Nasuh Malas

Pediatric Somatic Symptom Disorders

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.

Pediatric Somatic Symptom and Related Disorders: Primary Care Provider Perspectives:

Somatization, or physical symptoms that are inconsistent with a physiological cause that may or may not involve an identified stressor, is common in outpatient pediatrics. When these symptoms persist, they can impair function and progress to a somatic symptom and related disorder (SSRD), resulting in increased health care use and increased demands on primary care providers (PCPs). We performed a needs assessment among PCPs to better understand how best to support providers caring for children with SSRDs. Pediatric PCPs (n = 77) were surveyed to better understand their training, experience, perceptions, and practices of SSRD care. Findings indicate that PCPs have limited training in SSRD care but express interest in learning more. Many barriers to effective care were reported. We hope to use these findings to develop training materials and support services for pediatric PCPs managing SSRDs.

Quality Improvement Initiative to Reduce Pediatric Intensive Care Unit Noise Pollution With the Use of a Pediatric Delirium Bundle

Objectives: Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. Methods: This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. Results: A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]). Conclusions: Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.

Pediatric Delirium: Evaluation, Management, and Special Considerations

Delirium describes a syndrome of acute brain dysfunction with severe consequences on patient outcomes, medical cost, morbidity, and mortality. It represents a final common pathway of numerous pathophysiologic disturbances disrupting cerebral homeostasis. The diagnosis is predicated on recognition of the clinical features of the syndrome through ongoing clinical assessment. Early identification can be aided by routine screening, particularly in high-risk populations. Evaluation and management are continuous and simultaneous processes involving a multidisciplinary care team including child psychiatry consultation. Prevention, early identification and management are critical in alleviating symptoms, improving outcomes, and reducing distress for patients, families, and care teams. This review highlights our current understanding regarding pediatric delirium, its mechanisms, clinical manifestations, detection and management.

National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings

BACKGROUND Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management. METHODS In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondents respective hospital. RESULTS Responses were obtained from 38 North American academic childrens hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management. CONCLUSION Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

Partnerships with Primary Care for the Treatment of Preschoolers

This article reviews mental health access issues relevant to preschool children and data on this population obtained through the Michigan Child Collaborative Care Program (MC3). The MC3 program provides telephonic consultation to primary care physicians (PCPs) in 40 counties in Michigan and video telepsychiatric consultation to patients and families. Attention-deficit/hyperactivity disorder and disruptive behavioral disorders are frequent initial presenting diagnoses, but autism spectrum disorders, parent-child relational issues, trauma, and posttraumatic stress disorder should also be considered. Collaborative care programs provide promising ways to promote access to child psychiatric services when these services are distant to local PCP offices.

Exploring the Telepsychiatry Experience: Primary Care Provider Perception of the Michigan Child Collaborative Care (MC3) Program

BACKGROUND Pediatric mental healthcare is a growing component of primary care practice. However, there is a lack of access to mental health services, particularly those provided by Child and Adolescent Psychiatrists. The Michigan Child Collaborative Care (MC3) Program is a telepsychiatry service that offers embedded behavioral health consultants within primary care practices, telephonic consultation, video consultation and embedded care. Primary care provider (PCP) utilization of telepsychiatry services is predicated on perceiving the consultation service as user-friendly, helpful, and feasible in their practice. OBJECTIVE A survey of PCPs was conducted over a 5-year period to assess PCP attitudes and perceptions regarding MC3 consultation, including measures of efficiency, user-friendliness, and confidence in providing mental healthcare. The survey contained 4 items, (2 quantitative and 2 qualitative), and took less than 2 minutes to complete. RESULTS 649 responses were received out of 1475 possible responses (44% response rate). Common themes elicited from the qualitative items included perception of improved patient care for youth with mental illness (45.3%), improved comfort and confidence in caring for youth with mental illness (30.9%), greater comfort with the prescribing and monitoring of psychotropics (25.9%) and improved access to mental healthcare for youth (23.1%). PCPs strongly agreed that MC3 was user-friendly, efficient, and enhanced their confidence in managing pediatric mental health concerns. CONCLUSIONS This study demonstrates that the MC3 Telepsychiatry Program is well accepted by PCPs with self-reported improvements in providing mental healthcare to patients. Future research should explore how PCP perception impacts PCP practice, knowledge, as well as outcomes for patients and families longitudinally.

Addressing stigma on the child and adolescent psychiatry consultation service through use of video

Methodology & Theoretical Orientation: We selected 17 households with H. pylori patients. 50 H. pylori strains were isolated from patients and family members, of whom 17 were from pediatric patients, 33 from family members including fathers, mothers and brothers/sisters. All 50 H. pylori strains were analyzed by RAPD technique from January, 2012 through September, 2013 in National hospital of pediatrics, Hanoi, Vietnam.Background: Sign and symptoms of urinary tract infections (UTI) are not specific in infants and young children, fever being the commonest sign. Therefore, collecting urine samples for culture is required to diagnose or exclude UTI. Obtaining a clean catch urine sample in neonates and infants is a great challenge as it is unpredictable, time consuming and requires lot of patience. Objectives: The objectives of the study were to determine the effect of bladder and lumbar stimulation technique (BLST) for collection of midstream urine in newborns and to evaluate contamination rates of urine samples collected. Methods: An experimental research was conducted in BPKIHS, Dharan, Nepal including total of 54 term newborns. Urine culture was indicated for different reasons to the admitted newborns. They were randomly assigned either to the experimental group or the control group. Twenty-five minutes after feeding, the genitals and perineal area of the babies were cleaned. The newborns were held under the armpits with legs dangling. Bladder and Lumbar stimulation technique was only applied to the newborns in the experimental group. Success was defined as collection of urine sample within 5 minutes (<300s) of starting the stimulation maneuver in the experimental group and of holding under the armpits in the control group. Results: The success rate of urine collection was significantly higher in the experimental group (88.88%) than in the control group (25.92%) p<0.001. The median time for sample collection was 1.07 minutes (64.2s) [IQR=1.52minutes (91.2s)] in experimental group and 1.52minutes (91.2s) [IQR= 2.78 minutes (166.8s) for control group (p=0.069). Contamination was not found in urine samples collected by BLST in experimental group. Conclusion: The study suggests that bladder and lumbar stimulation technique is safe, quick and effective way of collecting midstream clean catch urine in newborns.

The Impact of Psychotropic Medications on Bone Health in Youth

Purpose of ReviewPsychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use.Recent FindingsThrough a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health.SummaryAwareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.

Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents

Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.