Transcript

Lee Tetreault:

Welcome to frequently asked questions from the session, Primary Care providers Guide to autism. We are joined by Doctor Bosco. Before we begin with these questions doctor, would you be able to reiterate a few key pointers from today's session to our audience?

Dr. Brosco:  

Sure, I think we decided to talk about autism today because although it's relatively rare only about one or 2% of kids have autism, it is something that comes up fairly frequently, with families. And so I wanna talk a little bit today about the primary care provider's role, in autism, and that really focuses on screening and early referral, and I think it's very important that everyone understands that it is the job of the primary care provider to recognize when a child has any concerns about development and make it immediately thorough, because we know that early intervention improves outcomes. In my talk, we spend a little time on diagnosis and treatment. Though that's really not so much the province of the primary care provider. We also do talk a little bit about vaccines because that is something that comes up fairly frequently, 'cause some parents still have worries about vaccines and autism, even though the research is very clear that there is no connection between the two.

Lee Tetreault:

Great, let's get into some questions. First, what do you do when the M-CHAT screening tool is abnormal but the child seems fine?

Dr. Brosco:  

Sure, for those of you who weren't part of having heard the talk already, the M-CHAT is one of the easiest ways to screen for autism in your office. And what I've often heard is that sometimes physicians and other primary care providers will see that the M-CHAT was positive. That means it is indicating a referral is necessary. But they see the child and they're not sure, and they don't really think that they need to send the child. And what I want folks to understand is that these screening tools are designed very specifically to say if there is a positive, really the child probably should be seen by a professional. Now, some of you are gonna have more experience than others and will feel comfortable ruling out things like autism on your own, but as a general rule, when a screen test is positive, it's probably the right thing to do is to have another professional evaluate the child.

Lee Tetreault:

When do you need to refer a child suspected with ASD to a neurologist?

Dr. Brosco:  

So child neurologists, have lots of expertise in, of course, Child Development and seizures and motor disorders. Some child neurologists also have a lot of expertise in autism, but some do not, and at least in some parts of the country, there is a general tendency that if it's a neurological condition that a neurologist should be the expert to see them. And again, that may be true, and depending on the specific child neurologist, in my experience though, many child neurologists see children in a regular doctor's office, and it's very hard to judge the behavior of a two or a three-year-old in a doctor's office. And so you often want to see these children where there is couch and a rug and toys and a chance to see the child play and interact. So, a neurologist can be most helpful when there's concerns about seizures, when there's regression, when there might be some medication complications. In terms of making the diagnosis, it tends to be pediatric psychologists and developmental behavioral pediatricians, who spend the most time trying to find out if a child has autism or not and what might be the best behavioral and educational interventions.

Lee Tetreault:

Do we still need to screen for anemia or lead, in all kids?

Dr. Brosco:  

So this is a question that comes up sometimes in the more general context of screening for developmental delay and the answer is, well, first of all, there are clear guidelines for the Marian Academy of Pediatrics and from the Centers of Disease Control CDC. So I would refer everyone to their websites to take a quick look at what their latest recommendations are regarding screening for anemia and screening for lead. I think a lot of people will recognize, lead is a major problem in some geographic areas and less of a problem in other geographic areas, and it is very reasonable for a primary care provider to say "I wanna check with my local department of health, I wanna see what the prevailing community standards are to decide where the screening for lead, that is a blood lead level, and every one and two-year-old is truly necessary."

Keep in mind, sometimes insurance requires that as part of your HEDIS measures. So you'll also wanna keep track of that. Similarly with anemia, there tends to be some variation depending on your geography in your patient population, and there's some recent research suggesting that anemia may not be the best way to notice that a child has iron deficiency, which of course is the reason why we're screening for anemia. So the bottom line is that there is probably some place for blood lead levels and blood hemoglobin levels in screening for anemia and to try to improve child development, but it's important to look closely at the guidelines and check in with your local health department to see if it's truly necessary in your area.

Lee Tetreault:

How you handle parents vaccines and refusal due to religious reasons, for example, the waiting room?

Dr. Brosco:  

I think all of us who have done primary care and give vaccines have had some families that prefer not to vaccinate their child and have concerns for a variety of reasons. As far as I know, there's not any major religion that's truly against vaccines although sometimes it sort of gets couched in religious or spiritual terms, regardless of why the family has concerns about vaxxing their child, if they refuse it always reads as a dilemma for us as physicians and primary care providers. I have to say that emotionally, my first response was, "Well then get out of my office. You can't do this, this is not good, it's not safe, it's not the right thing to do." And then as I reflect on it and talk to some of my colleagues, I realized that my patient is the child, it's not the family and the family may have views that disagree with mine, but at the end of the day my job is to make sure that child is safe, and that that child gets vaccinated, and it's probably true that the longer they spend coming to a practice like mine or yours and hear positive messages about vaccines, that child is ultimately more likely to get vaccinated. If we turn someone like that away or get too aggressive about it, then they're likely to end up in a place where they're not gonna hear pro-vaccine messages, and that child's likely never to be vaccinated.

And you actually, in some ways, get the family to dig in, against established medicine. I know that many of us then worry about what... What about in our waiting room? Suppose we... Some child exposes another child to some horrible condition and obviously that's a risk, right? I mean, if a child's not vaccinated against measles, and a child comes in with measles and you have a young baby there, that's an issue, but I'd also point out that that's really true, of the influenza as well. And that probably all of us should have some way of separating out kids who are sick when they come in, so they're not near a well baby. And I would push a little further and say, "We know that flu vaccine rates are probably 40 to 60% depending on how good you are in your practice". I don't think any of us would fire the other patients from our practice 'cause they weren't getting a flu vaccine. And yet we know that this is probably the most prevalent vaccine preventable condition around, so I think we should resist the urge to fire a patient that refuses vaccines and try to figure out ways to work with them, and make sure that the sick kids and the healthy kids are separated in our waiting areas, and our rooms.

Lee Tetreault:

If there's concerns about vaccines and childhood and severe side effects why are we not encouraging the parents to think about spacing the vaccines? Could it be that giving numerous vaccines to infants causes harm?

Dr. Brosco:   

So this is always the kind of question that you'll hear from a family, and let's take each of these different parts of them. The first is this thing about so many vaccines. In the old days, it was only a few vaccines, and now there's so many more. And that is true, certainly the number of vaccines has gone up, and that is a wonderful thing. I think some of you may be like me old enough to remember when H-flu and Pneumococcus were causing kids to have meningitis, and bacteremia, and we spent a lot of time learning about kids with fever. And really, that's not an issue anymore. So I think the first thing we need to recognize is that the increase in the number of vaccines has been an incredible boon to child health. Kids are so much healthy than they were before, and a lot safer, and while it's true that the number of vaccines has gone up, the number of antigens has actually reduced. So again, some of you may, like me, be old enough to remember when the old DTP used to cause lots of side effects 'cause it had hundreds of antigens. The number of antigens in the vaccines today is much smaller than much more refined and of course the number of antigens that a child is exposed to a vaccine are infinitesimal compared to how many antigens they're exposed to his babies in their every day lives.

So, yes, the number of vaccines has gone up, but the number of antigens has gone down and the safety of the vaccines has improved dramatically. You also get families asking about spacing out. Can we separate out individual ones? And what I often say to them, is that we know that when we give vaccines according to the schedule that they are safe and effective. If we start going against the schedule and lining them up in different ways and we honestly don't know, we don't know how they interact with each other and therefore, be less effective, or maybe interact with something else and be more dangerous. So, in some sense, if you wanna space out the vaccines or do your individual schedule, then in some sense you're experimenting with that child, 'cause we really don't know what the research shows. At the end of the day, what I typically say to families is, we know the giving vaccines according to the schedule is the best way to protect your child's health. So I don't say that vaccines are completely safe but I say they're the best way to protect your child's health.

Lee Tetreault:

This is great information. Doctor, thank you so much for your time.

Dr. Brosco:  

Thank you.



 

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