Charting Pediatrics

In this episode, we discuss the management of and treatments for nocturnal enuresis, nighttime bedwetting. Joining us is pediatric urology nurse practitioner, Marguerite Korber, NP, who runs many of the enuresis clinics at Children's Colorado.

In this episode:

• At age 5, the primary care physician should make a formal diagnosis of nighttime wetting and give the family a proactive, therapeutic treatment plan.
• It's recommended that families come to a urology specialist or enuresis clinic around age 7
• The reasons for bedwetting may differ according to whether patient has primary or secondary nocturnal enuresis.
• Before making a referral to urology, primary care physicians can perform an initial workup, evaluating:
  • If the child is ready to become potty-trained and, therefore, dry at night
  • Functional bladder capacity to see if nocturnal enuresis has anything to do with diabetes or UTI concerns
  • If their bladder is releasing earlier than it should and/or doesn't have the appropriate, expected capacity
• Despite the parents' frustration, until the child is affected by their nighttime bedwetting, initiating them to be responsible for some of their behavioral modifications during the day will be difficult.
• The important aspects to focus on in a physical exam are the abdominal exam, lumbar spine evaluation, neurologic evaluation and urethral opening evaluation.
• Constipation plays a large role in nocturnal enuresis.
  • The abdominal exam will tell you whether or not constipation is a contributing factor, specifically in that descending colon. "If you can palpate stool, then you know that it's probably sitting in the rectum as well."
• The urethral opening tends to be more of an issue for boys specifically.
• Bedwetting enuresis management options include behavioral therapy, fluid shifting and addressing constipation.
• How to effectively implement the use of alarm therapy as a bedtime wetting management option – and what parents need to know up front.
• What criteria allows for using Desmopressin, a DDAVP, as the right option when pursuing pharmacologic therapy
• Options for managing chronic nocturnal enuresis:
  • By changing any dysfunctional voiding components to their day time habits, patients will be better prepared for the natural progression of the night time to occur.
• Providers need to provide alternative treatments for patients when cost is a barrier to care, such as with a bed alarm.
  • Pull-ups can be a cost effective solution to involuntary nighttime bed wetting.
• Oftentimes with nocturnal enuresis, it's necessary to treat the whole family, helping parents to manage their frustration.

On today's episode, we're discussing the diagnosis and management of neck masses in children. Joining us is Melissa Scholes, MD, Director of the Pediatric Balance and Vestibular Disorders Clinic at Children's Colorado.

In this episode:

• Common presentations of neck masses in children
• The questions pediatricians should be asking when they encounter a neck mass
• The various locations and types of neck masses that can be found
• How to evaluate and address the consistency of a neck mass
• What information in the child's history is particularly important to look at
• The increase in head and neck malignancies in children today
• Possible lab tests and imaging for neck masses in children
• When pediatricians should send children to an ENT clinic
• Antibiotics and treatments to consider for infectious neck masses
• Infectious lymph nodes and the possibilities of them going viral

Joining us is Ricky Mohon, MD, to discuss the most common sleep disorders and sleep issues affecting pediatric and adolescent patients.

Dr. Mohon is Medical Director of Sleep Medicine and Program Director of Pediatric Pulmonology here at Children's Colorado, as well as a professor of pediatrics at CU Medicine.

In this episode:

• The prevalence of sleep disorders in children and how these issues have evolved
• Answering "How much sleep should my child be getting?"
• How to counsel family members on their teenager's sleep needs
• The disruptive impact electronic devices have on children's sleep patterns
• The most common sleep disorders Dr. Mohon sees in infants, children and adolescents
• Whose responsibility is it to change the diaper in the middle of the night?
• Behavioral changes that parents can make to limit continuous night calls
• The full extinction technique: How and why parents should let baby learn to self-soothe
• Managing sleep-related breathing disorders and snoring in children
• The process of conducting pediatric sleep studies and what sleep specialists monitor
• The effects of sleep apnea and insomnia on a child's health and school life

In this podcast, Bill Anderson, MD, co-director of the multidisciplinary Asthma Program at Children's Colorado and assistant professor of pediatrics at the University of Colorado School of Medicine, talks about asthma. He discusses challenges in the management of asthma, the effect of asthma on pediatric patients and treatment options now available.

In this episode, Dr. Anderson discusses:

• Common challenges for managing asthma in pediatric patients
• Factors that come into play when choosing controller medications
• Why steroids are better suited for atopic patients
• Teaching patients and families how to use a spacer
• How co-morbidities affect children with asthma
• The impact that psychosocial factors have on asthma
• Working with social workers to help families overcome hurdles
• Latest treatment options for treating pediatric asthma
• Overcoming the adherence barrier using technology
• Natural medications available to pediatric asthma patients
• Advice for people with dog allergies

In this episode, Daniel Searing, MD, Professor of pediatrics and allergies at Children's Colorado, talks about seasonal allergies and pollen. He discusses the effects of pollen, how to treat and alleviate allergies, and more.

In this episode, Dr. Searing discusses:

• Pollen and how it affects allergies
• Why cottonwood trees are a big pollinator, especially in the springtime
• Why rain and humidity shut down pollen levels
• Why Colorado's climate makes people more susceptible to allergies
• How allergy symptoms will vary from year to year
• The importance of monitoring the quantitative level of pollen in the environment
• How physicians should manage the initial approach to a child with allergy symptoms
• Key features to look out for
• Why treating pollen allergies with persistent treatment is more effective
• What role the prescription drug Montelukast plays in treating allergic rhinitis
• What you can do to help prevent pollen from spreading
• Which medicines and therapies can help alleviate allergies
• When to see a doctor for seasonal allergies
• The approach of an immunotherapy treatment plan and the two phases of a typical treatment schedule

Today, we're discussing celiac disease with guest Edwin Liu, MD. Dr. Liu is an international leader in the research and management of celiac disease, the Director of the Colorado Center for Celiac Disease at Children's Colorado and a professor of pediatrics at the CU School of Medicine.

In this episode:

• How the prevalence of celiac disease has changed over time and what that means
• The hygiene hypothesis and its role in infectious diseases
• The ways that the clinical representations of children with celiac disease have changed
• Untraditional symptoms and signs of celiac disease in children
• The relationship between type 1 diabetes and celiac disease
• An outline and definition of the non-genetic, environmental triggers of celiac disease
• The tests to order if you suspect a child may have celiac disease
• The populations that should be screened for celiac disease because of their risk factors
• What distinguishes celiac disease from gluten sensitivity
• The importance of and how to go about educating families on diet after their child is diagnosed with celiac disease
• The answer of whether or not there's a chance that children can grow out of having celiac disease
• Exploring the misconception of celiac disease as an "under dog" condition

In this episode, Stephanie Mayer, MD, joins us to share her insights on diagnosing hip pain in pediatric patients. We're discussing this issue from its symptoms and causes to how to manage hip pain.

Dr. Mayer is a pediatric orthopedic surgeon at Children's Colorado and an assistant professor of orthopedics at the CU School of Medicine.

In this episode:

• The common hip pain causes to watch for in adolescents
• Sports that lend themselves to hip pain
• Practices for starting an evaluation of the patient and their injury
• The importance of the patient history when dealing with and considering hip pain
• The questions to ask, signs to look for and specifics to consider when diagnosing hip pain and differentiating between infection and oncologic hip injuries
• Signs and factors possibly indicating a patient's hip pain is systemic or rheumatological and when it's time to look for Lyme disease
• How to determine where hip pain originates from and the conditions to consider
• The mechanical indicator that the cause of hip pain is slipped capital femoral epiphysis (SCFE)
• Diagnosing and addressing other causes of hip pain such as Legg-Calvé-Perthes
• Discussing urgency and when it's time to refer to an orthopedic specialist
• When and why it's appropriate to order an MRI early on
• The central role imaging plays in determining a proper hip pain treatment and when it's the right time to order an x-ray for hip pain
• The benefits of getting images of the entire hip versus radiation exposure

In today's episode we discuss autism spectrum disorder with Elizabeth Coan, PsyD. Dr. Coan is a doctor of psychology at the Neuroscience Institute at Children's Colorado and is an instructor of developmental pediatrics at the CU School of Medicine.

In this episode:

• How a PCP can take the first steps towards diagnosing autism
• How you can implement autism screening tools in your practice
• How to sensitively discuss autism spectrum disorder with parents and families
• Tips for managing screenings and referrals after diagnosing autism
• The reason why there are things to celebrate once you've made an autism diagnosis
• Tips PCPs can share with families to help develop the strengths of a child with autism
• Counseling families on how they use the internet when researching autism

Autism Speaks

ABA Therapy

M-CHAT Screening Tool

In this episode, we explore the stigmatized topic of physician burnout with Jenny Reese, MD, Director of the Resilience Program at CU Anschutz and Inpatient Medicine at Children's Colorado and Sonja O'Leary, MD, Medical Director of Denver Health's School-Based Health Centers Team.

Drs. Reese and O'Leary share their personal experiences with burnout and offer valuable insights on what physician burnout is, its effects and how hospitals can reduce burnout by implementing preventative measures.

In this episode:

• Defining burnout and the golden measurement of burnout
• The three main domains of burnout
• The prevalence of burnout according to the numbers
• The trends surrounding burnout over time
• The effects and realities behind compassion fatigue and the second victim phenomenon amongst physicians
• Outlining if and how burnout differs according to a physician's gender and parental role
• Why it's important to implement reflective supervision in the workplace
• Actions to prevent, normalize and reduce the stigma of burnout in medicine

Our guest for this episode is Jessica Malmberg, PhD, the Clinical Director of Outpatient Services at the Pediatric Mental Health Institute and assistant professor of child psychiatry at CU School of Medicine.

Dr. Malmberg talks us through a common behavioral issues of school-aged children – school refusal – and provides insights, advice and tools to help prevent, manage and understand this behavior.

In this episode:

• Outlining and identifying the underlying symptoms and signs associated with a child refusing to attend school
• How primary care providers (PCPs) can assist parents who are experiencing guilt
• Identifying the four most common reasons that children refuse to go to school
• Exploring the effects of social media on children's behavior when it comes to school refusal
• How a PCP should approach treatment of school refusal
• The recommended frequency of follow-up care for kids who are refusing to go to school
• The importance of connecting parents to community-based resources
• Preventative practices parents can set up in the home to prevent this behavioral issue
• What an excellent prognosis looks like for children experiencing school refusal
• When it's time to refer to a mental health professional
• PCPs in the Denver Metro Area can refer patients to the Children's Hospital Colorado Outpatient Psychiatry Clinic or to a local community mental health center

Resources for dealing with school refusal:

• School Refusal: Information for Educators (.pdf) from the National Association for School Psychologists
• School Refusal in Children and Adolescents from American Family Physician
• The Functional Assessment of School Refusal Behavior
• Effective Child Therapy
• Division 53 of the Society of Clinical Child & Adolescent Psychology website
• School Refusal from the American Academy of Child & Adolescent Psychiatry