Pediatric Disorders of Today

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Pediatric Disorders of Today

  1. 1. Region 8 EMS Continuing Education April 2009 Pediatric Disorders of Today Let’s face it—EMS is a perfect fit for those of us who have a short attention span (Hey! I’m talking here!) and need immediate gratification for our actions. We can honestly say that we like helping people, and eagerly await the results of our interventions. Knowing how to secure spider straps, start an IV, terminate some abnormal heart rhythm…all of these (and many more) are skills which enable us to care for our patients. It is equally as important to be current on events, disease conditions and trends because sooner or later, these things will affect how we deliver patient care. The focus of this month’s C.E. will be on two disorders affecting the pediatric population: Autism and Obesity. 1
  2. 2. OBJECTIVES: I. Autism 1. Define Autism and list distinctive behaviors and other symptoms which typically characterize this disorder. 2. List developmental milestones of children, and how they relate to assessing overall wellness of the pediatric patient. 3. State prehospital considerations when assessing/caring for and interacting with autistic individuals. II. Childhood Obesity 1. List factors which contribute to childhood obesity. 2. State physiologic and psychological consequences of obesity in the pediatric patient. 3. List actions for resolution of childhood obesity. 2
  3. 3. AUTISM APRIL IS NATIONAL AUTISM AWARENESS MONTH For many, the movie “Rainman” provided the first exposure of what we know now as autism. Certainly, the past decade has seen a rise in autism awareness. This disorder has gotten much attention from the media, parents and the medical community. A complex disorder affecting so many, we have seen parents and some of the world’s most respected professionals working tirelessly to find the cause(s) of autism, and a cure for all. STATISTICS  Current studies suggest the incidence of autism is 1:150 children ages 10 and younger.  Males are affected 4x more than females  Autism is 5x as common as Down Syndrome, and 3x as common as juvenile diabetes WHAT EXACTLY IS AUTISM? Autism is a general term used to describe a spectrum of developmental disorders. These are also referred to as Autism Spectrum Disorders (ASD). Autism is classified as a “spectrum” disorder, because there is a wide range not only of the symptoms and behaviors, but also differences in their severity. These disorders affect the child’s ability to interact and communicate with others, and can also interfere with their ability to learn and play. The signs and symptoms of autism typically present during the first three years of life. Autism is characterized by three distinctive behaviors, which can range from mild to completely disabling. These behaviors are:  Impaired social interaction  Problems with verbal and non-verbal communication  Unusual, repetitive or severely limited activities and interests IMPAIRED SOCIAL INTERACTION 3
  4. 4. The hallmark feature of autism is impaired social interaction, and is usually one of the first symptoms noticed first by the parents. The onset of this symptom differs from child to child. Some children demonstrate impaired social interaction from infancy. These behaviors include failure to respond to their name, or not smiling in recognition of their parents’ faces. When this occurs, many parents suspect that the child has a hearing deficit and seek a medical evaluation. Other behaviors include fixation on one object, and resistance to being cuddled or hugged. A thorough hearing exam is necessary prior to diagnosing a child with autism. Other autistic children begin to withdraw from social interaction after a seemingly normal developmental period. Imagine what this must be like for these parents. Many parents will comment that their normally happy, and interactive child “disappeared.” These children prefer to play alone, do not make eye contact with others, and seem to live in a world of their own. PROBLEMS WITH VERBAL AND NON-VERBAL COMMUNICATION Communication skills in children with autism develop much differently than in other children. And, as previously mentioned, symptom severity differs from child to child. Verbal Communication Some children will remain mute, whereas others will speak in a sort of sing-song voice. If you grew up in a household with other children (or perhaps are raising your own family), does this sound familiar?...”MOM! Tell (insert name of sibling here) __________ to stop copying what I say!!” Echolalia is the term used to describe this “copying” or “echoing” of word(s), and is another feature observed in those individuals affected by autism. Speech tends to develop later in children with autism, and many times the child will refer to themselves by name (rather than “I” or “me”). The topics of conversation are usually limited to very narrow areas or interests; and there is little regard to another’s participation in the conversation. Non-verbal communication These children also avoid eye contact with others. They are unable to interpret non- verbal and social cues, such as reading facial expressions and body language, while also 4
  5. 5. having difficulties interpreting what others think or feel. To many, these children appear to lack empathy. UNUSUAL, REPETITVE OR SEVERELY LIMITED ACTIVITIES AND INTERESTS Autistic children are extremely resistant to change. They prefer to maintain set environments and schedules. Many times, they engage in ritualistic and/or repetitive behaviors, such as rocking, spinning/twirling, and arm flapping. Disruption of these routines or rituals can lead to tantrums, and/or inconsolable crying spells. Many autistic children also demonstrate decreased sensitivity to pain. They may engage in self-injurious activities, such as biting and head-banging, especially when they are frustrated or exposed to a stressor. Despite this apparent heightened pain threshold, children with autism can be very sensitive to sensory stimulation, such as sound and touch. Loud noises, bright lights, and even hugging or cuddling these children appears to be very painful for them, and may provoke crisis. These children may also exhibit unpredictable behaviors such as tantrums and hyperactivity. Remember some of these children lack the verbal skills to communicate their distress. They then “act out” as a means of communication. An area of major concern is that autistic children tend to have poor judgment skills, such as running into a busy street without fear. Consequently, they are perpetually at risk for danger; and require close supervision. Sometimes these children will run away from people or things which they perceive as stressful. These “runners” also tend to be very attracted to water. First responders should always check nearby swimming pools or bodies of water in the event you are dispatched to a scene involving such an individual who is missing. WHAT CAUSES AUTISM? There are no certain causes for autism. In the “olden days,” maternal behaviors were blamed for the social withdrawal associated with autistic children. These moms were labeled as “refrigerator mothers” and it was supposedly due to their cold and unfeeling relationship with their children that caused these kids to become socially withdrawn. This has since been disproved, yet it wasn’t until the 1970’s that other possibilities causing the disorder were investigated. Since then, many theories have been proposed, and research has investigated possible underlying neurologic, genetic, physiologic and environmental causes of autism. It is a complex and puzzling disorder, with its spectrum of symptoms, and varying time of onset amongst individuals. Several studies point to the role of genetics in causing 5
  6. 6. autism. Researchers have identified a number of genes associated with the disorder, but have not isolated which gene(s) are directly responsible for causing the symptoms. Epidemiology, the study of factors affecting health and illness of populations (Wikipedia.com), is what flags many areas in need of research. Consequently, the fuel for a huge chunk of research stems from the incidence of autistic symptoms developing 12-15 months after birth. Prior to 1990, approximately 2/3 of autistic children were autistic from birth. After the 1980’s, the trend actually reversed; and 2/3 of autistic children became autistic in their second year of life. (Adams, et. al, 2008) Due to this shift in the onset of autistic symptoms, many scientists believe that while genetics appear to play a large role, it is the exposure to certain environmental toxins (such as mercury and pesticides) that causes the onset of symptoms. YouTube contains several clips filmed by the parents of autistic children. Many of them show images of the “normal, joyous, and interactive” child; and in the next frame, show the progression of the autistic symptoms. OTHER INTERESTING RESEARCH FINDINGS:  Blood from umbilical cords has been examined. Results revealed that certain pollutants and chemicals are able to pass through the placental barrier.  Studies have found irregularities in several regions of the brain in people with autism.  Studies suggest that people with autism have abnormal levels of serotonin or other neurotransmitters in the brain.  Studies of identical twins show there is a much greater probability of them being autistic than fraternal twins.  Parents with an autistic child have an increased likelihood that their future children will also develop autism. HOW IS AUTISM DIAGNOSED? 6
  7. 7. Diagnosing a child with autism doesn’t come about from one single trip to the pediatrician. Typically, parents are the first link in identifying behaviors demonstrated by autistic children. Most parents/caregivers have a general knowledge of what developmental tasks children should be capable of by a certain age. This knowledge comes from previous experience with children, or by observing how other babies behave in comparison to their own. These tasks/behaviors are also known as developmental milestones. Failure to reach developmental milestones (such as social smiling, cooing, and babbling) or regression from these milestones indicates the need for further investigation. DEVELOPMENTAL MILESTONES AND YOU Anyone caring for pediatric patients must know important developmental milestones because they influence both the assessment and treatment of these patients. But it doesn’t stop there. Our knowledge and responsibilities as pre-hospital providers/health care workers extend into our personal lives as well. How many times have you been asked by various friends and family members to “take a look” at something? How ‘bout when you’re out to dinner? The elderly guy at the next table is having a coughing fit, and you’re thinking about what size ET tube you could stick down his throat. Or when you’re sitting in a movie theatre, you’re scanning the room for the emergency exits. We are always assessing and planning our interventions. Most of us don’t even realize we’re doing it because it’s become automatic! Every piece of knowledge we learn has to do with PEOPLE. People who become our patients by calling us to help them. People who become our patients by default: i.e. the coughing guy in the restaurant, and by sheer closeness, our neighbors, parents, nieces, nephews and even our own children. While noting abnormal or delayed development may not bring about the adrenaline rush you may feel after a structure fire or successful resuscitation, its importance should not be overlooked. Think about the 7
  8. 8. impact that reporting your observations could have not only on an individual, but on an entire family! (For more details go to www.cdc.gov/ncbddd/autism/actearly/milestones) Just because an individual is diagnosed as autistic, does not infer that they have mental disability. Mental retardation can be found in autistic individuals, as it can in any other. Autism does not mean that these children are incapable of learning. They simply process information differently. Sometimes, autistic children will be especially (and surprisingly) brilliant at some skill or task, such as: playing a piece of music on the piano after hearing it one time, painting/drawing, or other skills involving memory. “Autistic savant” is another way of referring to such a child. 8
  9. 9. DEVELOPMENTAL MILESTONES By the end of 3 Months, By the end of 7 Months, children: children: Begin to develop a Enjoy social play social smile Respond to their own Watch faces intently name Follow moving objects Use their voice to express joy and Smile at the sound of displeasure your voice Respond to other Begin to babble and people’s expressions of imitate some sounds emotions Turn their head towards Appear joyful often the direction of sound Babble chains of sounds By the end of 12 By the end of 24 Months, Months, children: children: Cry when mom or dad Get excited about leave company of other children May be fearful in some situations Imitate behavior of others Develop “stranger danger” Use simple phrases and 2-4 word sentences Respond to simple verbal requests Follow simple instructions Babble with inflection (changing tones) Repeat words overheard Try to imitate words 9
  10. 10. Screening tools have been developed to assist in the initial phases of diagnosing autism. While some details contained in these screening tools may slightly differ, included are: a series of questions to ask the parents/caregivers, and/or areas for direct observation of the individual regarding social interaction of the child and their communication skills. Based on this information, referrals to a multi-disciplinary team (including, but not limited to: psychologists, neurologists, other specialists) is instituted. Autism’s symptoms can overlap with those of other diseases/disorders. Consequently, diagnosing an individual with autism requires ruling out other possible causes, such as brain tumors, metabolic disorders, hearing deficits and seizures. TREATMENTS FOR AUTISM There are no known cures for autism. Treatment for this disorder is based on the type and severity of symptoms the child shows. The most effective treatment plans are pointed at treating the three primary symptoms of autism. EDUCATIONAL AND BEHAVIORAL TREATMENTS Educational and Behavioral Treatments are key ingredients in maximizing these children’s potential. Sessions are very structured and aimed at helping the child to develop skills in socialization and language. More and more, specialized schools and treatment programs for autistic individuals have come into existence in our communities. PREHOSPITAL CONSIDERATIONS Education for first responders/prehospital personnel has become an important focus for autism advocacy groups. Included in the live C.E. sessions is a pamphlet designed for paramedics and ER staff by the Autism Society of America . It briefly defines autism, and some common characteristics/behaviors of the autistic individual. Most importantly, the pamphlet lists some effective measures to implement when responding to an individual with autism. (For those on-line C.E.-ers, log onto http://www.autism- society.org/site/DocServer/Paramedics_and_Emergency_Room_Staff.pdf?docID=1094 2 and you will be able to print a copy of the PDF file for this pamphlet) 10
  11. 11. Families of autistic children, much like those of chronically ill or other special needs children are a wonderful resource to utilize during your assessment/treatments. They tend to be very detail oriented, and are extremely knowledgeable about their child’s symptoms, and behavior. Remember that many autistic individuals are highly resistant to change, touch and loud noises…all things that are common elements of emergency care. Obviously if there’s a life or death situation, all bets are off; but if time permits, follow the suggestions offered by the caregiver. They know the most effective ways to calm their child, and allow you to do your job. In addition to the previously mentioned symptoms, children with autism often suffer other maladies. These include: ADHD, Obsessive-compulsive disorders, food allergies, pica, seizures and depression. Treatment varies, according to practitioner and the severity of symptoms. Pica When a person eats non-food items, it is called pica. Chalk, dirt, sand and paint are some examples. 30% of autistic children have moderate to severe pica. MEDICATIONS Autistic individuals may be prescribed medications by their physician to alleviate some of their symptoms.  Anti-depressants help with depressive symptoms, and sometimes with obsessive-compulsive behaviors o Prozac, Zoloft  Anti-psychotics may also be used to help with anxiety, impulsiveness or aggression o Risperidone(Risperdal), Zyprexa  Stimulant drugs for treating hyperactivity disorders o Ritalin, Adderall, Concerta  Anti-convulsants for treating seizures o Dilantin, Tegretol, Depakene SEIZURES AND AUTISM 11
  12. 12. For reasons not yet fully understood, seizure disorders are present in 20-35% of autistic individuals. The incidence of the seizures increase as the child gets older, so one thought is that hormones contribute to the onset of the seizures. (Epilepsy Ontario.org) As with other symptoms observed in children with autism, the severity of seizures differs as well. Some individuals do suffer grand mal seizures; those types of seizures we frequently encounter in EMS. They are preceded by an aura, and usually have that post-ictal phase; where the child is unresponsive to others, or does not immediately resume their normal activity. On the opposite end of the spectrum are those children who suffer milder forms of seizures; and they demonstrate a variety of different actions or behaviors. Some symptoms seen in these milder seizures include staring off into space, a sort of absence seizure. Still others demonstrate what are classified as subclinical seizures, and are associated with symptoms such as: tantrums, aggression, and/or losing some behavioral and/or cognitive gains. Stop. Rewind. That’s no typo. Subclinical seizures can present as just like some of the behaviors which are commonly observed in the autistic individual. A thorough history is needed to distinguish these behaviors from subclinical seizures. Seizures do not necessarily require a trigger event; they can just suddenly occur. If these behaviors are thought to result from fear or frustration, they are not seizures. Again, the child’s caregiver will be of great value in deciphering such information. OTHER PROMISING TREATMENTS A group of physicians, many of whom are parents to autistic children are investigating methods (biomedical treatments) for treating autism, such as special diets and supplements. This program is called the Defeat Autism Now! (DAN!®) program. One of the methodologies utilized include chelation therapy, which removes heavy metals from the body. Many physicians in the (DAN!®) program strongly suggest that the bodies of autistic children are not able to rid themselves of metals, and this is what predisposes them to developing autism. Other promising treatments include supplements such as Vitamin B₁, Vitamin B₁₁, Cod Liver Oil, Melatonin, and Zinc. Additionally, special diets which address food allergies, and specific carbohydrate diets, and gluten-free/casein-free diets have shown to improve autistic symptoms. 12
  13. 13. A listing of doctors who utilize the DAN!® approach can be found on the website for the Autism Research Institute (www.autism.com). There you will also find the Summary for Biomedical Treatments for Autism, written by James B. Adams, Ph.D. PROGNOSIS Prognosis for autistic individuals, while dependent on language ability and intelligence, is largely influenced by early diagnosis and treatments. This includes family involvement in the treatment process. Each member of the family needs to be educated and involved in order to ensure continuity of the treatment plan. Many autistic individuals can be taught job skills, and how to live in community-based housing (with adult supervision). There are many great resources to help educate, motivate, and encourage those dealing with the challenges of autism. SUPPORT GROUPS/RESOURCES: Autism Society of America( www.autism-society.org) provides education, current events and links to finding a local chapter in your area. The Autism Research Institute (ARI) (www.autism.com), is a non-profit organization, was established in 1967. For more than 40 years, ARI has devoted its work to conducting research, and to disseminating the results of research, on the trigger of autism and on methods of diagnosing and treating autism. They provide research- based information to parents and professionals around the world. ARI's Autism Resource Call Center: 1-866-366-3361 National Autism Association (ANA) (www.nationalautismassociation.org) The mission of the ANA is to educate and empower families affected by autism and other neurological disorders, while advocating on behalf of those who cannot fight for their own rights. There are several links to local events and groups, as well as to current research and treatment modalities One Place for Special Needs (www.oneplaceforspecialneeds.com) links for all special needs families to services, support groups, organizations and events in your local area. 13
  14. 14. Childhood Obesity Another issue of growing concern is that of childhood obesity, especially in the United States. In this country, “We want everything hot, fresh, and now!” (Dr. Mark Cichon, 2008) Statistics  The National Health and Nutrition Examination Survey (NHANES) determined the obesity rates among children. The increase in obesity rates are made by comparing the results of the surveys conducted during 1976-1980, and 2003-2006. In children and adolescents: ages 2-5, obesity rates increased from 5% to 12.4% ages 6-11, obesity rates increased from 6.5% to 17% ages 12-19, obesity rates increased from 5% to 17.6%  Obesity-related hospital costs for our youth has increased from $35 million (1979-1981) to $127 million (1997-1999).  Approximately 60% of obese children ages 5-10 years old have at least one cardiovascular disease risk factor (i.e. elevated total cholesterol, insulin, blood pressure, etc.; and 25% had two or more risk factors. 14
  15. 15. Obesity is defined in the American Heritage Dictionary as “…increased body weight caused by excessive accumulation of fat.” Conduct any sort of A Recipe for Disaster 1. Take our expectation of immediate gratification and add to it the increasing costs of food, gas and energy. 2. Mix in parent/caregiver’s working 60-80 hours per week; or as of late, the many people who have lost their jobs. 3. Sprinkle in a little ignorance regarding healthy living. 4. Remove any remaining physical education from the school systems. 5. Top with your choice of: TV, internet, and/or video games. Serves: the entire American public. engine search on obesity or weight-related topic, and most likely you will be directed to a location where you can calculate your BMI. 15
  16. 16. What is BMI? BMI, or body mass index, is a calculation of body fatness using a person’s height and weight. The CDC (Centers for Disease Control and Prevention) has published recommendations for acceptable BMI in both adult and pediatric populations. While BMI does not directly measure body fat, its results have proven to correlate with results of other body fat measures, such as underwater weighing. 1 Mei Z, Grummer-Strawn LM, Pietrobelli A, Goulding A, Goran MI, Dietz WH. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. American Journal of Clinical Nutrition 2002;7597–985. What’s a “good” BMI? The general scale for interpretation is as follows:  Healthy Weight is having a BMI between 18.5 and 24.9  Overweight is having a BMI between 25 and 29.9  Obese is having a BMI over 30 BMI is calculated differently in pediatric populations than it is in adult populations. This is due to the fact that normal fat deposits differ between age groups and also between boys and girls. Screening our Children In the 2003 mission statement of the American Academy of Pediatrics, Prevention of Pediatric Overweight and Obesity, pediatricians were called upon to calculate their patients’ body mass index (BMI) as a tool to aid in the early recognition of obesity. You might be saying to yourself, how can someone, namely a parent or a doctor, not be able to just look at a child and tell if they are obese?!? Before casting any hasty judgment, doctors and researchers investigated that very question. Studies have been conducted to survey people’s views on what they consider to be obese and/or overweight. Know what they found? There were major discrepancies amongst various ethnic groups in regards to what is “normal” bodyweight…hence the reason why BMI screening was implemented! The BMI results only comprise a portion of what is involved in the screening process. A thorough patient and parent/caregiver history of both the child’s activity level and diet are important components as well. These pieces provide a foundation for recognizing obesity, and also key in on those children who, because of poor habits, are at risk for becoming obese adults. 16
  17. 17. In order to realize the urgency in addressing childhood obesity, it is important to understand the general consequences of obesity. These consequences are both physical and psychological. That being said, the concern regarding overweight/obese individuals is one of health, not physical appearance. Cardiovascular Risks:  High blood pressure (twice as common in obese individuals)  Elevated triglycerides, with low levels of the “good cholesterol” (HDL)  Increased risk of heart disease…arrhythmias, sudden cardiac death, CHF, MI… Respiratory Problems:  Sleep apnea  Higher incidence of asthma Reproductive Complications  Increased risk of maternal high blood pressure (reference Region 8 C.E. “OB Emergencies”, April 2008)  Increased risk of birth defects (i.e. spina bifida)  Increased risk of gestational diabetes  Increased risk of complications during labor and delivery Diabetes  Over 80% of people with diabetes are overweight or obese.  A weight gain of 11 to 18 pounds increases a person’s risk of developing Type 2 diabetes twice over those who haven’t gained that weight. Diabetes in Children Recall what you have learned about diabetes (Reference Region 8 C.E., February 2009 on diabetes. Building blocks of knowledge we are here! ) In the past, most children have been diagnosed with Type I diabetes (juvenile diabetes). Remember with Type I diabetes, the pancreas (for a number of reasons) doesn’t produce the insulin needed. Regular insulin supplementation (via injections, insulin pumps, etc.) is required. 17
  18. 18. Type II diabetes had previously been considered mostly an “adult disease.” It has been associated with many causes and risk factors. Insulin resistance and obesity are highlighted specifically as to their roles in the development of Type II diabetes. Insulin resistance comes about when people’s muscles, liver and fat cells do not respond properly to insulin. The body doesn’t know exactly what to do, so it signals the pancreas to produce more insulin. As the lonely little pancreas just churns out insulin to keep up with this workload, two things happen. First, the body is unable to use this insulin to shuttle glucose into the cells. That’s where “insulin resistance” gets its name. Secondly, when the need for more insulin arises, the pancreas is unable to produce more. When a person carries more weight in their abdominal area, this is called central obesity. The fat tends to accumulate around vital organs (visceral fat), and is known to predispose people to developing insulin resistance. Central obesity and lack of physical activity are two major (and preventable) causes of insulin resistance. Over the past decade, Type II diabetes has been diagnosed in the pediatric population at an alarming rate. What’s the link? Increased obesity rates contribute to increased incidence of diabetes. If you could, would you relive your adolescence? That “awkward” phase that seemed to take forever to get through? (Admit it, you have at least one school picture you refuse to show ANYONE.) Remember what it was like? The insecurities? Getting picked on because you weren’t good at sports, or because you didn’t have the latest fashion accessories, or because you made the honor roll, or because your next door neighbor was the social outcast of the school…kids can be so cruel, can’t they? For most, body image plays a 18
  19. 19. major role in our mental well-being. It’s a part of growing up. What’s even tougher, is growing up in American society, where we have created a ridiculous standard for men and women to live up to, especially when it comes to physical appearance. For the average individual, pre-occupation with this standard is enough to make you want to pull your hair out. For anyone who has ever been overweight or obese, or knows a loved one who suffers because of obesity, the consequences run much deeper. Many individuals who struggle with weight concerns also suffer from depression, low self-esteem and anxiety. Think about how that might affect an adult, and superimpose it into the mindset of an adolescent. Of course no two children react the same way, but how do these children respond to their insecurities and self-consciousness when it comes to weight? Well, some eat more; food is a source of comfort for them. Others may develop eating disorders such as anorexia and/or bulimia. In fact, some adolescents who have been diagnosed with Type I diabetes have taken this a step further. Prior to diagnosis, many diabetics lose weight. This is because the body needs insulin to shuttle glucose into the cells. As mentioned, Type I diabetics lack this insulin, and require regular doses of insulin to properly utilize that glucose. There have been several cases of Type I diabetic adolescents who don’t take their insulin on purpose, in order to lose weight. Kudos to their creativity, but this is dangerous! Even potentially life-threatening behavior! Diabetes and Depression  9% of adolescents w ith diabetes have moderately or severely depressed mood symptoms.  Females are affected more so than males.  Depressed mood is associated with poor blood sugar control, and leads to an increased likelihood of ER visits (Pediatrics, 2006, 117: 1348-58) Are these issues starting to unfold in your brain? One thing leads to another…short-term problems cause long-term maladies. When it comes to health, those long-term maladies are chronic, and sometimes irreversible. Again, diabetes lends itself to a wealth of complications, and increases the risk for so many other disease processes. Not only does the quality of life 19
  20. 20. potentially suffer as these children grow older, but think about the amount of economic strain caused on an individual, a family and society from all of the medical costs associated with this disease process! Armed with the knowledge that obesity-related diabetes may be preventable, don’t you think it would be prudent to focus some effort on preventing obesity? Other Obese individuals are at increased risk for developing some types of cancer, arthritis, and gall bladder disease. To sum it all up, individuals who are obese (BMI >30) have a 50 to 100% increased risk of premature death from all causes, compared to those of a healthy weight. Food for Thought… What is the #1 cause of death in the United States? Coronary Artery Disease (CAD) What are some of the risk factors for developing CAD? High blood pressure (hypertension) High cholesterol (hyperlipidemia) Diabetes Obesity What did we just learn about obesity and cardiovascular risk? Obesity contributes to the development of these risk factors!! 20
  21. 21. All of these problems have previously been associated with ADULTS. We hold them responsible for the choices they have made and continue to make, and the consequences they suffer. But now, our babies, our two year olds, who are fully dependent on us, have a 12.4% obesity rate? What is going on? PHYSICAL ACTIVITY Most of us have common knowledge as to how our body ends up storing more fat. The number of calories consumed is greater than the number of calories needed to fuel the body’s activities. Fine. But kids usually run around, they ride their bikes, and play all day, right? Come on, is this really what today’s children are doing? Do they have physical education at school? (Some states do not require P.E. in school) Do they play tag? What are they doing after school? Maybe some sports, but the amount of time spent texting, or in front of the TV, computer and video games has increased exponentially! “Mom don’t shut it off! I just got to level 7!” Our children are not addicted to these modern electronics because of their novelty, but rather, because they have become a part of our culture. Therein lies the first of many causes contributing to our obesity rates: Lack of physical activity. NUTRITION Long gone are the days when families ate all three home-cooked meals (with a healthy after-school snack) at the table, served by a smiling mom in an apron. How have American family dynamics changed over the past 4 decades? Working moms. Single parent homes. Both parents working. Who makes dinner now? Many children are responsible for feeding themselves these days. What’s for dinner? Fast food, microwaved something…all washed down with some sugar-laden drink (pop, fruit-juice drink, etc.). Fresh fruits and vegetables? Nope. Milk? Not so much. “All my kid will eat is macaroni-and-cheese and french fries!” (Some parents actually laugh when they say that) We are teaching our children that it is ok to insert fast food to accommodate our fast lifestyle. And now, like the electronics, fast food/junk food is an addiction because it is a part of our culture. In addition to the amount of calories that we feed our children/our children eat, we must also look at the nutritional sources of those calories as well. Let’s throw back to Old School… 21
  22. 22.  Remember the food pyramid? How many of us as adults actually follow those guidelines? We are the first models for our children’s behaviors. If we don’t follow healthy guidelines, why would our children?  How about Popeye? “…Strong to the finish, ‘cuz I eats me spinach!” SPINACH! Not stuffed pizza with spinach!  “An apple a day keeps the doctor away.” Amazing…with all of the advances in technology, medicine and overall know-how, why is it that the older generations understood health and nutrition better than we do? Hmmm. Another problem of nutrition is that healthy food can be more expensive than not-so-healthy-foods. This leads us to a rather interesting discussion regarding the patterns of obesity amongst various socioeconomic groups. SOCIOECONOMICS: Obesity can be found amongst all socioeconomic groups. However, the reasons for why they exist are different. In wealthier socioeconomic classes, some factors which contribute to the overweight/obesity incidence are:  Divorce guilt—Parents give their children whatever they want to earn their love/trust or to “make up” for the divorce.  Children have easier access to technology-computers, video games, cell phones… this lends itself to a more sedentary lifestyle.  There’s more food in the home to eat.  These children may have easier access to buying whatever food they want, especially if they are given an allowance to spend. In lower socioeconomic classes other factors contribute to the incidence of overweight/obesity:  Many healthy foods are more expensive than fast food/junk food.  Many children have working parent(s), and are responsible for feeding themselves. The solution? Fast food/junk food/microwaveable food. 22
  23. 23.  Healthy food costs more. Neither these families nor the school systems may be The President’s Challenge able to afford healthy, fresh food. is a program which  Ignorance as to healthy choices. promotes an active  Fewer playgrounds in the neighborhoods where they live lifestyle.  Less access to extra-curricular (www.fitness.gov) Here, activities/sports kids may earn medals for their fitness efforts. It’s a The rise in childhood obesity is not unique to fun way to get children the United States. The overall obesity rate is increasing across the world. Global studies of and their families countries/areas of the Western Hemisphere involved. have shown that the relationship between socioeconomics and obesity depends on the stage of economic transition. Early in the transition, the more wealthy an area is, the greater the obesity rate. Later in the transition, the less wealthy an area is, the greater the obesity rate. WHAT DO WE DO NOW? As with anything, identifying that there is a problem is the first step. As with every facet of life, we need to be accountable for ourselves first. WE are responsible for our children. Not the school systems, not the government, but us as parents and adults. Children model behaviors that they see. Treating obesity and implementing a healthy lifestyle for our children will only be successful if we are motivated to actually practice what we preach! WHERE DO WE BEGIN? Several governmental bodies have been developed to educate the public and have taken initiatives encouraging healthy lifestyles. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, and The President’s Council on Physical Fitness and Sports are two examples. GET MOVING! One of the most important things we can do for our children is to get them physically active. The U.S. Department of Health and Human Services released the 2008 Physical Activity Guidelines for Americans (www.health.gov/paguidelines) which discuss all aspects of the “how’s” and “why’s” as they pertain to physical activity for Americans ages 6 and older. 23
  24. 24. There’s TONS of information here! These recommendations are for health- related fitness; NOT performance-related fitness. Chapter 3, Active Children and Adolescents, provides the guidelines for physical activity in our youth. Key Guidelines for Children and Adolescents  Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily. o Aerobic: Most of the 60 or more minutes a day should be either moderate- or vigorous-intensity aerobic physical activity, and should include vigorous-intensity physical activity at least 3 days a week. o Muscle-strengthening: As part of their 60 or more minutes of daily physical activity, children and adolescents should include muscle-strengthening physical activity on at least 3 days of the week. o Bone-strengthening: As part of their 60 or more minutes of daily physical activity, children and adolescents should include bone-strengthening physical activity on at least 3 days of the week.  It is important to encourage young people to participate in physical activities that are appropriate for their age, that are enjoyable, and that offer variety. YOU ARE WHAT YOU EAT Another area to improve is nutrition. Again, we must set the example. Providing healthy foods for our children to eat. Here’s a tip when grocery shopping: avoid the middle aisles! The healthy foods are usually around the perimeter of the store (barring the bakery section). What are the two most common reasons people give as to why they cannot do something? Lack of time, and lack of money. “But I don’t have time to cook…” Don’t sell yourself Currently, the Acting Surgeon short! Americans are creative and full of General, Steven K. Galson is on a ingenuity!! nation-wide tour promoting the Healthy Youth for a Healthy Future Get a slow-cooker. project. This is to recognize several communities throughout our country Pack lunches before going to sleep at night. who have taken measures to promote healthy lifestyles, and decrease Prepare meals ahead of time and freeze them. childhood obesity. Engage your family to help come up with some solutions. 24
  25. 25. Even though they may complain, roll their eyes, and make all sorts of huffing sounds of disgust, engaging our children in these activities will help their self-esteem! How? They are directly involved in tasks which keep the family healthy. There is one caveat: we must explain WHY their participation is important, AND express our appreciation for that participation. It’s not what you say, it’s how you say it! “It’s too expensive…” Another great resource is from The National Heart Lung and Blood Institute, entitled: WeCan! Ways to Enhance Children’s Activity & Nutrition (www.wecan.nhlbi.gov). There are all sorts of money-saving tips while eating healthily. Don’t forget to utilize the resources your pediatrician may have access to, such as a nutritionist. Weight loss, especially in the pediatric population needs to be monitored by a physician. Children are not tiny adults; remember their bodies are still growing. They have unique nutritional requirements that must be adhered to, to promote things such as healthy bones, to last long into adulthood. We can come up with excuses from now until eternity. This is about our children and teaching them good habits. This is about arresting the increase in childhood obesity, and preventing further complications of this disorder. If your “why” is great enough, you’ll find a way. 25
  26. 26. Drug of the month - Versed (A.K.A. Midazolam) Short-acting benzodiazepine with CNS depressant, muscle relaxant, amnestic and anti-convulsant effects. Dosage depends on age group and indication o Pediatrics: (IV/IO route) 0.05mg/kg up to 0.2mg/kg maximum o Adults o Drug Assisted Intubation o Sedation o Intranasal o Side Effects: o Drowsiness o Respiratory depression o Amnesia o Hypotension o Dizziness o Agitation o Contraindications: Hypersensitivity, pregnancy, narrow-angle glaucoma. Caution in COPD, renal failure, CHF, elderly, concomitant alcohol or CNS depressant medication use. 26
  27. 27. Rhythm of the Month Sinus Bradycardia and Pediatric Bradydysrhythmias Causes: Hypoxia, hypothermia, increased vagal tone, increased intracranial pressure, drug toxicity, sedation Findings:  Regular rhythm  HR < 60  P-wave : QRS = 1:1  PRI = < 0.20 sec, does not change  QRS < 0.12 sec 27
  28. 28. Illinois Region 8 Emergency Medical Services Central DuPage, Edward, Good Samaritan, Loyola EMS Systems Standard Operating Procedures Illinois Region 8 EMS Systems - Revised 2006 Page 16 PEDIATRIC BRADYDYSRHYTHMIAS ALS 1. Assess for causative factors, such as hypoxemia, acidosis and hypothermia. Initiate corrective resuscitative measures as necessary 2. Initial Medical Care  Adequate airway and ventilation is essential  Initiate CPR if, after adequate ventilation, the heart rate remains < 60 per minute  If signs of hypovolemia: NORM AL SALINE 20 ml/kg IV push 3. EPINEPHRINE 1:1000 0.1 mg/kg (0.1 ml/kg) ET or EPINEPHRINE 1:10,000 0.01 mg/kg (0.1 ml/kg) IV/IO. Repeat q 3 minutes as long as dysrhythmia with hypoperfusion persists. 4. ATROPINE 0.02 mg/kg rapid IV/IO or 0.03 mg/kg ET. Minimum dose 0.1 mg. Repeat q 3 minutes until maximum total dose admin.  Maximum single IV/IO dose is 0.5 mg ≤8 years, 1 mg > 8 years.  Maximum total IV/IO dose is 1 mg ≤8 years, 3 mg > 8 years. 5. External Transcutaneous Pacing: Contact Medical Control. Notes:  Flush all IV/IO drugs with 5 ml NS  Flush or dilute all ET drugs with 5 ml NS  Attempt to keep child warm with protected hot packs and blankets as a 28
  29. 29. Sources (n.d.). Retrieved December 02, 2008, from Health Scout: http://www.healthscout.com/ency/68/317/main.html (n.d.). Retrieved December 02, 2008, from The President's Challenge: http;//www.presidentschallenge.org/home_kids.aspx Adams, J. B., Edelson, S. M., Grandin, T., & Rimland, B. (2008, Revised). Advice for Parents of Young Autistic Children. Autism Research Institute, San Diego. American Heritage Dictionary of the English Language, 4th edition. (2006). Houghton Mifflin Co. Autism Society of America. (n.d.). Autism Information for Paramedics and Emergency Room Staff. Retrieved December 10, 2008, from http://www.asa.gov Epilepsy Ontario. (n.d.). Epilepsy/Seizures and Autism. Retrieved December 02, 2008, from http://www.epilepsyontatio.org/eo/eoweb.nsf Ford, E. S., & and Mokdad, A. H. (2008). Epidemiology of Obesity in the Western Hemisphere. The Journal of Clinical Endocrinology and Metabolism , 93, 51-58. Jensen, C. D., & Steele, R. G. (2008). Body Dissatisfaction, Weight Criticism and Self- Reported Physical Activity in Preadolescent Children. Journal of Pediatric Psychology , v1, 131. Lawrence, J., Liese, A., Liu, L., Dabeela, D., Anderson, A., & Imperatore, G. B. (Published on line September 22, 2008). Weight-Loss Practices and Weight-Related Issues among Youth with Type I or Type II Diabetes. Diabetes Care , 31, 2251-2257. Levine, S., & and Stein, R. (2008, May 17). Obesity Threatens a Generation. Retrieved December 01, 2008, from Washingtonpost.com: http://www.washingtonpost.com/wp- dyn/content/article/2008/05/17 National Health and Nutrition Examination Survey (NHANES). (2006). NHANES Health and Statistics Prevalence of Overweight Among Children and Adolescents: United States. CDC National Center for Health Statistics. www.cdc.gov. National Institute of Neurological Disorders and Stroke. (n.d.). Retrieved December 02, 2008, from http://www.ninds.nih/gov/disorders/autism/detail_autism.htm? 29
  30. 30. U.S. Department of Health & Human Services. (n.d.). Retrieved December 01, 2008, from http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.html U.S. Department of Health and Human Services. (n.d.). Retrieved December 01, 2008, from www.health.gov/paguidelines 30

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