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Transcript

Lee Tetreault:

Hello, and welcome to frequently asked questions from the session, Medical Literature Updates: Pediatric Highlights from 2018 and 2019. We are joined today by Dr. Tommy Latimer. Doctor, welcome.

Tomitra Latimer:

Thank you.

Lee Tetreault:

And before we get started doctor, can you go into a little bit of an overview of what the session entail today, and then some of your own background? 

Tomitra Latimer:

Sure, so I'll start first with, I'm the Medical Director of a primary care clinic, at Lurie Children's, it's called Lurie Children's Pediatrics, and it's in the Lincoln Park location. And I was asked to provide updates, medical literature, in pediatric literature. And really, I phrase the question of, "Are you choosing wisely?" And some key pointers from my session was, were PPIs are not effective in infants less than one year of age, we should be checking the blood pressure starting at three years of age for preventive visits, and then universal HIV screening is advised for all adolescents between 16 and 18 years of age.

Lee Tetreault:

That's great. Let's get into some of these frequently asked questions from the session, doctor. First, what would you tell parents who have an infant spitting up for reflux symptoms? 

Tomitra Latimer:

I would first just get a careful history about how frequent they're feeding, the volume. I would go over the growth chart. I would assess for any red flags like choking or turning blue or difficulty feeding, and if everything looked really good, in particular the growth chart, then I would provide reassurance. I think a lot of parents have read that PPIs and H2 blockers will help my baby that's spitting up, and I think it's our role as clinicians to provide reassurance, to talk about these side effects of H2 blockers and PPIs. And also to mention that they're not effective, they're not approved for infants less than one, and what can we do to help their happy spitter and reassure the parents and help guide them through this kind of challenging period and it can be distressing. And so I would recommend offering smaller, more frequent feeds, avoiding prolonged periods in the car seat, and also just re-emphasizing that this is a temporary condition, this will pass, it tends to peak around four or five months of age, and really, by the time the infant is one year of age, and even sooner, 'cause you're starting solid foods, that symptoms of reflux will no longer be present.

Lee Tetreault:

What do you do if the blood pressure percentile is greater than the 90th percentile? 

Tomitra Latimer:

And so, this is a new guideline for the American Academy of Pediatrics that came out in 2017, and if the blood pressure is elevated, then the blood pressure should be repeated two times, and then average it. And it's probably easier to do oscillatory method, you can't do oscillometric, but if the blood pressure is elevated, greater than 90th when you average them, then you're gonna be forced to do the oscillatory method. So, it's probably easier to just stick to the oscillatory method, times two. The patient should be seated, feet flat on the floor, back supported, appropriate size cuff and the arms should be supported at the level of the heart. And then after that, then you can classify, "Oh, it's elevated blood pressure," if it's greater than 90th. If it's greater than the 95th, then that might support a classification of stage one hypertension or stage two, and that leads you to different recommendations.

Lee Tetreault:

The AAP recommends universal screening of HIV, 16 to 18 years of age for all adolescents, but how do you perform this in a confidential manner? 

Tomitra Latimer:

It's a great question. And first of all, the question, the adolescent psychosocial assessment should be done without the parent in the room. And then if they fit the age to obtain HIV at 17 years of age, then at the completion of the visit, regardless of whether they've said that they are having sex or they've had sex or they've been tested, I say, "You know, according to the guidelines, we want you to be safe and so I'm gonna recommend that we test you for HIV."

Lee Tetreault:

Can you speak to the importance of modified Centor score in the ER setting? 

Tomitra Latimer:

So the modified Centor score is based on the Centor score, but it's validated in children because there's an age component. And you get a series of, a point for each symptom so absence of cough is one point, fever is one point, age three to 14, and if you have tonsillar exudate. And then based on that score, if you have a score of two or greater, then that should prompt you to do a rapid strep. The whole point of the modified Centor is really to help guide the clinician either in the emergency room or ambulatory setting to, "Hey, is it appropriate to do a rapid strep?" And if the score is zero or one, it really, should really help make the clinician feel comfortable that there is no need to do a rapid strep, or any kind of confirmatory tests. And if the rapid strip is negative, then that should force the clinician to do a confirmatory test, which is either a throat culture or the DNA assay.

Lee Tetreault:

What is the antibiotic of choice for group A strep pharyngitis? 

Tomitra Latimer:

The antibiotic of choice is amoxicillin or penicillin. There was a study that looked at penicillin twice a day, and amoxicillin once a day, and it found that amoxicillin for the treatment of strep pharyngitis once a day, 50 mg per kilo is non-inferior. And so, I routinely prescribe amoxicillin especially for my younger children because it comes in a liquid, the flavor profile is superior to penicillin, which doesn't taste so good. It's a once-a-day medication versus twice, so that really, I think aids in adherence, which is very important because usually the child is feeling much better at day one or two, and maybe the parent might be inclined to discontinue, but it's important that they complete 10 days fully to prevent rheumatic heart disease.

Lee Tetreault:

So, if you treat group A strep pharyngitis, will that prevent rheumatic heart disease and acute glomerulonephritis? 

Tomitra Latimer:

So, yes and no. The treatment of group A strep with the appropriate antibiotics, amoxicillin or penicillin can prevent rheumatic heart disease, which is a low incidence in the US, but we can't see it. But the treatment of group A strep pharyngitis does not, does not prevent acute glomerulonephritis, only rheumatic heart disease.

Lee Tetreault:

This is great information, doctor. Thank you so much for your time today.

Tomitra Latimer:

Thank you.