Title: Caring for Our Transgender Patients: The Basics

By Atsuko Koyama
atsuko.koyama@emory.edu

 

 

 

 

 

 

 

 

 

Chief Complaint: Rash

Andrew is a 16-year-old transman (female-to-male, FTM) presenting with a red, painful rash of his bilateral inner thighs. On exam, you note an area in the inguinal region concerning for cellulitis. Upon questioning him alone, he reports that he began using a “STP” device 2 weeks ago. “What is a STP device?” He answers that it is a stand-to-pee device that he straps on with a waist harness in order to urinate standing, as other males do. STP devices are used by some FTM who have not had bottom surgery. They can cause skin irritation/breakdown if ill-fitting.

Transgender youth

Transgender is an umbrella term for those whose gender identity (a person’s sense of their own gender as male, female, or some other gender) differs from their biologic sex (typically assigned at birth based on chromosomes or anatomy). Population estimates for transgender youth is not well defined. One study estimates that 0.7 to 3.2% of 13 to 18 year olds identify as transgender.1 A study from 2017 estimated that 1 in every 250 adults are transgender. 2

What’s in a name? Definitions.

There are many terms you may hear when discussing gender. Transgender can refer to an individual or a larger community, and it is an umbrella term for those whose gender identify differs from their biologic sex and from conventional notions of gender. Alternatively, cisgender is someone whose gender identity DOES match up with our cultural notions about gender. Gender identity: A personal conception of oneself as male, female, both, or neither, experienced in self-awareness or behavior. Gender expression: A person’s outward expression of gender. Gender dysphoria: Discontent a person may feel about the biological sex they were assigned at birth.

Gender and sexuality

Gender and sexuality can be viewed on a spectrum and considered fluid rather than being binary entities. They are not either/or concepts. One can be biologically male, identify with a feminine gender identify (as female), and can be attracted to and have sexual relationships with males, females or both. Gender play is a passing interest that involves playing out different gender-typical roles. Gender nonconforming youth behavior is more persistent, consistent and insistent. It is cross gender expression, wanting other gender body parts, or not liking one’s gender or body.

Transgender youth, mental health, and healthcare access

Transgender adolescents have a 2 to 3-fold increased risk of depression, suicidality, anxiety, and mental health treatment. 3 Given these risks, it is important to understand that identifying as transgender is not in and of itself a mental health disorder. It is social stigma, familial rejection, and social isolation that contribute to the higher rates of mental health issues. Research shows that with acceptance and access to healthcare to help transition, youth are protected from gender dysphoria and reactive depression. 4 Lack of access to accepting and transgender friendly health care services is also a barrier to health for transgender youth. One study revealed that 52% of patients who presented to an ER experienced trans-specific negative experiences, while another showed that 13% of transgender patients were denied equal treatment in an ER setting due to their gender identity/expression. 5,6 

How should we communicate with our patients? Language is important so that we can communicate with our transgender patients in a way that is respectful and affirming.

Conversations can start with something as simple as asking, “Do you feel more like a girl, boy, neither, both?” “What name or pronoun fits you/do you prefer?” When examining a patient, use non sex-specific terms. Going back to the initial patient vignette, one may say to Andrew, a FTM teen, “I need to perform a genital exam,” instead of “I need to perform a vaginal” exam. Use the word “chest” vs. “breast,” “genital” vs. “vaginal or penile.” When speaking with transgender patients, ask questions necessary to assess the issue, but avoid unrelated probing. “What’s your anatomy and what surgeries have you had? I need to know this information in order to best treat you.” If you have a patient who presents with a broken finger, it is unnecessary to ask about their reproductive anatomy.

What might we expect from a patient who is transitioning?

Chief complaint: Chest pain, shortness of breath, and URI symptoms

Jenny is a 17-year-old transwoman (male-to-female, MTF) on estrogen therapy. She has a PMH of moderate persistent asthma. What is her risk of a pulmonary embolus?

Phenotypic transitioning occurs in phases: reversible, partially reversible, irreversible, and surgical. The reversible portion of transition includes the adoption of preferred gender hairstyles, clothing, play, perhaps a new name and suppression of biologic gender puberty using GnRH analogues (defined below). The portions of the reversible phase that do not involve suppression of puberty will sometimes occur before the age of ten. Some children may begin GnRH analogues at around age 12 or 13, when they are still Tanner Stage 2, and initiate hormones several years later. GnRH analogues lead to fully reversible changes, provide extra time for psychotherapy and a relief of their gender dysphoria. They prevent secondary sex characteristics that would have required more invasive intervention later. Partially reversible changes are brought about with hormone therapy, which is offered in most centers around age 15 or 16, and irreversible changes with surgery, typically not before age 18.

Medications

All medications have potential side effects and risks, and it is important for providers on the front lines in primary care and urgent/emergency care know what those potential risks are. However, it is important to frame the risks and benefits of treatment for transgender youth in light of the risks of depression, anxiety, and suicide that youth without treatment face. Studies support the mental health of trans youth being much improved with appropriate, early access to health care including the medications discussed below.

GnRH analogues stop puberty. There are few side effects aside from injection pain and withdrawal bleed if menstruating. Estrogens induce the development of female secondary sexual characteristics. The greatest risk for estrogen therapy is the 20-45 fold increase of venous thromboembolism (VTE). 2-6% of hormonally treated MTF patients experience a VTE. Other lower risk, possible complications include prolactinomas, pituitary adenomas, hypertension, hypertriglyceridemia causing pancreatitis, gall bladder and liver disease, and the potential biological female risk of breast cancer. Anti-androgens reduce the effects of endogenous male sex hormones. Most pertinent are spironolactones causing hyperkalemia, hypotension, or ataxia. Testosterone induces the development of male secondary sexual characteristics. Risks include hepatotoxicity, insulin resistance, weight gain, decreasing high-density lipoproteins (HDL), increasing triglycerides and homocysteine levels, and polycythemia. There is a theoretical risk of breast cancer and endometrial cancer (testosterone is aromatized to estrogen), so patients who have chest or genital symptoms need workup appropriate to their anatomy.

Transgender youth flourish

Research shows that transgender people report numerous positive aspects related to successful transitioning. 7 Familiarizing yourself with local resources (medical, mental health, peer and parent support groups) and learning more about transgender youth will help to create a more supportive health care system for trans youth and their families for successful transitioning.

Last words from experts in the field of transgender care

  • Lack of trans friendly health services, transphobia, and real or perceived prejudice and discrimination lead to mental health disorders and undertreatment of medical conditions.
  • Transgender kids need love and acceptance by family, school, and community, like all teens.
  • Using incorrect names or pronouns and misgendering IS a big deal to patients, and we all need to help systems counteract or eliminate this.

 

Local Physicians Accepting Referrals of Transgender Youth

  1. Comprehensive care of transgender youth: David Levine, MD, Morehouse Healthcare, 1800 Howell Mill Rd, Atlanta, Georgia 30318, 404) 756-1400
  2. Comprehensive care of transgender youth: Isabel Lowell, MD, MBA QMed,Website: queermed.com, Email: info@queermed.com, Office phone: 404-445-0350
  3. For medications only: Leonidas Panagiotakopoulos-CHOA Endocrinology-404-785-KIDS

 

Provider Resources 

References

  1. Herman JL, et al. “Age of Individuals Who Identify as Transgender in the United States.” The Williams Institute, UCLA School of Law. January 2017.
  2. Meerwijk EL, et al. “Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples.” Am J Public Health, 2017;107:e1-8.
  3. Reisner SL, et al. “Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study.” J Adolesc Health. 2015;56:274-79.
  4. Ryan C, et al. “Family Acceptance in adolescence and the health of the LGBT Young Adults.” J Child Adolesc Psychiatr Nurs. 2010;23:205-13.
  5. Bauer GR, et al. “Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey.” Ann Emerg Med. 2014;63:713-720.
  6. Grant, JM et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
  7. Riggle, ED et al. “The Positive Aspects of Transgender Self-Identification.” Psychol Sex, 2011;2:147-58

 

 

 

 

 

 

 

 

 

 

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CHOA Constipation Guideline

By Beesan Agha, MD
beesan.agha@pemaweb.com

 

 

 

 

 

 

 

Constipation is a common problem throughout childhood and affects up to 30 percent of children and accounts for an estimated 3 to 5 percent of all visits to pediatricians.1 Early intervention is key to avoid complications such as anal fissures, stool withholding, fecal incontinence (encopresis), and psychosocial consequences. This guideline represents a collaboration of several specialties including pediatric emergency medicine, urgent care, and gastroenterology with the goals of:

  • Understanding the diagnostic criteria for functional constipation
  • Being aware of red flags that may indicate organic causes of constipation
  • Establishing a uniform process for the evaluation and management of constipation
  • Decreasing utilization of abdominal x-rays to diagnose constipation

Patients >1 month of age who meet the diagnostic criteria for functional constipation are included in the guideline.

Diagnostic criteria for functional constipation must include TWO or more of the following:

  1. Two or fewer defecations per week
  2. At least one episode per week of incontinence after the acquisition of toileting skills
  3. History of retentive posturing or excessive stool retention
  4. History of painful or hard bowel movements
  5. Presence of a large fecal mass in the rectum
  6. History of large diameter stools which may obstruct the toilet

Functional constipation is responsible for more than 95% of cases of constipation in healthy children one year and older.2 Although constipation is common, it is still important to evaluate children and be diligent to identify the few that have organic causes of constipation. Some red flags that should raise your suspicion to a possible organic cause include:

  • Midline dimple; Tuft of hair over lower back
  • New onset lower limb weakness/motor delay
  • Signs of systemic illness: fevers, mouth sores, joint pain, rash
  • Weight loss
  • First passage of meconium after 48 hours of life
  • Persistent abdominal distension/vomiting
  • Bloody diarrhea
  • Bilious emesis
  • Failure to thrive, Malabsorption
  • Tight rectum gripping finger; explosive stool/air from rectum upon withdrawal of examining finger
  • Family history of Hirschsprung’s disease

The treatment of functional constipation begins with determining whether the patient has fecal impaction. If fecal impaction is determined by a digital rectal exam it recommended the patient receive a glycerin suppository for children <1 year of age and a soap suds enema for children >1 year of age. Enema dosing can be found in the guideline.

Upon discharge the patient will receive education on appropriate dose and home use of miralax to continue the treatment of constipation as an outpatient. These recommendations are included below:

1-3 years old

Cleanout: Take 1 capful (17 grams) Miralax every day for 3 days in 8 oz. of juice

Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking  

4-5 years old

Cleanout: Take 2 capfuls (34 grams) Miralax every day for 3 days in 16 oz. of juice Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking

6-11 years old

Cleanout: Take 7 capfuls (119 grams) Miralax for 1 day in 32 oz. Gatorade

Maintenance: On day 2 take ½ capful (8.5 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/4 capful but do not stop taking

12 years and older

Cleanout: Take 14 capfuls (238 grams) Miralax for 1 day in 64 oz. Gatorade

Maintenance: On day 2 take 1 capful (17 grams) Miralax daily in at least 8 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/2 capful but do not stop taking

  • Encourage fluid intake (especially during cleanout)
  • Referral to PCP in 2 weeks. Continue maintenance dosing until seen by PCP

The constipation guideline can be accessed on CHOA Physician Portal: md.choa.org

Under clinical excellence clinical practice guidelines

  1. Epidemiology of childhood constipation: a systematic review.

Van den Berg MM, Benninga MA, Di Lorenzo C

Am J Gastroenterol. 2006;101(10):2401.

  1. Prevalence, symptoms and outcome of constipation in infants and toddlers.

Loening-Baucke V

J Pediatr. 2005;146(3):359

 

Joining Forces-the NEW ALL CHOA Emergency Department Newsletter

Welcome to the new newsletter including ALL Emergency Departments of Children’s Healthcare of Atlanta. This newsletter now includes collaboration from the Emergency Department of Scottish Rite. The information included in this newsletter combines the efforts of the two largest groups of pediatric emergency medicine physicians in the Atlanta Metro area.  The Division of Pediatric Emergency Medicine at Emory University and Pediatric Emergency Medicine Associates (PEMA). Emory Physicians staff the Hughes Spalding and Egleston EDs while PEMA physicians staff Scottish Rite and 7 other pediatric emergency departments throughout the metro area including one hospital in Chattanooga, Tennessee.  We are continuing to expand our outreach and collaborative efforts to all metro Atlanta area physicians who care for children including Emergency Medicine, Pediatric and Family Medicine Physicians.  Please feel free to forward this newsletter link to your colleagues. Don’t hold onto this valuable information pass it on. Sometimes with growing and merging  we can experience some delays thus we recognize this newsletter is delayed in publication.  Stay tuned in the next few months as our website will move to a new location and we will be offering continuing medical education.  Also check out this article on Medbytes-Partnering to Improve Pediatric Emergency Medicine Care here is the link that is accessible to those with md portal access-https://md.choa.org/articles/2017/07/20/ed-partnership-fraser-doh.

 

Please enjoy this quarter’s newsletter articles on summer safety tips and new  information on the effects of acetaminophen. Finally, see below the history of PEM (Pediatric Emergency Medicine) in Atlanta including the history of Emory Pediatric Emergency Medicine and Pediatric Emergency Medicine Associates.

 

The Story of Pediatric Emergency Medicine in Atlanta

By Thuy Bui thuy.bui@pemaweb.com

By Wendy Little
wendalyn.little@emory.edu

 

 

 

 

 

 

 

 

Children’s Healthcare of Atlanta is one of the largest and busiest pediatric healthcare systems in the United States. The three CHOA emergency departments collectively encounter over 220,000 visits per year and the hospitals, with their full complement of pediatric subspecialty providers, care for some of the sickest and most medically complex patients in the state and the region.

While specialized pediatric healthcare in Atlanta dates back to the early 1900s, there were no pediatric emergency departments and no pediatric emergency specialists in Atlanta until the mid-1980’s.  The growth of emergency medical care for children in Atlanta over the past 30 years has been phenomenal!

The first children’s hospital in Atlanta, Scottish Rite Convalescent Home for Crippled Children, opened its doors in 1915. Key movers behind this included orthopedic surgeon Dr. Michael Hoke (the hospital’s first medical director), philanthropist Mrs. “Bertie” Wardlaw, real estate developer Mr. Forrest Adair and the Scottish Rite Masons.  The hospital started out as two rented cottages in Decatur with 20 beds and became a full medical building housing 50 beds in 1919.  The medical facility stayed in Decatur until 1976 when it moved to its current seven-acre site in North Atlanta and became Scottish Rite Children’s Hospital.

The Henrietta Egleston Hospital for Children was founded in 1928.  Thomas R. Egleston Jr, a wealthy Atlantan, left money in his will for the founding of a children’s hospital to be named after his mother, Henrietta Egleston. The first Egleston hospital was located in Atlanta on what is now Ralph Magill Avenue.  In 1956 , Emory University donated land for an expanded facility on the Emory campus, thus beginning the long-standing relationship between Emory University and Egleston. The “new” Egleston Children’s Hospital on Clifton Road opened in 1959.

Pediatric Emergency Medicine (PEM) is a relatively new specialty with the first fellowship established in 1980.  The first board subspecialty exam, a collaboration of the American Board of Pediatrics and American Board of Emergency Medicine, was administered in 1992.  In 1998, Pediatric Emergency Medicine Fellowship became an accredited specialty.  There are just over 1700 Pediatric Emergency Medicine board certified physicians in the country and 68 in the State of Georgia.

Pediatric emergency medicine became available to the children of Atlanta in 1984. Pediatric emergency medicine pioneer, Dr. Joseph Simon, opened Atlanta’s first freestanding pediatric emergency department at Scottish Rite. It was comprised of eight exam rooms with one trauma bay and staffed by a group of four pediatric trained physicians doing 24 hour shifts.  During its first full year of operation, the department saw 5,000 patients. That same year, Egleston opened its Acute Treatment Area. It had two exam rooms and a four bed holding area. It was initially open for 9 hours overnight on weekdays and 24 hours per day on weekends, and saw approximately 8800 patients per year.  Patients could not walkin to the facility, but had to be referred by a physician. A formal emergency department opened in 1988 with 24-hour physician coverage. In 1986, Egleston was designated as a pediatric trauma center with Scottish Rite receiving its designation the following year.

The Hughes Spalding Pavilion opened in 1952 as a private hospital on the campus of Grady Memorial Hospital. Until 1992, pediatric patients were first seen in a 24-hour walk-in clinic on the second floor of Grady, staffed mainly by Emory pediatric residents. Seeing over 60,000 patients per year, wait times were notoriously long, with patients routinely waiting over 12 hours to be seen.  In 1992 , Hughes Spalding was re-opened as a dedicated pediatric facility, including an emergency department consisting of a six-bed observation room, an asthma room with chairs to accommodate approximately 10 patients, three private emergency department rooms, an urgent care/clinic area and a single resuscitation room. In 2006, Children’s Healthcare of Atlanta assumed clinical operations at Hughes Spalding.

In 1998, to help preserve and improve pediatric health care in the region, Scottish Rite Children’s Hospital and Egleston Children’s Healthcare System officially merged to become Children’s Healthcare of Atlanta.  With its assumption of responsibility at Hughes Spalding Children’s Hospital in 2006, Children’s Healthcare of Atlanta became one of the largest pediatric healthcare systems in the country.  Currently, the system’s three emergency departments (Egleston, Hughes Spalding, and Scottish Rite) manage more than 220,000 patient visits per year.

Each of the emergency departments has undergone major changes over the years. Today CHOA Egleston has 36 private patient rooms (including dedicated beds  for orthopedic and gynecologic care, as well as mental health rooms with video-monitoring capability) and four trauma bays, caring for more than 70,000 patients a year. In 2009,  CHOA Egleston became the first and only Level 1 Pediatric Trauma Center in the state of Georgia. Similarly CHOA Scottish Rite has 50 private patient rooms (including rooms dedicated for orthopedic and gynecologic care, and mental health rooms with video-monitoring capability) and four trauma bays. Designated as a Level 2 Pediatric Trauma Center, it now provides care for over 100,000 patients annually. CHOA Hughes Spalding underwent a major renovation in 2010. The updated facility includes a new emergency department with 32 private rooms (including rooms designated for orthopedic and gynecologic care, as well as mental health rooms with video-monitoring capability) and one resuscitation room, and provides care for more than 52,000 patients annually.

The variety of options and easy accessibility of pediatric emergency medicine care make Atlanta unique. This validates the need for all 3 Children’s Healthcare of Atlanta hospitals to collaborate and reach out to referring partners in the community and work together to improve children’s health in our community. The universal theme that joins us in our diversity of roles and practice is that we are dedicated to making all children better today and healthier tomorrow.

 

Childhood Injury

by Sarah Gard Lazarus sarah.lazarus@pemaweb.com

 

Childhood injury remains the number one cause of death for children ages 1 to 19 in the US. To address this problem, a multidisciplinary group of Children’s Healthcare of Atlanta physicians and staff from the departments of trauma, emergency medicine, advocacy, and primary care came together to form Children’s Injury Prevention Program (CHIPP) in January 2016. CHIPP’s mission is to provide a multidisciplinary approach to reduce childhood injury, both unintentional and intentional in the greater Atlanta area through evidence-based injury prevention programs, research, education, and community outreach.  CHIPP is a CHOA-based organization that has grown rapidly as a pediatric injury prevention coalition since it’s inception and includes representatives from multiple specialties at all three of CHOA’s campuses.  In addition, CHIPP partners with Safe Kids, Georgia Department of Public Health, Center for Disease Control, Injury Prevention Research Center at Emory, and the Injury Free Coalition for Kids.

The coalition is doing active work in motor vehicle safety, safe sleep, non-accidental trauma, and recently received a grant to establish a Safety Store at the Scottish Rite campus. This store will provide low-cost safety equipment, including car seats, bike helmets, and smoke detectors to families of patients. An injury prevention specialist will staff the store, and also work as a car seat technician, able to inspect car seats that were purchased on site.

As summer continues, CHIPP thanks you for reminding families of the following safety information and tips:

– Drowning is the leading cause of injury death in children ages 1 through 4

-Nothing is as effective as one-on-one supervision in drowning prevention: stay within arms reach

-If you have a pool, make sure that there is a four-sided fence surrounding it. The fence should be at least four feet tall and should have a lock on it.

-Consider taking a CPR and first-aid class

-At parties, appoint a parent as the designated “watcher”. This person should abstain form drinking, not have their phone in hand, and keep their focus on the children in the pool. They should wear a sign that establishes them as the “Water Watcher”

-Empty collapsible baby pools after each use. Children can drown in as little as an inch of water

-Anytime you go to a beach or the lake, place your child in a life jacket

Thank you for keeping children safe in our community!

Acetaminophen, Asthma, ADHD and Autism: At what point do we change our practice?

By Claudia Morris
claudia.r.morris @emory.edu

Acetaminophen (APAP, Tylenol) is the most commonly dispensed medication in the United States, representing 5% of all treatments, and is generally used to alleviate pain and/or fever. Most agree that treating pain is important, however, treatment to reduce fever is not “medically necessary”. Fever is an evolutionarily conserved natural protective mechanism to fight infection, yet unfounded fever phobia is common among parents and practitioners. This creates an ideal market for antipyretics like acetaminophen, the drug of choice for fever in young children. Originally marketed internationally in the 1950s, its use increased significantly in the 1980s due to concerns of aspirin use and Reye’s syndrome. However nearly 20 years ago, new concerns were raised about the safety of acetaminophen and its potential link to asthma1, including a case-control study that suggested that frequent acetaminophen use in adults was associated with asthma, and among those who already had asthma, with more severe disease2. The mechanism for this association was thought to be the depletion of glutathione in the lung, leading to greater oxidative stress3,4. With asthma prevalence increasing world-wide, this concern leads to more than a decade of observational research on acetaminophen use and asthma in adults, children and pregnant women, with over 2500 publications now in the literature on this topic5-19. A 2009 meta-analysis that considered all clinical and observational studies at the time, ultimately including 425,140 subjects, found a pooled odds ratio for asthma in patients using acetaminophen to be 1.6 [1.46-1.77], increased risk of asthma with prenatal acetaminophen use, and an increased risk of asthma and wheezes in both children and adults exposed to acetaminophen, with a dose-dependent response noted in many studies12. Some experts in the field have begun to take a stand: Dr. Holgate wrote “There is now overwhelming evidence establishing a link between APAP and asthma20, while Dr. McBride stated in Pediatrics “In my opinion, the balance between the likely risks and benefits of acetaminophen has shifted for children with a history or family history of asthma. I can understand how those responsible for regulation or policy statements of professional organizations might be more comfortable waiting for incontrovertible evidence. There remains a possibility that confounding variables might explain some or all of the association between APAP and asthma. For this reason, we need further studies. At present, however, I need further studies not to prove that APAP is dangerous but, rather, to prove that it is safe. Until such evidence is forthcoming I will recommend avoidance of APAP by all children with asthma or those at risk for asthma and will work to make patient’s, parents, and primary care providers aware of the possibility that APAP is detrimental to children with asthma”21. Fortunately, some reassurance was recently provided by Sheehan and colleagues, in the Acetaminophen versus Ibuprofen in Children with Asthma (AVICA) trial, a 48-week prospective, blinded, randomized controlled trial that compared the as–needed use of acetaminophen with that of ibuprofen for fever or pain in 300 children 12-59 months of age with mild-persistent asthma receiving treatment with asthma controller therapies. The investigators did not find any significant difference in the primary outcome of asthma exacerbations leading to treatment with systemic glucocorticoids or in any of the secondary outcomes between the two groups, suggesting no greater risk of asthma exacerbation with acetaminophen use compared to ibuprofen22,23. However, the AVICA trial does not address whether acetaminophen use can lead to the development of asthma in otherwise healthy children, nor whether it is associated with worsening of symptoms in children with moderate to severe asthma. Questions and clinical equipoise remain. Several large epidemiologic studies linking acetaminophen use in pregnancy and ADHD 24-26 warrant further investigation. Recent studies identifying an association of ADHD with asthma and allergies 27-30 may foreshadow a potentially unrecognized mechanistic overlap between these conditions. Epidemiologic studies linking maternal use of acetaminophen during pregnancy to increased risk of autism gives further pause 31-34. A small study linking acetaminophen but not ibuprofen use with MMR, and autism, may warrant the discouragement of acetaminophen use during vaccination until more information is available35,36.

According to a 2007 CDC report, acetaminophen is responsible for approximately 56,000 emergency department visits, 26,000 hospitalizations, and over 450 deaths per year. Now, large epidemiologic studies have found an association with acetaminophen use and asthma as well as ADHD and autism. Although a causal relationship cannot be assumed based on the current literature, more studies of safety are needed. In the meantime, just like cold medicines and antibiotic overuse, the risks of acetaminophen need to be reassessed. I personally echo the sentiments of Dr. McBride, and have changed my practice in pediatric emergency medicine. Fever is your friend. It is a physiologic mechanism with benefits. Worried caregivers need reassurance to combat fever phobia and education on appropriate use of antipyretics. Treat misery and discomfort rather than a cut-off temperature. Alternatives to acetaminophen may also be considered, however all medications have risks that need to be weighed against their true benefits.      

References

  1. Varner AE, Busse WW, Lemanske RF, Jr. Hypothesis: decreased use of pediatric aspirin has contributed to the increasing prevalence of childhood asthma. Ann Allergy Asthma Immunol. 1998;81(4):347-351.
  2. Shaheen SO, Sterne JA, Songhurst CE, Burney PG. Frequent paracetamol use and asthma in adults. Thorax. 2000;55(4):266-270.
  3. Fitzpatrick AM, Teague WG, Holguin F, Yeh M, Brown LA. Airway glutathione homeostasis is altered in children with severe asthma: evidence for oxidant stress. J Allergy Clin Immunol. 2009;123(1):146-152 e148.
  4. Stephenson ST, Hadley G, Brown LA, Fitzpatrick AM. Decreased expression of acetaminophen-metabolizing enzymes and glutathione in asthmatic children after acetaminophen exposure. J Allergy Clin Immunol. 2012;129(3):867-869.
  5. Lesko SM, Louik C, Vezina RM, Mitchell AA. Asthma morbidity after the short-term use of ibuprofen in children. Pediatrics. 2002;109(2):E20.
  6. Barr RG, Wentowski CC, Curhan GC, et al. Prospective study of acetaminophen use and newly diagnosed asthma among women. American journal of respiratory and critical care medicine. 2004;169(7):836-841.
  7. Eneli I, Sadri K, Camargo C, Jr., Barr RG. Acetaminophen and the risk of asthma: the epidemiologic and pathophysiologic evidence. Chest. 2005;127(2):604-612.
  8. Koniman R, Chan YH, Tan TN, Van Bever HP. A matched patient-sibling study on the usage of paracetamol and the subsequent development of allergy and asthma. Pediatr Allergy Immunol. 2007;18(2):128-134.
  9. Persky V, Piorkowski J, Hernandez E, et al. Prenatal exposure to acetaminophen and respiratory symptoms in the first year of life. Ann Allergy Asthma Immunol. 2008;101(3):271-278.
  10. Beasley R, Clayton T, Crane J, et al. Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme. Lancet. 2008;372(9643):1039-1048.
  11. Rebordosa C, Kogevinas M, Sorensen HT, Olsen J. Pre-natal exposure to paracetamol and risk of wheezing and asthma in children: a birth cohort study. Int J Epidemiol. 2008;37(3):583-590.
  12. Etminan M, Sadatsafavi M, Jafari S, Doyle-Waters M, Aminzadeh K, Fitzgerald JM. Acetaminophen use and the risk of asthma in children and adults: a systematic review and metaanalysis. Chest. 2009;136(5):1316-1323.
  13. Bakkeheim E, Mowinckel P, Carlsen KH, Haland G, Carlsen KC. Paracetamol in early infancy: the risk of childhood allergy and asthma. Acta Paediatr. 2011;100(1):90-96.
  14. Farquhar H, Stewart A, Mitchell E, et al. The role of paracetamol in the pathogenesis of asthma. Clin Exp Allergy. 2009;40(1):32-41.
  15. Shaheen SO, Newson RB, Sherriff A, et al. Paracetamol use in pregnancy and wheezing in early childhood. Thorax. 2002;57(11):958-963.
  16. Perzanowski MS, Miller RL, Tang D, et al. Prenatal acetaminophen exposure and risk of wheeze at age 5 years in an urban low-income cohort. Thorax. 2010;65(2):118-123.
  17. Lowe A, Abramson M, Dharmage S, Allen K. Paracetamol as a risk factor for allergic disorders. Lancet. 2009;373(9658):120; author reply 120-121.
  18. Thomsen SF, Kyvik KO, Skadhauge L, Steffensen I, Backer V. Intake of paracetamol and risk of asthma in adults. J Asthma. 2008;45(8):675-676.
  19. Beasley RW, Clayton TO, Crane J, et al. Acetaminophen use and risk of asthma, rhinoconjunctivitis, and eczema in adolescents: International Study of Asthma and Allergies in Childhood Phase Three. American journal of respiratory and critical care medicine. 2011;183(2):171-178.
  20. Holgate ST. The acetaminophen enigma in asthma. American journal of respiratory and critical care medicine. 2011;183(2):147-148.
  21. McBride JT. The association of acetaminophen and asthma prevalence and severity. Pediatrics. 2011;128(6):1181-1185.
  22. Sheehan WJ, Mauger DT, Paul IM, et al. Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma. N Engl J Med. 2016;375(7):619-630.
  23. Litonjua AA. Acetaminophen and Asthma–A Small Sigh of Relief? N Engl J Med. 2016;375(7):684-685.
  24. Thompson JM, Waldie KE, Wall CR, Murphy R, Mitchell EA, group ABCs. Associations between acetaminophen use during pregnancy and ADHD symptoms measured at ages 7 and 11 years. PloS one. 2014;9(9):e108210.
  25. Liew Z, Ritz B, Rebordosa C, Lee PC, Olsen J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr. 2014;168(4):313-320.
  26. Brandlistuen RE, Ystrom E, Nulman I, Koren G, Nordeng H. Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int J Epidemiol. 2013;42(6):1702-1713.
  27. Chen MH, Su TP, Chen YS, et al. Asthma and attention-deficit/hyperactivity disorder: a nationwide population-based prospective cohort study. J Child Psychol Psychiatry. 2013;54(11):1208-1214.
  28. Tsai CJ, Chou PH, Cheng C, Lin CH, Lan TH, Lin CC. Asthma in patients with attention-deficit/hyperactivity disorder: a nationwide population-based study. Ann Clin Psychiatry. 2014;26(4):254-260.
  29. Borschuk AP, Rodweller C, Salorio CF. The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder. J Asthma. 2017:1-7.
  30. Miyazaki C, Koyama M, Ota E, et al. Allergic diseases in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis. BMC Psychiatry. 2017;17(1):120.
  31. Olsen J, Liew Z. Commentary: Acetaminophen use in pregnancy and neurodevelopment: attention function and autism spectrum symptoms. Int J Epidemiol. 2016;45(6):1996-1997.
  32. Avella-Garcia CB, Julvez J, Fortuny J, et al. Acetaminophen use in pregnancy and neurodevelopment: attention function and autism spectrum symptoms. Int J Epidemiol. 2016;45(6):1987-1996.
  33. Andrade C. Use of acetaminophen (paracetamol) during pregnancy and the risk of autism spectrum disorder in the offspring. J Clin Psychiatry. 2016;77(2):e152-154.
  34. Liew Z, Ritz B, Virk J, Olsen J. Maternal use of acetaminophen during pregnancy and risk of autism spectrum disorders in childhood: A Danish national birth cohort study. Autism Res. 2016;9(9):951-958.
  35. Schultz ST, Klonoff-Cohen HS, Wingard DL, Akshoomoff NA, Macera CA, Ji M. Acetaminophen (paracetamol) use, measles-mumps-rubella vaccination, and autistic disorder: the results of a parent survey. Autism. 2008;12(3):293-307.
  36. Schultz ST, Gould GG. Acetaminophen Use for Fever in Children Associated with Autism Spectrum Disorder. Autism Open Access. 2016;6(2).

 

ED Usage Tips

(ways to make things easier for your patients when referring them)

 

* Utilize CHOA App for ED/urgent care wait times

* Encourage patients to utilize MyChart to see labs

* If sending patient for a procedure, for ex: abscess drainage, fracture reduction keep them NPO

* ALWAYS call transfer center before referring a patient

* Hughes Spalding is different: no access to surgeons, no ICU, no 24 hour ultrasound, no MRI, minimal subspecialists-Hematology and the O’s (Opthalmology, Non-surgical Orthopedics, Oral Surgery)

* When referring a patient leave a cell phone number to contact you and update your colleagues on patients being referred to the ED

* Labs and X-rays can be done at the hospital as outpatients with an order from you – the patient doesn’t have to come via the ED unless you also want them seen by an ED physician.

* Respiratory viral panel testing is generally not indicated for previously healthy children in whom treatment for influenza is not necessary (or can be done on clinical grounds)

To Tamiflu or Not to Tamiflu?

 

shpic

Sherita Holmes, MD sherita.holmes@emory.edu

Every year we expect a flu epidemic which usually starts in the fall and lasts until spring (as early as October and last until late May).  According to the most recent CDC Weekly U.S. Influenza Surveillance Report (week 8 – February 25th), flu activity remains elevated in the United States; although it appears to be downtrending.1
We know that in a majority of patients; the flu manifests as a nuisance that causes our patients to have high fevers with self-limited respiratory symptoms, fatigue, and myalgias. However, we also know that in the very young (age < 2 years) or very old (age > 65 years) as well as those with underlying medical conditions (i.e. asthma, immunosuppression, diabetes, heart disease) [see Table 1]; the flu can be fatal. This flu season there have been 40 pediatric deaths reported thus far [Figure 1].1 This underscores the importance of prevention and why it is critical that we encourage flu vaccination, especially in these high risk groups.

 

While vaccination is important in preventing influenza, we can use antiviral medications to shorten the length of illness (by 1-2 days), reduce complications such as pneumonia, and lessen severity.2 Antiviral medications should be started as soon as possible – ideally within the first 48 hours of illness – for any patient with suspected or confirmed influenza who: has severe, complicated, or progressive illness; is in a high risk group; or is hospitalized.3 Consider chemoprophylaxis in patients in high risk groups with known exposure to influenza.

 

There are two classes of antivirals for influenza: neuraminidase inhibitors (oseltamivir, zanamivir) and adamantanes (amantadine, rimantadine). The adamantanes are not effective against influenza B and there are high levels of resistance against the current influenza A viruses. For 2016-2017 flu season, the CDC only recommends using the neuraminidase class of antivirals. Oseltamivir (Tamiflu) is available in pill or liquid form, while zanamivir (Relenza) only available in inhaled form. Please refer to Tables 2 and 3 for further information regarding antiviral medication age designations, contraindications, adverse effects, and dosages.3,4

 

In the battle against influenza, we must do our best to not only identify the appropriate patients that would benefit from antiviral medications, but most importantly to encourage all patients and their loved ones to get vaccinated.

 

 

 

 

CDC https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm

Table 3 Harper et al. https://doi.org/10.1086/598513

 

 

 

 

 

References:

 

  1. CDC Weekly U.S. Influenza Surveillance Report

https://gis.cdc.gov/grasp/fluview/flu_by_age_virus.html

 

  1. Campbell, Angela. CDC Expert Commentary 2016-2017 Influenza Antiviral Recommendations

http://www.medscape.com/partners/cdc/public/cdc-commentary

 

  1. Centers for Disease Control (CDC) and Prevention 2016-2017 Flu Season

https://www.cdc.gov/flu/about/season/current.htm

 

  1. Harper, S.A., Bradley, J.S., Englund, J.A., et al. Seasonal Influenza in Adults and Children—Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America

https://doi.org/10.1086/598513