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AAFP Journal Review. Karam Makhni. Health Maintenance in School-aged Children: History, Physical Examination, Screening, and Immunizations. The aim of the well-child examination in school-aged children is to promote health and prevent future health problems.
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AAFP Journal Review Karam Makhni
Health Maintenance in School-aged Children: History, Physical Examination, Screening, and Immunizations • The aim of the well-child examination in school-aged children is to promote health and prevent future health problems. • Lack of time limits provision on preventive care. • This section focuses on history, physical examination and screening for health maintenance in school-aged children
History • A complete well-child examination history includes multiple screening questions. • Social history, living situation and lifestyle habits, can be particularly important in this age group • Important to inquire about safety habits and the presence of firearms in the home. • Consider giving a questionnaire to the family to complete before the visit.
Physical Examination • A full physical examination should be performed during any health maintenance visit. • Abnormality found in less than 4 percent of patients, and most of these abnormalities are not clinically significant. • More than 1 million abused children are identified annually in the United States.
Screening Recommendations for School-aged Children and Adolescents
Supplements • VITAMIN D • Inadequate vitamin D levels are associated with a wide range of conditions • Studies have shown that up to 50 percent of children are vitamin D deficient • The AAP recommends 400 IU of vitamin D daily for all • There are no clear guidelines for screening for vitamin D deficiency in children.
Supplements • Children six months to 16 years of age living in areas with inadequate fluoride in the water supply should be counseled on fluoride supplementation.
Immunizations • Two sets of immunizations recommended for school-aged children. • In addition to these primary vaccines, the influenza virus vaccine is recommended annually for all children older than six months. • Certain high-risk groups may need additional vaccines. At every well-child visit, the immunization record should be reviewed to ensure that catch-up immunizations are not needed. • Nationally, there is a high level of vaccine completion for the four- to six-year-old vaccines. • Completion rates for vaccines recommended in early adolescence are significantly less, • Less than 20 percent completing the human papillomavirus vaccine series. • physicians should adopt strategies to increase immunization completion in their patients.
Health Maintenance in School-aged Children: Counseling Recommendations • Anticipatory guidance is appropriate at all ages, but it is particularly important in school-aged children • Focus on counseling recommendations • There is little evidence to suggest the best methods for health counseling in school-aged children • School aged children are concrete thinkers • Discuss high risk behaviours
Screening and Counseling Recommendations for School-aged Children and Adolescents
Screening and Counseling Recommendations for School-aged Children and Adolescents
Counseling • Well-child visits for school-aged children are typically conducted with a parent present. • Discussions about sensitive issues, such as substance use and sexual activity, should occur without the parent in the room.
DIETARY COUNSELING • Poor definitive evidence on how to best advise patients and families. • The most effective are comprehensive behavioral interventions • Most experts recommend providing some dietary counseling to children and their families at the well-child examination focusing • Families should also be advised to limit sugary beverages, fast food, and highly processed foods, and be educated on appropriate portion sizes.
NIH Recommendations for Physical Activity in School-aged Children • At least 60 minutes of physical activity per day • Moderate-intensity aerobic activity, such as walking, running, skipping, playing on the playground, playing basketball, and biking, on most days • Vigorous-intensity aerobic activity, such as running, doing jumping jacks, and swimming fast, at least three days per week • Muscle-strengthening activities, such as climbing trees, playing tug-of-war, and doing push-ups and pull-ups, at least three days per week • Bone-strengthening activities, such as hopping, skipping, doing jumping jacks, playing volleyball, and working with resistance bands, at least three
Screen Time • The average child spends 7.5 hours per day in front of a screen • Obesity rates are lowest in children who have less than one hour of screen time daily, and are highest in those who have greater than four hours of screen time daily. • Screen time may also negatively affect body image and school performance, and promote violent behavior. • Physicians should counsel families to limit screen time, and encourage children to replace screen time with physical activity. • The AAP recommends limiting screen time to no more than one to two hours of quality programming daily.
High-Risk Behaviors • Tobacco, alcohol, and illicit drug use may begin in early adolescence. • According to a 2007 survey of youth in the United States, 24 percent of those younger than 13 years had had their first drink of alcohol, 15 percent had smoked an entire cigarette, and 8 percent had tried marijuana. • The effectiveness of physician counseling in this area is unknown. • The AAP recommends asking adolescents directly about tobacco alcohol, and drug use annually beginning at 11 years of age. • If the patient reports substance use, additional questioning on duration, amount, and frequency is appropriate
High Risk Behavior • The CRAFFT (car, relax, alone, forget, friends, trouble) questionnaire is one brief screening tool that has been validated in the primary care setting to identify substance abuse in adolescents • Have you ever ridden in a car driven by someone who was “high” or had been using alcohol or drugs? • Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? • Do you ever use alcohol or drugs when you are by yourself? • Do you ever forget things you did while you were using alcohol or drugs? • Do your family or friends ever tell you that you should cut down on your drinking or drug use? • Have you ever gotten into trouble while you were using alcohol or drugs? • Physicians would give one point for each “yes” answer to the previous questions. A score of 2 or more should prompt concern for substance abuse or dependence
Differentiation and Diagnosis of Tremor • Tremor is an involuntary, rhythmic, oscillatory movement of a body part. • It is the most common movement disorder encountered in clinical practice. • There is no diagnostic standard to distinguish among common types of tremor • History and physical examination can provide a great deal of certainty in diagnosis. • The most common tremor in patients presenting to primary care physicians is enhanced physiologic tremor, followed by essential tremor and parkinsonian tremor. • All tremors are more common in older age
Broad Classification of Tremor • Action -Occurs with voluntary contraction of muscle. Includes postural, isometric, and kinetic tremors • Postural - Occurs when the body part is voluntarily maintained against gravity. Includes essential, physiologic, cerebellar, dystonic, and drug-induced tremors • Kinetic- Occurs with any form of voluntary movement. Includes classic essential, cerebellar, dystonic, and drug-induced tremors • Intention-Subtype of kinetic tremor amplified as the target is reached.Presence of this type of tremor implies that there is a disturbance of the cerebellum or its pathways • Rest- Occurs in a body part that is relaxed and completely supported against gravity. Most commonly caused by parkinsonism, but may also occur in severe essential tremor
Tremors • http://www.youtube.com/watch?v=xVRKO-Sz0x4 • http://www.youtube.com/watch?v=GQm8klm6ub8 • http://www.youtube.com/watch?v=DaIN2zRQn8w
ESSENTIAL TREMOR • The most common pathologic tremor is essential tremor. • In one-half of cases, it is transmitted in an autosomal dominant fashion, and it affects 0.4 to 6 percent of the population. • Careful history reveals that patients with essential tremor have it in early adulthood (or sooner), but most patients do not seek help for it until 70 years • Despite being sometimes called “benign essential tremor,” essential tremor often causes severe social embarrassment, and up to 25 percent of those afflicted retire early or modify their career path • Essential tremor is an action tremor, usually postural, but kinetic and even sporadic rest tremors have also been described. It is most obvious in the wrists and hands when patients hold their arms out • It is generally bilateral, is present with a variety of tasks, and interferes with activities of daily living.
DRUG- AND METABOLIC-INDUCED TREMORS • Dozens of medications can cause or exacerbate tremor • Patients with new-onset tremor should have a comprehensive medication review with specific attention to medications prescribed and over-the-counter • Medications particularly prone to inducing or exacerbating tremor are those that stimulate the sympathetic nervous system (e.g., amphetamines, terbutaline, pseudoephedrine) and psychoactive medications (e.g., tricyclic antidepressants, haloperidol, fluoxetine [Prozac]). • Metabolic causes of tremor are varied.8 Initial workup of tremor may include blood testing for hepatic encephalopathy, hypocalcemia, hypoglycemia, hyponatremia, hypomagnesemia, hyperthyroidism, hyperparathyroidism, and vitamin B12 deficiency
Selected Medications and Substances That May Exacerbate Tremor • Amphetamines • Atorvastatin (Lipitor) • Beta-adrenergic agonists (e.g., albuterol) • Caffeine • Carbamazepine (Tegretol) • Corticosteroids • Cyclosporine (Sandimmune) • Epinephrine • Fluoxetine (Prozac) • Haloperidol • Hypoglycemic agents • Lithium • Metoclopramide (Reglan) • Methylphenidate (Ritalin) • Pseudoephedrine • Terbutaline • Theophylline
PSYCHOGENIC TREMOR • Differentiation of organic from psychogenic tremor can be difficult. • Features consistent with psychogenic tremor are abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction. • Often, there is an associated stressful life event. • Based on clinical experience, the prevalence of psychogenic tremor is thought to be high, but there are no precise estimates.
Physiological Tremor • A physiologic tremor is present in all persons • It is a low-amplitude, high-frequency tremor at rest and during action that is not reported as symptomatic. • This tremor can be enhanced by anxiety, stress, and certain medications and metabolic conditions. • Patients with a tremor that comes and goes with anxiety, medication use, caffeine intake, or fatigue do not need further testing.
Diagnostic Approach • The diagnosis of tremor is based on clinical information obtained from a thorough history and physical examination. Although there is overlap and variability among the individual tremor syndromes, the intrinsic features of the tremor usually provide key diagnostic clues • The first step in the evaluation of a patient with tremor is to categorize the tremor based on its activation condition, topographic distribution, and frequency. The activation condition should be described as rest, kinetic (or intention), postural, or isometric • The examiner can have the patients sit with their hands in their laps to check for rest tremor. A sequential test for postural and kinetic tremors can be done by having the patient stretch his or her arms and hands out, followed by a simple finger-to-nose test. • A rest tremor is virtually synonymous with parkinsonism, whereas an intention tremor often indicates a cerebellar lesion. • Several historical clues can play important roles in the differentiation of tremors Tremor in older patients is more likely to be parkinsonian or essential tremor. Patients with sudden onset of tremor should be evaluated to determine if the tremor is caused by medications, toxins, a brain tumor, or a psychogenic cause. Patients with a gradual onset of tremor should prompt questions about Parkinson disease.
Transfusion of Blood and Blood Products: Indications and Complications • Blood transfusion can be a lifesaving procedure, but it has risks, including infectious and noninfectious complications. There is debate in the medical literature concerning the appropriate use of blood and blood products. Clinical trials investigating their use suggest that waiting to transfuse at lower hemoglobin levels is beneficial.1,2 This review will consider the indications for transfusion of blood and blood products, and will discuss common noninfectious complications associated with transfusion
Red Blood Cells • Packed red blood cells (RBCs) are prepared from whole blood by removing approximately 250 mL of plasma. One unit of packed RBCs should increase levels of hemoglobin by 1 g per dL (10 g per L) and hematocrit by 3 percent. In most areas, packed RBC units are filtered to reduce leukocytes before storage, which limits febrile nonhemolytic transfusion reactions (FNHTRs), and are considered cytomegalovirus safe • RBC transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues. Transfusion of RBCs should be based on the patient's clinical condition.4 Indications for RBC transfusion include acute sickle cell crisis (for stroke prevention), or acute blood loss of greater than 1,500 mL or 30 percent of blood volume.4 Patients with symptomatic anemia should be transfused if they cannot function without treating the anemia.4 Symptoms of anemia may include fatigue, weakness, dizziness, reduced exercise tolerance, shortness of breath, changes in mental status, muscle cramps, and angina or severe congestive heart failure. The 10/30 rule—transfusion when a patient has a hemoglobin level less than or equal to 10 g per dL (100 g per L) and a hematocrit level less than or equal to 30 percent—was used until the 1980s as the trigger to transfuse, regardless of the patient's clinical presentation.4,5 • In 1999, a randomized, multicenter, controlled clinical trial evaluated a restrictive transfusion trigger (hemoglobin level of 7 to 9 g per dL [70 to 90 g per L]) versus a liberal transfusion trigger (hemoglobin level of 10 to 12 g per dL [100 to 120 g per L]) in patients who were critically ill.1 Restrictive transfusion practices resulted in a 54 percent relative decrease in the number of units transfused and a reduction in the 30-day mortality rate. The authors recommended transfusion when hemoglobin is less than 7 g per dL, and maintenance of a hemoglobin level between 7 to 9 g per dL.1 A recently updated Cochrane review supports the use of restrictive transfusion triggers in patients who do not have cardiac disease.6
Red Blood Cells • similar study was carried out in critically ill children.2 The restrictive transfusion trigger was a hemoglobin level of 7 g per dL, with a target level of 8.5 to 9.5 g per dL (85 to 95 g per L). The liberal transfusion trigger was a hemoglobin level of 9.5 g per dL, with a target level of 11 to 12 g per dL (110 to 120 g per L). Patients in the restrictive group received 44 percent fewer blood transfusions, with no difference in rates of multiple organ dysfunction syndrome or death. The restrictive transfusion strategy is useful for children who are stable patients in intensive care. It should not be used in preterm neonates or in children with severe hypoxemia, active blood loss, hemodynamic instability, or cyanotic heart disease.2
Plasma • Plasma products available in the United States include fresh frozen plasma and thawed plasma that may be stored at 33.8 to 42.8°F (1 to 6°C) for up to five days. Plasma contains all of the coagulation factors. Fresh frozen plasma infusion can be used for reversal of anticoagulant effects. Thawed plasma has lower levels of factors V and VIII and is not indicated in patients with consumption coagulopathy (diffuse intravascular coagulation). • Plasma transfusion is recommended in patients with active bleeding and an International Normalized Ratio (INR) greater than 1.6, or before an invasive procedure or surgery if a patient has been anticoagulated.7,8 Plasma is often inappropriately transfused for correction of a high INR when there is no bleeding. Supportive care can decrease high-normal to slightly elevated INRs (1.3 to 1.6) without transfusion of plasma. Table 1 gives indications for plasma transfusion
Platelets • Platelet transfusion may be indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects. • Contraindications to platelet transfusion include thrombotic thrombocytopenic purpura and heparin-induced thrombocytopenia • Transfusion of platelets in these conditions can result in further thrombosis.10,11 One unit of apheresis platelets should increase the platelet count in adults by 30 to 60 × 103 per μL (30 to 60 × 109 per L).3 In neonates, transfusing 5 to 10 mL per kg of platelets should increase the platelet count by 50 to 100 × 103 per μL (50 to 100 × 109 per L).12 One apheresis platelet collection is equivalent to six pooled random donor platelet concentrates
Cryoprecipitate • Cryoprecipitate is prepared by thawing fresh frozen plasma and collecting the precipitate. Cryoprecipitate contains high concentrations of factor VIII and fibrinogen. Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy. • Each unit will raise the fibrinogen level by 5 to 10 mg per dL with the goal of maintaining a fibrinogen level of at least 100 mg per dL. The usual dose in adults is 10 units of pooled cryoprecipitate.
Transfusion Complications • Transfusion-related complications can be categorized as acute or delayed, which can be divided further into the categories of noninfectious and infectious. • Acute complications occur within minutes to 24 hours of the transfusion, whereas delayed complications may develop days, months, or even years later. • Transfusion-related infections are less common because of advances in the blood screening process; the risk of contracting an infection from transfusion has decreased 10,000-fold since the 1980s. • Noninfectious serious hazards of transfusion are up to 1,000 times more likely than an infectious complication. However, there has been no progress in preventing noninfectious serious hazards of transfusion, despite improvements in blood screening tests and other related medical advances. Therefore, patients are far more likely to experience a noninfectious serious hazard of transfusion than an infectious complication.
Hemolytic transfusion reactions are caused by immune destruction of transfused RBCs, which are attacked by the recipient's antibodies. The antibodies to the antigens of the ABO blood group or alloantibodies to other RBC antigens are produced after immunization through a previous transfusion or pregnancy. There are two categories of hemolytic transfusion reactions: acute and delayed. Nonimmune causes of acute reactions include bacterial overgrowth, improper storing, infusion with incompatible medications, and infusion of blood through lines containing hypotonic solutions or small-bore intravenous tubes.16,18,19 • In acute hemolytic transfusion reactions, there is a destruction of the donor's RBCs within 24 hours of transfusion. Hemolysis may be intravascular or extravascular. The most common type is extravascular hemolysis, which occurs when donor RBCs coated with immunoglobulin G (IgG) or complement are attacked in the liver or spleen.17 Intravascular hemolysis is a severe form of hemolysis caused by ABO antibodies. Symptoms of acute hemolytic transfusion reactions include fever, chills, rigors, nausea, vomiting, dyspnea, hypotension, diffuse bleeding, hemoglobinuria, oliguria, anuria, pain at the infusion site; and chest, back, and abdominal pain.19 Associated complications are clinically significant anemia, acute or exacerbated renal failure, disseminated intravascular coagulation, need for dialysis, and death secondary to complications.18 • The incidence of acute hemolytic reactions is approximately one to five per 50,000 transfusions.19 From 1996 to 2007, there were 213 ABO-incompatible RBC transfusions with 24 deaths.17 Systems using bar codes for blood and patient identification have decreased errors.17
ALLERGIC REACTIONS • Allergic reactions range from mild (urticarial) to life threatening (anaphylactic). Urticarial allergic reactions are defined by hives or pruritus.20 Patients experiencing allergic transfusion reactions have been sensitized to the antigens in the donor unit. These antigens are soluble, and the associated reaction is dose-dependent. Allergic transfusion reactions occur in 1 to 3 percent of transfusions.16 • Patients with anaphylactic transfusion reactions, like those with urticarial reactions, may present with hives, but they are distinct in that they also develop hypotension, bronchospasm, stridor, and gastrointestinal symptoms.16 Anaphylaxis occurs in response to a recipient's presensitization to a variety of proteins in donor plasma. For example, anaphylaxis occurs because of donor IgA being infused into a recipient who is IgA deficient and has preexisting circulating anti-IgA.17 In addition, anti–human leukocyte antigen (HLA) antibodies and anticomplement antibodies have been linked to anaphylactic reactions, which are estimated to occur in one in 20,000 to 50,000 transfusions • Prevention of anaphylactic transfusion reactions includes avoiding plasma transfusions with IgA in patients known to be IgA deficient. Cellular products (e.g., RBCs, platelets) may be washed to remove plasma in patients with an IgA deficiency.16 The best precaution is observation of the patient during the initial 15 minutes of transfusion.
FEBRILE NONHEMOLYTIC TRANSFUSION REACTIONS • An FNHTR is defined as a rise in body temperature of at least 1.8°F (1°C) above 98.6°F (37°C) within 24 hours after a transfusion; it may involve rigors, chills, and discomfort.10 The fever occurs more often in patients who have been transfused repeatedly and in patients who have been pregnant.25 Leukoreduction, which is the removal or filtration of white blood cells from donor blood, has decreased FNHTR rates.26 FNHTRs are caused by platelet transfusions more often than RBC transfusions and have an incidence that ranges from less than 1 percent to more than 35 percent. • Two mechanisms have been proposed to explain FNHTRs: a release of antibody-mediated endogenous pyrogen, and a release of cytokines. Common cytokines that may be associated with FNHTRs include interleukin-1, interleukin-6, interleukin-8, and tumor necrosis factor.25 FNHTR is a diagnosis of exclusion that can be made only after ruling out other causes of fever (e.g., hemolysis, sepsis).
TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD • Transfusion-associated circulatory overload is the result of a rapid transfusion of a blood volume that is more than what the recipient's circulatory system can handle. It is not associated with an antibody-mediated reaction. Those at highest risk are recipients with underlying cardiopulmonary compromise, renal failure, or chronic anemia, and infants or older patients.17 Signs and symptoms include tachycardia, cough, dyspnea, hypertension, elevated central venous pressure, elevated pulmonary wedge pressure, and widened pulse pressure. Cardiomegaly and pulmonary edema are often seen on chest radiography • The diagnosis is made clinically, but may be assisted by measuring brain natriuretic peptide levels, which are elevated in response to an increase in filling pressure.28 A study comparing patients who have transfusion-associated circulatory overload with patients who have TRALI found significantly greater levels of brain natriuretic peptide in those with transfusion-associated circulatory overload.28 Transfusion of lower volumes or at a slower rate may help prevent it.16 The treatment is diuresis to decrease volume overload.
