Pediatrics and Adolescent Medicine I: Introduction to Pediatrics & Ethical Concerns PDF

Pediatrics and Adolescent Medicine I: Introduction to Pediatrics & Ethical Concerns Angela Deubel, PA-C University of New Mexico PA Program Roadmap Introduction to Course & Syllabus Pediatrics Pediatric Patient vs. Adult Mortality Legal & Ethical Concerns Communication...

Pediatrics and Adolescent Medicine I: Introduction to Pediatrics & Ethical Concerns Angela Deubel, PA-C University of New Mexico PA Program Roadmap Introduction to Course & Syllabus Pediatrics Pediatric Patient vs. Adult Mortality Legal & Ethical Concerns Communication Narrator’s Work.com “Pediatrics is the specialty of medical science concerned with the physical, mental, and social health of children from birth to young adulthood. Pediatric care encompasses a broad spectrum of health services ranging from preventive health care to the diagnosis and treatment of acute and chronic diseases.” (Source: American Academy of Pediatrics (AAP) Subspecialties Adolescent Medicine Pediatric Infectious Diseases Pediatric Cardiology Neonatal-Perinatal Medicine Child Abuse Pediatrics Pediatric Nephrology Pediatric Critical Care Medicine Pediatric Pulmonology Developmental-Behavioral Pediatric Rheumatology Pediatrics Pediatric Surgery Pediatric Emergency Medicine Hospice and Palliative Medicine Pediatric Endocrinology Pediatric Gastroenterology Medical Toxicology Pediatric Hematology-Oncology Sleep Medicine Pediatric Hospital Medicine Sports Medicine Pediatric Transplant Hepatology American Board of Pediatrics  Diagnose and Treat Areas of Disease Importance Full Immunizati Adult Growth & Developme on Potenti nt al Nutrition Source: Dr. Tauhid Iqbali How old is a pediatric patient? It depends! 0-1 year old 0-2 years Infa nt Neonate: 0-28 days Infa nt old 1-3 years old Tod dler 2-11 years 3-5 years old old Pre Chil sch d ool er 11-21 years Chil 6-11 years old Ado d lesc ent old Ado 12-17 years old AAP lesc ent CDC* Adolescence Classifications E 11-14 years ar old ly Mi 15-17 years d dl old e 18-21 years La te old These age ranges are different than AAP Bright Current textbook: early 11-13, mid 14- Futures 16, late 17+ Pop Quiz! 2 month old 17 year old 11 year old 3 year old 18 month old 7 day old 21 year old How is pediatrics different than adult medicine? Physical Histories Physiologic Examination Developme Prevention Disease and ntal and Safety Injury Legal/ Ethical The Pediatric History Parent as historian Differences between parent and child histories Prenatal and birth histories Maternal/Family histories Developmental histories Social history Immunization history The Pediatric Physical Exam Age and condition specific General vs focused Newborn Infant Toddler/Child Adolescent Physical Milestones Examples of physiological differences between pediatrics & adults Proportion: BSA is greater than adults Thinner skin Immature blood-brain barrier Respiratory & heart rates are faster Infants & young children are obligate nose breathers Airways are smaller: short & narrow “Not small Lungs are more prone to collapse adults” How would the common cold impact an infant differently than an adult? Examples of Pediatric Vital Signs vs Adult AGE BP mmHg RR Awake HR Sleep HR bpm bpm bpm Neonate (0-1mo) 39-84/16-53 30-53 100-205 90-160 Infant (1-12mo) 72-104/37- 30-53 100-190 90-160 56 Toddler (1-2yrs) 86-106/42- 22-37 98-140 80-120 63 Preschool (3-5yrs) 89-112/46- 20-28 80-120 65-100 72 School-age (6- 97-120/57- 18-25 75-118 58-90 11yrs) 80 Peds TEMP 97.9°F- Adolescent (12- 110-131/64- 12-20 100.4°F 60-100 50-90 15yrs) *83 Adult TEMP 98°F- Examples* show average of ranges for98.6°F boys, girls, weight and age group. Some patients may have normal ranges outside Adult 120/80 (or those given. Normal ranges may vary by reference. Sources: 16-20 60-100 less) https://www.pedscases.com/sites/default/files/VitalSignsChart3.pdf (Based on PALS guidelines) * https://emedicine.medscape.com/article/2172054-overview (adult values) Examples of physiological differences between pediatrics & adults Metabolism & absorption are higher Higher proportion of rapidly growing How do you tissue think More prone to dehydration medication Poor temperature control s might Immature immune system need to be adjusted in Require more water and calories than infants and adults children? Immature organ systems affects medication metabolism  Examples of Medication Pharmacokinetics in Pediatric Patient Reduced GI motility and increased stomach pH Longer time to reach max concentration; changes bioavailability of drugs (PO) Thinner, moister skin; greater cutaneous perfusion Increased skin absorption; increased systemic exposure (Topical) Less muscle mass, weaker muscles, less muscle blood flow Reduced bioavailability, erratic absorption (IM) Increased water volume (proportion) Changes in distribution in water- or lipid-soluble drugs Reduced metabolic enzyme activity Lower drug clearance Reduced renal function neonates; elevated renal clearance/kg in >1yr Changes in renal clearance of drugs armacokinetic considerations in pediatric pharmacotherapy; Limm and Pettit; American Journal of Health-Sstem Pharmacy, Volume 76, Issue 19, 1 October 2019  Medications in Pediatrics Smaller doses than adults Not proportional to difference in weight Commonly use weight-based dosing for infants and smaller children ie: 2mg/kg/day Limited clinical trial information Less standardized guidance for dosing and outcomes Medications are often used off-label armacokinetic considerations in pediatric pharmacotherapy; Limm and Pettit; American Journal of Health-System Pharmacy, Volume 76, Issue 19, 1 October 201 Examples of Pediatric Lab Values vs Adult AGE ALT U/L AGE Creatinine Clearance (males) mL/min Infant 60-50 0-30days 25-55 4-6yrs 10-25 1-5mo 50-90 12- 10-55 6-11mo 75-125 13yrs >1yr 90-150 >19yrs 21-72 AGE Bilirubin (full-term) AGE Glucose mg/dL mg/dL 1-12hrs 30-65 (premature) 1day 50-58 0-23hrs 1-8 2-6 2days 58-60 3-5days 10-14 4-8 >3days 70-110 >1mo 0.2-1.0 Lab value ranges may differ based on individual labs. Source: https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781444345186.app2  Developmental differences between pediatrics & adults Development varies tremendously by age Mental & emotional capabilities start egocentric and concrete thinking with limited resilience Depend on sensory experiences Limited concentration span “Windows of development” Have a longer life expectancy CNS development continues throughout adolescence Examples of prevention & safety differences in pediatrics Need adult assistance and protection Don’t understand how to keep themselves safe Have unique and different environmental exposures than adults Placental and breastfeeding Spend more time outside and on the ground Vaccinations (a lot!) Exposure to media  Examples of disease & injury differences between pediatrics and adults More likely to get sick or severely injured Some diseases are considered child specific (or adult specific) Younger age at disease onset may mean increase in severity Head and neck injuries more common Fractures require more force and have bigger impact Infants and children metabolize medications differently There are few medication clinical trials done with children  Common Childhood Acute Common Childhood Chronic Illnesses Diseases “The Cold” (viral URI) Dental Caries #1 Respiratory Syncytial Virus Asthma (RSV) Ear Infections Cystic Fibrosis Roseola Diabetes Gastroenteritis Obesity & Overweight Hand-Foot-Mouth Disease Malnutrition 5th Disease Developmental Disabilities Group A Strep Cerebral Palsy Influenza Consequences of Conjunctivitis Prematurity Fevers Mental/behavioral Disorders What are vital statistics and why do we use them? Continuous data on births and deaths (marriage, disease, health…) Local level > states > National Center for Health Statistics Maternal & infant mortality: 2 essential indicators of national health Help us understand: Quality of medical care Access to medical care Racial, ethnic and socioeconomic disparities Helps to guide public health and health policy decisions ACOG & NCHS  U.S. Infant Mortality Rate per 1000 births 1930* Total Infant 64.6 1970* Total Infant 20.0 1990* Total Infant 9.2 2017** Neonatal 3.85 Post-Neonatal 1.94 **National Vital Statistics Reports, Vol. 68, No. 10, August 1, 2019  *U.S. & New Mexico Infant Death by Cause 2017 U.S. Total Infant New Mexico Total Infant Deaths: Deaths: 23,161 140 Congenital malformations, deformations & 4,816 (20.8%) 25 (17.9%) chromosomal abnormalities Disorders due to short gestation & low- 3,927 (17.0%) 19 (13.6%) birthweight Sudden Infant Death Syndrome (SIDS) 1,500 (6.4%) 0 Maternal complications 1,402 (6.5%) 11 (7.9%) Accidents 1,219 (5.3%) 9 (6.4%) Assault 276 (1.2%) 56 (40.0%) *New Mexico State Bureau of Vital Records and Health Statistics ¹The number of infant deaths per 1,000 live births  Ethical & Legal Concerns United States Supreme Court: “Parents are free to become martyrs themselves. However, it does not follow that they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves.”  Group Please get into 4 groups Work: Elect a SPOKESPERSON and a SCRIBE Ethical & Answer the questions posed to your groups Legal Write answers on the board Concerns Spokesperson will report your findings  Communication https://www.youtube.com/watch?v=RIQQZGjxuSg https://youtu.be/39bZYNnpH9k Group “Once upon a time, parents would bring their sick child to a doctor, and Work: be happy to leave with a prescription. Explanations, empathy, and politeness were never expected of Communica doctors.” tion -PARANG N MEHTA The End