10/4/2016 FROM WAAAH! TO AAAH! An Evidence-Based Update to the - PDF document

10/4/2016 FROM WAAAH! TO AAAH! An Evidence-Based Update to the Well-Child Check Madeleine Sanford, FNP OHSU Department of Family Medicine 1

10/4/2016 AAP Periodicity Schedule Objectives For each well-child check topic, the participant will be able to: Summarize the epidemiology and risk factors WCC Describe the impact of the Screening problem Update Integrate the recommendation into practice Choose Your Own Adventure! Well Child Check Topic Choices Iron Deficiency / Lead Obesity/ Exposure Dyslipidemia Adolescent Depression/ Oral Health Substance Abuse Screening/ Topical Developmental / Fluoride in Office Autism Screening Matters 2

10/4/2016 Iron Deficiency: The Problem US Prevalence % US % Iron Deficiency in High Risk Children Toddlers IDA Iron Deficiency 25 25 20 20 20 17 15 12 15 10 10 10 7 6 5 4 5 3 2 1 0 0 Age 0-2 Age 3-5 Age 6-11 Poorer cognition in adulthood Risk Factors for Anemia • NUTRITION SOCIAL HX Breastfeeding > • Low income 4 mos without PREMATURITY SPECIAL LEAD • Low literacy iron NEEDS EXPOSURE • Race • Weaning to milk/ non-iron rich foods • Obesity Anemia Screening WHEN: USPSTF: I (insufficient) AAP: 12 months universal, after based on risk factors HOW: Hgb <11 3

10/4/2016 Prevention Nutrition Iron Deficiency counseling USP AAP AAP AAP STF • Preterm Breastfed > Marginally High Risk <37 wks ½ LBW age 6-12 • Age 2-4 wks  Age 4 mos  Age 8 wks  mos iron rich foods iron-rich foods iron-rich foods Grade B Evidence Lead Exposure Why It Matters ADHD Motor Lower skills IQ Pb >2 • NO safe levels • Chelation doesn’t CV Anti- improve Effects social neurocognitive scores 4

10/4/2016 Lead Exposure in Oregon The Problem Results for Oregon children screened for lead 10+ 2% 5 to 10 12% 2 to 5 22% <2 64% (Oregon Department of Human Services Childhood Lead Poisoning Prevention Program, 2010) Risk Factors for Lead Exposure POVERTY PRE-1978 RECENT HOUSING / MINORITY IMMIGRANTS PARENTAL DAYCARE / SIBLING LEAD EXPOSURE Lead Screening / Prevention WHEN: USPSTF: I (insufficient) AAP: Risk assessment 6 mos- 6 yrs Medicare: 12 and 24 mos* PREVENTION / counseling 5

10/4/2016 Adolescent Depression Screening Adolescent Depression Suicide is Oregon's number two cause of death among youth Oregon Health Division (2008) Adolescent Depression Why It Matters 4%-9% of adolescents 01 Girls > Boys 20% admitted to ED met 02 criteria for depression Sequelae 03 poor academic performance, legal problems substance use, early pregnancy, family disruption Most depressed adolescents receive no 04 treatment (Biros MH et al., 2008) 6

10/4/2016 Risk Factors for Adolescent Depression OBESITY POVERTY MAJOR PARENT WITH NEGATIVE CIGARETTE DEPRESSION LIFE EVENT SMOKING Adolescent Depression Screening WHEN: USPSTF AAP: Yearly, age 11-21 HOW: PHQ-A PHQ-A: Same as PHQ-2 with 2 extra questions Just like the PHQ-9, but with 2 extra questions: 7

10/4/2016 Adolescent Depression Fluoxetine (Prozac) and escitalopram (Lexapro) are approved for use in children. Adolescent Substance Abuse The Problem % US Teens, 2011 Ever took rx drug that wasn't theirs Marijuana past 30 d Drinking + driving past 30 days 5+ drinks past 31 days Alcohol in past 30 days First drank alcohol before age 13 0 10 20 30 40 (CDC Youth Risk Behavior Surveillance System, 2011) Adolescent Substance Abuse Screening WHEN: USPSTF: I (Insufficient) AAP: Yearly risk assessment age 11-21 HOW: CRAFFT 8

10/4/2016 Adolescent Substance Abuse Screening CRAFFT: Car, Relax, Alone, Forget, Friends, Trouble Adolescent Substance Abuse Screening CRAFFT: Car, Relax, Alone, Forget, Friends, Trouble Childhood Obesity The Problem • 17% aged 2 -19 years are obese • Improving in 2-5 year age range (13% down to 9%) • Higher among Hispanics (22.4%) and non-Hispanic blacks (20.2%) than among non-Hispanic whites (14.1%). 9

10/4/2016 Risk Factors for Pediatric Obesity • POVERTY GENETIC SEDENTARY • Self-regulation • Screen time PRENATAL of food via SWEET FTO gene BEVERAGES • juice Pediatric Obesity Screening / Intervention WHEN: USPSTF: AAP: Every visit, starting age 2 HOW: BMI Dyslipidemia Screening WHEN: USPSTF: AAP: Once age 9-11, again age 17-19 HOW: Direct LDL (non-fasting) BMI 10

10/4/2016 Dyslipidemia Intervention per AAP • <1% qualify for statin • Primarily genetic • LDL > 190 after 6 mos trial lifestyle change • LDL > 160 with fam hx 1 st degree premature CV disease • Lifestyle modification Oral Health Screening / Topical Fluoride Oral Health: The Problem 11

10/4/2016 Pediatric Oral Health Screening WHEN: USPSTF AAP: Risk assessment and visual screen age 6 - 30 mos, refer to dental home by age 1 Oral Health Risk Assessment Topical Fluoride Application 1. Dry teeth w/ gauze 2. Paint fluoride on teeth Counsel: • No food for 1 hr (drinks ok) • Soft foods for next meal • No sticky foods today • Don’t brush teeth today • Yellow discoloration fades 12

10/4/2016 Fluoride Remineralization of enamel Inhibits demineralization of enamel Makes cariogenic bacteria less able to produce acid from carbohydrates. TOPICAL (most important) Fluoride paste at WCC or at dentist every 3-6 months (CDC Grade IA) Fluoride toothpaste for all (CDC Grade 1A) – Smear for < 2 – Pea-size age 2-5 SYSTEMIC – age 6 months- 16 years – CDC Grade I IA evidence fluoride 6 mos-5 yrs, Grade IA 6 -16 yr – ADA & USPSTF Strength of recommendation :B NO chance of fluorosis after age 6, most likely 15-30 months CDC Grade I IA evidence fluoride Why Developmental/ Autism Screening Matters Jee, et al (2010), Hix-Small (2007) ASQ http://agesandstages.com/age-calculator/ 13

10/4/2016 Adjust for prematurity if : • Born <37 weeks and • Current age <2 35 (score) / 5 (answered) = 7 41 Scoring ASQ-3 Avoid pass/fail terms • “Above Cutoff” • “Near Cutoff” • “Below Cutoff” 14

10/4/2016 GET CONSENT DURING VISIT FAX COPY OF ASQ/ MCHAT SIGN HERE 43 Autism Screening Without screening, mean age 1 st eval 48 mos, mean age dx 61 mos – Parents usually notice something wrong by 18 mos M-CHAT revised w/ follow-up – TWICE between 16 and 30 months (18 & 24) – Why twice? MCHAT/ MCHAT-R 15

10/4/2016 MCHAT: Positive Screen Simultaneously refer to: – Early Intervention – CDRC • COUNSEL PARENTS: 9+ month wait AFTER family gets paperwork back – Audiology 16