The Peds NP: Pearls of Pediatric Evidence-Based Practice

When accelerated BSN student Sam Mahaney wanted more practical bedside application of his knowledge of pediatric cardiology, we sat down to discuss the approach to assessment and management of undiagnosed and undifferentiated congenital heart disease from a primary care perspective.  The primary care clinician should be on the lookout for red flags in the history and physical exam that might suggest critical congenital heart disease and screen appropriately.  This episode has helpful perspectives for both the nurse and advanced practice provider.

References:

Abdurrahman, L., Bockoven, J. R., Pickoff, A. S., Ralston, M. A., & Ross, J. E. (2003). Pediatric cardiology update: Office-based practice of pediatric cardiology for the primary care provider. Current problems in pediatric and adolescent health care, 33(10), 318–347. https://doi.org/10.1016/s1538-5442(03)00137-8

CDC. (2022). Critical congenital heart defects. Retrieved from https://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html.

Cleveland Clinic. (2022). Cyanotic heart disease. Retrieved from https://my.clevelandclinic.org/health/diseases/22441-cyanotic-heart-disease

Glidewell, J., Grosse, S.D., Riehle-Colarusso, T., Pinto, N., Hudson, J., Daskalov, R., Gaviglio, A., Darby, E., Singh, S., & Sontag, M. (2019) Actions in support of newborn screening for critical congenital heart disease — United States, 2011–2018. Morbity and Mortality Weekly Report, 68:107–111. DOI: http://dx.doi.org/10.15585/mmwr.mm6805a3external icon

Mahle, W. T., Martin, G. R., Beekman, R. H., 3rd, Morrow, W. R., & Section on Cardiology and Cardiac Surgery Executive Committee (2012). Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics, 129(1), 190–192. https://doi.org/10.1542/peds.2011-3211

Martin, G. R., Ewer, A. K., Gaviglio, A., Hom, L. A., Saarinen, A., Sontag, M., Burns, K. M., Kemper, A. R., & Oster, M. E. (2020). Updated Strategies for Pulse Oximetry Screening for Critical Congenital Heart Disease. Pediatrics, 146(1), e20191650. https://doi.org/10.1542/peds.2019-1650

Puri, K., Allen, H. D., & Qureshi, A. M. (2017). Congenital Heart Disease. Pediatrics in review, 38(10), 471–486. https://doi.org/10.1542/pir.2017-0032

Strobel, A. M., & Lu, l. (2015). The Critically Ill Infant with Congenital Heart Disease. Emergency medicine clinics of North America, 33(3), 501–518. https://doi.org/10.1016/j.emc.2015.04.002

Infant dyschezia refers to the discomfort an infant experiences when bearing down against a closed anal sphincter, and is often misidentified as constipation by parents.  As long as red flags are absent, this functional, self-limited condition is easily diagnosed using the Rome IV Criteria.  In this episode, you will learn how to reassure parents and what contraindicated treatments should be discussed.  

References:

Children’s Wisconsin. (2020). Infants straining to move bowels. https://childrenswi.org/-/media/chwlibrary/publication-media-library/2020/03/30/20/48/2144en.pdf

LeLeiko, N. S., Mayer-Brown, S., Cerezo, C., & Plante, W. (2020). Constipation. Pediatrics in review, 41(8), 379–392. https://doi.org/10.1542/pir.2018-0334

Tabbers, M. M., DiLorenzo, C., Berger, M. Y., Faure, C., Langendam, M. W., Nurko, S., Staiano, A., Vandenplas, Y., Benninga, M. A., European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, & North American Society for Pediatric Gastroenterology (2014). Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of pediatric gastroenterology and nutrition, 58(2), 258–274. https://doi.org/10.1097/MPG.0000000000000266

Zeevenhooven, J., Koppen, I. J., & Benninga, M. A. (2017). The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric gastroenterology, hepatology & nutrition, 20(1), 1–13. https://doi.org/10.5223/pghn.2017.20.1.1

Vision screening is one of the most important preventative health screenings that a primary care provider does at well visits.  But the infant eye exam can feel obtuse and complicated if you don't understand vision development, physical exam maneuvers, and red flags for referral.  Because of the risk of significant amblyopia if ocular pathology is left untreated, every pediatric provider should know how to complete an age-appropriate vision screening in an infant.

References:

American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. (2012). Preferred practice pattern guidelines. Pediatric eye evaluations. American Academy of Ophthalmology.

Bell, A.L., Rodes, M.E., & Collier Kellar, L. (2013). Childhood eye examination. American Family Physician, 88(4), p. 241-248.

Brookman K. E. (1983). Ocular accommodation in human infants. American journal of optometry and physiological optics, 60(2), 91–99. https://doi.org/10.1097/00006324-198302000-00001

Loh, A.R., & Chiang, M.F. (2018). Pediatric vision screening. Pediatrics in Review, 39(5), 225-234.

Rosenfield, M. Development of accommodation in human infants. Retrieved from https://entokey.com/development-of-accommodation-in-human-infants/

Wang, J., & Candy, T. R. (2010). The sensitivity of the 2- to 4-month-old human infant accommodation system. Investigative ophthalmology & visual science, 51(6), 3309–3317. https://doi.org/10.1167/iovs.09-4667

With national formula shortages over 40% and growing, the pediatric provider can encourage the establishment and maintenance of breastfeeding in moms who have chosen this path.  Breastfeeding isn't without struggles and woes, so providers can help support mothers by understanding these tips based on breastfeeding physiology and advising the pair when the process isn't as easy as it seems.

References:

American Academy of Pediatrics. (2021). Breastfeeding overview. Retrieved from https://www.aap.org/en/patient-care/breastfeeding/breastfeeding-overview/

La Lache League. (2022). Breastfeeding info A to Z. Retrieved from https://www.llli.org/breastfeeding-info/

Laura R. Kair, Daniel Kenron, Konnette Etheredge, Arthur C. Jaffe, Carrie A. Phillipi (2013). Pacifier restriction and exclusive breastfeeding. Pediatrics, 131 (4): e1101–e1107. 10.1542/peds.2012-2203

Nice, F.J., & Francell, M. (2020). Selection and use of galactogogues. Leader Today. Retrieved from https://www.llli.org/selection-and-use-of-galactagogues-2/

Pisani, J. (2022). Why is there a baby formula shortage? What to know and what is being done about it. The Wall Street Journal. https://www.wsj.com/articles/why-baby-formula-shortage-11652188230

Thompson, D. (2022). What’s behind America’s shocking baby-formula shortage? The Atlantic. https://www.theatlantic.com/ideas/archive/2022/05/baby-formula-shortage-abbott-recall/629828

Two of the most common over-the-counter medications in pediatrics are not as simple and benign as you might think.  This episode uncovers the dark past of acetaminophen, the pearls and pitfalls of prescribing them, and how to talk to families about giving the medications safely.

References:

Clark, E., Plint, A.C., Correll, R., Gaboury, I., & Passi, B. (2007). A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics , 119 (3): 460–467. doi: 10.1542/peds.2006-1347

Jones, K., Engler, L., Fonte, E., et al. (2021). Opioid reduction through postoperative pain management in pediatric orthopedic surgery. Pediatrics, 148(6):e2020001487

Kleinman, K., McDaniel, L., & Molloy, M. (2021). The Harriet Lane handbook (the Johns Hopkins Hospital) (22nd ed.). Elsevier.

Miller, T.C. & Gerth, J. (2013). Dose of confusion. Propublica. https://www.propublica.org/article/tylenol-mcneil-fda-kids-dose-of-confusion

National Capital Poison Center. (2020). Poison statistics. https://www.poison.org/poison-statistics-national.

Sullivan, J.E., Farrar, H.C., & the Section on Clinical Pharmacology and Therapeutics, Committee on Drugs. (2011). Fever and antipyretic use in children. Pediatrics , 127(3): 580–587. doi: 10.1542/peds.2010-3852

Trippella, G., Ciarcià, M., de Martino, M., & Chiappini, E. (2019). Prescribing controversies: An updated review and meta-analysis on combined/alternating use of ibuprofen and paracetamol in febrile children. Frontiers in Pediatrics, 7:217. doi: 10.3389/fped.2019.00217.

Yin, H.S., Neuspiel, D.R., Paul, I.M., et al. (2021). Preventing home medication administration errors. Pediatrics,148(6): e2021054666

Children with acute gastroenteritis and mild or moderate dehydration can be managed at home with oral rehydration.  Learn how to partner with families and take an extra five minutes in your visit to explain the reasoning, detailed instructions, and expectations of home care as we discuss the evidence behind the rationale.  

References:

Carson, R.A., Mudd, S.S., & Madati, P.J. (2016). Clinical practice guideline for the treatment of pediatric acute gastroenteritis in the outpatient setting. Journal of Pediatric Health Care, 30(6), p. 610-616. http://dx.doi.org/10.1016/j.pedhc.2016.04.012

Carson, R.A., Mudd, S.S., & Madati, P.J. (2017). Evaluation of a nurse-initiated acute gastroenteritis pathway in the pediatric emergency department. Journal of Emergency Nursing, 43(5), p. 406-412. doi: 10.1016/j.jen.2017.01.001

Fedorowicz, Z., Jagannath, V. A., & Carter, B. (2011). Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. The Cochrane Collaboration, 9. doi: 10.1002/144651858.CD005506.pub5.

Freedman, S.B., Ali, S., Oleszczuk, M., Gouin, S., & Hartling, L. (2013). Treatment of acute gastroenteritis in children: An overview of systematic reviews of interventions commonly used in developed countries. Evidence-Based Child Health: A Cochrane Review Journal, 8, 1123-1137. doi: 10.1002/ebch.1932

Freedman, S. B., Gouin, S., Bhatt, M., Black, K. J., Johnson, D., Guimont, C.,…Plint, A. (2011). Prospective assessment of practice pattern variations in the treatment of pediatric gastroenteritis. Pediatrics, 127(2), e287-95. doi: 10.1542/peds.2010-2214

Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966–1974.

Hartman, S., Brown, E., Loomis, E., & Russell, H.A. (2019). Gastroenteritis in children. American Family Physician, 99(3), p. 159-165. PMID: 30702253.

Nir, V., Nadir, E., Schechter, Y., & Kline-Kremer, A. (2013). Parents’ attitudes toward oral rehydration therapy in children with mild-to-moderate dehydration. The Scientific World Journal, 2013, 1-3. http://dx.doi.org/10.1155/2013/828157

Schnadower, D., Tarr, P.I., Casper, T.C., Gorelick, M.H., Dean, J.M., O’Connell, K.J., Mahajan, P., Levine, A.C., Bhatt, S.R., Roskind, C.G., Powell, E.C., Rogers, A.J., & The PECARN Probiotics Study Group. (2018). Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. New England Journal of Medicine, 379(21), p. 2002-2014. doi: 10.1056/NEJMoa1802598

World Health Organization. (2005). The treatment of diarrhoea: A manual for physicians and other senior health workers. 2005. http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf. Accessed March 3, 2022.

The well visit is time to screen for issues in primary care, which includes diet and nutrition.  Picky eating is a common problem that often plagues parents, especially when parenting styles or child development clashes with recommended feeding practices.  Dr. John Lyles joins The Peds NP to discuss evaluation and recommendations for feeding difficulties in primary care. 

References:

Boruta, M.K.R., Lyles, J., Mavis, A.M., & Morgan, S. (in press). Pediatric gastrointestinal and liver disorders. In Encyclopedia of Child and Adolescent Health.

Kerzner, B., Milano, K., MacLean, W.C., Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2), p. 344-353. doi: 10.1542/peds.2014-1630

Menella, J.A., & Bobowski, N.K. (2015). The sweetness and bitterness of childhood: Insights from basic research on taste preferences. Physiology & Behavior, 152(0), p. 502-507. doi: 10.1016/j.physbeh.2015.05.015

Dr. Mansi Kotwal, Allergy and Immunology fellow at Johns Hopkins, joins The Peds NP podcast again to talk about a few dermatologic manifestations of allergy.  She discusses how history is an essential component of diagnosis and goes on to discuss management of these common and benign conditions in pediatrics.  

Season 5 of The Peds NP returns with an introduction to the first exam a person will ever get: The newborn exam.  This episode focuses on that first encounter from the prenatal and birth history to the exam and screenings.  Learn to concentrate on the unique features of a newborn and consider how to document the findings on this ever-changing patient.

References:

Chiocca, E. (2019). Advanced pediatric assessment (3rd ed.). Springer Publishing Company.

Hagan, J.F., Shaw, J.S., & Duncan, P. (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). American Academy of Pediatrics.

Maaks, D.L.G., Starr, N.B., Brady, M.A., Gaylor, N.M., Driessnack, M., & Duderststadt, K.G. (2019). Burn’s Pediatric Primary Care (7th ed.). Saunders Elsevier.

Provider variation has plagued the management of febrile neonates for decades, but the wait for standardization is over!  The AAP published its long-awaited recommendations on the evaluation and management of well-appearing febrile infants 8 to 60 days old in August 2021.  This episode picks apart the nuances and key features to help pediatric providers provide fast, safe, and effective care to this population.  Follow along with full guideline available at https://doi.org/10.1542/peds.2021-052228

 

References:

Pantell, R.H., Roberts, K.B., Adams, W.G., Dreyer, B.P., Kupperman, N., O’Leary, S.T., … & Subcommittee on Febrile Infants. (2021). Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics, 148(2), p. 1-38. https://doi.org/10.1542/peds.2021-052228