Speech and Language Delay in Children.

Childhood speech and language concerns are commonly encountered in the primary care setting. Family physicians are integral in the identification and initial evaluation of children with speech and language delays. Parental concerns and observations and milestone assessment aid in the identification of speech and language abnormalities. Concerning presentations at 24 months or older include speaking fewer than 50 words, incomprehensible speech, and notable speech and language deficits on age-specific testing. Validated screening tools that rely on parental reporting can serve as practical adjuncts during clinic evaluation. Early referral for additional evaluation can mitigate the development of long-term communication disorders and adverse effects on social and academic development. All children who have concerns for speech and language delays should be referred to speech language pathology and audiology for diagnostic and management purposes. Parents and caretakers may also self-refer to early intervention programs for evaluation and management of speech and language concerns in children younger than three years.

Pruritus: Diagnosis and Management.

Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. An exposure history may reveal symptom triggers. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. Primary skin lesions indicate diseased skin, and secondary lesions are reactive and result from skin manipulation, such as scratching. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

Foreign Bodies in the Skin: Evaluation and Management.

Foreign bodies may be introduced into the skin through lacerations and soft tissue wounds. Long-term complications of retained foreign bodies include chronic pain and neurovascular impairment. Wound exploration and initial imaging with radiography or ultrasonography should be considered before foreign body removal. Risks and benefits of removal should be discussed with the patient. Although some foreign bodies may be left in place, removal should be considered if the risk of complications is high. A cooperative patient and adequate wound visualization are important for successful foreign body removal. Adequate analgesia and judicious use of anxiolytics and sedation may be helpful. Wound irrigation with normal saline or tap water is recommended after foreign body removal. Antiseptic solutions for wound irrigation may impair healing and should be avoided. Although there is no consensus on the use of antibiotic prophylaxis, several indications exist. The patient's tetanus immunization history should be reviewed, and vaccine should be administered if indicated.

Relationship of Training in Acupuncture to Physician Burnout.

BACKGROUND: Physician burnout is an ongoing problem that affects both physician wellbeing and patient care. Burnout is characterized by emotional exhaustion and depersonalization. Studies have explored ways to prevent and alleviate burnout. Receiving training in acupuncture may reduce physician burnout. OBJECTIVE: The purpose of this study is to determine if acupuncture training is associated with less patient depersonalization and less emotional exhaustion among physicians. METHODS: These self-reported data were collected from a cross-sectional survey of family physicians at the Uniformed Services Academy of Family Physicians 2017 conference. Physicians answered questions regarding their level of acupuncture training as well as questions about burnout (depersonalization and emotional exhaustion). RESULTS: The overall response rate was 66% (325/492). Of these, 233 cases provided complete datasets. In a model controlling for years' practice and clinical pace, acupuncture training was significantly associated with decreased depersonalization, F (1, 194) = 5.82, P < .05. CONCLUSION: Study data show an association between decreased physician depersonalization and acupuncture training, suggesting acupuncture training may be a helpful strategy to reduce family physicians' depersonalization of patients.

Nutrition in Toddlers.

The establishment of eating practices that contribute to lifelong nutritional habits and overall health begins in toddlerhood. During this time, children acquire the motor skills needed to feed themselves and develop preferences that affect their food selections. Classifications for faltering weight (also called failure to thrive or growth faltering) and overweight are based on World Health Organization child growth standards (for children younger than two years) and Centers for Disease Control and Prevention growth charts (for children two years and older). Breast milk or whole cow's milk should be offered as the primary beverage between one and two years of age. Sugar-sweetened beverages should be avoided in all toddlers, and water or milk should be offered instead. Allergenic foods such as peanuts should be introduced early to infants at higher risk of allergies. Vitamin D and iron supplementation may be advisable in certain circumstances, but multivitamins and other micronutrient supplements are usually unnecessary in healthy children who have a balanced diet and normal growth. Optimal food choices for toddlers are fresh foods and minimally processed foods with little or no added sugar, salt, or fat (e.g., fruits, vegetables, lean protein, seeds, whole grains). Parents and caregivers are responsible for modeling healthy food choices and dietary practices, which shape children's food preferences and eating behaviors. Parents should avoid practices that lead to overeating in toddlers (e.g., feeding to soothe or to get children to sleep, providing excessive portions, pushing children to "clean their plates," punishing with food, force-feeding, allowing frequent snacks or grazing). In general, parents should use the approach of "the parent provides, the child decides," in which the parent provides healthy food options, and the child chooses which foods to eat and how much.

Evaluation of Patients with Leukocytosis.

An elevated white blood cell count has many potential etiologies, including malignant and nonmalignant causes. It is important to use age- and pregnancy-specific normal ranges for the white blood cell count. A repeat complete blood count with peripheral smear may provide helpful information, such as types and maturity of white blood cells, uniformity of white blood cells, and toxic granulations. The leukocyte differential may show eosinophilia in parasitic or allergic conditions, or it may reveal lymphocytosis in childhood viral illnesses. Leukocytosis is a common sign of infection, particularly bacterial, and should prompt physicians to identify other signs and symptoms of infection. The peripheral white blood cell count can double within hours after certain stimuli because of the large bone marrow storage and intravascularly marginated pools of neutrophils. Stressors capable of causing an acute leukocytosis include surgery, exercise, trauma, and emotional stress. Other nonmalignant etiologies of leukocytosis include certain medications, asplenia, smoking, obesity, and chronic inflammatory conditions. Symptoms suggestive of a hematologic malignancy include fever, weight loss, bruising, or fatigue. If malignancy cannot be excluded or another more likely cause is not suspected, referral to a hematologist/oncologist is indicated.