Showing posts with label diagnosis. Show all posts
Showing posts with label diagnosis. Show all posts

Thursday, September 17, 2015

Screening for iron Deficiency Anemia – what do we really know?

By: Lydia Furman, MD,  Assistant Editor 
     Is screening for iron deficiency anemia at both ages 12 and 24 months a bedrock part of preventive medicine or a poor use of resources? Although national data is unavailable on rates of screening 1, collegial conversations suggest that many pediatricians practicing in affluent areas without an onsite laboratory have long ago concluded that the routine complete blood count at age one year is neither well accepted by parents nor very informative.  While many pediatricians serving families of lower socioeconomic levels linked to academic centers routinely test for anemia when screening for lead exposure per Centers for Disease Control recommendations the question remains, who is best serving the child and family? The recent US Preventive Task Force (USPTF) Recommendations on screening for iron deficiency anemia in healthy asymptomatic young children give us an extraordinarily well researched answer: there is not enough evidence to know.1  While intellectually unsatisfying, because we all hope for an “ah-ha” bottom line, this report gives great “food for thought” for all practitioners.
      It is uncomfortable that many of our practices are insufficiently evidence based, based on limited studies that are not generalizable to the populations we serve, or are habits based on personal advice from a trusted mentor. What a great opportunity this represents to do a national study, perhaps involving the American Academy of Pediatrics (AAP) Pediatric Research in Office based Settings (PROS- ), that is designed and powered to answer the simple questions we still cannot conclusively resolve. National rates of screening are not known, so who is screening, when and why? Is there a possibility that some children in the US with asymptomatic iron deficiency, perhaps a well-defined at risk subpopulation of these children (for example, those with lead levels 5-10 micrograms/dL living in high poverty census tracts), will have long term benefit from iron supplementation?  It will take a lot of collaboration, excellent planning and long term data collection to answer such queries, but in the end the benefits are potentially profound, in terms of children whose outcome is improved, or alternately, who are not exposed to unnecessary testing or attempted treatments.
      As a trainee, I well remember learning that the 3 top causes of anemia in children are 1- iron deficiency, 2-iron deficiency, and 3- (yes) iron deficiency. Dr. Siu et al. (doi: 10.1542/peds.2015-2567) at the USPFT reference data from a prior AAP statement which clearly contradicts this information.1,2 Based on NHANES (National Health and Nutrition Examination Study) data from 1999-2002, only 40% of childhood anemia is due to iron deficiency.2 The NHANES definition of anemia was hemoglobin under 11.0 gm/dL, and iron deficiency was defined as an abnormal value for two of three recognized indicators (serum ferritin, zinc protoporphyrin, and transferrin saturation). Whether this is true a decade later, or whether perhaps even fewer cases of anemia are due to iron deficiency now thanks to increasing fortification of food products and formula, is not discussed, but certainly is of interest to those who choose to continue screening. The USPTF guidelines do not address the issue of identifying iron deficiency in the presence of  hemoglobin less than 11.0 gm/dL: are red blood cell indices or a reticulocyte hemoglobin or other more expensive add on tests needed or useful? Given the study findings, this question is moot, but likely will continue to bedevil those who feel strongly about continued screening until there is definitive evidence about the impact of treatment.
       With estimated US national rates of 8% for iron deficiency and 1-2% for iron deficiency anemia among infants and toddlers, it is unlikely this issue will go away quietly.3 The work of Siu and colleagues at the USPSTF is a refreshing and transparent starting point for new thinking about iron deficiency anemia in young children.

1. Siu et al. Screening for Iron Deficiency: Anemia in Young Children USPSTF Recommendation Statement.  Pediatrics 2015, doi: 10.1542/peds.2015-2567 Epub 2015 Sept. 7

Wednesday, September 16, 2015

Dexamethasone for Septic Arthritis? Does It Make a Difference?

By: Lewis First, MD, MS; Editor-in-Chief         
       We can all note the benefits of using dexamethasone in a number of disease processes, but how many of us think about it when a child presents with a septic joint?  Fogel et al. (doi: 10.1542/peds.2014-4025) opted to study the effect of dexamethasone in combination with antibiotics in hospitalized children at one pediatric center.   
      While not randomized, 26 of the 116 patients with septic arthritis got antibiotics and dexamethasone. There were not striking differences in the demographics of who did and did not get the steroid. Yet when children received dexamethasone in this study, there were marked clinical improvements including shorter duration of fever, faster clinical improvement, quicker drop in C-reactive protein as a marker of inflammation and others including a shorter hospital stay. 
      Just how much dexamethasone to use, and what if any side effects occurred, as well as lots of other interesting information about this newer usage of a steroid in combination with antibiotics awaits your perusal by linking to this study being released this week.  Have you used dexamethasone in the care of your patients with septic arthritis? If so, tell us about it by responding to this blog, sending us an e-letter, or posting your comments on our Facebook or Twitter sites.

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Wednesday, June 10, 2015

New Standards of How to Classify Vascular Anomalies Are Here

By: Lewis First, MD, MS; Editor-in-Chief

      It has been almost two decades since there was an attempt to classify vascular lesions into categories like vascular malformations and proliferative vascular lesions (tumors).  Since then new complexities in vascular lesions have been identified that do not lend themselves to the older classification and call for a relook at how we classify these lesions with the hope of improving not just our diagnosis but treatment approaches to these disorders. 
     Wassef et al. (doi: 10.1542/peds.2014-3673) present the recommendations of the International Society of the Study of Vascular Anomalies (ISSVA) in a special article being released this week in our journal.  The authors expand on the prior categories such as classifying tumors as benign, locally aggressive and malignant, and now have added new sections as well—including one dealing with malformations of individually named vessels and one for lesions of uncertain nature (e.g. malformation vs. tumor).  There is even information on genetic defects underlying the vascular anomalies as part of the appendix of this article. 
      So what is the relevance of our publishing this classification in our journal?  Dermatologist Dr. Sheila Friedlander provides us with some important commentary (doi: 10.1542/peds.2015-0688) to accompany this article that is well worth reading in regard to the relevancy of knowing this classification exists since often these lesions are first noticed or diagnosed in the primary care setting. 
      Mark some time to review the new classification guidelines and you will able to do far more than just skin the surface in better identifying the various lesions and in turn know when and when not to refer them.

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