Tag Archives: Journal of Pediatrics

Understanding pediatric sudden cardiac arrest (SCA)

Would you recognize the warning signs of pediatric sudden cardiac arrest (SCA)? If not treated in minutes, SCA can result in death.

In a new policy statement to be published online on Monday, March 26, the American Academy of Pediatrics (AAP) provides guidance for pediatricians on underlying cardiac conditions that may predispose children to SCA.

Although the risk for SCA increases when children with underlying cardiac disorders participate in athletics, SCA can occur at very young ages and also when a child is at rest.

Research supports the need for a SCA registry, says the AAP. A registry would help experts gain a better understanding of the nuances of the condition.

Plus, many cardiac disorders are known to be genetic, so the evaluation of family members, even if asymptomatic, could be a critical step in the overall diagnosis of disorders predisposing to pediatric and young adult SCA.

We asked Arizona Pediatric Cardiology Consultants (APCC), members of the Arizona Chapter of the American Academy of Pediatrics, to weigh in on what parents need to know about SCA.

How common is SCA?  

According to the Centers for Disease Control, each year 2,000 individuals less than 25 years of age will die suddenly with the majority of these having a cardiac etiology.

What causes SCA?

Pediatric sudden cardiac arrest and sudden cardiac death can occur with various types of cardiac causes, including conditions in the heart muscle (such as hypertrophic cardiomyopathy), unusual positioning of a coronary artery, or an electrical disturbance within the heart. (Long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia).

More on genetic cardiac conditions from the Sudden Arrhythmia Death Syndrome Foundation (SADS)

How are family members evaluated, and what symptoms may be indicators that a child is pre-disposed to this? 

Signs that may suggest an increased risk for SCD include fainting or seizure with exercise, excitement, or startle, significant dizziness with exertion, unusual and consistent shortness of breath or chest pain with exercise.

If a family member has died suddenly or unexpectedly at a young age, has unexplained seizure disorder, died at a young age from a heart problem, or has a history of fainting, then screening is appropriate.

How do doctors determine if a child is at risk? What tests are performed?

Evaluation by a pediatric cardiologist will include a thorough individual and family history, ECG, physical exam and perhaps an echocardiogram, an exercise stress test, and genetic testing if necessary.

Would automatic external defibrillators (AED) on playing fields and in schools help?

A great majority of these deaths relate to a life-threatening arrhythmia, ventricular fibrillation. CPR and use of an AED may be life saving.  AEDs are often found in airports, casinos, and government buildings.

However, there is no law in Arizona currently requiring AED within schools, recreational sports fields, or other private facilities.

Are efforts being made to increase the availability of AEDs?

The decision about whether to have an AED on location is left up to the individual organization.  APCC’s electrophysiologists are making an effort to educate schools, sports organizations, and families regarding the importance preparation to prevent SCD.

The role of an ECG in all sports physicals remains a debated topic within the United States.  It is, however, very important to ask specific questions (use the attached screening tool) for risk factors and then refer to a pediatric cardiologist for further assessment.

What should parents or caregivers do if they believe a child might be at risk?

Once an individual is identified as having any of the conditions listed above, it is very important for first degree relatives to also be evaluated by a pediatric cardiologist even if they are not experiencing symptoms.

Sudden Cardiac Death is devastating to not only the families of those affected but to the communities in which they live.  Educating  families, schools, sports leagues, and primary care providers about quick and effective screening for children at risk for SCD is a first step in prevention.

Increased community awareness and the availability of AEDs in schools and sporting venues will help avert a tragedy.

Karen S. Eynon, RN, MSN, CPNP, MATS,  compiled these answers with support from Mitchell Cohen, MD, Andrew Papez, MD, and Jennifer Shaffer, RN, MS, CPNP, all of Arizona Pediatric Cardiology Consultants along with information from SADS.org.  

Check with your child’s physician if you are concerned about risks for SCA.

More from Parent Heart Watch, a network of parents and partners dedicated to reducing the effects of SCA.


An increase in synthetic marijuana use among teens

Synthetic versions of marijuana are sending some teens to the hospital, says a case report to be released in the April issue of Pediatrics.

The drugs, created in uncontrolled settings and sold in gas stations and convenience stores, consist of herbs sprayed with chemicals that mimic the

Courtesy DrugFreeAZ.org

psychoactive properties of THC, Continue reading

New findings on what may lead kids to binge drinking

A recent study published by the American Academy of Pediatrics found that that the more exposure teens had to alcohol use in movies, the more likely they were to binge drink.

The age, affluence and rebelliousness of the teens did not seem to matter. And this pattern was observed across cultures in countries with different norms regarding teen and adult alcohol use and drinking culture.

What can parents do to make sure kids don’t pick up the cues from the many movies out these days that show alcohol use? And what are some ways that parents can prevent a child from binge drinking?

Dr. Dale Guthrie, a pediatrician in practice at Gilbert Pediatrics, says communication is the key.

Guthrie, who serves as vice president of the Arizona Chapter of the AAP, encourages parents to stay involved — and to make sure to meet and know their children’s friends, from the early days of pre-school right on through high school.

More tips from Dr. Guthrie on how to help prevent your child from using alcohol and other drugs:

  • Know where your teen is at all times.  Teens may act as if they don’t like it but teens are actually more secure knowing their parents care enough to know where they are and what they’re doing.
  • Consciously and genuinely praise your teen for something good he does every day.
  •  Make sure she knows she can talk to you about anything, at any time, if it is important to her and that she won’t be interrupted judgmentally with a lecture.
  •  Remember you are his parent, (not his best friend, afraid to step on his toes) and offer advice when requested and at opportune teaching moments in short phrases, not long lectures which are tuned out anyway.
  •  Better yet, ask inspired questions of your teen—the kind which help her arrive at the correct solution.
  •  Attend movies with your teen and then ask open-ended questions about what he thought about it.
  •  At a nonthreatening time, (not right as your teen is headed out to a movie), sit down as a family and discuss what are your family goals and standards.  As part of that, set family standards for what types of movies you will view and which are beneath your family standards.
  •  When your teen returns from being out with friends, it is helpful to have a “check-in” with parents.  If the tradition has been set that he will give parents a hug (or even a kiss) no matter what time he returns, parents will know more about what he’s been doing  just by being close to him, listening and observation.

Parents of younger children might not be thinking about the teenage years, but is there anything they can do to lower the risk that their child will abuse alcohol down the road?

Will your six-year-old become a teen drinker?

One very simple way is for parents to make sure they truly listen to their child right from the start.

Guthrie says that children need to feel that what they say is of prime importance to their parents. “Then when she has something really serious to discuss, he adds, “she will feel comfortable coming to you.”

Modeling healthy behaviors themselves, and engaging kids in conversation at opportune moments (short snippets in lieu of lengthy lectures) are other ways parents can make a difference, says Guthrie.

RAK Archives: Talking to teens about alcohol poisoning

More on talking to kids about drugs and alcohol, and upcoming Parent Workshops from the Partnership for a Drug-Free America, Arizona Affiliate

Snoring linked to behavior problems in children

Children who snore or who have other sleep-related breathing problems are more likely to have behavioral problems years later, says a new study to be published in the April 2012 issue of Pediatrics.

Researchers asked a group of parents about their children’s snoring, mouth breathing, observed apnea and behavior, starting at age 6 months and then periodically until age 7 years.

By age 4, the children with sleep-disordered breathing were 20 percent to 60 percent more likely to have behavioral difficulties. By age 7, the likelihood jumped to 40 to 100 percent.

The worst symptoms were associated with the worst behavioral outcomes, meaning that the kids who faced more serious sleep-related breathing problems also tended to be more likely to struggle with behavior issues.

Study authors conclude that sleep-disordered breathing early in life can have a strong effect on behavior later in childhood.

Kids who have these difficulties may miss out on critical periods of brain development that researchers believe take place during deep sleep.

The study findings suggest that these symptoms may require attention as early as the first year of life.

Dr. Mark Brown, pediatric pulmonologist at the University of Arizona College of Medicine, and a member of the Arizona Chapter of the AAP, weighs in on kids and snoring:

 When should a parent be concerned about snoring?

  •  When a child can be heard snoring outside of their room.
  • When a child has disrupted sleep with short “pauses, snorts, or gasps” in their sleep.
  • If the child is having behavioral problems, a short attention span and problems at school.
  • If the child, especially an older child, frequently falls asleep during the day (i.e. in the car, during a TV show or movie, while reading).
  • In severe cases, there can be difficulty with weight gain or obesity, or high blood pressure.

Is a little light snoring okay?

Light snoring without any of the above associated signs/symptoms may be “normal.” If there is any concern, the parent should consult with their child’s primary care physician.

How do you know when snoring needs medical attention?

 If any of the above signs/symptoms are seen or if the parent is unsure about the significance of their child’s snoring they should consult with their child’s primary care physician.

RAK Archives: More on the consequences of too little sleep, and what families can do about it.

RAK Resources on respiratory issues: Take a Deep Breath by Dr. Nina Shapiro

Find out what technicians at the Sleep Center at Cardon Children’s Medical Center learn by watching children sleep:

Play ball — but protect young athletes from overuse injuries

The rates of injury for baseball and softball are relatively low compared to other sports, but the degree of injury severity is relatively high.

To protect young athletes, the American Academy of Pediatrics recommends that qualified adults instruct kids on proper throwing mechanics, training and conditioning.

Adults need to encourage athletes to stop playing and seek treatment when signs of overuse injuries arise.

Dr. Mike Perlstein, AzAAP board of directors member, says that over the past 20 years, the range of sports available through schools and through city recreational departments for children of all ages to participate in has grown.

But as the opportunities for playing sports has increased, so has the perceived competitive level.  Often, says Perlstein, the difference between a select or competitive team and the corresponding recreational team has been blurred.

And as the competitive nature of sports has heated up, the pressure applied by coaches and/or parents to succeed can be stifling.

In reality, an extremely small percentage of student athletes continue participating in competitive sports through high school, college, and beyond, Perlstein says.

So, parents should take a step back and think about what else young athletes can learn from participating in sports. “ I feel the lessons involved in competition are important for kids to learn,” he adds, “but should be secondary to the more important in lessons of having fun and exercising.

Perlstein, who practices at  Palo Verde Pediatrics in Gilbert, recommends that patients and their families avoid hyper specializing in any given sport until at least age 12.  “Experiencing a broad range of sporting activities, and developing different skill sets focusing on different muscle groups, is very important.”

Perlstein says that helps kids to develop in to well-rounded athletes and avoid overuse injuries. Which is important at any age — but especially in those younger athletes who have not yet reached puberty.

Overuse injuries, by definition, are almost all preventable, according to Perlstein. And the list of significant injuries documented in today’s young athletes continues to grow.

That is a source of frustration, he adds, because many of these injuries could be minimized or prevented with appropriate training strategies.

“Physical stresses on the pre-pubertal body need to be managed differently than in an athlete with a fully mature body,” he says. “For example, I do not recommend weight training with free weights until the student athlete is well into pubertal development.”

Repetitive activities, especially in relation to the upper arm, such as involved in tennis, swimming, and baseball/softball  need to be managed closely.  “Student athletes, their coaches, and their families all need to listen to the student athlete and for potential signs or symptoms of possible evolving overuse injuries.”

Have a young athlete with a single sport interest? Here are Perlstein’s recommendations:

  • Make sure the child continues to enjoy the activity, and is not simply feeling the pressure to continue.
  •  Spend intermittent time away from the sport to allow their body time to heal and to “re-charge their battery”.
  • Follow up with a sports medicine trained staff to watch for evidence of physical stress or imbalance in their flexibility or strength to avoid overuse injuries.

Not everyone may know exactly when an athlete begins to show signs of overuse, says Stephen Rice, MD, FAAP, a co-author of the AAP policy statement. “But it is important to know to never pitch when one’s arm is tired or sore. Athletes must respect the limits imposed on throwing, including pitch counts and rest periods.”

Additional AAP recommendations for young athletes include:

  • All players should wear appropriate protective gear to avoid injury. Polycarbonate eye protection or metal cages on helmets should be worn when batting.
  • Coaches should be prepared to call 911 and have rapid access to an automated external defibrillator if a player experiences cardiac arrest or related medical condition.
  • All coaches and officials should be aware of extreme weather conditions (heat, lightning) and postpone or cancel games if conditions worsen and players are at risk.
  • Not all children will develop at the same rate, so repeated instruction and practice are essential for young baseball and softball players to acquire basic skills when learning the fundamentals of the game.

RAK Archives:

Strength training for teens

Twitter chat with Cardon Children’s Medical Center sports medicine specialist Udall Hunt, MD

What you can learn from training the best: A conversation with veteran strength and conditioning coach Tim McClellan

Helping children with gender identity disorder (GID)

Children who are persistently uncomfortable with their gender who display strong and consistent cross-gender behaviors may be experiencing gender identity disorder, or GID.

A new study to be published in the March 2012 issue of Pediatrics found that children who do not receive medical treatment or counseling for GID can be at high-risk for certain behavioral and emotional problems.

Researchers found that of the 97 patients younger than 21 years who met the criteria for GID, 44 percent had a prior history of psychiatric symptoms, 37 percent were taking psychotropic medications, and 21.6 percent had a history of self-mutilation and suicide attempts.

Study authors advocate for early evaluation of children exhibiting GID, but treatment with medications should not be started until they reach puberty.

Why would a child be uncomfortable with his or her gender?

Pediatric surgeon Kathy Graziano, M.D., of Pediatric Surgeons of Phoenix, treats patients who are born with reproductive anomalies.  She says that one reason is that some girls are exposed to excess hormones at birth, and are born with male-looking parts. And some girls are born without some parts, like a vagina or a uterus.

Those are relatively rare conditions, says Graziano, who is a member of the Arizona Chapter of the American Academy of Pediatricians (AzAAP). “But there is a condition, also rare, in which a child is born with all the “right” reproductive organs but identifies with the other gender.”

This is known as gender identity disorder, gender dysphoria or gender incongruence. “This is a problem for the child and the parents from early on.”

Graziano recalls meeting — and being inspired by — a patient who always knew that she was a boy.

“She dressed as a boy, insisting on wearing a boy’s bathing suit for example, as early as anyone could remember,” says Graziano.  “She only once wore a dress…at her sister’s wedding.”

Then, in middle school, she became deeply depressed — and even suicidal.

The patient and her family attended counseling. That’s where she was able to admit that she wanted to be a boy, says Graziano. “The family took an accommodative approach.  They allowed her to change her name to a male name and act in society as a boy.  They sought surgical solutions for her to start transforming her anatomy.”

This was slow-going, says Graziano, since in this country there have been few surgical interventions for children under the age of 18.

Graziano says that the patient ultimately started a support group for other adolescents with gender identity issues. She entered college as a male, although not anatomically.  “Her story is a success in that her family’s intervention saved her life.”

There is also a therapeutic approach to treat, and try to reverse, gender identity disorder when it is recognized early, adds Graziano, but research on the success of these two approaches is lacking.

Pediatricians dealing with these issues should screen for depression and intervene as soon as possible. Parents who suspect that a child is dealing with GID should talk to their child’s physician.

“The most important thing,” says Graziano, “is to focus on the mental health of the child and the family.”

Pediatricians and parents should consult with experienced mental health professionals for children and adolescents experiencing gender-related issues. When patients are sufficiently physically mature to receive medical treatment, they should be referred to a medical specialist or program that treats patients with GID.

Resources for parents

Central Arizona Gender Alliance

TransYouth Family Allies

Smoker in the family? Pediatricians can help

There’s good news on second-hand smoke exposure among middle schoolers and teens, according to a new study issued this week by the American Academy of Pediatricians (AAP).

Data reviewed by the National Youth Tobacco Survey found that second hand smoke exposure decreased among both nonsmoking and smoking kids in grades six through twelve.

Send a "Love your heart- quit smoking" valentine e-card courtesy of the CDC

But there’s also not-so-good news. In 2009, 22.8 percent of non-smoking students and 75.3 percent of smoking students still reported second hand smoke exposure in a car within the past week.

Second hand smoke exposure has deleterious health effects.

According to the Centers for Disease Control, second hand smoke contains around 7,000 chemicals. Around 70 of those chemicals are known carcinogens.

Acute respiratory infections, middle ear disease, delayed lung growth, and more severe cases of asthma increase when the air kids breathe contains smoke from tobacco products.

Voluntary smoke-free policies, or expanding existing comprehensive smoke-free policies that prohibit smoking in worksites and public areas, could reduce second hand exposure in cars, says the AAP.

It can be tough for parents who smoke to limit their children’s exposure to tobacco smoke.

How to become an anti-smoking role model—even if you smoke

And discussing the issue during an office visit can sometimes be tricky, says Dr. Theresa LoCoco, a member of the Arizona Chapter of the American Academy of Pediatrics.

LoCoco, who practices with Pediatric Associates in Phoenix, says she finds it best to remember that both parents and their pediatricians have a common goal-optimum health for their children.

“This opens the door to discuss the risks of second-hand smoke: increased rates of ear infections, allergies, asthma and asthma exacerbations, pneumonia and other upper respiratory tract infections.”

There’s also an association between parental smoking and Sudden Infant Death Syndrome (SIDS) as well as behavioral issues such as ADHD/ADD, says LoCoco.

Kids whose parents smoke are more likely to smoke themselves, increasing the risk for cancer later on in life. 

But quitting smoking is tough.  And while many parents would like to for the health of their child, some are not currently ready or able to so. Sometimes it’s not the parent who smokes, says LoCoco, but instead a close family member or friend who has close contact with the child.

LoCoco advises those parents to try to limit tobacco smoke exposure to their children as much as possible.  This includes never having the child in the car or house with someone who is smoking.

Still, she emphasizes that no amount of exposure to tobacco smoke is considered safe.

Recent research warns of the dangers of “third-hand smoke,” which is exposure to nicotine and other harmful substances in the residue left by tobacco smoke.  This residue can be found on drapes, upholstery, clothing, hair and skin and has many of the same health consequences for children as second-hand smoke.

Limiting this exposure can often times be difficult. LoCoco suggests that a smoker  change clothes and shower or bathe before contact with a child to keep exposure to a minimum.