public awareness and vaccine uptake among the targeted age group, early adolescent females, remain less than optimal. Unlike some other countries, the US has no universal school-related mandates or school-based vaccination programs with regard to HPV. However, the school setting may be an important vehicle for increasing adolescents’ HPV awareness. Young adolescents are a captive audience in school settings, and schoolbased health education, whether delivered in classrooms or in school clinics, should include HPV vaccine content. Much more work must to be done for this strategy to fulfill its potential with the age group targeted for the HPV vaccine, however. In a recent 6-state sur-

vey, only two-thirds of school health education teachers reported teaching about adolescent vaccines, and information about HPV was far more likely

Preventive visits are recommended less often in the teen years, and problem-focused visits are generally few for this relatively healthy age group. to be given to high school students than those in middle schools.19 Looking to other alternative strategies, educational videos shown in schools or clinical settings seem to hold promise as a vehicle for informing adolescents and parents about HPV and HPV vaccines.20,21 Also, technology such as texting and social media should be explored. Healthcare providers must support the spread of the preventive potential of the HPV vaccine in a variety of ways and settings. The futures of the children in our care depend upon it. References 1. Centers for Disease Control and Prevention. Human papillomavirus (HPV)-associated cancers. http://www. cdc.gov/cancer/hpv/. Accessed October 4, 2010. 2. World Health Organization. Human papillomavirus infection and cervical cancer. http://www.who.int/vacci ne_ research/diseases/hpv/en/. Accessed October 4, 2010. 3. National Cancer Institute. Cervical cancer. http://www.cancer.gov/cancertopics/types/cervical/. Accessed October 4, 2010 4. American Cancer Society. Human papilloma virus (HPV), cancer, and HPV vaccines – frequently asked questions. http://www.cancer.org/acs/groups/cid/documents /webcontent/002780-pdf.pdf. Accessed October 4, 2010. 5. Markowitz LE, Dunne EF, Saraiiya M, et al. Quadrivalent human papillomavirus vaccine. Recommendations of the Advisory Committee on Immunization

Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2007;56(RR02):1-24. 6. ACOG Practice Bulletin No. 109: Cervical cytology screening. Obstet Gynecol. 2009;114:1409-1420. 7. Pedersen C, Petaja T, Strauss G, et al. Immunization of early adolescent females with human papillomavirus type 16 and 18 L1 virus-like particle vaccine containing AS04 adjuvant. J Adolesc Health. 2007;40:564-571. 8. Slade BA, Leidel L, Vellozzi C, et al. Postlicensure safety surveillance for quadrivalent human papillomavirus recombinant vaccine. JAMA. 2009;302:750-757. 9. Centers for Disease Control and Prevention (CDC). National, state, and local area vaccination coverage among adolescents aged 13-17 years – United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;59:1018-1023. 10. Dempsey A, Cohn L, Dalton V, et al. Patient and clinic factors associated with adolescent human papillomavirus vaccine utilization within a university-based health system. Vaccine. 2010;28:989-995. 11. Askelson NM, Campo S, Lowe JB, et al. Using the theory of planned behavior to predict mothers’ intentions to vaccinate their daughters against HPV. J Sch Nurs. 2010;26:194-202. 12. Rosenthal SL, Rupp R, Zimet GD, et al. Uptake of HPV vaccine: demographics, sexual history and values, parenting style, and vaccine attitudes. J Adolesc Health. 2008;43:239-245. 13. Yeganeh N, Curtis D, Kuo A. Factors influencing HPV vaccination status in a Latino population; and parental attitude towards vaccine mandates. Vaccine. 2010;28:4186-4191. 14. Dempsey AF, Abraham LM, Dalton V, et al. Understanding the reasons why mothers do or do not have their adolescent daughters vaccinated against human papillomavirus. Ann Epidemiol. 2009;19:531-538. 15. Neubrand TP, Breitkopf CR, Rupp R, et al. Factors associated with completion of the human papillomavirus vaccine series. Clin Pediatr (Phila). 2009;48:966-969. 16. Cates JR, Shafer A, Carpentier D, et al. How parents hear about human papillomavirus vaccine: implications for uptake. J Adolesc Health. 2010;47:305-308. 17. Hughes J, Cates JR, Liddon N, et al. Disparities in how parents are learning about the human papillomavirus vaccine. Cancer Epidemiol Biomarkers Prev. 2009;18:363-372. 18. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med. 2000;18(1 suppl):97-140. 19. Dempsey AF, Schaffer S. Middle- and high-school health education regarding adolescent vaccines and human papillomavirus. Vaccine. 2010;28:7179-7183. 20. Chapman E, Venkat P, Ko E, et al. Use of multimedia as an educational tool to improve human papillomavirus vaccine acceptability – a pilot study. Gynecol Oncol. 2010;118:103-107. 21. Vallely LA, Roberts SA, Kitchener HC, et al. Informing adolescents about human papillomavirus vaccination: what will parents allow? Vaccine. 2008; 26:2203-2210.

EDITORIAL

I Am a Nurse Practioner...continued from page 7 to other professions outside of healthcare, others do not seem to have the same issues; teachers are teachers, accountants are accountants. I could go on and on. I also asked several of my nurse practitioner colleagues how they felt about the term “mid-level provider.” Their reactions were similar: “I hate it,” “It makes me crazy,” “It is offensive, derogatory,” and perhaps my favorite, “I refuse to buy into the paradigm.” Yet despite the instant outrage when asked about the term, it lives on. My search on the Internet for the origin of the term yielded an article, “The Rise of the Midlevel Professional.”1 Fantastic. What or where have we risen from? Nurse practitioners have been a vital

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part of healthcare delivery in the United States since the mid 1960s. Research has demonstrated our effectiveness and versatility.2-7 Our patients appreciate the high-quality, cost-effective care we provide.8,9 The care nurse practitioners provide is, at the very least, as good as that of our physician colleagues.4 Isn’t there already enough confusion about who nurse practitioners are and what we do? Do we really need to allow more confusion? I can only imagine the reaction of an adolescent at the check-in desk when asked, “Are you here to see the mid-level provider?” or to a sign above the door reading, “Mid-Level Provider Office.” I took the first step at that meeting, as the only nurse practitioner in the room –

I pushed the microphone button and stated “as a nurse practitioner, I find the term mid-level provider offensive.” There was silence, no argument or comment, but some nodding in agreement. I encourage all nurse practitioners and physician assistants to do the same. Healthcare reform will change how Americans receive and experience healthcare. We need to talk about what we do and how well we do it. Enough is enough! I realize I am preaching to the choir so to speak, but if not us then who is going to speak up for us? There are too many people who need high-quality, dedicated providers; we are such providers and deserve the appropriate respect, recognition, and support from the healthcare community.

References 1. Loeb M. MarketWatch. The rise of the midlevel professional. http://finance.yahoo.com/career-work/arti cle/103122/The-Rise-of-the-Midlevel-Professional. Accessed June 15, 2010. 2. American College of Nurse Practitioners. What is a nurse practitioner? http://www.acnpweb.org/files/public/What _is_a_Nurse_Practitioner.pdf. Accessed November 19, 2010. 3. Allen PJ, Fennie KP, Jalkut MK. Employment characteristics and role functions of recent PNP graduates. Pediatr Nurs. 2008;34:151-158. 4. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283:59-68. 5. Newland JA. 2006 nurse practitioner salary & practice survey. Nurse Pract. 2006;31:39-43. 6. Pearson L. The Pearson report. The American Journal for Nurse Practitioners. 2008;12:9-80. 7. Roblin DW, Becker ER, Adams EK, et al. Patient satisfaction with primary care: does type of practitioner matter? Medical Care. 2004;42:579-590. 8. Agosta LJ. Patient satisfaction with nurse practitioner-delivered primary healthcare services. J Am Acad Nurse Pract. 2009;21:610-617. 9. Bauer JC. Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. J Am Acad Nurse Pract. 2010;22:228-231.

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“WHEN I HAVE AN ASTHMA ATTACK I FEEL LIKE A FISH WITH NO WATER.” –JESSE, AGE 5

ATTACK ASTHMA. ACT NOW.

1- 866 - NO -ATTACKS W W W. N O AT TA C K S . O R G CDDIS 10/01

Pulmonology

Bronchiolitis: What’s the Big Deal Anyway? Janette H. Prokop, MSN, APRN-C The Children's Hospital, Aurora, Colorado

ronchiolitis! It comes obstruction of airflow in the around every year at bronchioles, resulting in air roughly the same trapping. This in turn caustime. Along with influenza, es mismatched ventilation it is the cornerstone of what to perfusion ratio, also is referred to in pediatrics known as VQ ratio, and as “respiratory season.” Aloften leads to hypoxemia. though it is viral in etiology The upper airway obstrucwith a relatively low mortaltion from mucous can also ity rate, it causes a great deal cause hypoxia as it decreasof stress for parents and es the amount of oxygen Janette H. Prokop, MSN, APRN-C healthcare providers alike. that actually reaches the So what is the truth about lungs. Because infants are bronchiolitis, and what is the big deal obligate nose breathers, upper airway anyway? obstruction in younger infants can lead to decreased feeding, which can eventuThe Nuts and Bolts of the Illness ally result in dehydration. Bronchiolitis is an illness of infancy The course of illnesses is similar for and early childhood, occurring before most children. Symptoms last between the age of 2 years. Peak occurrence is 3 and 9 days, with the peak of the illness between 3 and 6 months of age. It is usually occurring on days 3 to 5. After more common in males, infants who this peak, most patients start showing have not been breast-fed, those living in gradual improvement of symptoms. crowded conditions, and those who Knowing the duration of illness is helpattend daycare, but it can affect any ful in determining treatment such as child. More than one-third of all chil- hospital admission, oxygen therapy, and dren in the United States develop this appropriate home care. Most patients illness during the first 2 years of life.1 Of who are started on home oxygen therathose children, approximately 1 in 10 py may only need to continue oxygen (10%) will be hospitalized. The number through the duration of the illness. of hospitalizations has increased from Some may need continued oxygen for 1% in the 1970s and is now the leading several weeks to months after the sympcause of hospitalization of children in toms have subsided. This is often due to this age group. underlying conditions or prematurity. Bronchiolitis is always viral in etiolo- Some children may go on to develop gy. Fifty percent to 80% of bronchiolitis secondary bacterial infections such as is caused by respiratory syncytial virus otitis media and pneumonia following (RSV); other viruses responsible in- bronchiolitis. clude human metapneumovirus, rhiHospitalization rates secondary to novirus, influenza, parainfluenza, aden- bronchiolitis continue to rise, and ovirus, and enterovirus. All of these some hypothesize that this is due to the cause similar symptoms such as fever, common use of pulse oximetry in nasal congestion and discharge, cough, screening patients, as hospitalizations and crackles and/or wheezing on lung most often occur due to the need for examination. Patients may also present oxygen therapy. From 1980-1996 it is with signs of increased work of breath- estimated that hospitalizations of ing such as tachypnea, nasal flaring, or infants younger than 6 months retractions. The American Academy of increased 239%.3 One study showed Pediatrics (AAP) guidelines has defined that patients had a longer stay in the bronchiolitis as “a constellation of clin- hospital for oxygen therapy despite ical symptoms and signs including a having normal oral intake and viral upper respiratory prodrome fol- improved work of breathing. Approxlowed by increased respiratory effort imately 26% of patients had an and wheezing in children less than 2 extended stay by 1.6 days due to continued oxygen therapy need based on years of age.”2 Just as the symptoms of bronchiolitis pulse oximetry readings.4 Although are the same regardless of the causative hospitalization rates have continued to viral agent, the pathophysiolgy is also increase over the past few decades, the similar. The illness starts as an upper mortality rate has remained low. Most respiratory infection, then over a few patients who do die of bronchiolitis days moves into the lower respiratory have an underlying condition such as tract. The lower bronchioles become prematurity, cardiopulmonary disease, inflamed and edematous as they are or immunosuppresion. Infants under infiltrated with leukocytes. As portions the age of 3 months are at greater risk of the epithelium become necrotic and of dying as they are more likely to have are sloughed off, plugs form that cause apnea due to the illness.

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To Test or Not to Test? Rapid testing for RSV is becoming more widely used. The rapid tests today have a sensitivity and specificity ranging between 80% and 90% depending on the type of test used.5 But how important is testing? Because the symptoms and duration of illness are similar regardless of the causative virus, determining the exact cause may not help with clinical decision making. Many parents like having a culprit to pin their child’s illness on, and telling them whether it is RSV can be comforting to them. However, it can also cause parents to worry unnecessarily. Some parents may not understand what RSV or bronchiolitis is. There have been many print and television ads urging parents to have their infants vaccinated against RSV. These ads don’t always do a good job of explaining what RSV is and instead focus on the rarely occurring bad outcomes. If parents know their child has RSV, they may equate this with those bad outcomes. It may be more advantageous for the clinician to spend the time educating the parents about bronchiolitis: its viral cause; the course of illness; and the warning signs of worsening illness they should watch for in their child at home, such as increased work of breathing and signs of dehydration.

There are currently no antiviral medications approved for treatment of the viruses responsible for bronchiolitis, with the exception of influenza in limited cases.

In some situations, testing for the causative agent can be helpful. In institutions where cohorting is still necessary, testing can be helpful in that children with the same virus can be put together rather than with other children who may infect them with a different virus. Testing can be very helpful when used in infants younger than 3 months who present with fever. This may save the child a full workup for sepsis (including blood draw, catheterization for urine and/or lumbar puncture) or unnecessary antibiotic treatment. However, a sepsis workup should not be spared in these children if the fever is abnormally high (greater than 40°C) or

if they are ill appearing. There is always the possibility of concurrent bacterial illness, although it is very small. Treatment Because bronchiolitis is a viral illness, antibiotics have no role in the treatment. There are currently no antiviral medications approved for treatment of the viruses responsible for bronchiolitis, with the exception of influenza in limited cases. The focus of the treatment should be on making sure the patient is maintaining adequate ventilation and oxygenation and is taking in sufficient amounts of oral fluids, and on making the patient as comfortable as possible. The most effective intervention parents can provide is proper nasal suctioning. Teaching parents how to properly suction their child’s nose using a bulb syringe and saline solution can be the most important tool you give them. Nasal suctioning is most helpful before feeding and before sleep to ensure the child is taking adequate fluids as well as resting. Remind parents that their child may tire more easily during feeds and may require smaller, more frequent feeds. When a patient’s oxygen saturation is not optimal for the altitude, hospitalization and oxygen therapy are required. Many primary care providers will manage patients on an outpatient basis while on low levels of oxygen (usually under 1 liter per minute [LPM]). With outpatient management, careful followup is key. The patients should return every few days for a check of their oxygen saturation. Parents must be reliable and educated on the disease and given careful return precautions. At The Children’s Hospital in Denver, patients between the ages of 3 and 18 months who have hypoxia due to bronchiolitis and can maintain saturation above 90% on 0.5 LPM of oxygen are observed for 8 hours to ensure that they can feed and sleep without a decrease in their oxygen saturation. After those 8 hours they may be discharged home on oxygen therapy. Discharge is based on factors such as whether they have a pediatrician, if there are smokers in the home, if the parents are reliable, etc. Children who do not have a regular pediatrician may not be safely managed at home and would benefit from hospitalization. Family dynamics, living situations, smokers in the home, and underlying medical conditions might also be a reason to hospitalize a patient who is requiring low-level oxygen therapy. Many nebulizer medications have been used to treat bronchiolitis. Continued on page 28

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Pulmonology Bronchiolitis...continued from page 27 Albuterol, Xopenex®, Atrovent®, and racemic epinephrine are often given in the hospital or office setting, and some are prescribed for home use. The AAP Subcommittee on Diagnosis and Management of Bronchiolitis does not recommend the use of bronchodilators for bronchiolitis. There are multiple studies evaluating the use of bronchodilators, and some show modest improvement in clinical scores and/or oxygen saturation. Other studies have shown improvement at 30 minutes after treatment but no significant changes 60 minutes out. Inpatient studies have shown no significant improvement to warrant routine use. These medications are not recommended because the cost and risk outweigh the benefits. Anticholinergics such as Atrovent have not shown any significant clinical benefits. Nebulized racemic epinephrine has been shown to offer slightly more improvement than albuterol. Racemic

epinephrine does not change the overall course of illness, and side effects can be much more serious than those seen with albuterol, so it is not prescribed as

Hospitalizations due to bronchiolitis remain the number one reason for hospitalizations in young children.

an outpatient medication. Corticosteroids are not recommended for routine bronchiolitis as the risk outweighs any benefits they may offer.1 Prevention can also play an important part of the treatment for premature infants or those with underlying medical conditions. Synagis® is a 5-dose

vaccine series that helps prevent RSV. It is usually administered every 28 to 30 days from November through March. So What Is the Big Deal? As bronchiolitis is a common childhood illness with a very low mortality rate, taking a minimalistic approach is sometimes the best way to treat. Medications prescribed for home use are of little or no benefit. Children may be easily managed at home if they have normal oxygen saturation levels and are feeding well. If managed at home, parents must be able to recognize worsening respiratory symptoms or signs of dehydration and know when to return to care. That being said, hospitalizations due to bronchiolitis remain the number one reason for hospitalizations in young children. It is difficult to determine if the number of hospitalizations is actually due to how ill the patients appear overall or their decreased oxy-

gen saturation level. More and more patients are being managed at home on supplemental oxygen, and this may be a trend for the future. Regardless of the ease of treatment and the relatively short length of the disease, it will continue to cause many visits to the emergency department, urgent care, and primary care office. References 1. Yorita KL, Holman RC, Sejvar JJ, et al. Infectious disease hospitalizations among infants in the United States. Pediatrics. 2008:121;244-252. 2. American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774-1793. 3. Shay DK, Holman RC, Newman RD, et al. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA. 1999;282:1440-1446. 4. Schroeder AR, Marmor AK, Pantell RH, et al. Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med. 2004;158:527-530. 5. Slinger R, Milk R, Gaboury I, et al. Evaluation of the QuickLab RSV test, a new rapid lateral-flow immunoassay for detection of respiratory syncytial virus antigen. J Clin Microbiol. 2004;42:3731-3733.

CARDIOLOGY

Congestive Heart Failure...continued from page 22 CHF often require admission for diuresis with IV agents that are then converted to oral agents prior to discharge. Careful attention to the patent’s volume status is essential. Parents should be directed to consult practitioners if symptoms change or worsen. Additionally, if the patient shows signs of dehydration or acute illness that decrease oral intake or increase fluid output such as diarrhea, parents should hold the next dose of diuretic and contact their practitioner. Spironolactone is a weak diuretic used as an adjunct to diuretics. It has the effect of sparing potassium that is wasted by loop diuretics. Adult studies have found a mortality benefit thought to be secondary to reduced cardiac remodeling. Cardiac contractility is most frequently supported in the decompensated state in the hospital setting. Common agents are dopamine and epinephrine. Mixed agents such as milrinone and dobutamine also provide the benefit of increased contractility and modest

venous and pulmonary dilation. Milrinone tends to be preferred since dobutamine has been found to be arrhythmogenic. Milrinone also serves to reduce afterload and promote pulmonary vasodilation. The oral agent digoxin appears to have some benefit, but its use is controversial and sometimes reflects institutional preferences. Contractility

Advances in CHF management and careful outpatient follow-up continue to offer infants and children with CHF improved quality of life, fewer hospitalizations, reduced need for cardiac transplant, and longer lives.

agents are frequently used in conjunction with preload-reducing agents in the acute CHF setting. Patients with profound CHF often require long-term contractility infusions while awaiting orthotopic heart transplantation. Afterload reduction works by

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decreasing the amount of work the heart must generate to deliver tissue perfusion. They are indicated in patients with large left-to-right shunts, aortic and mitral valvular regurgitation, and poor systolic function such as dilated cardiomyopathy. Angiotensin-converting enzyme (ACE) inhibitors are the most frequently used class of med-

ications for afterload reduction. Other agents such as hydralazine and nitroprusside are less frequently used in the inpatient setting. Beta blockade with either selective beta-1 activity (metoprolol) or a nonselective beta-1 and beta-2 blocker (carvedilol) has been used in adult patients with mild to moderate CHF. They act to reduce myocardial oxygen consumption and decrease myocardial work. Pediatric patients have been treated with beta blockade with encouraging results and experience. However, a recent study comparing carvedilol with placebo failed to show a reduction in either symptoms or mortality. CHF secondary to arrhythmias should be managed by a pediatric elec-

trophysiologist. Patients presenting in symptomatic complete heart block must be paced using Pediatric Advanced Life Support (PALS) protocols for transcutaneous pacing. An experienced intensivist or pediatric cardiologist can also place a transvenous pacing wire. Severe decompensated CHF may require additional circulatory support in the tertiary hospital setting. Extracoporeal membrane oxygenation therapy can augment tissue perfusion and oxygenation. Ventricular assist devices (VADs) can also be used to provide long-term support to patients awaiting cardiac transplantation. Future Direction Advances in CHF management and careful outpatient follow-up continue to offer infants and children with CHF improved quality of life, fewer hospitalizations, reduced need for cardiac transplant, and longer lives. It is our hope that the medical community will continue to evaluate, develop, and advance CHF therapies in the pediatric population. Resources Allen HD, Driscoll DJ, Shaddy RE, Feltes TE, eds. Moss and Adams’ Heart Disease in Infants, Children and Adolescents, Including the Fetus and Young Adult. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. Shaddy RE. Optimizing treatment for chronic congestive heart failure in children. Crit Care Med. 2001;29(10 Suppl):S237-S240. Rosenthal D, Chrisant MR, Edens E, et al. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant. 2004;23:1313-1333. Kay JD, Colan SD, Graham TP Jr. Congestive heart failure in pediatric patients. Am Heart J. 2001;142:923-928.

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Reader Survey

What Inspired You to Become a Pediatric Healthcare Professional?

ediatric NP/PA recently asked our online reading community to share with us their inspiration for becoming a pediatric healthcare professional. The response was overwhelming. It became abundantly clear to us that those involved in the field are passionate, caring, and extremely optimistic. We repeatedly read responses that included the words “blessing” and “love” – what wonderful sentiments, especially at this time of year. Below, we share with you excerpts from several of the responses. To view more responses, please visit us at www.pediatricNPPA.com.

I love children; their carefree approach to life and their upbeat attitude. It is infectious! Children always cheer me up. I am glad I am in a profession where I am surrounded by such positive energy. Jennifer Hartman, MSN, CPNP Chicago, Illinois Helping those who cannot help themselves boosts my heart and soul. Terri Hannan, PA-C Marshalltown, Iowa At the beginning of my junior year in high school, I experienced third-degree heart block. I endured a very lengthy period of observation, testing, invasive procedures and finally, a thoracotomy for pacemaker insertion. This experience made me want to become a member of such an amazing profession. Mary D. Joyce, RN, MS, CPNP Salt Lake City, Utah I have always loved babies and children and feel it is such a blessing to work with this population every day. I love their smiles and hugs and their refreshing outlook on life. Nancy Day, RN, MSN, CPNP Gainesville, Florida I was inspired to become a pediatric nurse practitioner because I love watching and helping children grow into adults. Working with children and families is a blessing in my life. Sara Husarik, MSN, CPNP Puyallup, Washington During my community health rotation I met and worked with a pediatric nurse practitioner who organized and worked at a newly developed school health clinic. Her autonomy, knowledge, and advanced skill level impressed and intrigued me so much even at that early stage of my career. I hope to inspire a future pediatric/advanced practice nurse. Lisa Romard, BSN, MS, PNP Sayville, New York My sister was born in 1977 with gastroschisis. She was in the NICU for over 4 months and I was only 6, but the memory of visiting her in that hospital is as vivid now as when it was happening. Watching her being taken care of by those dedicated NICU nurses was my first inspiration to become a pediatric nurse. I now love being a PNP! Stephanie Slater, RN, MSN, CPNP Georgetown, Texas

I have always loved children and wanted to do something to help make their lives better. Marai Valente, FNP Bristol, Tennessee Working with all pediatric ages is like nurturing a garden. It is great to see children grow and blossom! One gets to provide care not only for the infant/toddler/ child/adolescent or young adult but their parents too. Where else can one share in the family joys and hardships while teaching wellness and still have fun? Pat Ryan, BS, MS, APRN Enfield, New Hampshire I spent 10 years as a new nurse working in an adult rehabilitation unit in a major hospital while I raised my 4 children. As soon as I was able, I went back to school for my PNP degree. While I knew I made a difference in the lives of those I touched in rehab, I felt a much stronger calling to care for children and their families. The difference I can make in their futures inspired me to pursue my career as a PNP, and I have never looked back. It’s been 7 years since I graduated, and every day is a challenge, a blessing, and an opportunity to make a difference in the life of children and their families. Terry Kollenbroich, RN, MSN, CPNP Rochester, Wisconsin My Aunt Vicky; she was a nurse and loved working with kids! Amy Albert, RN, MSN, PNP Ann Arbor, Michigan Prior to being a PA, I was a nurse. As a nurse I was driven toward pediatrics, as children are forgiving and strong. I wanted to work in a clinical area where I was reminded that how we deal with life’s experiences all depends on our outlook. I wanted to regularly remember “how would a child deal with this,” as it gives me a completely different outlook on life. I love kids with all my heart, and somehow they seem to know that, which makes my job something that I love! Michelle Wasson, RN, CHA/PA-C Rapid City, South Dakota I enjoyed my pediatric rotation in nursing school and did my practicum on the peds floor. I was so inspired and in awe with the dedication, compassion, and big hearts displayed by some of the ped nurses during my practicum that it was an easy choice for me. Monica Busbee, RN, BSN Mobile, Alabama

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.

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The Gr wth Chart NeWS foR the AgeS

Babies

Toddlers

Risk of Overdose With Liquid Vitamin D The Food and Drug Administration (FDA) has warned parents and caregivers of the potential risk of overdosing when administering liquid vitamin D to infants. The problem involves droppers that can hold a greater amount of liquid vitamin D than an infant should receive. Vitamin D promotes calcium absorption and is essential for the development of strong bones. Vitamin D deficiency can lead to rickets (the development of thinning, soft, and misshaped bones). Liquid supplements are frequently recommended, especially for infants who are breast-fed. The FDA has issued the following recommendations to parents and caregivers: • Limit the daily dose of vitamin D to 400 IU • Keep the vitamin D supplement product in its original package; read and follow the package instructions carefully • Use only the original dropper • Make sure the vitamin D dropper is clearly marked with units of measurement that correspond to the instructions • If you cannot determine the dose delivered by the dropper, speak with a healthcare professional • If your child takes infant formula, check with your pediatric healthcare profes sional before giving your child vitamin D supplements In addition to the warning addressed to consumers, the FDA issued a letter to industry stating, “To reduce the likelihood of dosing errors, FDA recommends that 400 units be clearly and accurately marked on the dropper accompanying your product. In addition, for products intended for infants, FDA recommends that the dropper hold no more than 400 units.” Sources: http://www.fda.gov/forconsumers/consumerupdates/ucm214343.htm; http://www.fda.gov/Food/DietarySupple ments/GuidanceComplianceRegulatoryInformation/ucm215527.htm.

School-Age Kids

Preference for Moving Patterns May Be an Indicator of Autism in Toddlers

Researchers at the University of California, San Diego (UCSD) report that a strong preference for watching moving patterns may be an early indicator of autism spectrum disorder (ASD). Children with autism often perform repetitive movements or stare at spinning objects. Since early identification of risk factors is essential for early treatment of ASD, the UCSD study was designed to determine if toddlers with ASD prefer to look at dynamic geometric images more than social images, and whether such visual fixation can correctly identify ASD. During the study, 110 toddlers (37 with ASD, 22 with developmental delay, and 51 with typical development) between 12 and 42 months of age sat on their mother’s lap to watch a 1-minute film. On one side of the screen were moving geometric patterns from a computer screen saver and on the other side, dynamic social images of active children. Infrared light beam technology tracked eye movement. Karen Pierce, PhD, assistant director of the UCSD Autism Center of Excellence, and colleagues reported that 40% of toddlers with ASD, 9% of the developmentally delayed toddlers, and 2% of the typical toddlers preferred the geometric images. Thus, 60% of toddlers with ASD were similar to the other groups in preferring dynamic social images. However, Dr Pierce reported that “all of the toddlers who spent more than 69% of their time fixing their gaze on geometric images could be accurately classified as having an autism spectrum disorder or ASD.” The researchers concluded, “A preference for geometric patterns early in life may be a novel and easily detectable early signature of infants and toddlers at risk for autism.” Sources: http://health.ucsd.edu/news/2010/9-7-autism-spectrum-disorder.htm. http://www.ncbi.nlm.nih.gov/pubmed/ 20819977.

Teens

Chronic Abdominal Pain May Be Due to Fructose Intolerance

Sex Education for Teenagers in the United States

Children with recurrent abdominal pain may be fructose intolerant. According to a report presented at the American College of Gastroenterology (ACG) 75th Annual Scientific Meeting in San Antonio, Texas, by Daniel Lustig, MD, and Bisher Abdullah, MD, pediatric gastroenterologists with the Mary Bridge Children’s Hospital and Health Center in Tacoma, Washington, fructose intolerance, or fructose malabsorption, is common in children with recurrent or functional abdominal pain, but a low‐fructose diet is effective in managing the condition. The study included 245 patients with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea (150 female; 95 male; median age 11 years). According to the researchers, fructose intolerance is typically diagnosed by exclusion. After conditions such as Crohn’s disease and ulcerative colitis have been eliminated, the patient is given a hydrogen breath test. If the patient’s breath hydrogen is more than 20 points above baseline, the patient is likely to be fructose intolerant. The breath hydrogen test was performed in all 245 patients and was positive for fructose intolerance in 132 (53.9%). These children met with a registered dietician and were placed on a low‐fructose diet. Using a standard pain scale for children, 88 of the 132 patients (67.7%) reported resolution of symptoms on the low‐fructose diet. It can be a challenge to find low-fructose foods and maintain nutrition in a diet that patients will adhere to. “But the good news is that over half of patients who are fructose intolerant and are able to maintain a low‐fructose diet will notice an immediate improvement in their symptoms,” Dr Lustig said.

Using data from the 2006-2008 National Survey of Family Growth, the National Center for Health Statistics of the CDC recently reported on sex education among American teenagers 15 to 19 years of age. Researchers asked 2767 teenagers if they had received formal instruction at school, church, a community center, or other place before they were 18 years old on four topics of sex education: how to say no to sex, methods of birth control, STDs, and HIV/AIDS prevention. They were also asked the grade they were in when this instruction first occurred and whether they had talked to their parents before they were 18 about those four topics, as well as where to get birth control and how to use a condom. Researchers found that most teenagers in the US received formal sex education before they were 18 (96% of female and 97% of male teenagers). However, females were more likely than males to receive initial instruction on birth control methods in high school (47% vs 38%, respectively); younger females were more likely to have talked to their parents about sex and birth control; and nearly two out of three female teenagers talked to their parents about how to say no to sex compared with about two out of five males. Data from this survey indicate that parental communication about sex education is associated with delayed sexual activity among teenagers and increased birth control and condom use among those who are sexually active. Formal sex education can also be effective at reducing risky behaviors. About one-half of teenagers reported first receiving instruction on how to say no to sex, STDs, and HIV/AIDS prevention while in middle school. Most teenagers have talked to their parents about at least one of the six sex education topics surveyed. Female teenagers are more likely than males to talk to their parents about how to say no to sex, methods of birth control, and where to get birth control.

Source: http://www.acg.gi.org/media/releases/10ACG_FructoseIntoleranceKids.pdf.

Source: http://www.cdc.gov/nchs/data/databriefs/db44.pdf.

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december 2010 I VOL 1, NO 2

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