Psychological Care of the Family of Children with Medical Complexities.

Advances in medical knowledge and treatments have made possible the survival of children with diseases that require lifelong care, and increasing numbers of families with children with medical complexity are presenting for health care. Owing to an increase in home-based care, the responsibility of complicated treatment regimens falls on parents and family caregivers. Based on studies and national survey, parents of children with medical complexity fare worse in mental health and family functioning. This review describes screening tools and research studies for family functioning and psychological health. These data also help in designing a family centered approach to the care of parents and caregivers to create a medical home and community support systems that integrate psychological and emotional interventions. Physician communication can be optimized by educational tools of brief intervention and community connections. [Pediatr Ann. 2024;53(3):e93-e98.].

Febrile infants without respiratory symptoms or sick contacts: are chest radiographs or RSV/influenza testing indicated?

BACKGROUND: Serious bacterial infection rates in febrile infants < 60 days are about 8-11%. Less than 1% of febrile infants with no respiratory symptoms will have pneumonia however, chest radiography (CXR) rates remain between 30 and 60%. Rapid Respiratory Syncytial Virus (RSV) and influenza (flu) testing is common, however, there is not enough data to determine if febrile infants without any respiratory symptoms should be tested. The goal of this study is to determine the rate of positive CXR and RSV/flu results in febrile infants with no respiratory symptoms and no sick contacts. METHODS: Well-appearing febrile infants between 7 and 60 days of age who presented to the pediatric emergency department (PED) from September 1st, 2015 through October 30th, 2017 were enrolled. Demographic data, respiratory symptoms, CXR findings and RSV/flu results were collected. SAS statistical software was used for analysis. RESULTS: 129 infants met enrollment criteria. Of the 129 infants, 58 (45.0%) had no respiratory symptoms and no sick contacts. Of these 58, 36 (62.1%) received a CXR and none of them had any abnormal findings, 48 (82.8%) had RSV/flu testing, no patients tested positive for RSV and only one patient tested positive for flu. Costs of CXR and RSV/flu testing for this cohort was $19,788. CONCLUSION: The absence of positive CXRs in this patient population reinforces the current recommendations that CXR is not indicated. The low incidence of RSV/flu indicate that routine testing may not be necessary in this population especially outside of the flu season. Reduced testing could decrease overall costs to the healthcare system as well as radiation exposure to this population.

Approach to Children with Aggressive Behavior for General Pediatricians and Hospitalists: Part 1-Epidemiology and Etiology.

Children and adolescents are increasingly presenting to the hospital and emergency department with aggressive behavior and psychiatric emergencies. The rise in pediatric mental health problems, coupled with a lack of much needed resources, necessitates that pediatricians safely diagnose and treat patients presenting with aggressive behavior. In this article, we discuss the broad differential diagnosis that should be considered when initially evaluating a patient presenting with aggression or altered mental status; underlying causes include predisposing factors, comorbid conditions, and acute organic causes involving almost every organ system. Emergency and hospital physicians should tailor their examination and testing individually based on the patient's history and presentation. [Pediatr Ann. 2018;47(10):e402-e407.].

Approach to Children with Aggressive Behavior for General Pediatricians and Hospitalists: Part 2-Evaluation, Tests, and Treatment.

After reviewing the various etiologies that can contribute to a presentation of aggressive behavior in a child (see part 1), a physician should conduct a thorough history and physical examination. The history should be obtained from the patient and caregivers, both together and separately in adolescents. A good physical examination starts with assessment and interpretation of vital signs, followed by a head-to-toe examination focusing on the skin, eyes, and thyroid, and then a neurologic examination. The testing and observation should be tailored to the individual patient, including laboratory results, imaging, and specialist consultation. Management of aggressive behavior can often be achieved through a combination of environmental modifications and verbal techniques, with special consideration given to children with neurodevelopmental problems such as autism. Pharmacologic agents are a good next step, and physical restraints can be used as a last resort. Evaluation of suicidality with thorough and complete questioning as well as assessment of a safety plan can aid in determining patient disposition such as need for admission to a psychiatric facility. [Pediatr Ann. 2018;47(10):e408-e412.].

A Diagnostic Approach to Autoimmune Disorders: Laboratory Evaluation: Part 2.

Pediatricians and other pediatric health care providers in primary care settings are often faced with the challenge of evaluating patients with suspected autoimmune disorders. The first and most important step in evaluating children with suspected autoimmune disorders is taking a detailed history and performing a thorough physical examination. This step helps narrow the diagnosis, and thus helps determine appropriate laboratory evaluations. The results of laboratory tests need to be interpreted within the clinical context. It is also important to recognize that the laboratory tests have different diagnostic values in children as compared to adults. [Pediatr Ann. 2016;45(7):e265-e271.].

A Diagnostic Approach to Autoimmune Disorders: Clinical Manifestations: Part 1.

Autoimmune disorders are not commonly encountered in a general pediatric practice, but they may mimic many other disorders. Although they occur infrequently, it is always important to pause and consider an autoimmune disorder in the differential diagnosis. A detailed history and careful physical examination play an important role in guiding laboratory evaluation for these disorders. Many autoimmune disorders present with symptoms that involve multiple organ systems. The common symptoms that may make one consider a rheumatic disorder in the differential diagnosis are fever, fatigue, joint pain, rash, ulcers, and muscle weakness. The most common reason for referral to a pediatric rheumatologist is joint pain. A good joint examination may be performed by the use of the pediatric Gait, Arms, Legs, Spine screen, which is a validated screening tool. A small portion of children with fever of unknown origin may have an autoimmune disorder, with a majority of them having an infectious disease. Some patients with undiagnosed rheumatic disorders may present to the emergency. department. The characteristics of historic and clinical examination features of various autoimmune disorders are discussed in this article. [Pediatr Ann. 2016;45(6):e223-e229.].