Charting Pediatrics

Today Robert Fuhlbrigge, MD joins us to discuss the 10 most common pediatric rheumatology diagnoses. Dr. Fuhlbrigge is the Chair of Rheumatology at Children's Colorado and professor of pediatrics and rheumatology at the University of Colorado School of Medicine.

In this episode:

• What swollen joints can indicate when assessing potential diagnoses in the realm of rheumatology
• The most common identifier in determining a systemic problem
• The role of morning stiffness in the differential diagnosis
• The difference between mechanical pain and inflammatory disorders
• Defining how helpful an elevated ANA is in treating a patient with Lupus
• Outlining the best tests for inflammation: CSR, CSR and ANA
• Why rheumatologists find unexpected fevers in children interesting
• Unexplained weakness and what it means
• Which rashes may indicate that it's necessary to refer to rheumatology
• The role fatigue plays in the rheumatology world
• Usefulness of radiology studies, MRI, CT and other imaging modalities
• Helpful apps clinicians use for rheumatological diseases today
• The role of genetics and development in rheumatological diseases

Today on the podcast, Dave Scudamore, MD, joins us to talk about neonatal jaundice. Dr. Scudamore is the Director of Inpatient Medicine for the Network of Care at Children's Colorado, and he is also an assistant professor of pediatrics in hospital medicine at the University of Colorado School of Medicine.

In this episode:

• The major risk factors for severe jaundice that can cause complications with neonates
• How to assess mom and baby for the risk factors of neonatal jaundice by reviewing patient history and birth data
• Difference between the risk factors for elevated bilirubin and the risk factors for neurotoxicity
• The significance of the ratio between albumin and bilirubin
• Standard protocols for bilirubin workups and monitoring for risk factors
• How you can provide elevated patient care by using a patient-centered care approach and considering the context of the case
• The way to utilize the Bhutani curve to assess risk and the AAP guidelines to initiate phototherapy
• Understanding the importance of follow ups and their role in intervention

With us today is Matthew Greenhawt, MD, associate professor of pediatrics and allergy at the University of Colorado School of Medicine. Dr. Greenhawt discusses hot topics surrounding food-related allergies, including the early introduction of peanuts.

In this episode:

• What initial steps to take before referring patients to an allergist
• The importance of getting a complete patient history to diagnose food allergies
• Tools primary care providers can utilize in the diagnostic process
• Why the presence of IGE may not be an effective marker for a food allergy
• Understanding the cross-reactivity between different allergies
• How to implement a food allergy action plan
• Methods and recommendations for early introduction of the peanut
• Where providers can find resources for on-going food allergy education
• Recommendations on prescribing epinephrine

Links from today's episode

• Food allergies
• Research on how to avoid food allergies
• UpToDate

The host of this podcast is Dr. David Brumbaugh, pediatric gastroenterologist and Associate Chief Medical Officer at Children's Colorado. In this episode, Joel Friedlander, MD, pediatric gastroenterologist at Children's Colorado, addresses the management of constipation and the effects of leaving it untreated, especially in young children.

In this episode, Dr. Friedlander discusses:

• Addressing constipation and uncomfortable stools early
• Potential long-term complications associated with constipation
• Two key components to focus on in the physical examination
• Miralax, a common used laxative for the treatment of constipation
• The use of lactulose for young children
• Categorizing medications for constipation
• Different medications with different adverse effects
• Steps to behavioral modification
• Constipation split between organic and functional
• Why medication to treat constipation won't work without a change in behavior

In this episode, Johannes von Alvensleben, MD, pediatric cardiologist and electrophysiologist at Children's Hospital Colorado and assistant professor of pediatrics at the University of Colorado School of Medicine, talks about heart arrhythmias. He discusses some of the most common heart arrhythmias in the primary care setting, including identifiable characteristics and treatments.

In this episode:

• Palpitations and syncope (commonly known as fainting) as symptoms for heart arrhythmia
• Characteristics of common heart arrhythmias
• Supraventricular tachycardia (SVT) in an infant versus a young child
• Differences in children with syncope
• Inherited heart arrhythmia syndromes
• Importance of obtaining an electrocardiogram (ECG)
• Co-morbidities in children that can impact diagnosis with arrhythmias
• Drug-related arrhythmias in older children
• Treatment options for heart arrhythmias in young children
• The success rate of ablation for arrhythmia

In this episode we discuss attention-deficit/hyperactive disorder (ADHD) medication management with Marissa Schiel, MD. Dr. Schiel is the Medical Director of the Outpatient Psychiatry Program at Children's Colorado and an assistant professor of child psychiatry at the University of Colorado School of Medicine. Also joining us is Danielle Stutzman, R.Ph., a clinical pharmacist at Children's Colorado with a special interest in psychiatry medication.

In this episode:

• The importance of getting a detailed history when assessing a child for ADHD
• Understanding the spectrum of ADHD symptoms and how they affect a child's function
• How to approach the medication management conversation when it comes to ADHD
• The most common side effects that are associated with stimulants or psychotropic medication
• Management strategies for dealing with potential medication side effects
• The importance of screening a child for cardiac concerns before prescribing stimulant medications
• Understanding the functional benefits of the two different classes of stimulants
• The ideal target doses for specific ADHD medications
• A recommended follow-up regime and titration strategy for patients
• How to counsel families on medication management as the child ages
• Medication recommendations to consider when trialing the non-stimulant class
• Techniques to use in therapeutic relationships with ADHD patients

In this episode, Sean O'Leary, MD, discusses vaccine safety and hesitancy from parents. He also suggests motivational interviewing techniques to use when talking with your patients and families. Dr. O'Leary is a pediatric infectious disease specialist at Children's Colorado and associate professor pediatrics and infectious diseases at the University of Colorado School of Medicine.

In this episode:

• How to help families identify the good information from misinformation regarding vaccines
• The prevalence of vaccine resistance
• Effectively and efficiently delivering vaccines information to parents
• Using motivational interviewing techniques when talking with parents about vaccines
• How to pivot the conversation when a parent is resistant to a care plan
• Why asking permission is a key component to motivational interviewing
• Understanding the differences between a recommended and alternate vaccine schedule
• Techniques for communicating relative risks about vaccines
• Working with parents who are vaccine resistant
• Vaccines that receive the most resistance and hesitancy

In this episode, Eliza Buyers, MD, talks about reproductive health in teenagers. Dr. Buyers is a pediatric and adolescent gynecologist at Children's Colorado and a senior instructor of obstetrics and gynecology at the University of Colorado School of Medicine.

In this episode:

• How to talk to teens and their parents about reproductive health
• Implementing a universal screening approach in your practice
• Dealing with push back from parents
• Setting up one-on-one time with adolescent patients
• Misconceptions about teens and their reproductive health
• Long-acting reversible contraceptive (LARC) methods
• Non-contraceptive benefits of LARC
• Importance of hormonal therapy
• Reversing long-term hormonal care and contraception
• Talking to teens about screening for sexually transmitted diseases
• When to send a patient to a specialist

This episode is the season one wrap up show; thank you to all of our listeners! In light of this celebratory occasion, we're going to take a little departure from our regular clinical episodes to reflect on season one and preview what listeners can look forward to in season 2 starting August 7, 2018.

Suggestions or feedback? Write to us at [email protected]

Joining us today are Terry Fry, MD and Mike Verneris, MD to explore cellular therapy for the treatment of pediatric cancers.

Dr. Fry is the Robert and Kathleen Clark Endowed Chair in Pediatric Cancer Therapeutics and Dr. Verneris is the Barton Family Endowed Chair of Bone Marrow Transplant at Children's Colorado.

In this episode:

• A new immunotherapy known as cellular therapy, or specifically the chimeric antigen receptor T cell therapy (CAR-T cell), is bringing hope to pediatric patients with blood cancers.
• Two breakthrough events in the field of immunotherapy made CART-T cell therapy possible:
  • Checkpoint inhibitors: a concept where agents can "take the brakes" off the immune, unleashing a sort of preexisting immune response against the tumor
  • Adult epithelia cancers
• For cancers like pediatric tumors, mutations aren't present or aren't present at high enough levels for checkpoint inhibitors to work.
• CAR-T cell therapy is different from checkpoint inhibitors in that the immune system, the T cells, are taken and essentially educated in a different way. The T cells are redirected so they can see the tumors that they weren't naturally developed to see.
• The FDA labor indication is refractory leukemia at the time of diagnosis, relapse or second relapse.
• There is a 70 to 90% complete remission induction rate in phase one CAR-T therapy clinical trials in patients who had estimated durations of survival of only weeks to months.
• The CAR-T cell approach may be considered an alternative to chemotherapy.
• Side effects of CAR-T cell therapy include:
  • Patients become neutropenic, have low counts and are at risk for bacterial infection (because chemotherapy is given before cells are infused)
  • Cytokine release syndrome
  • Transient neurotoxicity, ranging from subtle neurologic changes to severe side effects like seizures or even coma
• Because of leukemic resistance, half of patients that go into remission will relapse by year, in spite of a successful CAR-T cell treatment upfront.
• The pros and cons of a bone marrow transplant (BMT) versus CAR-T cell therapy are:
  • BMT patients get mild oblation, likely face sterility, late complications, secondary malignancies and more. With CAR-T cells, patients get a single infusion and risk about a month of significant toxicity, but side effects are mitigated after that. The only long-term side effect is potentially a lack of b-cells.