Update in Pediatrics, 2e (Feb 6, 2024)_(3031415418)_(Springer) 9783031415418, 9783031415425

Table of contents :
Contents
Editors and Contributors
Section Editors
Contributors
Part I: Update in Adolescent Medicine
1: Update in Adolescent Medicine
Adolescence 101
What?
Who/When?
How?
Psychosocial and Risk Behavior Assessment
Order of Topics
Indications for Use
Interacting with Caregivers
Navigating the Psychosocial Assessment
Additional Interview Tips
Breaking Confidentiality
Eating Disorders
Diagnostic Clarification
Resources for Patients and Families
Resources for Healthcare Providers
Technology and Social Media
The Changing Technological Landscape
Medical and Developmental Health Concerns
Mental, Emotional, and Social Challenges
Electronic Health Record (EHR) Privacy
Emerging Social Media Risks
Resources for Patients and Families
Resources for Healthcare Providers
Substance Use
SBIRT: Screening Brief Intervention Referral and Treatment
Screening
Brief Intervention
Abstinence/No Substance Use: Positive Reinforcement
Substance Use Without SUD: Brief Intervention
Mild to Moderate SUD
Severe SUD (Addiction)
Acute Risk of Harm
Referral to Treatment
Prescribing Controlled Substances
Resources for Healthcare Providers
Sexually Transmitted Infections (STIs)
STIs in Adolescent Medicine
Assessing STI Risk
STI-Related Consent and Confidentiality
Screening and Testing Recommendations by Infection
Updated STI Treatment Guidelines: Quick Reference
Evaluation of Vaginal Discharge
Safe Sex Practices and Prevention
Tips on External Condom Use (Male (External) Condom Use 2022)
Adolescent Sexual Health: An Overview
Male-Bodied Reproductive Health
Benign Variants
Sexual Satisfaction and Sexual Dysfunction
Female-Bodied Reproductive Health
Benign Variants
Sexual Satisfaction and Sexual Dysfunction
Menstrual Cycle Irregularities
Dysmenorrhea
Polycystic Ovarian Syndrome
Premenstrual Dysphoric Disorder
Resources for Patients and Families
Resources for Healthcare Providers
Transitioning to Adult Healthcare
Provider Readiness
Family Readiness
Youth Readiness
Resources for Patients and Families
Resources for Healthcare Providers
References
Part II: Update in Pediatric Allergy
2: Update in Pediatric Allergy
Food Allergy
Introduction
Pathophysiology and Clinical Presentation
Diagnosis
Prevention and Management
Atopic Dermatitis
Introduction
Pathophysiology and Clinical Presentation
Diagnosis
Management
Allergic Rhinitis
Introduction
Pathophysiology and Clinical Presentation
Diagnosis
Management
Anaphylaxis
Introduction
Pathophysiology and Clinical Presentation
Diagnosis
Prevention and Management
References
Part III: Update in Pediatric Cardiology
3: Update in Pediatric Cardiology
Congenital Heart Disease: Epidemiology Update
Late Outcomes
Neurodevelopmental Outcomes in CHD
Psychosocial Outcomes and Quality of Life in CHD
Exercise in CHD
Fetal Cardiology
Fetal Cardiac Intervention
Fetal Arrhythmia
Cardiac Imaging
Updates in Echocardiography
The Growing Role of CMRI
The Role of Cardiac Computed Tomography
Interventional Cardiology
Atrial Septal Defect Device Closure
Pulmonary Valve Replacement
Patent Ductus Arteriosus Occlusion in Premature Infants
Genetic Testing in Pediatric Cardiology
Genetic Aortopathies
Marfan Syndrome
Loeys-Dietz Syndrome
Turner Syndrome
Hypertrophic Cardiomyopathy
Dilated Cardiomyopathy
Sudden Cardiac Death and Inherited Arrhythmias
Dyslipidemia
References
Part IV: Update in Child Maltreatment
4: Update on Child Maltreatment
Introduction
What Is Child Maltreatment?
How Does Maltreatment Affect Children?
Terminology and Definitions
Identifying Maltreatment
Clinical Approach to Physical Injuries That May Be Due to Maltreatment
General Approach
History
Physical Examination
Documentation
Providing an Opinion on the Cause of Findings
Physical Abuse
Bruising
Differential Diagnosis
History
Physical Examination
Documentation of Physical Findings
Medical Testing for Bruising
Testing for Occult Injuries
Fractures
Differential Diagnosis
History
Physical Examination
Medical Testing
Head and Spine Injuries
Differential Diagnosis
History
Physical Examination
Medical Testing
Abdominal Trauma
History
Physical Examination
Medical Testing
Burns
Differential Diagnosis
History
Physical Examination
Medical Testing
Neglect
Sexual Abuse and Assault
Timing of Examination
History
Physical Examination
Interpretation of Findings
Documentation
Forensic Evidence Collection
Testing for Sexually Transmitted Infections
Emergency Contraception
Psychosocial Support
Discharge and Follow-Up
Commercial Sexual Exploitation of Children
References
Part V: Update in Pediatric Critical Care
5: Update in Pediatric Critical Care
Introduction
Patient Monitoring and Technology
Near-Infrared Spectroscopy (NIRS)
Capnography
Continuous Electroencephalogram (EEG) Monitoring
Bioinformatics
Point-of-Care Bedside Ultrasound (US)
Video Laryngoscopy
Organ Systems-Based Updates
Neurology
Traumatic Brain Injury
Pain, Agitation, and Neuromuscular Blockade
Iatrogenic Withdrawal Syndrome
Delirium
Status Epilepticus
Stroke
Respiratory
Acute Respiratory Distress Syndrome (ARDS)
E-Cigarette and Vaping Product Use Associated Lung Injury (EVALI)
Cardiology
Cardiopulmonary Resuscitation
Gastroenterology/Nutrition
Nutritional Guidelines
Stress Ulcer Prophylaxis
Indirect Calorimetry
Glycemic Control
Hematology
Transfusion Strategies
Thromboprophylaxis
Infectious Disease/Immunology
Sepsis
Coronavirus-19 Pandemic
Quality Improvement
Standardized Handover Tools
Pediatric Early Warning Scores
Patient Care Bundles
Rehabilitation
Palliative Care
Education
Courses
Simulation
Electronic Learning (E-Learning)
Future Directions in Critical Care Education
Health Care Inequities
Conclusion
References
Part VI: Update in Development
6: Update in Infant Development
Infant Mental Health: Awareness Among Physicians
Serve and Return Interaction Shapes Brain Circuitry
Overview of Social Emotional Development
Hand in Hand: Growing Together Everyday: Social Emotional Milestones Overview
0–3 Months
4–6 Months
7–12 Months
13–18 Months
19–24 Months
25–36 Months
Ages and Stages Developmental Milestones
Six Areas of Child Development
The Amazing World of Your Baby: An Overview of Baby’s Development Birth to 6 Months
Your Baby at 1 Month
Your Baby at 2 Months
Your Baby at 3 Months
Your Baby at 4 Months
Your Baby at 5 Months
Your Baby at 6 Months
The Amazing World of Your Baby: An Overview of Baby’s Development at 7–18 Months
Your Baby at 7–9 Months
Your Baby at 10–12 Months
Your Child Between 13 and 18 Months
The Remarkable World of Your Toddler: An Overview of Your Toddler’s Development at 19–24 Months
Your Toddler Between 19 and 24 Months
The Remarkable World of Your Toddler: An Overview of Your Toddler’s Development at 25–36 Months
Your Toddler Between 25 and 30 Months
Your Toddler Between 31 and 36 Months
The Busy World of Your Preschooler: An Overview of Your Preschooler’s Development at 36–48 Months
Your Preschooler Between 36 and 48 Months
The Busy World of Your Preschooler: An Overview of Your Preschooler’s Development at 48–60 Months
Your Preschooler Between 48 and 60 Months
So What Derails Early Development?
Toxic Stress Derails Healthy Development
Infants Most at Risk
How Can This Information Change the Practice of Clinicians and Practitioners
References
Further Reading
7: Update in Autism Spectrum Disorder
Introduction
Prevalence Update
What Causes Autism?
Genetics
Epigenetic Factors
Other Possible Causes/Risk Factors for ASD
Assessment/Evaluation
Screening Tools for ASD
Physical Examination
Investigations
Common Differential Diagnosis and Co-occurring Diagnosis in ASD (see autism cormorbidities below for more details)
Autism Comorbidities and Management
Attention Deficit Hyperactivity Disorder
Anxiety
Anxiety Treatment
Emotional Dysregulation (Irritability/Aggression)
Treatment of Emotional Dysregulation (ED)
Epilepsy
Gastrointestinal Issues
Sleep Problems
Treatment for Sleep Disturbances
Developmental Coordination Disorder (DCD)/Dyspraxia
Treatment
Tics and Tourette Syndrome (TS)
Treatment
Intellectual Disability
Obsessive-Compulsive Disorder
Treatment
Eating Disorder
Gender Identity
Other Comorbidities
Treatment of Autism
Behavioural Approaches
Biomedical Interventions
A Brief Note on Complementary and Alternative Medical (CAM) Therapies
Summary
References
Suggested Readings
Part VII: Update in Clinical Genetics
8: Updates in Clinical Genetics
Genetic Variants and Genetic Testing
Exome and Genome Sequencing
Genetic Testing
Gaps and Recent Advances in Genetic Testing
Interpretation of Genetic Test Results
Prenatal Genetic Testing
Approach to the Genetics Referral
Updates to Treatments for Genetic Conditions
Support and Resources for Clinicians and Families
References
Part VIII: Update in Pediatric Emergency Medicine
9: Pain and Sedation in the Emergency Department
Introduction
Pain Assessment
Non-Pharmacologic Management of Acute Pain
Pharmacologic Management of Acute Pain
Mild Pain
Moderate-Severe Pain
Procedural Pain
Sucrose Solution
Topical Anesthetic Agents for Pain
Procedural Sedation
References
10: Resuscitation
Airway
Medications
Cardiopulmonary Resuscitation
Post Cardiac Arrest Care
References
11: Sepsis
Introduction
Definitions
Epidemiology and Risk Factors
Etiology and Microbiology
Pathophysiology
Diagnosis
Management
Summary
References
12: Interfacility Transport of the Pediatric Patient
Team Composition
Definitions to Inform most Appropriate Paediatric Transport Service i.e. Patient ≥5 kg
Transport Mode
Preparation for Transport
Supplies and Equipment
References
13: Pediatric Trauma
Introduction
Scope of Pediatric Trauma
Pre-hospital Care
The Trauma Team
Primary Survey
Airway
Breathing
Circulation
Fluid Resuscitation and Hemorrhage
Disability
Exposure and Temperature control
Adjuncts to Primary Survey
Secondary Survey
Traumatic Brain Injury (TBI)
Thoracic Trauma
Abdominal Trauma
Summary
References
Part IX: Update in Pediatric Endocrinology
14: Update in Pediatric Endocrinology
Adrenal Insufficiency
Introduction
Etiology
Investigations
Treatment
Growth
Introduction
Clinical Evaluation of Growth
Investigations in Children with Growth Failure
Growth Hormone
Other Therapies to Increase Final Adult Height
Puberty
Introduction
Pubertal Control
Precocious Puberty
Pubertal Delay
Environmental Exposures and Puberty
Thyroid Disease
Introduction
Congenital Hypothyroidism
Acquired Hypothyroidism
Acquired Hyperthyroidism
References
Part X: Update in Pediatric Gastroenterology
15: Update in Pediatric Gastroenterology and Nutrition
Reflux
Diagnostic Considerations
Management
Eosinophilic Esophagitis
Pathogenesis
Presentation
Management
Diet
Drugs
Dilation
Celiac Disease
Introduction and Epidemiology
Pathogenesis and Immunology
Genetics and Risk factors
Diagnosis
Treatment
Functional Gastrointestinal Disorders
Background
Neonate/Toddler Functional GI Disorders
Functional Diarrhea
Functional Constipation
Functional Disorders of Childhood and Adolescence
Functional Nausea and Functional Vomiting
Functional Abdominal Pain Disorder and Irritable Bowel Syndrome
Functional Constipation
Inflammatory Bowel Disease
Epidemiology
Pathophysiology
Clinical Presentation
Extra-intestinal Manifestations
Evaluation
Histology
Management
Corticosteroids
Enteral Nutrition Therapy
Aminosalicylates
Immunomodulators
Biologic Therapies
Surgical Management
Outcomes
Nutrition
Intestinal Rehab and Short Gut Syndrome
Definition and Pathogenesis
General Management Approach
Parenteral Nutrition Management
Enteral Nutrition Management
Central Access Preservation
Surgery
Transplant
Endoscopy
Esophagogastroduodenoscopy
Foreign Body Ingestion
Upper Gastrointestinal Bleeding
Future Directions
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Evaluation of the Small Intestine
Colonoscopy
References
16: Updates in Pediatric Hepatology and Pancreatology
Neonatal Cholestasis
Background
Pathogenesis
Presentation
Etiologies
Diagnosis
Management
Pediatric Acute Liver Failure
Pathogenesis
Presentation
Diagnosis
Management
Viral Hepatitis
Hepatitis B
Prevention
Monitoring and Therapy
Hepatitis C
Screening
Monitoring
Other Viruses
Nonalcoholic Fatty Liver Disease
Background
Pathogenesis
Presentation
Screening
Diagnosis
Laboratory Evaluation
Radiologic Evaluation
Histologic Evaluation
Management
Prevention
Pancreatitis
Presentation
Etiologies
Management
Acute Pancreatitis
Acute Recurrent Pancreatitis
Chronic Pancreatitis
References
Part XI: Update in Pediatric Hematology
17: Update in Pediatric Hematology
Introduction
Iron-Deficiency Anemia
Diagnosis of Iron Deficiency
Development of Iron Deficiency in Children
Treatment of Iron Deficiency Anemia
Hydroxyurea in Sickle Cell Disease
Iron Chelation in Thalassemia
Transfusion Medicine Controversies: Transfusion Triggers and Age of Blood
Red Cell Transfusion Triggers
Age of Blood
Management of Immune Thrombocytopenia
Evans Syndrome
Diagnosis and Management of DIC
Developments in Hemophilia Treatment
Long-Acting FVIII Products
FVIII-Fc Fusion
FVIII with Pegylated Liposomes
Long-Acting FIX Products
FIX-Fc Fusion
FIX-Albumin Fusion
Pegylated FIX
Gene Therapy
Oral Anticoagulants in Children
Autoimmune Lymphoproliferative Syndrome (ALPS)
Acquired Aplastic Anemia in Children
Neutropenia
Factors that Affect the Neutrophil Count
Signs and Symptoms of a Neutropenic Child
Management of a Neutropenic Patient
Conclusion
References
Part XII: Update in Pediatric Hospital Medicine
18: Update in Pediatric Hospital Medicine
Acute Viral Bronchiolitis
Introduction
Management
High Flow Nasal Canula
Cardiorespiratory and Pulse Oximetry Monitoring
Post-Hospitalization Follow-Up
Febrile Urinary Tract Infections in Young Infants
Introduction
Imaging After First Febrile UTI for Younger Infants
Duration of IV Antibiotic Treatment of UTIs in Younger Infants
Evaluation and Management of Febrile Infants
Background
Age 8–21 Days Old
Age 22–28 Days Old
Age 29–60 Days Old
Procalcitonin
Time to Discharge: A Review of Time to Culture Positivity
Brief Resolved Unexplained Event (BRUE)
Introduction
Risk Assessment and Outcomes
Management
COVID-19 Pneumonia
Introduction
Diagnostic Evaluation:
Treatment and Management of the Hospitalized Child with COVID-19 Pneumonia
Anticoagulation
Dexamethasone
Remdesivir
Multisystem Inflammatory Syndrome in Children (MIS-C)
Introduction
Case Definition and Diagnosis
Cardiac Involvement
Treatment
Acute Hematogenous Osteomyelitis (AHO)
Introduction
Diagnosis
Management
Early Transition to Oral Antibiotics
Treatment Duration
Monitoring
Hyperbilirubinemia
Introduction
Prevention
Risk Assessment and Monitoring
Management
Escalation of Care
Discharge and Follow-Up
High Value Care
References
Part XIII: Update in Pediatric Infectious Disease
19: Update in Pediatric Infectious Disease
Introduction
The Management of Febrile Infants
Pathogenesis of Neonatal Sepsis
Bacteria
Viruses
Herpes Simplex Virus
Enterovirus
Cytomegalovirus (CMV)
Advancing Diagnostic Tools
Cost of Unnecessary Care
Development of Guidelines
Updates to Antibiotic Management in the Primary Care Setting
When Less Is More
Treatment of Community-Acquired Pneumonia (CAP) in Children
Treatment of Urinary Tract Infection (UTI) in Children
Treatment of Skin and Soft Tissue Infection (SSTI) in Children
The Impact of the Covid-19 Pandemic on Pediatric Infections
Pediatric Infection Prevention and Control
Respiratory Syncytial Virus: The Rise and Anticipated Fall
Enterovirus D68 and Acute Flaccid Myelitis
Recent Challenges in Vaccine Hesitancy
Vaccine Hesitancy Definition and Current State of Affairs
Causes of Vaccine Hesitancy
Impact of Covid-19 Pandemic
Impact of Covid-19 on Vaccine Confidence
HPV
Solutions to Reducing Vaccine Hesitancy
Case Scenario
Conclusions on Vaccine Hesitancy
Conclusions
References
20: SARS-CoV-2, COVID-19, and Children: Myths and Evidence
Introduction
Myth 1: Lockdowns Were a Necessary Response to the Spread of SARS-CoV-2
Myth 2: We Needed to Protect Our Children from SARS-CoV-2
Myth 3: Sequelae of SARS-CoV-2 Warranted Protecting Our Children from SARS-CoV-2 Infection
Myth 4: Protecting Children Was Necessary to Prevent Their Spreading Infection to More Vulnerable Older Adults
Myth 5: Natural Immunity Does Not Protect as well as Vaccine-Induced Immunity
Myth 6: Vaccines for SARS-CoV-2 Are Safe and Effective for Children
Myth 7: There Were No Better Courses Open than to Try Lockdowns, Masking Mandates, School Closures, and Vaccine Mandates
Myth 8: There Was no Precedent for How to Respond to the SARS-CoV-2 Pandemic
Myth 9: It Is Time to Move on, and Give Amnesty to Leaders Who Did Their Best to Protect Us
Conclusions
References
Part XIV: Update in Pediatric Nephrology
21: Update in Pediatric Nephrology
Introduction
Evaluation and Management of Urinary Tract Infections in Children
Background
Pathogenesis
Clinical Presentation
Diagnosis
Treatment of Acute UTI
Urinary Tract Imaging
Update in Vesicoureteral Reflux
Introduction
Diagnosis
Antibiotic Prophylaxis
Surgical Intervention
Glomerular Diseases in Children
Introduction
Epidemiology
Clinical Manifestations
Diagnosis
Management
Prognosis
Nephrotic Syndrome
Acute Kidney Injury in Children
Introduction
Definition
Epidemiology
Etiology
Prevention and Treatment
Indications and Timing of KRT
Prognosis
Chronic Kidney Disease in Children
Introduction
Definition
New Equations to Estimate GFR
Advances in Markers of CKD Progression
Update in Pediatric Hypertension
Introduction
Epidemiology
Diagnosis
Evaluation of Target Organ Damage
Treatment
Genetics and the Kidney
Introduction
Glomerular Diseases
Ciliopathies
Renal Tubular Disorders
Congenital Anomalies of the Kidney and Urinary Tract (CAKUT)
Nephrolithiasis
References
Part XV: Update in Neonatalogy
22: Updates in Neonatology
Background
Normal Newborn Care
Neonatal Nutrition
Benefits of Breastfeeding
Contraindications to Breastfeeding
Supplements with Breastfeeding
Infant Formula
Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD)
Newborn Skin and Umbilical Cord Care
Umbilical Cord Care
First Newborn Cleaning
Routine Bathing
Diaper Care
Newborn Screening
Newborn Blood Spot Screening
Hearing Screening Program
Congenital Cardiac Disease
Future Perspective
Neonatal Resuscitation
Common Neonatal Problems
Prevention and Management of Procedural Pain in Neonates
Scoring System
Pain Management
Neonatal Sepsis
Diagnosis of Sepsis
Management of Newborns >35-Weeks of Gestation at Risk for Sepsis
Hypoxic Ischemic Encephalopathy
Pathophysiology of HIE
Diagnosis of HIE
Management
Prognosis
Neonatal Hypoglycemia
Definition of Hypoglycemia
Use of Dextrose Gel
Continuous Glucose Monitoring
Neonatal Abstinence Syndrome
Pathophysiology of NAS
Clinical Manifestation
Management
Long-Term Management
Other Drugs
NAS in Preterm Infants
Acquired Opioid or Benzodiazepam Dependency in Infants
Prematurity
Incidence and Risk Factors of Prematurity
Grey Zone or Limit of Viability
Initial Stabilization and Short-Term Morbidities
Post Discharge Care of NICU Graduate
References
Part XVI: Update in Pediatric Neurology
23: Update in Pediatric Neurology
Introduction
Definitions and Classifications
Epileptic Seizures and Epilepsy: Definitions and Current Concepts
Focal Epilepsies in Children
Epilepsy Syndromes in the Neonatal Period and in Infancy
Inheritance
Seizure Semiology and Evolution
Benign Familial Neonatal Seizures
Benign Familial Neonatal-Infantile Seizures (BFNIS)
Benign Familial Infantile Seizures (BFIS)
Epileptic Encephalopathy
Early Infantile Epileptic Encephalopathy
Seizure Semiology
Inheritance
Early Myoclonic Encephalopathy (EME)
Seizure Semiology and Evolution
Inheritance
Epilepsy of Infancy with Migrating Focal Seizures (Malignant Migrating Partial Seizures of Infancy (MMPSI)
Inheritance
Infantile Spasms (IS)
Seizure Semiology and Evolution
Etiology
Epilepsies of Early Childhood
Generalized Epilepsy with Febrile Seizures Plus (GEFS+)
Semiology
Inheritance
Severe Myoclonic Epilepsy of Infancy (SMEI, Dravet Syndrome)
Seizure Semiology and Evolution
Inheritance
Acquired Epileptic Aphasia
Semiology
Treatment
Clinical and Laboratory Evaluation of an Infant with Epileptic Encephalopathy
Investigations
The Role of Emerging Genetic Technologies
Conclusion
Epileptic Syndromes in the Pre-school and School Age Child
Benign Epilepsy with Centro Temporal Spikes (BECTS)
Seizure Semiology
Diagnosis
Treatment
Prognosis
Childhood Absence Epilepsy (CAE)
Seizure Semiology
Diagnosis
Treatment
Epileptic Encephalopathies in School Age Child
Lennox Gastaut Syndrome
Seizure Semiology
Diagnosis
Treatment
Epileptic Syndromes in the Adolescent Child
Juvenile Myoclonic Epilepsy (JME)
Seizure Semiology
Diagnosis
Treatment
Progressive Myoclonic Epilepsies (PME)
Nonepileptic Paroxysmal Events
Syncope
Vasovagal Syncope
Orthostatic Hypotension and Postural Orthostatic Tachycardia Syndrome (POTS)
Stretch Syncope
Self-Induced Syncope
Reflex Anoxic Seizure
Breathholding Spells
Pseudosyncope
Approach to the Investigation of Syncope
Benign Neonatal Sleep Myoclonus (BNSM)
Tic Disorders
Non-epileptic Seizures
Conclusion
References
Part XVII: Update in Pediatric Oncology
24: New Developments in the Treatment of Pediatric Acute Lymphoblastic Leukemia
Immunophenotype
Prognostic Factors
Clinical Features
Early Response to Therapy
Genetic Features
Aneuploidy
Hyperdiploidy
Hypodiploid
Structural Alterations
ETV6::RUNX1
BCR::ABL1, t(9;22)
KMT2A Translocations
TCF3 Translocations
iAMP21
Genomic Profile
BCR::ABL1-Like
Genetics of T-ALL
Current Treatment for Childhood ALL
Risk-adapted Therapy
CNS-directed Therapy
Hematopoietic Stem Cell Transplantation (HSCT)
Novel Therapy Approaches
Immunotherapy
Bispecific Antibodies
Antibody Conjugates
Chimeric Antigen Receptor (CAR) T-Cell Therapy
Toxicities of CAR T Cell Therapy
Precision Medicine Therapies
New Cytotoxic Agents
Bortezomib
Clofarabine
Nelarabine
Moving Novel Therapies into Frontline Treatment
Conclusions
References
25: Update in Solid Tumors of Childhood
Imaging, Biopsy, and Surgical Considerations
Delivery of Bad News
Neuroblastoma
Epidemiology, Pathophysiology, and Genetic Predisposition
Presenting Symptoms
Histology and Molecular Profile
Staging
Treatment and Outcomes
Kidney Tumors
Epidemiology, Pathophysiology, and Genetic Predisposition
Presenting Symptoms
Histology and Molecular Profile
Staging
Treatment and Outcomes
Other Renal Tumors
Sarcomas
Bone Tumors
Epidemiology, Pathophysiology, and Genetic Predisposition
Presenting Symptoms
Histology and Molecular Profile
Staging
Treatment and Outcomes
Soft Tissue Sarcomas
Epidemiology, Pathophysiology, and Genetic Predisposition
Presenting Symptoms
Histology and Molecular Profile
Staging
Treatment and Outcomes
Rare Tumors
Germ Cell Tumors
Presenting Symptoms
Histology and Molecular Profile
Staging
Treatment and Outcomes
Liver Tumors
Epidemiology, Pathophysiology, and Genetic Predisposition
Presenting Symptoms
Histology and Molecular Profile
Staging
Treatment, Outcomes, and Surveillance
Other Tumors
Retinoblastoma
Adrenocortical Carcinoma
Post-Treatment Care and Survivorship
Treatment-Related Toxicities & Long-Term Follow-Up
Psychosocial Impact
Future Directions
References
Part XVIII: Update in Pediatric Psychiatry
26: Update in Pediatric Psychiatry
Introduction
Prevalence Data on Mental Illness in Youth
SARS-CoV-2 and prevalence data on mental illness in youth: the “Mental Health Pandemic”
Anxiety
Depression
Eating Disorders
Social Media and Eating Disorder
Sleep Disorders
SARS-CoV-2: Mitigation Factors and Consequent Mental Health Concerns in Children and Youth
Identifying and Managing Psychiatric Illness in Children and Adolescence
Diagnostic Curiosity: The Psychiatric Assessment
Changes in the DSMV for Child and Adolescent Psychiatric Disorders
Neurodevelopmental Disorders
Disruptive, Impulse-Control and Conduct Disorders
Trauma and Stressor-Related Disorders
Depressive Disorders
Avoidant/Restrictive Food Intake Disorder (ARFID)
DSM V Research Criteria
Attention Deficit Hyperactivity Disorder (ADHD)
Prevalence
Diagnosis
Treatment
Clinical Point
Depression
Prevalence
Diagnosis
Suicide
Treatment
Safety
Clinical Point
SSRIs and Suicide Related Events
Long Term Effects of SSRIs and Youth
Non-suicidal Self-injury (NSSI)
Anxiety
Prevalence
Diagnosis
Treatment
Clinical Point
Obsessive Compulsive Disorder (OCD)
Bipolar Disorder
Prevalence
Diagnosis
Treatment
Safety
Clinical Point
Schizophrenia and Other Psychotic Spectrum Disorders
Prevalence
Diagnosis
Treatment
Clinical Point
Psychotic Experiences and Other DSMV Disorders
Clinical Point 2
Atypical Antipsychotics: Issue for Consideration
Antipsychotics and Aggressive Behavior
Adverse Effect Profile of SGAs
Weight Gain and Obesity
Diabetes
Dyslipidemia
Movement Disorders
Substance Related Disorders in Children and Adolescents
Prevalence
Diagnosis
Treatment
Clinical Point
Clinical Point—2
Cannabis and Psychosis
Screening Tools to Identify Children and Youth With Mental Health Concerns
Anxiety
Depression
The Children’s Depression Inventory (CDI)
The Beck Depression Inventory (BDI)
The Patient Health Questionnaire 9 (PHQ-9)
The Eating Disorders Examination Questionnaire (EDO-Q)
SARS-CoV-2 and New Models of Mental Health Care Provision
Clinical Note
Atypical Presentations of Psychiatric symptoms
Conclusion
References
Part XIX: Update in Pediatric Rheumatology
27: Update in Pediatric Rheumatology
Introduction
Musculoskeletal Assessment Tool: The pGALs—Pediatric Gait, Arms, Legs, and Spine (Foster et al. 2006)
Update on Juvenile Idiopathic Arthritis
Update on Non-inflammatory Musculoskeletal Pain
Macrophage Activation Syndrome
Multisystem Inflammatory Syndrome Temporally Associated with COVID-19
Autoinflammatory Disease (Periodic Fever syndromes)
Familial Mediterranean Fever
Periodic Fever, Aphthous Stomatitis, Adenitis and Pharyngitis (PFAPA)
Choosing Wisely in Pediatric Rheumatology
Summary
References
Index

Citation preview

Update in Pediatrics Shalea Beckwith Editor Second Edition

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Update in Pediatrics

Shalea Beckwith Editor

Update in Pediatrics Second Edition 2023

Editor Shalea Beckwith Pediatrician, Kidcrew Pediatric Medical Clinic Toronto, ON, Canada

ISBN 978-3-031-41541-8    ISBN 978-3-031-41542-5 (eBook) https://doi.org/10.1007/978-3-031-41542-5 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023, 2018 Springer International Publishing AG, part of Springer Nature This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Contents

Part I Update in Adolescent Medicine 1 Update in Adolescent Medicine������������������������������������������������������   3 Najiba Keshwani, Lauren Bretz, Asha Davidson, Julia Durante, and Ginny Claire Kim Part II Update in Pediatric Allergy 2 Update in Pediatric Allergy������������������������������������������������������������  61 Lubnaa Hossenbaccus, Sarah Garvey, and Anne Ellis Part III Update in Pediatric Cardiology 3 Update  in Pediatric Cardiology������������������������������������������������������  79 Jenna Ashkanase and Derek Wong Part IV Update in Child Maltreatment 4 Update  on Child Maltreatment������������������������������������������������������ 111 Sophia Sweatman, Tanya Deurvorst Smith, Amy E. Ornstein, Michelle G. K. Ward, and Karla Wentzel Part V Update in Pediatric Critical Care 5 Update  in Pediatric Critical Care�������������������������������������������������� 149 Trupti Ingle, Eleanor Allen, Michael Salt, and Lisa A. DelSignore Part VI Update in Development 6 Update  in Infant Development�������������������������������������������������������� 183 Madhavi Moharir and Chaya Kulkarni 7 Update  in Autism Spectrum Disorder�������������������������������������������� 253 Ronald Garth Smith, Dawa Z. Samdup, and Samsoor Akberzai

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Part VII Update in Clinical Genetics 8 Updates  in Clinical Genetics ���������������������������������������������������������� 285 Laurie Robak, Keren Machol, and Chaya Nautiyal Murali Part VIII Update in Pediatric Emergency Medicine 9 Pain  and Sedation in the Emergency Department������������������������ 299 Suzan Schneeweiss 10 Resuscitation������������������������������������������������������������������������������������ 307 Tania Principi 11 Sepsis ������������������������������������������������������������������������������������������������ 313 Deborah Schonfeld 12 Interfacility  Transport of the Pediatric Patient���������������������������� 323 Hilary Whyte 13 Pediatric Trauma ���������������������������������������������������������������������������� 331 Joshua K. Ramjist, Suzanne Beno, and Daniel Rosenfield Part IX Update in Pediatric Endocrinology 14 Update  in Pediatric Endocrinology������������������������������������������������ 345 Seth D. Marks and Brandy A. Wicklow Part X Update in Pediatric Gastroenterology 15 Update  in Pediatric Gastroenterology and Nutrition ������������������ 369 Teresa Y. Oh, Tatyana Hofmekler, and A. Jay Freeman 16 Updates  in Pediatric Hepatology and Pancreatology ������������������ 399 Teresa Y. Oh, Sirish Palle, and A. Jay Freeman Part XI Update in Pediatric Hematology 17 Update  in Pediatric Hematology���������������������������������������������������� 429 Ziad Solh, Anthony K. C. Chan, and Mihir D. Bhatt Part XII Update in Pediatric Hospital Medicine 18 Update  in Pediatric Hospital Medicine������������������������������������������ 449 Bradford Nguyen, Purva Patel, Cody Clary, and Ricardo Quinonez Part XIII Update in Pediatric Infectious Disease 19 Update  in Pediatric Infectious Disease������������������������������������������ 481 Danielle Daniels and Jana Shaw

Contents

Contents

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20 SARS-CoV-2,  COVID-19, and Children: Myths and Evidence������������������������������������������������������������������������������������ 503 Ari R. Joffe Part XIV Update in Pediatric Nephrology 21 Update  in Pediatric Nephrology ���������������������������������������������������� 523 Darcy Weidemann and Martin Bitzan Part XV Update in Neonatalogy 22 Updates in Neonatology������������������������������������������������������������������ 553 Faiza Khurshid and Imtiaz Ahmad Part XVI Update in Pediatric Neurology 23 Update  in Pediatric Neurology�������������������������������������������������������� 581 Andrea Andrade and Asuri N. Prasad Part XVII Update in Pediatric Oncology 24 New  Developments in the Treatment of Pediatric Acute Lymphoblastic Leukemia���������������������������������������������������������������� 605 Haley Newman and David T. Teachey 25 Update  in Solid Tumors of Childhood�������������������������������������������� 629 Nitin Shrivastava and Allison F. O’Neill Part XVIII Update in Pediatric Psychiatry 26 Update  in Pediatric Psychiatry ������������������������������������������������������ 665 Sabina Abidi Part XIX Update in Pediatric Rheumatology 27 Update  in Pediatric Rheumatology������������������������������������������������ 701 Roberta A. Berard and Ronald M. Laxer Index��������������������������������������������������������������������������������������������������������  721

Editors and Contributors

Section Editors Suzanne Schuh  Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Sick Kids Research Institute, Toronto, ON, Canada Jonathan Pirie  Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada

Contributors Sabina Abidi  Department of Psychiatry, Dalhousie University, Halifax, NS, Canada Imtiaz Ahmad  Queen’s University, Kingston, ON, Canada Samsoor  Akberzai Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada Eleanor Allen  Department of Pediatrics, Tufts Medicine, Boston, MA, USA Tufts University School of Medicine, Boston, MA, USA Andrea  Andrade Neurology Division LHSC, Department of Pediatrics, Schulich School of Medicine and Dentistry, London, ON, Canada Jenna  Ashkanase Division of Cardiology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, ON, Canada Suzanne  Beno  Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada Roberta A. Berard  Division of Rheumatology, Department of Paediatrics, Children’s Hospital, London Health Sciences Centre, Western University, London, ON, Canada Mihir  D.  Bhatt Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada

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Martin Bitzan  Kidney Centre of Excellence, Al Jalila Children’s Hospital, Dubai, United Arab Emirates Division of Nephrology, Department of Pediatrics, McGill University Health Center, Montreal Children’s Hospital, Montreal, QC, Canada Lauren Bretz  Division of Adolescent Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA Anthony  K.C.  Chan Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada Cody  Clary Division of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA Danielle  Daniels Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA Asha Davidson  Division of Adolescent Medicine, Department of Pediatrics, McGovern Medical School, Houston, TX, USA Lisa A. DelSignore  Department of Pediatrics, Tufts Medicine, Boston, MA, USA Tufts University School of Medicine, Boston, MA, USA Division of Medicine Critical Care, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA Julia Durante  Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA Anne  Ellis Department of Medicine, Queen’s University, Kingston, ON, Canada Kingston Allergy Research, Kingston Health Sciences Centre - KGH Site, Kingston, ON, Canada A. Jay Freeman  Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH, USA Sarah Garvey  Kingston Allergy Research, Kingston Health Sciences Centre KGH Site, Kingston, ON, Canada Tatyana  Hofmekler  Children’s Center for Digestive Health, Atlanta, GA, USA Lubnaa  Hossenbaccus Department of Medicine, Queen’s University, Kingston, ON, Canada Kingston Allergy Research, Kingston Health Sciences Centre - KGH Site, Kingston, ON, Canada Trupti Ingle  Division of Critical Care Medicine, Department of Anesthesia, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA Department of Anesthesia, Harvard Medical School, Boston, MA, USA

Editors and Contributors

Editors and Contributors

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Ari  R.  Joffe Department of Pediatrics, University of Alberta, Edmonton, AB, Canada Najiba  Keshwani Division of Adolescent Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA Faiza  Khurshid  Department of Pediatrics, Queen’s University, Kingston, ON, Canada Ginny  Claire  Kim Division of Adolescent Medicine, Department of Pediatrics, McGovern Medical School, Houston, TX, USA Chaya  Kulkarni Infant Mental Health Promotion, HSC, Toronto, ON, Canada Ronald  M.  Laxer Division of Rheumatology, Department of Paediatrics and Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Keren Machol  Baylor College of Medicine, Houston, TX, USA Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA Seth  D.  Marks Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada Madhavi  Moharir Infant Mental Health Promotion, HSC, Toronto, ON, Canada Chaya Nautiyal Murali  Baylor College of Medicine, Houston, TX, USA Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA Haley  Newman Division of Oncology and Center for Childhood Cancer Research, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Bradford Nguyen  Division of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA Allison  F.  O’Neill Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA, USA Teresa  Y.  Oh Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA Amy E. Ornstein, MDCM, MSc, FRCPC, FAAP  Suspected Trauma and Abuse Response Team (START), IWK Health, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada

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Sirish Palle  Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA Purva Patel  Division of Hospital-Based Medicine, Department of Pediatrics, Ann & Robert H.  Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Asuri  N.  Prasad Neurology Division LHSC, Department of Pediatrics, Schulich School of Medicine and Dentistry, London, ON, Canada Tania Principi  Division of Paediatric Emergency Medicine, Department of Paediatrics, Alberta Children’s Hospital, Calgary, AB, Canada Ricardo Quinonez  Division of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA Joshua  K.  Ramjist General & Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada Laurie Robak  Baylor College of Medicine, Houston, TX, USA Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA Daniel Rosenfield  Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada Michael Salt  Division of Pediatric Critical Care Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA, USA Dawa Z. Samdup  Department of Pediatrics, Queen’s University, Kingston, ON, Canada Suzan  Schneeweiss Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Deborah Schonfeld  Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto, ON, Canada Jana  Shaw Department of Pediatrics, Public Health & Preventative Medicine, SUNY Upstate Medical University, Syracuse, NY, USA Nitin  Shrivastava Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA, USA Ronald  Garth  Smith Department of Pediatrics, Queen’s University, Kingston, ON, Canada Tanya Deurvorst Smith, MN, NP-Paediatrics  The Suspected Child Abuse and Neglect (SCAN) Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Editors and Contributors

Editors and Contributors

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Ziad  Solh Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada Medical Services and Innovation, Canadian Blood Services, Hamilton, ON, Canada Sophia Sweatman, MD, FRCPC  The Suspected Child Abuse and Neglect (SCAN) Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada David T. Teachey  Division of Oncology and Center for Childhood Cancer Research, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Michelle  G.K.  Ward, MD, FAAP, FRCPC Department of Pediatrics, University of Ottawa and Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada Darcy  Weidemann Section of Pediatric Nephrology, Department of Pediatrics, University of Missouri—Kansas City School of Medicine, Children’s Mercy Kansas City, Kansas City, MO, USA Karla  Wentzel, MN, NP-Paediatrics The Suspected Child Abuse and Neglect (SCAN) Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada Hilary Whyte  Acute Care Transport Service & Neonatology, Toronto, ON, Canada Brandy A. Wicklow  Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada Derek Wong  Division of Cardiology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada

Part I Update in Adolescent Medicine

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Update in Adolescent Medicine Najiba Keshwani, Lauren Bretz, Asha Davidson, Julia Durante, and Ginny Claire Kim

Adolescence 101

Who/When?

Defining the term “adolescence” has been a conundrum in the medical and psychological literature, as the starting point and end point are not defined by a precise moment, but rather a spectrum of physical and neurochemical changes and evolving social roles.

Persons aged 10–24  years old (Sawyer et  al. 2018).

What? That dynamic period between sexual maturation and the attainment of adult roles and responsibilities. (Dahl 2004)

N. Keshwani (*) · L. Bretz Division of Adolescent Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]; bretz@bcm. edu A. Davidson · G. C. Kim Division of Adolescent Medicine, Department of Pediatrics, McGovern Medical School, Houston, TX, USA e-mail: [email protected]; [email protected] J. Durante Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]

• The “starting point” of adolescence is marked by pubertal physical or biological changes. –– In those assigned female at birth, the first sign of puberty is typically breast development (thelarche). Most girls start breast development between ages 9 and 10 years old (Biro et  al. 2013), though ~40% of African American girls and ~20% of European American girls may start as early as 8  years old (Dorn and Beltz 2023). In those assigned male at birth, the first sign of puberty is typically testicular enlargement (gonadarche). In European American boys in the United States, the average age of gonadarche is 10  years old, while African American and Latino boys tend to start 6  months earlier (Dorn and Beltz 2023; Secondary Sexual Characteristics in Boys: Data From the Pediatric Research in Office Settings Network 2012). As the onset of puberty has accelerated over time, the start of adolescence has shifted earlier than prior generations (Guyer et al. 2023). Since the 1970s, puberty in those assigned female at birth has been noted to start 3 months earlier with each passing decade (Dorn and Beltz 2023; Eckert-Lind et  al.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Beckwith (ed.), Update in Pediatrics, https://doi.org/10.1007/978-3-031-41542-5_1

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2020). Potential mechanisms that may contribute to earlier pubertal onset include the ongoing global obesity epidemic and increasing amounts of exposure to endocrine-­disrupting chemicals (Dorn and Beltz 2023). • The “end point” of adolescence is marked by a social transition into “adulthood” where an individual is now responsible for their own behavior and meets common milestones (e.g., completion of formal education, marriage, parenthood). –– As the age of completion of these milestones increases over generations, the ending age of adolescence has shifted later, and thus has subsequently increased the overall time spent in adolescence (Sawyer et  al. 2018). Currently, the World Health Organization (World Health Organization 2023) and the United Nations (UNICEF 2022) recognize age 19 as the ending point of adolescence; though Sawyer et  al. (2018) describe that broadening to age 24 “aligns more closely with contemporary patterns of adolescent growth and popular understandings of this life phase.”

N. Keshwani et al.

nalizing behavior, and internalizing behavior (Guyer et  al. 2023). These domains influence many behaviors of adolescents including their cognition, relationship skills, emotional processing, risk-taking behaviors, and morality. The changes observed in the ~14-year period of adolescence are dynamic and nonlinear. Thus, to help describe cohorts of changes, adolescence is divided into three phases: early, middle, and late (Allen and Brittany 2019). Late adolescence may also be referred to as emerging adulthood (Sawyer et al. 2018).

• Table 1.1 highlights important physical and psychosocial events during the three phases of adolescence. –– A complete review of physical developmental milestones as well as brain matter changes that contribute to psychosocial growth is beyond the scope of this chapter but can be readily found elsewhere (Rosen 2004; Section on Endocrinology 2014; Liew et al. 2023). –– With respect to development of gender identity, there remains a question of its consolidation before adolescence versus in early or late adolescence versus adulthood. While children between ages 18 and 24 months can identify gender identity in themselves and How? others, there is some thought that there may be further consolidation of gender identity, Initiation of puberty, and thus the beginning of potentially due to pubertal sex hormone adolescence, is marked by neuroendocrine impact on brain development, during adochanges leading to the activation of hypothalamic-­ lescence. This is notable in transgender pituitary-­ adrenal and hypothalamic-pituitary-­ youth, as most self-initiated gender transigonadal pathways (Guyer et  al. 2023). While tion begins in the period after the onset of physical changes are the most apparent marker of puberty (Steensma et al. 2013). pubertal changes, there are six domains of psy- • Along with the physical pubertal changes chosocial change associated with puberty: social themselves, the timing of how these changes processes, cognition and achievement, reward-­ manifest impact adolescents in numerous related processes, self-related processes, exterways (Table 1.2) (Dorn and Beltz 2023).

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Table 1.1  Key physical and psychosocial changes during adolescence

Physical body (Rosen 2004; Section on Endocrinology 2014, 2015; LoombaAlbrecht and Styne 2009)

Assigned female at birth

Assigned male at birth

Cognition (Keating et al. 2023)

Early adolescence (10–13 years) ~ middle school years – Body hair – Breast and appearance hip – Increased development perspiration and – Peak bone oil production of mass accrual skin and hair – Peak height velocity – Start of menstrual cycles – Testicular and penile enlargement – Deepening voice – Wet dreams, involuntary erections – Increased rate of fat-free body mass accumulation (e.g. muscle) – Concrete thinkers that engage in deductive reasoning

Relationship skills (Steinberg and Monahan 2007; Raley et al. 2007; Steinberg 1990) Emotional processing (Liew et al. 2023; Keating et al. 2023)

– Dependence on parents is replaced by dependence on peers

Risk taking behaviors (Dorn and Beltz 2023; Keating et al. 2023; Lapsley et al. 2023)

– Sense of invulnerability – Rise in sensation seeking behavior

Morality (Lapsley et al. 2023)

– Aware of what may cause moral ambiguity, but do not have system of working through the problem; thus, they may make decisions based on non-moral personal choice

– Emotional reactivity system (limbic system) more developed than self-­regulation system (prefrontal cortex)

Middle adolescence Late adolescence (14–17 years) (18+ years) ~ high school years ~ college years – Ongoing hip development – Stabilized fat-free – Continued body mass decrease in bone development mass – Increasing body fat percentage – Bone mass starts to decrease – Peak height velocity – Decreasing body fat percentage – Peak bone mass accrual

– Stabilized fat-free body mass development – Continued increase in bone mass

– Start of hypothetical thinking, inductive reasoning, and use of abstract thought – Largest linear increase in resistance to peer influence – Decreases in limbic system activity in response to negative stimuli – Increases in cortical regulatory regions – Reduction in impulsive actions in lieu of goal-directed behavior – Able to weigh moral vs non moral elements and systematically work through problem

– Advanced abstract thinking

– Engagement in romantic relationshipsa – Increased egocentrismb – Near adult levels of metacognitionc

– Increasing top-down regulation from prefrontal cortex – Continued ability for moral reasoning

By age 18, 69% of males and 76% of females have had a romantic relationship in the last 18 months Inclined to see their experiences as unique, believe they are a major focus of other’s thoughts, believe others perceive them as they perceive themselves c Ability to reason with one’s own thought processes a

b

N. Keshwani et al.

6 Table 1.2  Impact of timing of pubertal changes on psychosocial domains (Dorn and Beltz 2023) Social processes Family, friend, romantic relationships

Cognition and achievement Self-related processes

Reward-related processes/externalizing behaviors Rule-breaking, aggression Internalizing behaviors Anxiety, depression, somatic complaints

Early pubertal maturation – High parental conflict – Many romantic relationships (typically of low quality for females) – Females: high peer influence and negative relations – Females: poor academic achievement – Males: enhanced cognitive performance – Females: high body surveillance and body dissatisfaction – Males: high self-esteem – High substance use, deviance, delinquency, violence, risky sexual behavior

Late pubertal maturation – Males: High peer influence and negative relations

– Females: high depression, anxiety, eating pathology

– Males: high depression, eating pathology

 sychosocial and Risk Behavior P Assessment Adolescent providers use clinical communication tools in the psychosocial and risk behavior assessment of their patients, of which the HEEADDSSS assessment is the most utilized tool. Each letter of the HEEADSSS acronym stands for a different aspect of the interview— Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence. The HEEADSSS assessment for conducting the adolescent psychosocial interview was developed by Dr. Harvey Berman in 1972, and later refined by Dr. Cohen and Dr. John Goldenring. It has undergone several revisions and this section reviews the most recent update, namely “HEEADSSS 3.0” (2014).

Order of Topics The HEEADSSS assessment helps structure the patient interview to build rapport in a stepwise fashion, allowing the clinician to gain the patient’s trust before delving into more sensitive topics. For some patients, starting with questions

– Males: poor academic achievement – Males: high body surveillance and body dissatisfaction – Females: high self-esteem – Males: high substance use

about the home environment may feel intimidating as this may be a highly sensitive topic and potential stressor. Therefore, some clinicians choose to re-order the HEEADSSS assessment into the SSHADESS assessment (Strengths, School, Home, Activities, Drugs and substance use, Emotions/eating/depression, Sexuality, and Safety). Starting the interview with a discussion about strengths can support rapport building, shift the emphasis to positive topics, and allow an exploration of the patient’s ability to foster resilience rather than a focus on risk behaviors (Ginsberg and Brett Ramirez McClain 2020).

Indications for Use There is no strict age cut-off for when to start using the psychosocial assessment, though many providers add psychosocial and risk behavior assessments to their patient interviews with the onset of puberty (8–10  years old) (HEEADSSS 3.0 2014). Ideally, a complete psychosocial assessment is obtained at all visits, however, focused psychosocial assessments may be practical for sick visits (e.g., obtaining a sexual history of a patient presenting with a chief complaint of vaginal discharge).

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Interacting with Caregivers At all visits with an adolescent patient, introduce yourself to the patient first and then ask the patient to introduce the accompanying caregiver. This sets the precedent that you are the adolescent patient’s doctor, and not the caregiver’s provider, and helps clarify the relationship of the accompanying caregiver. While it is appropriate to involve the caregiver at the start of the encounter, as it can be helpful if the patient is unable to accurately describe their medical problems or unwilling to disclose certain details, it is also important to allow the adolescent patient an opportunity to describe their chief complaint in their own words. This practice may be a new experience for the caregiver as typically during prior pediatric visits the onus is on the caregiver to lead the interaction since the patient may have been not developmentally ready to describe their symptoms or concerns. After the initial conversation with the patient and the caregiver, invite the caregiver out of the exam room to allow time for a confidential patient interview. Aim to speak to the adolescent patients by themselves, even if only briefly, at each visit. Normalize this practice by stating the following: “At this time in the exam, I briefly speak with all my adolescent patients alone. After our conversation, I will invite the caregiver back to the room so that we can finalize all medical decisions together.” If there is resistance on the caregiver’s end about the need for a confidential conversation, consider stating the following:

“We speak privately with our adolescent patients to help them practice taking responsibility for their own healthcare. In a few years, they will go to their medical provider’s office without a caregiver present, and this opportunity allows them to practice what it is like to talk to their provider alone and build these skills over time. Many teenagers may find it easier to ask their provider some questions that they otherwise might find embarrassing sharing in front of their caregiver.”

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Given these explanations, most caregivers are willing to allow providers to speak to the adolescent alone (HEEADSSS 3.0 2014). Alternatively, some providers choose to explain this process at the very start of the visit to avoid any misconception that the need for a confidential interview is a response to a concern that arose during your interaction with the patient or caregiver. The authors have found both methods work well. Outline for Interacting with Caregivers

• Step 1: Introduce yourself to patient and ask them to introduce the caregiver • Step 2: Discuss the chief complaint first with the adolescent and then with the caregiver • Step 3: Invite caregiver out of exam room for confidential patient interview • Step 4: Invite caregiver back into exam room and finalize all medical decisions with both patient and their caregiver

Navigating the Psychosocial Assessment Once you are alone with the patient, start the discussion by explaining why you are speaking to them privately, as well as confidentiality and its limitations. It has been shown that when adolescents are assured confidentiality first, they are more willing to discuss personal topics (Ford et al. 1997). Consider the following as an example opening statement on confidentiality: “I talk to all my teenage patients by themselves because sometimes it’s easier to talk about things without our caregivers around. I’m here to be YOUR doctor so I ask these questions to make sure I’m helping you. I ask everyone these same questions. Everything you share is private and is kept between you and the medical team. I don’t tell anyone anything you don’t want me to. The only exception is if I am worried about your safety or the safety of someone else, like if you told me someone was hurting you or someone else, or you were hurting yourself or others. Do you have any questions about this?”

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Additional Interview Tips • Sit directly in front of patient or in a position to maintain eye contact • If you’re documenting on the computer during visit, periodically look away from computer, especially when patient is discussing a sensitive topic • Utilize concepts of motivational interviewing including: –– Open-ended questions –– Affirmations –– Reflective listening –– Summarizing –– Assess patient’s willingness to change –– Listen for “change talk” –– “Roll with resistance” –– Additional motivational interviewing resources may be found on the Motivational Interviewing Network of Trainer’s website: https://motivationalinterviewing.org/. • The HEEADSSS assessment is not just about collecting information, it is a bi-directional conversation. When a patient offers information, consider responding with appropriate counseling as shared in the subsequent sections of this chapter. • Table 1.3 highlights components of the HEEADSSS assessment and the Strengths section of the SHADES assessment. Not every question listed needs to be asked during each

interview. Consider adapting these questions so that they are suitable to your personal interviewing style. • Many clinicians choose to use a validated screening tool to gather information on some of the same issues addressed in the psychosocial assessment. There are many tools including Guidelines for Adolescent Preventive Services (GAPS) questionnaire (Gadomski et al. 2003), which can be given to the patient in the waiting room and then quickly reviewed by the clinicians prior to starting their psychosocial assessment. These tools can provide valuable information, guiding a busy clinician to a more focused discussion. However, these tools do not replace speaking with the patient directly.

Breaking Confidentiality If you elicit information during the assessment that warrants breaking confidentiality, first gently remind the patient of the exceptions to confidentiality which you discussed at the start of the visit. Then, discuss ways the topic should be addressed with the patient’s caregiver. Consider using motivational interviewing to facilitate conversation between patient and caregiver in situations where confidentiality does not need to be broken, however, the patient disclosed information that may warrant caregiver involvement.

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Table 1.3  High yield questions from HEEADSSS and SHADES assessment

Strengths

Home

Education

Employment

Eating

Activities

Drugs

Sample question (HEEADSSS 3.0 2014; Ginsberg and Brett Ramirez McClain 2020) • “What do you like most about yourself?” • “What would someone close to you say your strengths are?” • “Where do you live and who lives there with you? • “How are things at home?” • “Who do you feel closest to at home?” • “Do you ever worry that your family may not have enough money for food or basic necessities?” • “Have you ever run away from home?” • “What grade are you in?” • “What grades did you make last semester?” • “What do you want to do after you graduate?” • “Who do you eat lunch with at school?” • “Do you have a friend group?” • “Have you ever been bullied?” • “Where are you working?” • “What made you want to get a job? • “How many hours a week do you work? Do you have enough time do your homework and sleep?” • “Are you treated well at work?” • “Does your weight or body shape cause you any stress? If so, tell me about it” • “What do you like and not like about your body?” • “How many meals per day do you usually eat? What do you eat during these meals?” • “What are you doing for exercise?” • “What do you do for fun?” • “How many hours do you spend in front of a screen (computer, TV, phone)? Do you wish you spent less time online?” • “Some teens use the internet a lot. What do you use the internet for?” • “Have any your friends use/tried drugs or alcohol? Have you?” • “Have you ever wanted to cut back or stop your use?” • “What made you decide not to use/try drugs?”

Rationale and context • Start on a positive note to help build rapport

• Do not assume a patient lives with their biological parents • Gain understanding of home dynamics • Consider exploring financial insecurity and other social determinants/non-medical drivers of health

• “How’s school?” is ineffective interview question and often prompts one-word answers like “Good” • Understand their level of “connectedness” and relations with others • If grades dropping, investigate possible reasons why (e.g., depression, drugs, learning disorder)

• More than 20 h per week associated with negative outcomes (emotional distress, substance use) (Resnick et al. 1997)

• Normal BMI or weight trajectory does not exclude an eating disorder • Additional screening tools (SCOFF, Eating Disorder Examination Questionnaire) may be found on pages 18 and 19

• “Nothing” or “Always bored” may be a red flag for possible mental health condition (e.g., depression) • Screen for safe social media usage as described on pages 23 and 24

• Normalize curiosity and exploring behaviors to help build rapport • Additional screening tools (CRAFFT questionnaire and SBIRT) may be found on pages 25 and 26 • Reinforce positive behavior and explore protective factors as they are markers of resilience (continued)

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10 Table 1.3 (continued)

Sexuality

Sample question (HEEADSSS 3.0 2014; Ginsberg and Brett Ramirez McClain 2020) Rationale and context • “What name do you like to be called?” • Patient may disclose a different name and pronoun • “Do you think of yourself as male, that they do not yet feel comfortable sharing with caregivers—if so, be mindful and mirror patient female, both, nonbinary, or another language when caregiver is invited back into the identity?” room • “What pronouns do you use?” (such as she/her, he/him, they/them, other pronouns, or multiple sets of pronouns) The Center for Disease Control and Prevention (CDC) 5 P’s (CDC 2023) explore five important components of a sexual history. Prior to transitioning to these questions, consider the following opening: “The next part of our conversation will be about your sexual health and practices. These questions may feel personal, but I ask them to all my patients, and they are important for your overall health. Before I begin, do you have any questions or concerns about your sexual health?” Partners • “Are you currently having sex of any • Confirm the age of the patient’s partner as there kind—so, oral, vaginal, or anal—with may be potential legal consequences based on age anyone?” of sexual consent in your respective region • “In recent months, how many sex • “If a patient has had sex in the past, but is not partners have you had?” currently, it is still important to take a sexual history” (CDC 2023) • “What is/are the gender(s) of your sex partner(s)?” • “Do you or your partner(s) currently have other sex partners?” • “Have you talked about your sexual activity with your caregiver?” Practices • “What have you done in these • For younger patients consider starting with an relationships?” open-ended question and asking about benign behaviors (e.g., hugging, holding hands, kissing) • “What kind of sexual contact do you before asking about more advanced behaviors (e.g., have, or have you had? sex).    – Do you have genital sex (penis in vagina)? Anal sex (penis in anus)? • Using simple and explicit sentences helps minimize Oral sex (mouth on penis, vagina, confusion and decreases reliance on colloquial or anus)?” phrases (e.g., “second base”) which may be defined differently by different people • “What is sex like for you? Is it a good experience?” • Human trafficking may involve forced labor and/or • “Have you ever exchanged sex for basic sex and up to 88% of victims may engage with the healthcare system while being trafficked (McAmis needs like money, housing, or access to et al. 2022) drugs?”

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Table 1.3 (continued)

Suicide/ depression

Safety

Sample question (HEEADSSS 3.0 2014; Ginsberg and Brett Ramirez McClain 2020) Rationale and context Protection from sexually transmitted infections (STIs) • “What prevention methods do you use to • An external/internal condom may also be referred protect yourself from STIs?” (such as to as a “male/female” condom external or internal condoms) • The CDC website has “How To” documents for external/internal condom and dental dam usea Past history of STIs • “Have you ever been tested for STIs and • Consider obtaining direct contact information (e.g., HIV? Would you like to be tested?” cellphone number) for the patient to disclose results of any STI testing and discuss medication • “Have you ever been diagnosed with a recommendations as minors in all states may STI? When? Did you get treatment? independently consent for STI testing and Have you had any symptoms that keep treatment, especially if caregiver is unaware of coming back?” patient’s sexual history Pregnancy intention • “Would you like to become pregnant in • Respect patient autonomy and do not assume that the next year?” all patients are trying to prevent pregnancy • “How will you financially support the baby? Do you or your partner want to finish school? Do you have any family support?” • “Are you or your partner using contraception or practicing any form of birth control? Would you like to talk about ways to prevent pregnancy?” • “How would you describe your general • Screening tools (Patient Health Questionaire-9 mood over the last 2 weeks?” (PHQ-9) for depression, General Anxiety Disorder-7 (GAD-7) or Screen for Child Anxiety • “Do you ever feel so sad you wish you Related Disorders (SCARED) for anxiety) may wouldn’t wake up the next morning?” supplement but do not replace actual discussion • “Do you have a current plan to hurt about mood yourself or end your life?” • “Have you ever attempted to kill • If there are concerns for suicidality, the Columbia yourself? When? How?” Suicide Severity Rating Scale (Fig. 1.1) can help risk stratify patientsb • “Do you hurt yourself on purpose?” (such as cutting, hitting, or burning • While most self-harm behaviors are not attempts at yourself) suicide, engaging in self harming behaviors increases the risk of subsequent suicidal behaviors (Westers et al. 2016). The SOARS model can help in assessment of non-suicidal self-injury (Table 1.4) • “Do you feel safe at home? At school?” • Safety may be discussed throughout the interview • “Has anyone ever threatened you, hit as the patient discloses concerns and a separate portion of the interview may not be needed you, or touched you inappropriately?” • “Do you wear a seatbelt? Helmet?”

CDC Information on the External Condom, Internal Condom, and Dental Dam available at https://www.cdc.gov/ condomeffectiveness/ b If the patient is in imminent danger, confidentiality should be broken and the suicidal ideation and/or plan must be disclosed to the caregiver. For most primary care outpatient providers, the next step would assessment by in-house social worker to develop a safety plan for the patient or emergency room evaluation for behavioral health evaluation a

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Fig. 1.1 Columbia Suicide Severity Rating Scale (The Columbia Lighthouse Project 2016). (Reproduced with permission from The Columbia Lighthouse Project)

Table 1.4  The SOARS model for evaluation of non-­ (2001–2004) revealed a lifetime prevalence of suicidal self injury (Westers et al. 2016) 2.7% of eating disorders (using DSM-IV criteria Sample question for Anorexia Nervosa, Bulimia Nervosa, and Suicidal • Do you ever think about purposely Binge Eating Disorder) for adolescents aged ideation ending your life when you 13–17  years (Merikangas et  al. 2010) with a self-injure? median age of onset between 12 and 13  years Onset, • When was the first/most recent (Swanson et  al. 2011). Eating disorders occur frequency, time? methods • How many times a week/month do across all ethnic and racial groups, and current you self-injure? research interests involve the development of cul• What do you typically use? turally sensitive screening tools and diagnostic criAftercare • Have you ever hurt yourself so teria to inform culturally tailored treatment badly that you needed medical (Rodgers et al. 2018). A population-based study of attention, even if you never got it? Reasons • In what ways does it help? 2271 adolescents reported Asian females had the Stage of • Is this something you would like to highest rates of disordered eating behaviors when change stop? compared to Black, Hispanic, and White females

Eating Disorders Eating disorders affect adolescents of all sexes and cultural backgrounds. Analysis of National Comorbidity Survey Adolescent Supplement

(Rodgers et al. 2017). Disordered eating behaviors among males may center around muscularity concerns and while current diagnostic screening tools do not account for body image differences among males, recent literature describes 1  in 4 patients with either Bulimia Nervosa or Anorexia Nervosa are male (Gorrell and Murray 2019).

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Eating disorders cause significant mortality and morbidity in adolescents. Of all eating disorders, Anorexia Nervosa is associated with the highest mortality with an annual mortality rate of 5.1 per 1000 person-years (among adults and adolescents) (Arcelus et al. 2011) and a mortality risk of over 5× upon follow-up from inpatient treatment for Anorexia Nervosa compared to age-­ matched and gender-matched individuals in the general population. Anorexia Nervosa is second only to opioid use, which has a rate of 18.7 deaths per 1000 person-years (Bahji 2020). Suicide risk contributes greatly to mortality, with estimates of 1 in 5 individuals with Anorexia Nervosa who die by suicide (Arcelus et al. 2011) and 18× greater suicide risk than in age and gender matched control group (American Psychiatric Association 2022). Mortality and morbidity remain high despite treatment advances in eating disorder management due to prolonged illness duration and low remission rates. Across all eating disorders, 62–70% of those who previously received inpatient treatment and 35% of those who previously received outpatient treatment continued to meet full diagnostic criteria with symptoms at long-term follow-up (10 to ≥20  years) (van Hoeken and Hoek 2020). Eating disorders are associated with significant mental and physical health comorbidities as well as personal, familial, and societal costs (Gorrell and Murray 2019). Common comorbidities of eating disorders include concurrent mental health diagnoses (e.g., mood disorder, anxiety disorder, substance abuse or dependence, behavioral disorder) (Swanson et  al. 2011; American Psychiatric Association 2022). Patients with an eating disorder (n = 6560) had 5× higher odds of depressive disorders diagnosis and 6× higher odds of alcohol use disorder compared to age-­ matched and sex-matched controls (Demmler et al. 2020). Eating disorders are associated with risks in fertility, in pregnancy, and for the newborn (van Hoeken and Hoek 2020). For ­ example, mothers with eating disorders reported less awareness of hunger and satiety cues in their child (Martini et al. 2019). Those with eating disorders report significantly lower quality of life scores compared to

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non-eating disorder controls. Significant gender interaction was noted, where men with eating disorders were found to have incrementally worse quality of life scores compared to women with eating disorders (Hart et al. 2020). Former eating disorder patients continue to report lower quality of life scores in several areas of social functioning, and despite recovery psychological well-being, did not return to the level of healthy controls (Tomba et al. 2019). Family members of those with eating disorders report higher caregiver burden (worrying, tension, urging) compared to those family members of those with schizophrenia or depression (Martín et al. 2015). 3.3 million healthy life years were lost to eating disorder-related disability in 2017. From 2007 to 2017, the years lost to disability increased by 6% for AN and 10% for BN.  In this same period, rates remained constant or decreased slightly for all causes, noncommunicable diseases, and mental disorders overall (van Hoeken and Hoek 2020). Yearly costs for healthcare use are 48% higher for patients with eating disorders compared with non-eating disorder controls (van Hoeken and Hoek 2020). The COVID-19 pandemic exacerbated risk factors which may prime development of an eating disorder including stressful life events, anxiety, social isolation and decreased social support, trauma and abuse, and perfectionistic expectations (Cooper et  al. 2020). Medical admissions secondary to complications of restrictive eating behaviors increased significantly among adolescents during the pandemic (Otto et al. 2021). Although eating disorders may present with severe medical consequences, they are primarily psychiatric conditions. Therefore, their diagnostic criteria are outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). There are notable changes from the fourth to fifth edition of the DSM. DSM-­ 5 was published in 2013 and revised in March 2022. Summary of the criteria are described in Table 1.5. • The chapter titled “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” i.e. Pica, Rumination, and

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Table 1.5  Diagnostic features of eating disorders commonly seen in adolescents (American Psychiatric Association 2022) DSM-5 eating disorder Diagnostic features diagnosis All criteria must be met to make each diagnosis Anorexia nervosa A. N  egative energy balance (restriction of energy relative to requirements) leading to significantly low body weight (less than minimally expected in context of age, sex, developmental trajectory, physical health) B. Fear of weight gain or persistent behavior interfering with weight gain (typically not alleviated by weight loss) C. Body dysmorphia (distorted perception of body weight/shapea, overemphasis of body weight/shape on self-evaluation, lack of recognition of current low body weight) Subtypes refer to behaviors over the last 3 months. Patients may shift between both subtypes over the course of their diagnosis: – Restricting type: weight loss accomplished primarily through limiting food intake, fasting, and/or excessive exercise with no repeated episodes of binge eating or purging behaviors. – Binge-eating/purging type: patient engaged in binge-eating OR purging behaviors (self-induced vomiting, misuse of laxatives, diuretics, enemas) BMI percentiles are used to indicate severity. There are no minimum BMI percentile requirements to make the diagnosis itself. Diagnoses mentioned below can only be made once anorexia nervosa is excluded from the differential Bulimia nervosa A. Recurrent episodes of binge eating: Eating an amount of food that is objectively larger than what most individuals would eat in that same period of time (2 h) AND reporting a lack of control of eating during episode B. Recurrent inappropriate compensatory behavior to prevent weight gain (self-induced vomiting, medication misuse (e.g. laxatives, diuretics, diet pills, fasting) excessive exercise) C. Criteria A + B occur on average at least 1×/week for 3 months D. Self-evaluation is unjustifiability influenced by body shape and weightb Severity is described by frequency of inappropriate compensatory behavior per week and varies in severity as follows: mild (1–3), moderate (4–7), severe (8–13), (>14). Binge eating disorder A. Recurrent episodes of binge eating (as described above) B. Binge-eating episodes are associated with ≥3 of the following:  (a) Eating more rapidly than normal  (b) Eating until feeling uncomfortably full  (c) Eating large amounts of food when not feeling physically hungry  (d) Eating alone due to embarrassment of volume of food  (e) Feeling disgusted, depressed, or guilty after binge C. Criteria A + B occur on average at least 1×/week for 3 months D. Marked distress regarding binge E. No associated inappropriate compensatory behavior Avoidant restrictive A. Eating or feeding disturbance (e.g. lack of interest in eating/food, avoidance based on food intake disorder sensory characteristics of food, fear of choking/swallowing/vomiting/pain after eating) associated with ≥1 of the following:  (a) Significant weight loss/failure to achieve expected weight gain/faltering growth trajectory  (b) Significant nutritional deficiency  (c) Dependence on oral supplements or tube feeding  (d) Marked interference with psychosocial functioning B. Disturbance is not due to lack of available food or cultural practice (e.g. religious periods of fasting) C. No evidence of a disturbance in the way in which one’s body weight or shape is experienced D. No concurrent medical or mental disorder to explain the feeding/eating disturbance It is possible that a patient is initially diagnosed with ARFID, and subsequently develops behaviors that would meet criteria for anorexia nervosa; at this time this phenomenon is not described in the DSM-5, though is informally referred to as “ARFID plus”.

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Table 1.5 (continued) DSM-5 eating disorder diagnosis Other specified Feeding or eating disorder, examples

Diagnostic features All criteria must be met to make each diagnosis

Feeding/eating disorders that cause clinically significant distress or impairment in functioning but do not meet full criteria for above diagnoses Atypical anorexia

Bulimia nervosa of low frequency and/or limited duration Purging disorder Binge eating disorder of low frequency and/or limited duration Night eating disorder

Baseline diagnosis Anorexia nervosa

Bulimia nervosa

Bulimia nervosa Binge eating disorder

Exception Individual’s weight is within or above normal range despite significant weight loss Behaviors occur 20 h/ week visit 1×/ e.g. 2–3 h/day, e.g. 6–11 h/day, week 2–4 days/ 5–7 days/week – Therapy week 1×/week – Medical Provider visit every 1–3 months Yes, but typically requires in person or blinded at-home weights 1×/week

24 h/day

No

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describes treatment options for patients with eating disorders. Initial medical evaluation may provide insight about continued outpatient management or need to transition to inpatient facility. Common scenarios requiring inpatient admission involve bradycardia (HR 20% in 1 year, >5% in 1 month Disordered thoughts, bullying Limiting food intake, fasting, self-induced vomiting, medication misuse (e.g. laxatives, diuretics, diet pills), excessive exercise, purging, bingeing Exercise is prioritized above other activities of daily living typical for adolescents (sleep, school, nutrition); consider asking follow-up questions around personal purpose of exercise if >7–10 h/week Excessive of influence of body size on self-perception

Do you feel like you look too thin, too heavy, or just right? Fear of weight gain How would you feel if you gained 5–10 lb over the next month? Review of systems: – Fatigue, weakness – Dizziness, syncope – Dry skin, cold intolerance, missed menses, hair loss – Constipation – Muscle cramps, joint pain Clinically significant if upon standing: Orthostatic changes to heart rate and blood pressure – Heart rate increases by ≥40 beats/minute and symptomatic Have patient lay down for – Systolic blood pressure decreases by ≥20 mmHg 5 min to obtain first set of – Diastolic blood pressure decreases by ≥10 mmHg vitals, and then stand up for Or minimum values are: 5 min to obtain second set of – Heart rate 50% of youth had sent a “sext” and >70% had received one (Spencer et al. 2015) • Higher rates of depression and substance abuse among teens who engage in sexting. • Sexual minority youth may be more likely to have engaged in sexting • Risks of bullying and extortion from unauthorized sharing of images • Youth often underestimate privacy risks of content sharing • Risks of online stalking and undesired contact from strangers

an open environment in order to monitor responsible use at home. Table  1.10 explores mental, emotional, and social concerns for social media and technology use.

Recommendations for clinicians • Screen all youth for depression using validated screening tools such as the PHQ-9

• Ask all youth about cyberbullying • Discuss social, academic, and emotional impact of bullying • Screen all youth for suicide using validated screening tools such as the ASQ

• Counsel youth on the possible legal risks for sharing or receiving sexual photos of minors • Discuss strategies for safe technology use • Counsel on healthy relationships and boundaries • Ask about coercion to “sext” or receipt of unwanted sexual content

• Discuss online safety risks with children and parents • Encourage parents to actively remain aware of apps, messaging, and contacts on devices

 lectronic Health Record (EHR) E Privacy Advances in technology affect electronic adolescent confidentiality. Most individuals in the U.S.

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now have instant electronic access to their own medical records. Many questions remain unanswered surrounding how best to maintain confidentiality for documentation of sensitive conversations with adolescent patients. While adolescents have the right to confidential health care in most U.S. states, electronic systems that interface parent accounts may unintentionally disclose confidential information about sexuality, mental health, and other sensitive topics without sufficient protections (Carlson et  al. 2021; Bourgeois et al. 2018). Conversely, disclosure of weight may be distressing to patients undergoing treatment for eating disorders, whereas for parents this value may be necessary to guide implementation of their child’s nutritional plan. Partnering with parents and youth by setting expectations about records access while preserving confidential material can help avoid confusion and provide clarity for families (Carlson et al. 2020; Goldstein et al. 2020). Considerations to Maintaining Adolescent EHR Confidentiality • Parental and adolescent access to notes, results, and other sensitive information varies by EHR system. • Discuss EHR privacy with patients and parents to set expectations about whether notes or encounter contents will be released or blocked. • If the contents of the visit note are released to the parent via EHR, consider documenting confidential interview contents in a separate note that will be blocked from EHR release. (Policies vary depending on institutional policies and local laws). • For LGBTQ youth, EHR can facilitate the use of the chosen name and pronouns in medical encounters and notes. However, if an LGBTQ patient is not “out” to family about their sexuality and/or gender identity, ensure that shared EHR contents do not disclose confidential aspects of identity. • Private insurers typically send subscribers “Explanation of Benefits” that summarizes all charges billed to the insurance policy. These may specify information such as the date of

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office visits, identities of healthcare providers, lab tests (such as STI tests) and associated diagnoses. This may lead to unintentional disclosure of otherwise confidential care for adolescents and young adults who remain dependent beneficiaries on parental insurance plans.

Emerging Social Media Risks New platforms and trends are developing continuously, often entailing novel risks (Table  1.11) that healthcare providers and parents may not know to ask about (Social media 2023). Some current important apps and specific concerns are listed below. The landscape of social media platforms and interactions is likely to continue to grow and change.

Resources for Patients and Families The AAP “SafetyNet” website (http://safetynet. aap.org/) contains links to a number of high-­ quality websites for both parents and providers. The AAP’s www.healthychildren.org website also has a section on media with useful tips for parents. • www.youngwomenshealth.org: General information on health for adolescent and young adult females • www.youngmenshealthsite.org: General information on health for adolescent and young adult males • http://www.crisistextline.org/textline/: Web page including information on multiple crisis phone and text contacts

Resources for Healthcare Providers • American Academy of Pediatrics—Family Media Use Plan—HealthyChildren.org https://www.healthychildren.org/english/fmp/ pages/mediaplan.aspx

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Table 1.11  Online interactions and associated risks (Odgers and Jensen 2020; Council on Communications and Media et al. 2013; Hill et al. 2016; Chassiakos et al. 2016; Social media 2023) Methods of social media use Online profiles: May include a name, photograph, interests, and other identifying information. Often includes “Following” or “Requesting” known or unknown individuals to be “Friends” or connections Messaging/Chats: Using texting or instant messaging over the Internet or between smartphones to send messages. Messaging apps (Groupme, Telegram, Discord) may be used as an alternative to texting to coordinate friends, school groups, or other groups Comments, walls, feeds: Posting or sending messages that may be visible to the public or to only friends or followers Photo and video sharing: Uploading one’s own photos and videos, or sharing live video. May be public or private depending on privacy settings Video-feeds: Apps such as TikTok deliver a continuous short-video feed based on the user’s video consumption preferences. Users may interact with others’ content, share or “stitch” others’ videos, and post original content Vlogs: Stands for “video blogs”, typically posted to a video sharing platform (like YouTube) by “Vloggers”, who may develop large audiences Live-streaming: A live video-feed often involving interaction in an activity (such as gaming) and responses to audience chat messages Groups: Many apps allow creating groups. Users may “join”, “like” or “follow” groups to access information and have conversations with other members Playing games: Youth may play alone or with friends. Multiplayer games may involve team interactions to engage in group game challenges Online dating: Apps or websites to help individuals find romantic connections

Possible risks Potential for stalking, targeting, impersonation. Potential for bullying and harassment

Teens often value the privacy of platforms (such as Snapchat) that do not keep a chat history. However, different ways to “Screen-capture” or “Screen-shot” images may lead to sharing potentially sensitive images otherwise intended to remain private “Bots” may promote misinformation. May be used as a tool for online targeting, “brigading”, and/or harassment “Filtered” images promoting unrealistic portrayals of appearance. “Autoplay” on Youtube may lead to an endless stream of newly suggested content Videos of “Dares” and “Challenges” may lead to dangerous or fatal behavior. Reinforcement of content based on viewing history may lead users down a “rabbit hole” of negative topics. Potential for exposure to inappropriate sexual material Groups of similar-minded individuals may promote misinformation. May involve monetary solicitation for paid subscriptions May involve interactions with audience chat messages and soliciting small monetary “gifts” Voice and message “channels” with groups of interested individuals may provide valuable interpersonal connection, but may also expose youth to unintended, unmoderated content Even games targeted to children (such as Roblox) may have users introduce suggestive or sexual content. Group gaming may involve sharing voice channels with known or unknown individuals Potential for adolescents to lie about age to gain access to adult dating apps, leading to potential for grooming and exploitation

Substance Use Drug use continues to be highly prevalent among adolescents. Alcohol, marijuana, and tobacco are the most frequently used substances (Johnston et al. 2019). There are many risk factors associated with drug use including race, gender and sexual identity, and comorbid mental health disorders (Cummings et  al. 2011; Pinedo and Villatoro 2020; Stanley et al. 2021;

Swaim and Stanley 2018; Mereish 2019; Welsh et  al. 2017; Chan et  al. 2008). In 2022, the American Academy of Pediatrics released an updated policy statement calling upon general pediatricians to become better trained in substance use identification and treatment (Camenga and Hammer 2022). Furthermore, multiple studies have shown that adolescents have a desire to discuss their drug use, but do not if their pediatricians do initiate the conver-

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sation (Polydorou et al. 2008; Yoast et al. 2007; Levy and Williams 2016). It is essential for general practitioners to screen for drug use amongst adolescents.

stance use disorder (SUD) is described using the 11 symptoms described in Table 1.12. Severity is based on the total number of symptoms (American Psychiatric Association 2013).

 BIRT: Screening Brief Intervention S Referral and Treatment

• • • •

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends using the Screening Brief Intervention Referral and Treatment (SBIRT) system for universal screening for drug use as part of routine health care. This section reviews each part of SBIRT.

Screening Although screening for substance use occurs as part of the psychosocial assessment (as discussed on page 9), clinicians should also use validated tools to improve sensitivity of screening for substance use disorders (SUD). Multiple studies have shown that clinician interviews of patients alone have low sensitivity for detecting substance use disorders. Even if substance use is detected, the extent of use is underestimated. Patients are misdiagnosed as having only minimal substance use when they have substance abuse and dependence (Levy 2014). One of the most used tools is the CRAFFT (Car, Relax, Alone, Friends/Family, Forget, Trouble). It can be thought of as akin to the CAGE (Cut-down, Alone, Guilty, Eye-opener) questionnaire used in adult alcohol screening (Knight et  al. 2022). The CRAFFT has undergone several updates, with the most recent update including questions about vaping and edibles for marijuana as well as the Hooked on Nicotine Checklist (HONC). The latest version can be downloaded for free at https://crafft.org/. Brief Intervention After screening the patient, the next step is to identify the patient’s stage of use: abstinence, substance use without a disorder, mid-moderate substance use disorder, or severe substance use disorder. The Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) criteria for sub-

0–1 symptoms: no diagnosis 2–3 symptoms: mild SUD 4–5 symptoms: moderate SUD ≥6 symptoms: severe SUD

The provider then provides a “brief intervention” in which they encourage the patient to make healthy decisions so that the risky behavior is prevented, reduced, or stopped. Overall goals of brief intervention are based on the severity of the SUD.

 bstinence/No Substance Use: Positive A Reinforcement • Goal is to prevent/delay substance use through positive reinforcement. • Ask why they have decided not to use drugs, and reinforce this decision. • Give additional information about negative health effects.

 ubstance Use Without SUD: Brief S Intervention • Appropriate if use is infrequent (e.g., 1–2 times per year). • Give clear and direct advice to stop substance use and brief mention of negative health effects.

Mild to Moderate SUD • Use motivational interviewing (MI) (see page 8) to assess the patient’s stage of change (Precontemplation, Contemplation, Preparation, Action, Maintenance). Discussions about how to assess the patient’s stage of change are beyond the scope of this chapter but can be readily found elsewhere (Raihan and Cogburn 2021). • Use MI to help patient understand pros and cons of substance use. Help them analyze

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26 Table 1.12  Diagnostic criteria for substance use disorder (American Psychiatric Association 2013) Impaired control over substance use

Social impairment

Risk use

Pharmacological

1. Consuming the substance in larger amounts and for a longer amount of time than intended 2. Persistent desire to cut down or regulate use 3. Spending a great deal of time obtaining, using, or recovering from the effects of substance use 4. Experiencing craving, a pressing desire to use the substance 5. Substance use impairs ability to fulfill major obligations at work, school, or home 6. Continued use of the substance despite it causing significant social or interpersonal problems 7. Reduction or discontinuation of recreational, social, or occupational activities because of substance use 8. Recurrent substance use in physically unsafe environments 9. Persistent substance use despite knowledge that it may cause or exacerbate physical or psychological problems 10. Tolerance: Individual requires increasingly higher doses of the substance to achieve the desired effect, or the usual dose has a reduced effect; individuals may build tolerance to specific symptoms at different rates 11. Withdrawal: A collection of signs and symptoms that occurs when blood and tissue levels of the substance decrease. Individuals are likely to seek the substance to relieve symptoms

whether continued drug use aligns or not with their life goals. • Even if not currently ready for action, provide additional information on negative health effects of substances in a non-judgmental way. Sample phrasing shared below: –– “It sounds like you do not want to stop or reduce your use right now, which is OK. If it’s okay with you, I would like to give you some more information on this substance though, so that you can make an informed decision for yourself.” • Schedule a follow up afterwards to ensure ongoing conversation.

Severe SUD (Addiction) • Patient requires a referral to a substance use specialist (see Table 1.13). If adolescent and/ or family has trouble accepting referral, use MI to help navigate conversation. • Screen for concurrent other mental health disorders.

Acute Risk of Harm • Examples of behaviors that may pose acute risk to life include: –– Injection drug use –– Presence of drug withdrawal symptoms –– Mixing sedatives, alcohol, or opioids as this may lead to respiratory depression –– Frequent or excessive binge drinking as this may lead to alcohol poisoning –– Operating vehicle under the influence of a substance • If the drug use behavior poses an acute risk to life, confidentiality should be broken, and concerns should be discussed with the caregiver (see page 8). • Clearly recommend to patient and the caregiver that drug use/high risk behavior should be stopped. • Make a safety plan and advise on next steps. This may require involvement from in-house social worker or emergency room referral for behavioral health evaluation.

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Table 1.13  Drugs commonly used by adolescents (Wang and Hoyte 2018) % use in ages Physical exam findings 12–17 (2020) and possible sequelae 10.1% Distorted perception, poor concentration, tachycardia, sedation, ataxia, psychosis, anxiety, delirium, vomiting, hypotonia, respiratory depression, cardiotoxicity (Tai and Fantegrossi 2016) 8.2% Miosis, ataxia, agitation or sedation, tachycardia or bradycardia, hypotension, respiratory depression, nausea, vomiting

Drug Marijuana

Slang terms Weed Pot Grass Dope Reefer Hash Mary Jane

Alcohol

Booze Alc Juice Sauce

Tobacco and nicotine (including cigarettes, vaporized, and smokeless nicotine)

Cigs Nic E-Cigs Nic

6.5%

Low dose: nausea, vomiting, tachycardia, hypertension, euphoria High dose: CNS depression, seizures, paralysis

Inhalants

Huffing Bagging Poppers

2.7%

CNS depression, euphoria, tachycardia, angioedema

Stimulants

Uppers Skittles Vitamin R Crystal Meth Ecstasy Coke Crack

1.2–1.7%

Tachycardia, hypertension, agitation, psychosis, mydriasis, nausea, vomiting, diarrhea, hyperthermia, diaphoresis

Other health effects Electronic Vape Associated Lung Injury (EVALI) Cannabinoid hyperemesis syndrome Cannabis withdrawal syndrome

Patients with problematic use are at increased risk of alcohol withdrawal syndrome Long-term: Alcoholic liver disease, heart disease and stroke, multiple cancers (including liver, breast, colon, and esophageal) dementia, Fetal alcohol syndrome if used during pregnancy (Poznyak and Rekve 2018) Leading preventable cause of death in US (U.S. Department of Health and Human Services et al. n.d.) Long-term health effects: cancer, heart disease, dementia “Sniffing death syndrome”: Risk of sudden death due to asphyxiation, cardiac arrhythmias, or seizures Intracerebral hemorrhage, stroke, seizures, myocardial infarction, ischemic colitis, dysrhythmias (Derlet et al. 1969) (continued)

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28 Table 1.13 (continued) % use in ages Physical exam findings 12–17 (2020) and possible sequelae 1.6% Mental status depression, hypoventilation, miosis, and hypoperistalsis (Wang and Hoyte 2018)

Drug Opioids

Slang terms Lean Purple drink Vikes/Vics Percs Oxy Dope Smack Bupes

Hallucinogens

Magic Mushrooms Acid blotter Special K Peyote PCP

1.5%

Sedative Hypnotics/ Tranquilizers

Bars Benzos Z-Bars Downers

0.9%

Dextro-methorphan (DXM)

Dexing Robotripping CCC Skittles

Hallucinations, pupillary dilation, diaphoresis, tremors, incoordination and hyperreflexia (Weaver 2016) Hyperthermia, rhabdomyolysis, hepatic necrosis and disseminated intravascular coagulopathy (Wang and Hoyte 2018) CNS depression, nystagmus, ataxia

Agitation, Delirium, Nystagmus, Hyperreflexia, Hallucinations, Hyperthermia, Tachycardia, Hypertension, Flushing

Other health effects Abrupt cessation leads to non-life threatening withdrawal—anxiety, irritability, diaphoresis, vomiting and tremor (Wang and Hoyte 2018) Long term risks: overdose and death from respiratory depression, respiratory problems during sleep, falls/fractures, constipation (with possible intestinal blockage), hypogonadism, impotence, infertility, osteoporosis, sedation, disruption of sleep, hyperalgesia, dry mouth and tooth decay (Baldini et al. 2012) Theoretical risk of serotonin syndrome (Wang and Hoyte 2018; Weaver 2016)

Risk of life-threatening withdrawal Includes prescription drugs: • Zaleplon (sonata) • Zolpidem (Ambien) • Eszopiclone (Lunesta) May cause serotonin syndrome in high doses, especially if ingested with other serotonergic agents (SSRIs, opioids, ondansetron)

1  Update in Adolescent Medicine

Referral to Treatment Once an adolescent is identified as having a substance use problem, providers then face the challenge of assisting patients and families in identifying appropriate care for substance use issues. It is estimated that fewer than 10% of adolescents identified as needing substance abuse treatment receive appropriate care. This process is made even more complicated by the relative lack of substance abuse treatment programs for adolescents and complicated insurance coverage issues (Levy and Williams 2016). Substance abuse treatment generally occurs within mental health settings and levels of care are similar to those for mood disorders or eating disorders. Criteria to help decision making about selecting the appropriate level of care are outlined by the American Society of Addiction Medicine (Mee-Lee et al. 2013). Marijuana is the drug most used by adolescents (Johnston et al. 2019). Table 1.14 describes common methods and types of marijuana used by Adolescents. There are two important syndromes associated with marijuana use: Table 1.14  Common methods and types of marijuana used by adolescents (Sadhana et al. 2020) Method/type Joint Blunt

Edibles Hashish

Hash oil Dabs

Vaporizable cannabis concentrates

Synthetic Cannabinoids (Spice and K2)

Description Dried marijuana rolled in cigarette paper Marijuana leaves rolled in a hollowed-out cigar (dual effect of tobacco and cannabis) Food products infused with cannabis extract Semi-solid concentrate made by compressing psychoactive components of the cannabis plant Cannabis concentrate extracted from hashish Cannabis concentrate, heated to high temperature and you inhale the vapor “Shatter” (brittle, translucent material made from plant and solvent) “oil” “wax” “butane hash”. Can be used with vape pens, e-cigarettes, dabs Plant-derived material with substances similar to THC. More potent than natural plant (Marijuana and the pediatric population)

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• Cannabinoid Hyperemesis Syndrome is associated with chronic marijuana use and is characterized by epigastric abdominal pain, cyclic vomiting, and nausea relieved by hot bathing. • Cannabis Withdrawal Syndrome (CWS) was added to DSM-5 and is defined by ≥3 of the following after 1 week of discontinuation after heavy and prolonged use (daily or almost daily use for a few months: (1) irritability, anger, or aggression; (2) nervousness or anxiety; (3) sleep difficulty or insomnia; (4) decreased appetite or weight loss; (5) restlessness (6) depressed mood; and (7) at least one of the following: abdominal pain, shakiness or tremors, sweating, fever, chills, or headache (American Psychiatric Association 2013). Patterns of nicotine and tobacco use have changed significantly with the advent of e-­cigarettes, with e-cigarettes as the most used nicotine product among youth since 2014. As the landscape of available tobacco products is continually changing, it is best to screen for use of tobacco products with an open-ended question, such as, “What types of nicotine products have you used?” rather than asking about specific tobacco products. Many youth feel that vaping nicotine is “safer” than traditional tobacco use due to the lack of tar and other carcinogens in non-tobacco products. However, clinicians should educate youth that long-term nicotine exposure may still have long-term health consequences, such as atherosclerosis and cancer promotion (Weaver et al. 2014). Research will need to continue into the health outcomes of patients who vape nicotine long-term. Having vaping paraphernalia in the home may also be dangerous to smaller children, as bottles containing e-liquid to refill e-cigarette cartridges could be toxic if ingested. Patients presenting with problematic tobacco use may benefit from nicotine replacement therapy or pharmacotherapies for tobacco cessation (varenicline and bupropion) in addition to behavioral health interventions. Multiple online resources are available for teens for tobacco cessation support as shared at the end of this section.

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Alcohol is one of the most abused substances among teens and young adults (Johnston et  al. 2019). Adolescents drink less often than adults, but when they do, they consume higher quantities. Binge drinking is defined as consuming 5 or more drinks on an occasion for males or 4 or more drinks on an occasion for females. Of note, this definition was intended for adults and does not consider the smaller size of adolescents. Adolescents are likely to reach a blood alcohol level of 0.08  g/dL (threshold of being considered legally impaired in the United States) at lower levels of consumption. The consequences of adolescent binge drinking include acute alcohol poisoning, physical and sexual assault, increased risk for STI, as well as injuries from accidents (Chung et al. 2018). Inhalant use is of particular concern due to easy accessibility. Common products used as inhalants include volatile solvents (e.g., paint thinners and removers, dry cleaning fluids, degreasers, gasoline, glues, shoe polish, correction fluids, felt-tip markers), aerosols (e.g., spray paints, deodorant and hair sprays, fabric protector sprays, computer keyboard cleaner), gasses (e.g., ether, halothane, nitrous oxide, butane, propane), and nitrites (e.g., amyl nitrite, “poppers,” locker room deodorizers, “rush”) Substances are often inhaled from a paper or plastic bag or in an enclosed area, increasing the risk of suffocation.

Prescribing Controlled Substances Abuse of prescription drugs is the fastest-­growing substance use problem in the US, though it has been steadily declining among adolescents (Johnston et al. 2019). Prescription drugs most abused among teens include opioids, stimulants, and sedative-hypnotics (Fortuna et al. 2010). Thoughtful prescribing of controlled substances is the first line of defense in protecting teens against prescription drug abuse, as use of prescription opioids among high school students has been associated with an increased risk of future opioid misuse among young adults (Miech et al. 2015).

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While the national consciousness has become more aware of the dangers of prescription opioids over the past 20 years, prescribing rates of opioids to children and teens remained relatively stable from 2005 to 2015. The most common diagnoses associated with opioid prescriptions in teens are acute injuries (e.g., ankle sprain and metacarpal fracture) as well as abdominal pain, acute pharyngitis, and dental disorders (Hudgins et al. 2019). Providers can contribute to decreasing rates of adolescent prescription drug use by (Weaver 2009): • Utilizing non-opioid pain relief whenever possible, including complementary and alternative medicine therapies • Scheduling patients on controlled substances for frequent follow-up and only prescribing as many doses as would be required until follow-up • Counseling families on safe storage of potentially abused medications • Advocating for the institution of prescription monitoring programs • Screening for misuse of prescriptions medications in HEEADDSSS exam

Resources for Healthcare Providers • General information on Substance Abuse in Teens: NIDA Teens: https://teens.drugabuse. gov/ • Smoking Cessation: https://teen.smokefree. gov/ • Substance Use Screening, Brief Intervention, and Referral to Treatment: https://doi. org/10.1542/peds.2016-1210 • SAMHSA Substance Use Treatment Facility Locator: https://findtreatment.samhsa.gov/ locator • Slang Terms: https://www.dea.gov/sites/ default/files/2018-­07/DIR-­022-­18.pdf

1  Update in Adolescent Medicine

Sexually Transmitted Infections (STIs) STIs in Adolescent Medicine Typical sexual development in adolescence often includes initiation of sexual activity. Data from the national Youth Risk Behavior Survey (YRBS) shows a decrease in the percentage of teens who initiate sexual activity before age 13 between 2009 and 2019 from 5.9% to 3%, respectively (CDC 2019). However, 50% of seniors in high school endorse participating in some form of sexual activity (Data Briefs 2020). Data has also shown that teens are engaging in less condom use during sex which raises their risk for acquiring a STI (Szucs et  al. 2020). Although teens and young adults ages 15–24 make up less than a third of the sexually active population in the U.S., they are responsible for about half of all new STIs annually (Adolescents and Young Adults 2021; Shannon and Klausner 2018). The 2019 YRBS data indicated that only 20% of sexually active high school youth reported completing STI testing in the previous year (Liddon et al. 2022). STI screening is an important part of adolescent health care across various clinical settings and primary care providers are encouraged to screen as a routine part of preventive visits.

Assessing STI Risk Obtaining a detailed sexual history is the first step in determining a teen’s individual STI risk. The Centers for Disease Control and Prevention’s 5 P’s are a common list of prompts to use in obtaining this history and include: Partners, Practices, Protection from STIs, Past history of STIs, and Pregnancy Intention. Recommendations and suggestions on obtaining these history components are on pages 10 and 11. Young people are more likely to have multiple sexual partners either serially or concurrently; they are also more likely to use substances prior to sexual intercourse (Sexual Risk

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Behaviors 2021). Other aspects of a patient’s history that would increase their risk for STIs include involvement in juvenile justice, those who exchange sex for goods, safety, or survival, and young males who have sex with males (YMSM) (Sexual Risk Behaviors 2021; Halkitis et al. 2015).

STI-Related Consent and Confidentiality In the United States, all minors may consent to receive confidential STI testing and STI treatment. HIV pre-exposure prophylaxis (PrEP) is not necessarily covered in this confidentiality clause and may vary across states (National Alliance of State and Territorial AIDS Directors (NASTAD) 2022). Consent for HIV testing may also vary based on the state, although most U.S. states allow “opt-out” testing for this infection (Centers for Disease Control and Prevention 2017). The Guttmacher Institute website is a useful resource to understand state-based particularities in the U.S. regarding consent laws for minors (Guttmacher Institute 2022). Medical providers are encouraged to maintain confidentiality when testing and treating teens for STIs to maintain rapport and trust. This can be done by documenting a confidential phone number for the patient, obtaining permission to leave a confidential voicemail, or asking if a caregiver may receive test results. However, patients should be cautioned that although services can be provided without caregiver consent and adolescents in a confidential manner, this does not preclude billing mechanisms, such as the insurance “Explanation of Benefits”, from including the descriptions for STI testing charges (Centers for Disease Control and Prevention 2021). Clinics receiving federal Title X funding for family planning services (often including local health departments or Planned Parenthood® clinics) can provide free or sliding scale STI testing and treatment without billing insurance.

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Screening and Testing Recommendations by Infection Multiple national medical organizations recommend routine screening of adolescents for STIs. The recommendations from the United States Preventive Services Task Force (USPSTF), the Center for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) are summarized below (Centers for Disease Control and Prevention

2021; Shafii and Levine 2020; Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources 2021). These screening recommendations are intended for annual or periodic asymptomatic testing and are accompanied in the descriptions by additional considerations for t­esting in Tables 1.15, 1.16, 1.17, 1.18, and 1.19. For any STI, testing should be considered for those individuals with symptoms or for those who are exposed to infected partners. Genital lesion evaluation is described in Table 1.20 and Fig. 1.2.

Table 1.15  Screening and testing recommendations for Chlamydia and Gonorrhea Screening Who/When

What Where/How

Why

Test of Cure Retesting

Chlamydia trachomatis (CT) & Neisseria gonorrhea (Gonococcus, GC) • Sexually active females under the age of 25, annually • Young Males who have sex with Males (YMSM)a annually at all sites of contact • Teens in areas of high prevalence • High risk males who have sex with femalesb NAAT (nucleic acid amplification test) recommended • Vaginal or cervical swabs are more sensitive than urine tests • Self-swabbing is acceptable. For urine testing, a “first catch” is recommended instead of “clean catch” • Consider adding on site-specific testing for pharyngeal and rectal swabs in those who report engaging in oral or anal intercourse • A consideration: pooled, 3-site testing may also be an option to save cost and resources. For example, a rectal swab, a 1 mL gargle sample, and a 1 mL urine sample can be combined into a single transport (Almeria et al. 2021) • Also to be considered: some females who do not participate in anal sex may have a positive anal swab, such as when autoinoculation from the vagina occurs from urogenital infection (Dewart et al. 2018). Use shared decision making to test female patients for rectal infection based on behaviors and exposures • Otherwise, routine, annual screening of extra-genital sites is currently only recommended for YMSMa Untreated CT or GC infections can result in pelvic inflammatory disease (PID), cervicitis, epididymitis, or infertility. Untreated GC infections can also result in disseminated gonococcal disease GC/CT infections in pregnancy: 4 weeks after treatment and be retested within 3 months Gonococcal pharyngeal infection: 14 days after treatment All: Approximately 3 months after treatment Pregnancy: Test of cure at 4 weeks, retest at 3 months, in third trimester or at delivery YMSMa: Every 3–6 months if high riskb

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Table 1.16  Screening and testing recommendations for syphilis Screening Who/When

What

Where/How Why Retesting

Treponema pallidum (Syphilis) • Young males who have sex with males, at least annually • Pregnant females • Routine screening of non-high risk, asymptomatic adolescents not recommended for sexually active females or males who have sex with only females • Screen both males and females with increased syphilis risk (history of incarceration or transactional sex work, geography, race/ethnicity, and being a male younger than 29 years) Rapid Plasma Reagin (RPR) followed by confirmatory treponemal antibody detection test (TP-PA or FTA-ABS). However, some institutions are using a “reverse-screening” protocol by testing for the TP-PA or FTA-ABS first and performing the RPR secondarily Serum testing Untreated syphilitic infections can ultimately result in multiple systemic symptoms including disseminated infection involving the nervous system (neurosyphilis) Pregnancy: 28 weeks gestation, at delivery if high riskb YMSMa: Every 3–6 months if high riskb

Table 1.17  Screening and testing recommendations for trichomonas Screening Who/When

What

Where/How Why Retesting

Trichomonas vaginalis (TV) • Sexually active females under 25 with higher risk or in high prevalence settings (e.g., correctional facilities) • Sexually active females with HIV infection who are asymptomatic • Males receiving care in high prevalence settings Urine NAATs are recommended but can also use microscopy and note motile trichomonads on vaginal swab specimens, but the latter has low sensitivity. Some NAATs have not been FDA cleared for males. Instead for both males and females, one can use Max CTGCTV2 assay (Becton Dickinson) or for rapid testing, can use GeneXpert TV (Cepheid) Vaginal swabs are more sensitive than urine, self-swabbing is acceptable. For urine testing, recommend “first catch” instead of “clean catch” in asymptomatic females and all males Can remain untreated because most people who have it are asymptomatic. Results in adverse pregnancy outcomes, increased risk of HIV Females: Approximately 3 months after treatment

Table 1.18  Screening and testing recommendations for HIV Screening Who/When

What Where/How WHY

Retesting

Human immunodeficiency virus (HIV) • Everyone gets at least one screening test over the age of 13, regardless of risk • Frequency of re-testing is dependent on risk. Individuals at higher risk for HIV infection include YMSM and IV-drug users, who would benefit from annual screeninga • First prenatal visit in pregnancy HIV 1 and 2 antigen/antibody assay with reflex cascade based on positive screening Serum testing Early detection and treatment of HIV infection can prevent progression to acquired immunodeficiency syndrome (AIDS). Treatment initiation and adherence to regimen can lead to undetectable viral loads which prevents further transmission of the virus. Affected individuals are often reminded that “undetectable = Untransmissible” Pregnancy: In third trimester if high riskb YMSMa: Consider every 3–6 months based on risk

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34 Table 1.19  Screening and testing recommendations for herpes Screening Who/When What Where/How Why

Herpes simplex virus (HSV) Routine testing is not indicated. Test based on symptoms or in pregnancy if at risk for herpes infectiona HSV-1 or -2 DNA PCR or viral culture Swabbing the unroofed lesions for PCR testing, serum testing Can remain untreated but transmissible because most people who have it are asymptomatic. HSV can result in adverse pregnancy outcomes (including pre-term labor and neonatal complications), painful outbreaks with psychosocial impact, and increased risk of acquiring HIV

Can test specifically for HSV-2 using serologic assays in the case of higher risk for herpes infection, which include recurrent genital lesions, exposure to a partner with genital herpes, reporting ten or more lifetime partners, or lesions with a negative HSV PCR or culture, for example (Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources 2021) b The age range for YMSM are typically defined as those aged 13–24 (Halkitis et al. 2015) c Examples of high-risk sexual behavior include but are not limited to: multiple sexual partners, non-mutual monogamy, lack of barrier protection, sex while under the influence of substances, exchanging sex for money, drugs, goods, or safety, MSM on PrEP, or HIV infection (Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources 2021; Holden et al. 2008) a

Table 1.20  Evaluation of genital lesions Painful genital lesions Ulcers present Chancroid (Haemophilus ducreyi)

a

Ulcers or vesicles present Herpes Simplex 1 or 2

Painless genital lesions Painful lymphadenopathy Lymphogranuloma Venereum (C. trachomatis, serovars L1-L3)

Painless lymphadenopathy Single primary One or more primary lesion: lesions: Syphilisa Granuloma Inguinale (K. granulomatis) -orCondyloma Acuminatum (HPV)

Can also present as painful lesions or as multiple lesions (Towns et al. 2016)

 pdated STI Treatment Guidelines: U Quick Reference The following information is derived from the updated 2021 CDC Sexually Transmitted Infections Treatment guidelines that includes key changes in the treatment of several conditions including gonorrhea, chlamydia, and PID. Commonly used treatment options for STIs are in the Tables 1.21 and 1.22 (Centers for Disease Control and Prevention 2021; Workowski et al. 2021; Holland-Hall 2022), but the complete guidelines are available online at: https://www.

cdc.gov/std/treatment-­g uidelines/default.htm. The website also includes more complete alternative treatment options and recommendations on re-screening or for tests of cure.

Evaluation of Vaginal Discharge Vaginal discharge can be a common symptom in both STI-related and non-STI related vaginitis. The discharge may be accompanied by itching, burning, or odor, and a full sexual history should be obtained in all chief complaints of vag-

1  Update in Adolescent Medicine

Fig. 1.2  Algorithm to diagnose a genital lesion Table 1.21  Summary of treatment guidelines for common STI 2021 CDC STI guideline summary (Centers for Disease Control and Prevention 2021; Workowski et al. 2021; Holland-Hall 2022) Chlamydia trachomatis Doxycycline 100 mg PO BID × 7 days Neisseria gonorrhoeae Ceftriaxone 500 mg IM (150 kg) Epididymitis Ceftriaxone 500 mg IM × 1 (or 1000 mg if >150 kg) AND Doxycycline 100 mg PO BID × 10 daysa Pelvic inflammatory disease Ceftriaxone 500 mg IM × 1 (or 1000 mg if >150 kg) AND Doxycycline 100 mg PO BID × 14 days AND Metronidazole 500 mg PO × 14 days Trichomonas vaginalis For males: Metronidazole 2 g PO × 1 For females: Metronidazole 500 mg PO BID × 7 days PO by mouth, mg milligrams, IM intramuscular, BID twice a day a In men who practice insertive anal sex, levofloxacin 500 mg daily × 10 days should be used in lieu of doxycycline

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Table 1.22  Summary of treatment guidelines for other STIs and sexually associated infections 2021 CDC guidelines (Centers for Disease Control and Prevention 2021; Workowski et al. 2021; Holland-Hall 2022) Syphilis Earlya: penicillin G benzathine 2.4 million units IM × 1 Late Latentb: penicillin G benzathine 2.4 million units IM once weekly × 3 weeks Mycoplasma genitalium Macrolide sensitive: Doxycycline 100 mg PO BID × 7 days FOLLOWED BY Azithromycin 1 gm PO × 1 day, then 500 mg PO daily × 3 days Macrolide resistantc: Doxycycline 100 mg PO BID × 7 days FOLLOWED BY Moxifloxacin 400 mg PO daily × 7 days Treatment of female sexual assault survivors Ceftriaxone 500 mg IM × 1 (or 1000 mg if >150 kg) AND Doxycycline 100 mg PO BID × 7 days AND Metronidazole 500 mg PO × 7 days Consider Emergency Contraception, Postexposure Hepatitis B vaccination, HPV vaccination, HIV Postexposure Prophylaxis based on risk factors Treatment of male sexual assault survivors Ceftriaxone 500 mg IM × 1 (or 1000 mg if >150 kg) AND Doxycycline 100 mg PO BID × 7 days Consider Postexposure Hepatitis B vaccination, HPV vaccination, HIV Postexposure Prophylaxis based on risk factors HSV—initial treatment Acyclovir 400 mg PO TID × 7–10 daysd OR Famciclovir 250 mg PO TID × 7–10 daysd OR Valacyclovir 1 gm PO BID × 7–10 daysd HSV—suppressive therapy Acyclovir 400 mg PO BID OR Valacyclovir 500–1000 mg daily HSV—episodic therapy Acyclovir 800 mg PO BID × 5 days OR Famciclovir 1000 mg PO BID × 1 day OR Valacyclovir 500 PO BID × 3 days Alternative regimens found on CDC website Bacterial vaginosis Metronidazole 500 mg PO BID × 7 days OR Metronidazole gel 0.75% one full applicator (5 g) intravaginally, daily × 5 days PO by mouth, mg milligrams, IM intramuscular, BID twice a day, TID three times a day Early syphilis includes primary, secondary, and early latent infections. Early Latent Syphilis: asymptomatic, acquired the infection or seroconversion within the last 12 months b Late Latent Syphilis: asymptomatic, with positive serological testing for greater than 12 months or unknown duration of time c Or if resistance testing is not available d Extend duration if healing is incomplete after 10 days of therapy a

1  Update in Adolescent Medicine

inal discharge. History should be accompanied by a physical exam and diagnostic testing as history alone can be misleading. Relevant history may include sexual practices, menstrual history, and vaginal hygiene habits. Common causes of vaginal discharge in adolescents include: • Physiologic leukorrhea, which can appear as a thin, clear to milky, odorless discharge, and can present as a normal finding during puberty and at various points of the menstrual cycle. • Bacterial vaginosis (BV) is caused by an overgrowth of anaerobic bacteria including Gardnerella vaginalis. Findings include a foul “fishy” odor and gray appearing discharge and the presence of clue cells under microscopy. • Trichomonas vaginalis (TV), when symptomatic, is characterized by often copious, green-yellow, and malodorous discharge. Motile trichomonads are visible under microscopy with a basic pH of the fluid. • Cervicitis due to GC, CT, or Mycoplasma genitalium may cause possible green or yellow discharge with microscopy revealing sheets of white blood cells. • Candidiasis often results in thick, curd-like vaginal discharge without odor. Accompany symptoms including itching, skin irritation, and burning. A microscopy preparation with KOH will show budding yeast, pseudohyphae, or blastospheres.

Safe Sex Practices and Prevention Healthcare providers can encourage teens to engage in low-risk sexual behaviors, thereby lowering their risk for acquiring STIs. Characteristics of commonly used contraceptive methods are shared in Table  1.23. Of note, it is important to educate patients that starting contraceptive methods can be useful for preventing pregnancy, but some contraceptive methods alone (such as hormonal birth control) cannot prevent STIs. Some methods of lowering STI risk include:

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• • • •

Practicing abstinence Regular STI testing and screening Reducing number of sex partners Using barrier protection—effective with consistent and correct use –– External condoms –– Internal condom –– Dental dams—alternatives to formal dental dams include plastic wrap, gloves, and condoms (How to use a dental dam as a barrier for oral sex 2016) • Not sharing sex toys—if insertive toys are shared, a new condom should be used with each partner and if moving from the anus to the vagina These practices can be bolstered with education from a healthcare professional regarding STIs and STI transmission. If a teen endorses using a barrier method for protection, the provider should ensure the method is being used correctly to ensure efficacy. Teens can also educate themselves on STIs and infection prevention on publicly available forums such as the STD section on the CDC website (https://www.cdc.gov/std/prevention/default.htm) (How You Can Prevent Sexually Transmitted Diseases 2022).

 ips on External Condom Use (Male T (External) Condom Use 2022) 1. Check expiration date of condom 2. Do not use teeth or scissors to open condom package or wrapper 3. Do not reuse condoms 4. Do not use oil-based lubricants (cooking oil, petroleum jelly) as they break down condoms; water-based lubricants are safe to use 5. Store condoms in cool, dry place away from direct sunlight (not in wallet or car console) 6. When applying condom: ensure tip is right-­ side out with rim on outside, unroll condom to the base. 7. If condom is accidentally applied inside out, throw it away and use a new condom

Progestin-only methods

Contraception category Combined hormonal contraceptives (estrogen + progestin)

12 months from diagnosis). First-line management of ITP in non-bleeding children is observation of symptoms with reassessment of platelet count. If a rapid (24–48  h) increase in platelet count is desired to prevent the low (90% (Rogers et  al. 2004; Cushing et  al. 2004). Treatment of higher stage testicular disease in adolescents (>15 years) typically follows an adult treatment approach involving RPLND, risk stratification on the basis of histology, postoperative tumor markers, measure of serum LDH, and cisplatin-­ based chemotherapy with weekly bleomycin (termed BEP) (Williams et al. 1987). The combination of carboplatin, etoposide, and bleomycin, as a means by which to limit platinum exposure and lessen ototoxicity, has been studied in the UK; outcomes using this regimen were comparable to cisplatin-based therapies (Mann et  al. 2000). The ongoing COG AGCT1531 trial is the first randomized prospec-

648

tive head-to-head trial to assess the equivalency of cisplatin to carboplatin in maintaining outcomes while mitigating toxicity for patients with standard risk disease (patients for whom event free survival is anticipated greater than 80%). For patients with high-­risk disease, COG AGCT1532 is currently evaluating the impact of compressed BEP (i.e. delivered every two weeks compared with standard three-week BEP on survival. The successful treatment of extragonadal disease is highly dependent upon patient age and disease location. Patients with stage I or II disease can achieve a 90% OS while those with stage III or IV disease can achieve an 80% OS.  As noted, patients >11  years of age with mediastinal disease have a worse outcome with less than 60% OS (Bokemeyer et al. 2002).

Liver Tumors

N. Shrivastava and A. F. O’Neill

Hepatitis B or C infection, the former less common since institution of widespread vaccination programs, and other more rare hereditary syndromes predisposing to underlying liver dysfunction (e.g., glycogen storage disease, biliary atresia, alpha-1-antitrypsin deficiency, etc.) (Tajiri et  al. 2011; Bhadri et  al. 2005; Labrune et al. 1997). The vast majority of pediatric HCC cases occur de novo in an otherwise healthy liver.

Presenting Symptoms Pediatric patients with HB or HCC typically present with an enlarged abdomen and a palpable abdominal mass. Vital sign changes may include tachypnea secondary to restrictive lung indices or hypertension secondary to pain. Younger children may demonstrate irritability in excess of baseline. Similar to malignant GCTs, HB and up to 2/3rds of HCCs secrete AFP.  Clinicians must again be cognizant that in a child 90, or round to nearest 10, 25, 50, 75, or 90 %ile

Systolic Blood Pressure (mm Hg) Systolic Blood Pressure percentile3

Provide range (1000  ng/ml), elevated transaminases, hypertriglyceridemia, hypofibrinogemia, elevated lactate dehydrogenase (LDH), elevated d-dimers, fand evidence of hemophagocytosis on bone marrow aspirate (positive only in 60%) (Minoia et  al. 2014). Although the ESR decreases, the C-reactive protein level continues to increase in worsening MAS (Petty et al. 2020). Elevated markers of T cell activation, including soluble IL-2 receptor alpha chain and soluble CD163, have good sensitivity. They are helpful in detecting subclinical disease and following response to treatment (Bleesing et  al. 2007); however, they are challenging to access given that are only performed in specialized laboratories. MAS must be considered in patients with prolonged fever, defined as a single illness in which duration of fever exceeds that expected for the clinical diagnosis (e.g. >10 days for a viral URI) (Long 2005). The most common rheumatic causes of prolonged fever are KD, sJIA, systemic lupus erythematosus (SLE) and acute rheumatic fever (ARF). Early recognition and treatment of MAS is critical because the presentation is often acute and may be severe with rapid development of multiorgan failure that requires the admission of the patient to the intensive care unit (Petty et al. 2020). In the context of a patient with prolonged fever, a rheumatic cause should be considered in the presence of the following: isolated fever >5 days in young infant (90% of patients. Bacterial throat swabs are repeatedly normal. Cervical lymphadenopathy occurs in 60–80% and aphthous stomatitis in 40%. However, the full triad only occurs in 25% (Tasher et  al. 2006). It is not uncommon for patients to also complain of headache, abdominal pain, nausea, vomiting, arthralgias, and myalgia. The classification criteria proposed by Gattorno et al. include at least seven out of eight of the following: pharyngotonsillitis, duration of episodes (3–6  days), cervical lymphadenitis, periodicity with the absence of diarrhea, chest pain, skin rash and arthritis. A proposed “diagnostic test” in PFAPA is the dramatic response to one dose of prednisone (1–2  mg/kg) given at the onset of the attack; a positive response is typically seen within a few hours. With prednisone therapy, the intervals between the attacks may shorten. Studying the efficacy of therapy in PFAPA is challenging given the lack of diagnostic criteria (leading to inclusion of patients in studies that do not have PFAPA) and the natural history to outgrow this condition. Response to prednisone therapy is likely complete in 80–90% (Ter Haar et  al. 2013), occasionally a second dose is required 24  h later. Tonsillectomy (with or without adenoidectomy) is curative in the majority of patients with a meta-­analysis showing complete resolution in 83% (95% confidence interval, 77–89%) (Garavello et  al. 2011). Tonsillectomy is an option for those needing frequent dosing of corticosteroids or those patients with a marked negative impact on quality of life. A Cochrane review on the use of tonsillectomy for PFAPA concluded, based on two small trials, significant beneficial effects of surgery

R. A. Berard and R. M. Laxer

716

compared to no surgery on immediate and complete symptom resolution (number needed to benefit = 2) and a substantial reduction in the frequency and severity (length of episode) of any further symptoms experienced. Parents and caregivers of children with PFAPA syndrome must weigh the risks and consequences of surgery against the alternative of using medications. It is uncertain whether adenoidectomy combined with tonsillectomy adds any additional benefit to tonsillectomy alone (Burton et al. 2019). Although there is no known risk for the development of amyloidosis or other long-term sequelae, this relatively common AID has significant morbidity, including absence at school/daycare, work days missed for parents/other caregivers, and frequent clinical symptoms. Morbidity is one of the main reasons for treatment. The frequency and severity of attacks tends to decrease with time and most will outgrow this condition during the second decade of life.

Choosing Wisely in Pediatric Rheumatology In 2022, the Canadian Rheumatology Association Pediatric Committee joined the national Choosing Wisely Canada campaign to develop a list of tests and treatments with evidence that they may not add value or be harmful to clinical management. Pediatric rheumatology providers can play a key role in improving healthcare quality and delivery by identifying and addressing areas of overuse in practice. The Choosing Wisely list and summary paragraph for the “Seven Tests and Treatments to Question in Pediatric Rheumatology.” are ­available on the Choosing Wisely Canada website https://choosingwiselycanada.org/recommendation/rheumatology/#pediatric-­r heumatology (Table 27.5). These recommendations are intended to provide guidance to pediatric rheumatology providers, pediatricians, and other practitioners who

Table 27.5  Seven Tests and Treatments to Question in Pediatric Rheumatology  1.  Do not order ANA as a screening test without specific signs or symptoms of a rheumatic condition.  2. Do not order labs for drug toxicity monitoring (i.e. CBC, liver enzymes, creatinine) more often than every 12 weeks for patients on a stable dose of non-biologic DMARDs.  3.  Do not order HLA-B27 unless spondyloarthropathy is suspected based on clinical signs or symptoms.  4.  Do not order RF or anti-CCP in patients with arthralgia but no arthritis on exam.  5. Do not order Lyme disease serology as an explanation for musculoskeletal symptoms without an exposure history and exam findings.  6. Do not use intra-articular corticosteroid injections as a treatment approach for a large number of joints or joints that have been injected multiple times.  7. Do not order a periodic fever genetic panel in patients with a classic presentation of PFAPA syndrome without features concerning for other genetic periodic fever syndromes. Reproduced with permission from https://choosingwiselycanada.org/recommendation/rheumatology/#pediatricrheumatology ANA anti-nuclear antibody, DMARDs disease modifying antirheumatic drugs, RF rheumatoid factor, anti-CCP anticitrullinated protein, PFAPA periodic fever, aphthous stomatitis, pharyngitis, adenitis

27  Update in Pediatric Rheumatology

evaluate children with suspected rheumatic conditions, the most common of which is juvenile idiopathic arthritis (JIA). The goal of these recommendations is to encourage meaningful conversation among physicians and patients about high-value and quality care.

Summary There have been significant advances in our understanding of the etiopathogenesis for many of the rheumatic diseases, with ensuring impressive additions to the armamentarium of treatment options for rheumatic disease. Particularly for JIA, treating to remission of disease is an achievable target and ultimately finding a cure for the disease is at the forefront of research agendas. The major objectives for the pediatric rheumatology community are to increase awareness of the relatively uncommon pediatric rheumatic conditions and to educate and empower community practitioners with skills to confidently assess MSK complaints and appropriately triage referrals to specialist care when needed. Certainly in JIA, earlier referral and treatment has been linked to improved outcomes in terms of disease control and quality of life. With increasing awareness of the AIDs, previously undiagnosed children have been identified and now receive care. There still exist a delay in time to referral to specialist care and shortening this gap has the potential to reduce morbidity and potentially improve outcomes overall. Encouraging thoughtful discussion amongst care providers and patients/caregivers of appropriate use of tests and treatments is imperative for the delivery of high-value and quality care to patients suspected of having rheumatic disease.

References Angeles-Han ST, et  al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the screening, monitoring, and treatment of juvenile idiopathic arthritis-associated Uveitis. Arthritis Care Res (Hoboken). 2019;71(6):703–16. https://doi. org/10.1002/acr.23871.

717 Behrens EM, Beukelman T, Paessler M, Cron RQ. Occult macrophage activation syndrome in patients with systemic juvenile idiopathic arthritis. J Rheumatol. 2007;34:1133–8. Ben-Chetrit E, Touitou I. Familial Mediterranean fever in the world. Arthritis Rheum. 2009;61:1447–53. https:// doi.org/10.1002/art.24458. Bleesing J, et  al. The diagnostic significance of soluble CD163 and soluble interleukin-2 receptor alpha-chain in macrophage activation syndrome and untreated new-onset systemic juvenile idiopathic arthritis. Arthritis Rheum. 2007;56:965–71. https://doi. org/10.1002/art.22416. Burton MJ, Pollard AJ, Ramsden JD, Chong LY, Venekamp RP.  Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA). Cochrane Database Syst Rev. 2019;12(12):CD008669. https://doi. org/10.1002/14651858.CD008669.pub3. Cacchio A, De Blasis E, Necozione S, di Orio F, Santilli V.  Mirror therapy for chronic complex regional pain syndrome type 1 and stroke. N Engl J Med. 2009;361:634–6. https://doi.org/10.1056/ NEJMc0902799. Cassidy J, et  al. Ophthalmologic examinations in children with juvenile rheumatoid arthritis. Pediatrics. 2006;117:1843–5. https://doi.org/10.1542/ peds.2006-­0421. Cochard M, et  al. PFAPA syndrome is not a sporadic disease. Rheumatology. 2010;49:1984–7. https://doi. org/10.1093/rheumatology/keq187. Doherty M, Dacre J, Dieppe P, Snaith M.  The ‘GALS’ locomotor screen. Ann Rheum Dis. 1992;51:1165–9. Foster HE, Jandial S. pGALS—paediatric gait arms legs and spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol Online J. 2013;11:44. https://doi.org/10.1186/1546-­0096-­11-­44. Foster HE, Kay LJ, Friswell M, Coady D, Myers A.  Musculoskeletal screening examination (pGALS) for school-age children based on the adult GALS screen. Arthritis Rheum. 2006;55:709–16. https://doi. org/10.1002/art.22230. Foster H, Rapley T, May C.  Juvenile idiopathic arthritis: improved outcome requires improved access to care. Rheumatology. 2010;49:401–3. https://doi. org/10.1093/rheumatology/kep347. Garavello W, et al. Tonsillectomy in children with periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. J Pediatr. 2011;159:138–42. https://doi. org/10.1016/j.jpeds.2010.12.014. Gattorno M, et al. Eurofever Registry and the Paediatric Rheumatology International Trials Organisation (PRINTO). Classification criteria for autoinflammatory recurrent fevers. Ann Rheum Dis. 2019;78(8):1025–32. https://doi.org/10.1136/ annrheumdis-­2019-­215048. Goff I, Rowan A, Bateman BJ, Foster HE.  Poor sensitivity of musculoskeletal history in children. Arch Dis Child. 2012;97:644–6. https://doi.org/10.1136/ archdischild-­2011-­300853.

718 Gunz AC, Canizares M, Mackay C, Badley EM. Magnitude of impact and healthcare use for musculoskeletal disorders in the paediatric: a populationbased study. BMC Musculoskelet Disord. 2012;13:98. https://doi.org/10.1186/1471-­2474-­13-­98. Guzman J, et  al. ReACCh-Out investigators. The outcomes of juvenile idiopathic arthritis in children managed with contemporary treatments: results from the ReACCh-Out cohort. Ann Rheum Dis. 2015;74(10):1854–60. https://doi.org/10.1136/ annrheumdis-­2014-­205372. Haines KA.  The approach to the child with joint complaints. Pediatr Clin N Am. 2018;65(4):623–38. https://doi.org/10.1016/j.pcl.2018.03.003. Hayward K, Wallace CA.  Recent developments in anti-­ rheumatic drugs in pediatrics: treatment of juvenile idiopathic arthritis. Arthritis Res Ther. 2009;11:216. https://doi.org/10.1186/ar2619. Henderson LA, et al. American College of Rheumatology Clinical Guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19: Version 3. Arthritis Rheumatol. 2022;74(4):e1–e20. https://doi. org/10.1002/art.42062. Jandial S, Myers A, Wise E, Foster HE.  Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. J Pediatr. 2009;154:267–71. https://doi.org/10.1016/j. jpeds.2008.08.013. Long SS.  Distinguishing among prolonged, recurrent, and periodic fever syndromes: approach of a pediatric infectious diseases subspecialist. Pediatr Clin N Am. 2005;52:811–35. https://doi.org/10.1016/j. pcl.2005.02.007. Lovell DJ, et  al. Measuring process of arthritis care: a proposed set of quality measures for the process of care in juvenile idiopathic arthritis. Arthritis Care Res. 2011;63:10–6. https://doi.org/10.1002/acr.20348. Minden K, et al. Time of disease-modifying antirheumatic drug start in juvenile idiopathic arthritis and the likelihood of a drug-free remission in young adulthood. Arthritis Care Res (Hoboken). 2019;71(4):471–81. https://doi.org/10.1002/acr.23709. Minoia F, et al. Clinical features, treatment, and outcome of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis: a multinational, multicenter study of 362 patients. Arthritis Rheumatol. 2014;66:3160–9. https://doi.org/10.1002/art.38802. Myers A, et al. More ‘cries from the joints’: assessment of the musculoskeletal system is poorly documented in routine paediatric clerking. Rheumatology. 2004;43:1045– 9. https://doi.org/10.1093/rheumatology/keh245. Oen K. Long-term outcomes and predictors of outcomes for patients with juvenile idiopathic arthritis. Best Pract Res Clin Rheumatol. 2002;16:347–60.

R. A. Berard and R. M. Laxer Padeh S, et  al. Familial Mediterranean fever in children presenting with attacks of fever alone. J Rheumatol. 2010;37:865–9. https://doi.org/10.3899/ jrheum.090687. Petty RE, et  al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol. 2004;31:390–2. Petty R, Laxer R, Lindsey C, Wedderburn L, Fulbrigge R, Mellins E. Textbook of pediatric rheumatology. 8th ed. Amsterdam: Elsevier; 2020. Philpott JF, Houghton K, Luke A.  Physical activity recommendations for children with specific chronic health conditions: juvenile idiopathic arthritis, hemophilia, asthma, and cystic fibrosis. Clin J Sport Med. 2010;20(3):167–72. https://doi.org/10.1097/ JSM.0b013e3181d2eddd. Ravelli A, et  al. Classification criteria for macrophage activation syndrome complicating systemic juvenile idiopathic arthritis: A European League Against Rheumatism/American College of Rheumatology/ Paediatric Rheumatology International Trials Organisation Collaboration. Arthritis Rheum. 2016;68(3):566–76. Ravelli A, Consolaro A, Horneff G, Laxer RM, Lovell DJ, Wulffraat NM, Akikusa JD, Al-Mayouf SM, Antón J, Avcin T, Berard RA, Beresford MW, Burgos-Vargas R, Cimaz R, De Benedetti F, Demirkaya E, Foell D, Itoh Y, Lahdenne P, Morgan EM, Quartier P, Ruperto N, Russo R, Saad-Magalhães C, Sawhney S, Scott C, Shenoi S, Swart JF, Uziel Y, Vastert SJ, Smolen JS.  Treating juvenile idiopathic arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2018;77(6):819–28. https://doi. org/10.1136/annrheumdis-­2018-­213030. Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P.  Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics. 2005;115:e152–62. https://doi. org/10.1542/peds.2004-­0682. Siegal S. Benign paroxysmal peritonitis. Gastroenterology. 1949;12:234–47. Smith N, et  al. Paediatric musculoskeletal matters (pmm)—collaborative development of an online evidence based interactive learning tool and information resource for education in paediatric musculoskeletal medicine. Pediatr Rheumatol Online J. 2016;14:1. https://doi.org/10.1186/s12969-­015-­0062-­4. Tasher D, Somekh E, Dalal I. PFAPA syndrome: new clinical aspects disclosed. Arch Dis Child. 2006;91:981– 4. https://doi.org/10.1136/adc.2005.084731. Ter Haar N, et  al. Treatment of autoinflammatory diseases: results from the Eurofever Registry and a literature review. Ann Rheum Dis. 2013;72:678–85. https:// doi.org/10.1136/annrheumdis-­2011-­201268.

27  Update in Pediatric Rheumatology Tsoukas P, Laxer RM. Follow the complex bread crumbs: a review of autoinflammation for the general paediatrician. Paediatr Child Health. 2020;25(5):279–85. https://doi.org/10.1093/pch/pxz072. Uziel Y, Chapnick G, Jaber L, Nemet D, Hashkes PJ.  Five-­ year outcome of children with “growing pains”: correlations with pain threshold. J

719 Pediatr. 2010;156:838–40. https://doi.org/10.1016/j. jpeds.2009.11.078. Yalcinkaya F, et  al. A new set of criteria for the diagnosis of familial Mediterranean fever in childhood. Rheumatology. 2009;48:395–8. https://doi. org/10.1093/rheumatology/ken509.

Index

A Abdominal injury, 121 Abdominal trauma, 130, 338 history, 131 medical testing, 131, 132 physical examination, 131 red flags, 130 Abusive head trauma (AHT), 125 Acceleration-deceleration, 127 Acetaminophen, 155 Acute acetaminophen (APAP) toxicity, 404 Acute hematogenous osteomyelitis (AHO) bacterial etiology, 465 diagnostic testing, 465 laboratory analysis, 465 microbiologic etiology, 465 oral antibiotic therapy, 466 overview, 464 serial monitoring, 466 treatment duration, 466 Acute kidney injury (AKI) definition, 532, 533 epidemiology, 534 etiology, 534 indication and timings, 535 overview, 532 prevention and treatment, 534 prognosis, 535 Acute lung injury (ALI), 158 Acute lymphoblastic leukemia (ALL) B and T cell lineages, 605, 606 bortezomib, 618 childhood ALL, 611 CNS-directed therapy, 613 HSCT, 613 risk-adapted therapy, 612 clinical features, 606 clofarabine, 619 demographic features, 607 early response to therapy, 607 frontline treatment, 619, 620 genetic features, 608 BCR-ABL1 gene fusion, 610

BCR-ABL1 translocation, 610 ETV6-RUNX1 gene fusion, 609 genetics of T-ALL, 611 genomic profile, 610 hyperdiploidy, 609 hypodiploid, 609 iAMP21, 610 KMT2A translocations, 610 structural alterations, 609 TCF3 translocations, 610 immunophenotype, 605 immunotherapy, 614 bispecific antibody approach, 614 blinatumomab, 614 calecheamicin, 615 CAR T cell therapy, 615–617 ICANS, 617 inotuzumab, 615 tisagenlecleucel, 616 intensification of therapy, 608 MRD assessment of response to therapy, 607 nelarabine, 619 precision medicine therapies, 617, 618 Acute pain, 299 Acute pancreatitis, 418 Acute respiratory distress syndrome (ARDS), 158, 159, 165 Acute viral bronchiolitis cardiorespiratory, 450 high-flow nasal canula (HFNC), 449 management, 449 overview, 449 post-hospitalization follow-up, 450 pulse oximetry monitoring, 450 Adolescence, 3 adult healthcare, transitioning to, 48 family readiness, 49 provider readiness, 48, 49 youth readiness, 50 beginning of, 4 eating disorders Diagnostic and Statistical Manual of Mental Disorders, 14–15

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Beckwith (ed.), Update in Pediatrics, https://doi.org/10.1007/978-3-031-41542-5

721

722 Adolescence (Cont.) diagnostic clarification, 15 initial medical evaluation recommendations, 17–18 mental and physical health comorbidities, 13 mental health provider, interdisciplinary team of, 16 mortality and morbidity, 13 of sexes and cultural, 12 screening tools, 18–19 spectrum of, 16 treatment options, 16 end point of, 4 physical and psychosocial events, three phases of, 4, 5 psychosocial and risk behavior assessment, 6 additional interview tips, 8 breaking confidentiality, 8, 9, 11 caregivers, interacting with, 7 indications for use, 6 order of topics, 6 psychosocial assessment, navigating, 7 sexual health, 40 dysmenorrhea, 44 female-bodied reproductive health, 42, 43 male-bodied reproductive health, 41 menstrual cycle irregularities, 43, 44 polycystic ovarian syndrome, 44–46 premenstrual dysphoric disorder, 45–47 sexually transmitted infections, 31 assessing STI risk, 31 multiple national medical organizations, 32–34 safe sex practices and prevention, 37 STI-related consent and confidentiality, 31 treatment guidelines, 34–36 vaginal discharge, evaluation of, 34, 35, 37 starting point of, 3 substance use, 24 alcohol, 30 inhalant use, 30 marijuana, 29 nicotine and tobacco use, 29 prescribing controlled substances, 30 referral to treatment, 27–29 SBIRT, 25, 26 technology and social media changing technological landscape, 19, 20 electronic health record privacy, 22, 23 emerging social media risks, 23, 24 medical and developmental health concerns, 20 mental, emotional and social challenges, 20, 22 Adrenal insufficiency (AI) ACTH levels, 347 ACTH stimulation testing, 346 biochemical profile, 346 congenital hypopituitarism, 346 cortisol levels, 347 etiology, 345 fludrocortisone treatment, 347 glucocorticoid dosing and regimes, 347 hypoglycemia, 346

Index intermittent stress, 348 milder stress, 348 overview, 345 salt craving, 346 symptoms, 345 treatment, 347 Adrenocortical carcinoma (ACC), 651 Adult healthcare, transitioning to, 48 family readiness, 49 provider readiness, 48, 49 youth readiness, 50 Advanced Trauma Life Support (ATLS) program, 332 Aggressive hyperventilation, 328 Agitation, 154, 155 Air entrapment, 327 Airway, 307, 308 traumatic injuries, 332, 333 Alanine aminotransferase (ALT) concentration, 413 Alcohol, 30, 258 Allergen immunotherapy (AIT), 63 Allergic rhinitis, 67 diagnosis, 67, 68 management, 67–69 pathophysiology and clinical presentation, 67 Alpha2-agonists, 155 Alprolix®, 438 American Society of Parenteral and Enteral Nutrition (A.S.P.E.N), 387 Aminosalicylates (ASAs), 386 Anaphylaxis, 69 diagnosis, 70 pathophysiology and clinical presentation, 70 prevention and management, 71 Anticoagulation therapy, 439 Anxiety, 265–267 diagnosis, 678 heritability, 679 OCD, 680 prevalence, 678 treatment, 679 Aortic root dilation, 95 Aortic size index (ASI), 95 Aplastic anemia in children, 442 inherited and acquired causes, 442 management of, 442 pathophysiology of, 442 Applied behavioural analysis (ABA), 274 Areolas, 42 Arthritis Medication Choice Cards, 708 Assisted reproductive techniques (ART), 570 Associazione Italiana di Ematologie Pediatrica (AIEOP), 608 Atopic dermatitis (AD), 64 diagnosis, 64 management, 64–66 pathophysiology and clinical presentation, 64 Atrial septal defect (ASD), 81 Attention deficit hyperactivity disorder (ADHD), 262, 264, 265 clinical presentation, 674

Index diagnosis, 672 prevalence, 672 treatment, 673 Autism Diagnostic Interview-Revised (ADI-R), 260 Autism Diagnostic Observation Schedule 2nd edition (ADOS-2), 260 Autism spectrum disorder (ASD), 253, 254 actual prevalence, 254 assessment/evaluation, 259 diagnostic tools, 260 screening tools for, 259, 260 causes, 254 epigenetic factors, 255 genetics, 254 risk factors, 257–259 comorbidities, 263, 264 anxiety, 265–267 attention deficit hyperactivity disorder, 264, 265 developmental coordination disorder/dyspraxia, 270 eating disorder, 271, 272 emotional dysregulation, 267–268 epilepsy, 268 gastrointestinal disorders, 268 gender identity, 272, 273 intellectual disability, 271 obsessive-compulsive disorder, 271 sleep disturbances, treatment for, 269 sleep problems, 268, 269 tics and Tourette syndrome, 270 differential diagnosis and co-occurring diagnosis, 261–263 etiopathogenesis, 253 investigations, 261 physical examination, 261 spectrum diagnosis and long-term outcomes, 263 treatment, 273 behavioural approaches, 274 biomedical Interventions, 274 complementary and alternative medical, 275 spectrum disorders, 273 true increase in, 254 Autoimmune hepatitis (AIH), 404 Autoimmune lymphoproliferative syndrome (ALPS), 441 curative therapy, 442 diagnostic criteria, 441 management of, 441 Autoinflammatory disease (AID), 713 Autosomal dominant polycystic kidney disease (ADPKD), 539 Avoidant/restrictive food intake disorder (ARFID), 671–672 B Bacterial vaginosis (BV), 37 Bag mask ventilation (BMV), 308 Balanced blood resuscitation, 334 Basic Life Support courses, 171 Beck depression inventory (BDI), 689

723 Benign epilepsy with centro temporal spikes (BECTS), 592 diagnosis, 592 prognosis, 592 seizures, 592 treatment, 592 Benign familial infantile seizures (BFIS), 585 Benign familial neonatal-infantile seizures (BFNIS), 585 Benign familial neonatal seizures (BFNS), 584 Benign neonatal sleep myoclonus (BNSM), 599 Benign variants, 41 Biodevelopmental framework, 185 Bioinformatics, pediatric critical care, 151, 152 Bipolar disorder, 681 diagnosis, 681 mood dysregulation, 682 prevalence, 680 safety, 682 treatment, 682 Blended learning model, 171 Blood flow, 314 Brain circuitry, serve and return interaction, 185 Breast feeding, 375 benefits, 555 contraindications, 554–555 supplements, 555 Breast milk, 390 Breasts, 42 Breathing, traumatic injuries, 333, 334 Brief resolved unexplained event (BRUE) AAP guidelines, 459 clinical practice guidelines, 458 definition, 458 initial evaluation, 459 risk assessment and outcomes, 458 subspecialist consultations, 459 Broad spectrum antibiotics, 319 Broad-spectrum antimicrobial therapy, 164 Burns, 132 differential diagnosis, 133 history, 133 medical testing, 134 physical examination, 133, 134 red flags, 133 C CAKUT, see Congenital anomalies of the kidney and urological tract (CAKUT) Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA), 685 Candidiasis, 37 Cannabidiol (CBD), 266 Cannabis, 258 Capnography, pediatric critical care, 150, 151 Cardiac channelopathies, 98 Cardiac computed tomography, cardiac imaging, 88, 89 Cardiac imaging, 86 cardiac computed tomography, 88, 89 CMRI, 87, 88 echocardiography, 86, 87

724 Cardiac magnetic resonance imaging (CMRD), cardiac imaging, 87, 88 Cardiology, cardiopulmonary resuscitation, 159–161 Cardiopulmonary arrest, 307 Cardiopulmonary resuscitation (CPR), 159–161, 309, 310 Carrier screening, 290 Catheter-associated blood stream infections (CLABSI), 168 Catheterization, 89 Celiac disease behaviors/family, 375 diagnosis, 375, 376 epidemiology, 375 genetics and risk factors, 375 HLA typing, 375 pathogenesis and immunology, 375 signs, 375 treatment, 376 Central line associated infections (CLABSI), 390 Cenzodiazepine, 155 Cervical lymphadenopathy, 715 Cervicitis, 37 Child-centred approach, 300 Childhood absence epilepsy (CAE), 592 absence seizures, 593 diagnosis, 593 first line therapy, 593 treatment, 593 Childhood Autism Rating scale-2nd edition (CARS-2), 260 Childhood hypertension diagnosis, 538 epidemiology, 538 organ damage, 539 overview, 538 treatment, 539 Child maltreatment, 111, 112 affect children, 113 clinical approach, 114 cause of findings, 117 documentation, 116, 117 history, 115, 116 physical examination, 116 commercial sexual exploitation of children, 140, 141 identifying maltreatment, 114 legal and clinical definitions, 113 neglect, 134, 135 physical abuse, 117, 118 abdominal trauma, 130–132 bruising, 118–121 burns, 132–134 differential diagnosis, 120 fractures, 122–125 head and spine injuries, 125–130 medical testing for bruising, 121 red flags, 119 sexual abuse and assault, 135, 136 discharge and follow-up, 140 documentation, 138, 139 emergency contraception, 140

Index forensic evidence collection, 139 history, 136, 137 interpretation of findings, 138 physical examination, 137 psychosocial support, 140 sexually transmitted infections, testing for, 139, 140 timing of examination, 136 terminology and definitions, 113, 114 Child Post Traumatic Symptom Disorder (PTSD) symptom scale (CPSS), 690 Children’s depression inventory (CDI), 689 Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), 299 Chlamydia trachomatis (CT), 32 Chromosomal karyotyping, 590 Chromosomal microarray (CMA), 285 Chronic kidney disease (CKD) classification, 536 definition, 536 GFR estimating formulas, 537 hypertension, 537 overview, 536 Chronic pain syndrome, 710 Chronic pancreatitis, 418 Cigarette smoking, 258 Circulation, traumatic injuries, 334 Clinical genetics clinicians and families, support and resources for, 293, 294 exome and genome sequencing, 286 genetic conditions, treatments for, 292–293 genetics referral, approach to, 290–292 genetic testing, 286, 287 gaps and recent advances in, 287, 288 interpretation of, 288–290 genetic variants and genetic testing, 285, 286 prenatal genetic testing, 290 Clostridioides difficile, 487 Coffin–Siris syndrome, 288 Cognitive behavioural therapy (CBT), 266 Columbia Suicide Severity Rating Scale, 12 Comments, social media, 24 Commercial sexual exploitation of children (CSEC), 140, 141 Compensated shock, 313 Complementary and alternative medical (CAM), 275 Congenital adrenal hyperplasia (CAH), 345, 346 Congenital anomalies of the kidney and urological tract (CAKUT), 523, 543 Congenital heart block (CHB), 86 Congenital heart disease (CHD), 79, 80 cardiac imaging, 86 cardiac computed tomography, 88, 89 CMRI, 87, 88 echocardiography, 86, 87 dyslipidemia, 98, 99 exercise in, 83, 84 fetal cardiology, 85, 86 genetic testing in, 90–96 DCM, 96, 97

Index genetic aortopathies, 91 hypertrophic cardiomyopathy, 96 LDS, 94, 95 Marfan syndrome, 91, 93, 94 sudden cardiac death and inherited arrhythmias, 97, 98 interventional cardiology, 89 atrial septal defect device closure, 89 patent ductus arteriosus occlusion, in premature infants, 90 pulmonary valve replacement, 89, 90 late outcomes, 80 neurodevelopmental outcomes, 80, 81 psychosocial outcomes and quality of life, 81–83 Continuous electroencephalogram (EEG) monitoring, pediatric critical care, 151, 152 Contraception methods, 38–39 Copy number variants (CNVs), 254 Cortical visual impairment (CVI), 262 Corticosteroids, 164 therapy, 319 Courses, podiatric critical care, 170 COVID-19 pandemic, 164–166, 712 acute flaccid myelitis (AFM), 491, 492 enterovirus D68 (EV-D68), 491 impact of, 495 prevention and control, 490 respiratory syncytial virus (RSV), 490 SARS-CoV-2 (see Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)) vaccine hesitancy, 496 COVID-19 pneumonia anticoagulation, 461 dexamethasone, 461 diagnostic evaluation, 460 discharge criteria, 462 immunomodulators, 461 laboratory monitoring, 462 overview, 459 remdesivir, 461 CRAFFT, 25 Critical illness, 161 Critical value, 150 Crushing, 127 Crying, 125 Cystic fibrosis transmembrane conductance regulator (CFTR), 417 Cytokine release syndrome (CRS), 165 D Deaminated gliadin peptide (DGP IgG), 375 Decompensated shock, 313 Deferasirox, 432 Deferiprone, 432 Defibrillation, 309 Delirium, 155, 156 Depression diagnosis, 675 prevalence, 674

725 safety, 677 SSRIs long term effects, 677 NSSI, 677 suicide related events, 677 suicide, 676 treatment, 676 in youth, 675 Desferrioxamine, 432 Developmental Coordination Disorder (DCD)/dyspraxia, 270 Developmental delays (DD), 261 Dexmedetomidine, 155 Diagnostic imaging, 335 Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) criteria, 25 Diffusion-weighted images (DWI), 565 Dilated cardiomyopathy (DCM), 96, 97 Direct eye trauma, 128 Disability, traumatic injuries, 335 Disruptive mood dysregulation disorder (DMDD), 671 Disseminated intravascular coagulation (DIC), 435 causes of, 435 diagnosis of, 436 ISTH DIC scoring system, 436 laboratory testing, 436 management of, 436 Diversity, equity, and inclusion (DEI), 172 Domestic violence, 112 Dopamine, 164 Dravet syndrome, 585, 588 Dupilumab, 65 Dyserythropoiesis, 432 Dyslipidemia, 98, 99 Dysmenorrhea, 44 Dyspareunia, 43 Dyspraxia, 270 E Early childhood period, 183 Early infantile epileptic encephalopathy (EIEE), 586 inheritance, 586 seizure semiology, 586 Early myoclonic encephalopathy (EME), 586 inheritance, 586 seizure semiology, 586 Early-onset sepsis (EOS), 560 Eating disorders, 271, 272 Diagnostic and Statistical Manual of Mental Disorders, 14–15 diagnostic clarification, 15 initial medical evaluation recommendations, 17–18 mental and physical health comorbidities, 13 mental health provider, interdisciplinary team of, 16 mortality and morbidity, 13 screening tools, 18–19 of sexes and cultural, 12 spectrum of, 16 treatment options, 16

Index

726 Eating Disorders Examination Questionnaire (EDO-Q), 690 Echocardiography, cardiac imaging, 86, 87 E-cigarette and vaping product use associated lung injury (EVALI), 159 Eculizumab, 531 Education neglect, 135 pediatric critical care courses, 170 electronic learning, 171 future directions in, 171 simulation, 170 Electroencephalogram (EEG), 565 Electronic health record privacy, 22, 23 Electronic learning (E-learning), 171 Eloctate®, 437 Eltrombopag, 435 Emergency contraception, 140 Emergency Department Pediatric Sepsis Screening tool, 316 Emergency medical services (EMS), 324 Emotional development, 189 Emotional dysregulation, 267–268 Emotional neglect, 134 Endomysial antibody (EMA), 375 Endoscopic retrograde cholangiopancreatography (ERCP), 393 Endoscopy, 391 colonoscopy, 393 ERCP, 393 future directions, 393 pediatric esophagogastroduodenoscopy (EGD), 391, 393 small intestine, 393 Environmental allergens, 64 Eosinophilic esophagitis (EoE), 62, 372 diet, 373 dilation, 374 drugs, 374 esophagogastroduodenoscopy, 376 management, 373 pathogenesis, 372 presentation, 373 systemic corticosteroids, 374 Epicutaneous (EPIT) immunotherapy, 63 Epigenetics, 184 Epilepsy, 268, 582 of early childhood, 587 acquired epileptic aphasia, 589 Dravet syndrome, 588 generalized epilepsy with FS plus (GEFS+), 587 Epilepsy syndromes, 584 autosomal dominant inheritance, 584 benign familial infantile seizures (BFIS), 585 benign familial neonatal-infantile seizures (BFNIS), 585 benign familial neonatal seizures (BFNS), 584 Epileptic encephalopathy CDKL5 gene, 589

early myoclonic encephalopathy, 586 EIEE, 586 inheritance, 586 seizure semiology, 586 etiologies of, 585 genetic technologies, 591 in infancy, 585 infantile spasms, 586, 587 investigations, 590 MMPSI, 586 school age child, 594 Lennox Gastaut syndrome, 594 targeted and selective genetic testing, 591 Epileptic seizures, 581 Epinephrine, 71 Epstein-Barr virus (EBV), 404, 410 ESCAPE trial, 537 Esophagogastroduodenoscopy (EGD), 391 foreign body ingestions, 391 upper gastrointestinal bleeding, 393 European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), 370 Evans syndrome, 435 Exclusive enteral nutrition (EEN), 385 Exercise, in CHD, 83, 84 Exome, 286 Exome sequencing (ES), 287 Exposure and temperature control, traumatic injuries, 335 Extra-corporeal membrane oxygenation (ECMO), 128 Extreme prematurity, 258 F Face, Legs, Cry, Consolability (FLACC) scale, 299 Faces Pain Scale (FPS-R), 300 Familial Mediterranean fever (FMF), 714 Familial Wilms tumors, 635 Febrile infant, neonatal sepsis bacteria, 482 cytomegalovirus (CMV), 484 diagnostic tools, 485 early-onset GBS disease, 482 enterovirus, 483 guidelines development, 486 herpes simplex virus (HSV)., 483 unnecessary care cost, 486 Febrile urinary tract infection (UTI) age 8 to 21 days old, 453 age 22-28 days, 455 age 29 to 60 days old, 456 antibiotic treatment, 452 clinical practice guidelines, 453 imaging, 451 overview, 451 procalcitonin, 457 time to discharge, 457 Feeds, social media, 24 Female-bodied reproductive health benign variants, 42 sexual satisfaction and sexual dysfunction, 43

Index Fentanyl, 301 Fetal Alcohol Spectrum Disorder (FASD), 262 Fetal arrhythmia, 86 Fetal cardiology, 85 fetal arrhythmia, 86 fetal cardiac intervention, 85, 86 Fetal echocardiography, 85, 86 Fine motor development, 190 Fluid Expansion as Supported Therapy (FEAST), 164 Fluid resuscitation, traumatic injuries, 334, 335 Focal epilepsy, 583 Focal segmental glomerulosclerosis (FSGS), 540 Focused cardiac ultrasound, 153 Follicle stimulating hormone (FSH), 353 Food allergy, 61 diagnosis, 62, 63 pathophysiology and clinical presentation, 61, 62 prevention and management, 63, 64 Fractures, 122 differential diagnosis, 122, 123 history, 123 medical testing, 124 physical examination, 123, 124 types and characteristics, 122 Functional GI Disorders (FGID) abdominal pain disorder, 379 constipation, 380 definitions, 376 disimpaction, 380 functional constipation (FC), 377 functional diarrhea, 377 functional nausea, 378, 379 irritable bowel syndrome (IBS), 379 neonate/toddler, 377 overview, 376 treatments, 376 vomiting, 378 G Gastroenteritis, 126 Gastroenterologists, 370 Gastroenterology/nutrition glycemic control, 162 indirect calorimetry, 162 nutritional guidelines, 161 stress ulcer prophylaxis, 161, 162 Gastroesophageal reflux disease (GERD) diagnostic considerations, 370–371 esophageal manifestations, 369 lifestyle modifications, 371 overview, 369 PPI therapy, 370 prokinetic agents, 371 reflux symptoms, 371 Gastrointestinal disorders, 268 Gender identity, 272, 273 Gene therapy, 438 Genetic aortopathies, 91 Genetic disorders, 262

727 Genetic heterogeneity, 585 Genetic testing clinical genetics, 285–287 gaps and recent advances in, 287, 288 pediatric cardiology, 90–93 DCM, 96, 97 genetic aortopathies, 91 HCM, 96 Loeys-Dietz syndrome, 94, 95 Marfan syndrome, 91, 93, 94 sudden cardiac death and inherited arrhythmias, 97, 98 Turner syndrome, 95, 96 Genetic variants, 285, 286 Genital lesions, 34 Genome sequencing (GS), 286, 287 Germ cell tumors, 646 biopsy, 646 core-needle biopsy, 646 epidemiology, 646 genetic predisposition, 646 histology, 646–647 Molecular Profile, 646–647 outcomes, 648 pathophysiology, 646 presenting symptoms, 646 staging, 647 treatment, 647–648 Germ Theory of Disease, 490 Gestational alloimmune liver disease (GALD), 404 Gestational diabetes, 257 Global Allergy and Asthma European Network (GA2LEN), 63 Glomerulonephritis (GN) in children, 529 clinical applications, 530 diagnosis, 530 epidemiology, 530 management, 531 overview, 528 prognosis, 531 Glucocorticoid (steroid)-resistant nephrotic syndrome, 540 Glycemic control, 162 Gonadotropin- releasing hormone agonists (GNRHa), 353 Gross motor development, 189 Groups, 24 Growth aromatase inhibitors, 353 childhood and adolescence, 348 children with growth failure, 350 clinical evaluation, 349 congenital hypopituitarism, 351 GNRHa, 353 hormone, 351, 352 in humans, 348 hypothalamic pathology, 351 short stature, 349 therapies to increase final adult height, 352

Index

728 Gut microbiome, 257 Gynecomastia, 41 H Head and spine injuries, 125, 126 differential diagnosis, 126–128 history, 128 medical testing, 129, 130 physical examination, 129 red flags, 126 Head injury, 121 Head trauma, 127 Head-to-toe evaluation, 116 Healthcare inequities pediatric critical care, 171, 172 Health-related skills and knowledge, 50 Hearing impairment, 262 Heavy menstrual bleeding, 44 HEEADDSSS assessment, 6 HEEADSSS assessment, 9–11 Hematology thromboprophylaxis, 163 transfusion strategies, 162, 163 Hematopoietic stem cell transplantation (HSCT), 613 Hemodynamic monitoring, 334 Hemophilia, 437 Hemorrhage traumatic injuries, 334, 335 Hemorrhagic shock, 334, 335 Hepatitis B immunoglobulin (HBIG), 408 Hepatitis-B birth-dose vaccine, 495 Hepatocellular carcinoma, 650 Hereditary cystic kidney disease, 542 Hereditary renal cystic disease, 541 Herpes Simples Virus (HSV), 34 High frequency oscillatory ventilation (HFOV), 159 Hirschsprung’s disease, 370 Human Immunodeficiency Virus (HIV), 33, 140 Human leukocyte antigen (HLA) class II gene, 375 Hydromorphone, 301 Hydroxyurea, 431 Hymen, 42 Hyperbilirubinemia adequate feeding, 467 discharge recommendations, 469 discontinuation phototherapy, 469 escalation of care, 469 intensive phototherapy, 468 jaundice, 468 overview, 467 prevention of, 467 reliable follow-up, 470 risk assessment and monitoring, 468 Hypercarbia, 161 Hyperglycemia, 158, 162 Hyperoxia, 160 Hypertrophic cardiomyopathy (HCM), 96 Hypocalcemia, 317 Hypocarbia, 161

Hypoglycaemia, 317 Hypopituitarism, 346 Hypotension, 161, 315 Hypoxia, 327, 337 Hypoxic Ischemic Encephalopathy (HIE), 564 Hypoxic-ischemic liver injury, 404 I Iatrogenic Withdrawal Syndrome (IWS), 155 Idelvion®, 438 Image defined risk factors (IDRFs), 633 Immune effector cell-associated neurotoxicity (ICANS), 617 Immune thrombocytopenia (ITP), 434 Immunizations, 259 Immunoglobulin E (IgE), 61 Implantable cardioverter-defibrillator (ICD), 88 Indirect calorimetry, 162 Infant development ages and stages developmental milestones baby at 1 month, 190–192 baby at 2 months, 193–195 baby at 3 months, 196–199 baby at 4 months, 200–203 baby at 5 months, 204–207 baby at 6 months, 208–211 baby at 7–9 months, 212–216 baby at 7–18 months, 212 baby at 10–12 months, 217, 219, 220 baby at 13 and 18 months, 221–223 first 6 months, 190 preschooler’s development at 36–48 months, 238 preschooler’s development between 36–48 months, 238–243 preschooler’s development between 48–60 months, 243–247 six areas of child development, 189 toddler’s development at 19–24 months, 225 toddler’s development at 25–36 months, 229 toddler’s development between 19 and 24 months, 225, 227–229 toddler’s development between 25 and 30 months, 229, 231–233 toddler’s development between 31 and 36 months, 234–236, 238 clinicians and practitioners, information change practice of, 249 early development, 247 infant mental health, 183 infants most at risk, 248, 249 serve and return interaction shapes brain circuitry, 185 social emotional development, 185, 186 social emotional milestones 0–3 months, 186 4–6 months, 186, 187 7–12 months, 187 13–18 months, 187, 188 19–24 months, 188

Index 25–36 months, 188, 189 toxic stress derails healthy development, 247, 248 Infant mental health, 183 Infectious disease/immunology COVID-19, 164–166 sepsis, 163, 164 Inflammatory bowel diseases (IBDs), 380 aminosalicylates, 386 biologic therapies, 386 clinical presentation, 381 corticosteroids, 385 diagnosis of, 383 EEN therapy, 385 endoscopy, 384 epidemiology, 381 etiology of, 381 evaluation, 383 extra-intestinal manifestations, 381 histology, 385 immunomodulators, 386 magnetic resonance enterography (MRE), 383 outcomes, 387 surgical management, 387 Video Capsule Endoscopy (VCE), 383 INFORM trial, 433 Inhalant use, 30 Inhaled nitric oxide, 159 Inherited arrhythmias, 97–98 In-hospital cardiac arrests (IHCA), 159 Intellectual development, 189 Intellectual disability (ID), 261, 271 Intensive care recovery, 169 Interfacility transport, pediatric patient, 323 paediatric transport service, definitions, 324, 325 preparation for, 326 airway and breathing considerations, 326, 327 circulatory considerations, 327, 328 disability and exposure considerations, 328 supplies and equipment, 328–330 team composition, 323, 324 transport mode, 325, 326 International Neuroblastoma Risk Group Staging System (INRGSS), 633 Intestinal rehab and short gut syndrome CLABSIs, 391 definition, 389 enteral nutrition, 390 management approach, 389 parenteral nutrition, 390 pathogenesis, 389 surgery, 391 transplantation, 391 Intrachromosomal amplification of chromosome 21 (iAMP21), 610 Intranasal corticosteroids (INCS), 68 Intravenous (IV) access, 164, 317 Intravenous opioids, 301 Intricate neural connections, 183 Intubation, equipment for, 307 Iron deficiency

729 anemia, 429, 431 in children, 430 diagnosis, 429 in toddlers, 430 Irritable bowel syndrome (IBS), 379 J Juvenile fibromyalgia, 710 Juvenile idiopathic arthritis (JIA), 706 bDMARDs, 707, 709 categories, 707 csDMARDs, 707, 709 NSAIDs, 707 treatment of, 706 Juvenile myoclonic epilepsy (JME), 594 diagnosis, 594 seizures, 594 treatment, 594 K Kawasaki disease (KD), 165 Ketamine, 303, 337 L Labia, 42 Language development, 189 Laryngeal-mask airway (LMA), 308 Lennox Gastaut syndrome (LGS) diagnosis, 594 seizure semiology, 594 treatment, 594 Leukotriene receptor antagonists (LTRA), 68 Li Fraumeni Syndrome, 643 Ligamentous laxity, 336 Liver tumors, 648–650 epidemiology, 648 genetic predisposition, 648 histology, 648–649 molecular profile, 648–649 outcomes, 649 pathophysiology, 648 presenting symptoms, 648 PRETEXT staging, 649 surgical staging, 649 survival rates, 650 treatment, 649, 650 Live-streaming, 24 Locus heterogeneity, 585 Loeys-Dietz syndrome, 94, 95 M Macrophage activation syndrome (MAS), 165, 711 Magnetic resonance urography, 526 Male-bodied reproductive health, 41, 42 Malnutrition, 387, 388 Marfan syndrome, 91, 93, 94

730 Marijuana, 29, 688 Massive transfusion protocols, 334 Master organ, 183 Mechanical ventilation, 165 Medical neglect, 135 Menstrual cycle irregularities, 43, 44 Mental health disorders, 262, 665, 666 Mental health provider, 16 Messaging/Chats, 24 Methicillin Resistant Staphylococcus aureus (MRSA), 466 Microarray technologies, 90 Midazolam, 303 Mild head injury, 337 Mild pain, 300 Mindful parenting, 267 Moderate-severe pain, 300–302 Modified Checklist for Autism in Toddlers, Revised with Follow-Up (m-CHAT-R/F), 572 Morphine, 301 Multicenter Growth Reference Study (MGRS), 349 Multiple intraluminal impedance (MII) probes, 370 Multiplex ligation-dependent probe amplification (MLPA), 285 Multisystem inflammatory syndrome, 165 Multisystem inflammatory syndrome in children (MIS-C), 165, 462 cardiac involvement, 463 case definitions, 462 diagnostic evaluation, 463 treatment, 464 Musculoskeletal pain, 710 Mycoplasma pneumoniae, 488 Myoclonic epilepsy with red ragged fibers (MERRF), 595 N Naloxone, 160 Near-infrared spectroscopy (NIRS), pediatric critical care, 149, 150 Neglect, 112, 134, 135 Neisseria gonorrhea, 32 Neonatal adaptation syndrome, 258 Neonatal cholestasis bile acid deficiency, 400 causes of, 401 diagnosis, 401 etiology, 400 hepatic and systemic effects, 400 hepatoportoenterostomy, 402 malnutrition, 402 management, 401 neonatal jaundice, 400 overview, 399 pathogenesis, 399 ursodeoxycholic acid, 402 Neonatal Infant Pain Scale (NIPS), 299 Neonatal problems, 559–569 hypoglycemia, 566

Index definition of, 566 dextrose gel, 567 hypoxic ischemic encephalopathy diagnosis, 564 emerging therapies, 566 pathophysiological features, 564 prognosis, 566 supportive management, 565 therapeutic hypothermia, 565 neonatal abstinence syndrome (NAS), 567 clinical presentation, 568 long-term management, 568 management, 568 pathophysiology, 567–568 preterm infants, 569 SSRIs during pregnancy, 569 prevention and management, 559–560 analgesia use, 561 pain management, 560 scoring system, 560 sepsis, 560 diagnosis, 562 invasive tests and antibiotic usage, 562 red flag clinical indicators, 562 35-weeks of gestation, 562–564 Nephrotic syndrome, 528, 531 Neurocritical Care Society, 157 Neurology delirium, 155, 156 Iatrogenic Withdrawal Syndrome, 155 pain, agitation, and neuromuscular blockade, 154, 155 status epilepticus, 156, 157 stroke, 157, 158 traumatic brain injury, 153, 154 Neuromuscular blockade, 154, 155 Neuroprotective strategy, 337 Neutropenia, 443 count, 443 granulocyte transfusion, 444 inherited cause, 443 signs and symptoms, 443 values, 443 Next-generation sequencing (NGS), 285 N9-GP®, 438 Nicotine, 29 Nipples, 42 Nonalcoholic fatty liver disease (NAFLD) chronic liver disease, 411 complications, 411 diagnosis, 413 histopathologic evaluation, 414 laboratory evaluation, 413 management of, 414 overview, 411 pathogenesis, 411 presentation, 412 prevention, 415 radiologic evaluation, 414 screening, 413

Index Nonepileptic paroxysmal events, 595 BNSM, 599 breathholding spells, 598 investigation of syncope, 599 non-epileptic seizures, 600 POTS, 597 psychogenic pseudosyncope (PPS), 598 reflex anoxic seizures, 598 self-induced syncope, 597 stretch syncope, 597 tic disorders, 599 vasovagal syncope, 596 infants and children, 596 paroxysmal events, 596 syncopal events, 597 Non-steroidal agents, 155 Non-steroidal anti-inflammatory drugs (NSAIDS), 300, 707 Non suicidal self-injury (NSSI), 677 Non-value-added-time (NVAT), 337 Normal childhood bruising, 118 Normal newborn care, 554–559 diaper dermatitis, 557 neonatal nutrition breastfeeding, 554, 555 gastroesophageal reflux (GER), 556 gastroesophageal reflux disease (GERD), 556 infant formulas, 555 neonatal resuscitation, 559 newborn cleaning, 556–557 newborn screening, 557 blood spot screening, 557–558 critical congenital heart defects (CCHD), 558 future aspects, 559 hearing screening program, 558 routine bathing, 557 umbilical cord care, 556 Normothermia, 160 North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), 370 Nucleic amplification acid tests (NAATs), 139 Nutrition, 387, 388 guidelines, 161 O Obsessive compulsive disorder (OCD), 263, 271, 680 Ohtahara syndrome, 586 Omega3 fatty acid supplementation (fish oil), 531 Online dating, 24 Online profiles, 24 Opioid and benzodiazepine withdrawal score (OBWS), 155 Oral analgesics, 300 Oral opioid agents, 300 Organ systems cardiology, 159–161 gastroenterology/nutrition, 161, 162 hematology, 162, 163

731 infectious disease/immunology, 163–166 neurology, 153–158 respiratory, 158, 159 Oxygenation index (OI), 158 Oxygenation saturation index (OSI), 158 Oxygen saturation, 327 P Packed red blood cell transfusions, 164 Pain, 154, 155 assessment, 299, 300 mild pain, 300 moderate-severe pain, 300–302 non-pharmacologic management of, 300 pharmacologic management of, 300 procedural pain, 302 procedural sedation, 301, 303, 304 sucrose, 302 topical anesthetic agents for, 302, 303 Painful periods, 44 Palivizumab, 571 Palliative care, pediatric critical care, 169, 170 PALS Pediatric Septic Shock Algorithm, 318 Pancreatitis, 415 acute pancreatitis, 418 alcohol and biliary disease, 416 chronic pancreatitis, 418 chymotrypsin C (CTRC), 417 diagnosis of, 417 etiology, 416 hypercalcemia, 417 management of, 417 presentation, 415 Paroxysmal events, 581 Patent ductus arteriosus occlusion, premature infants, 90 Patient Health Questionnaire 9 (PHQ-9), 690 Pediatric acute liver failure (PALF) APAP toxicity, 404 coagulation abnormalities, 405 coagulation pathways, 403 diagnosis, 405 fresh frozen plasma (FFP), 407 hepatocyte injury, 404 herpes simplex virus (HSV), 404 intracranial hypertension, 406 Kupffer cells, 403 liver progenitor cell (LPC)-mediated regeneration, 404 medical management, 406 presentation, 404 renal dysfunction, 407 study group, 403 vital signs, 406 Pediatric Acute Liver Failure (PALF) Study Group, 403 Pediatric Acute Lung Injury Consensus Conference (PALICC), 158 Pediatric Advanced Life Support (PALS) algorithms, 307

732 Pediatric allergy allergic rhinitis, 67 diagnosis, 67, 68 management, 67–69 pathophysiology and clinical presentation, 67 anaphylaxis, 69 diagnosis, 70 pathophysiology and clinical presentation, 70 prevention and management, 71 atopic dermatitis, 64 diagnosis, 64 management, 64–66 pathophysiology and clinical presentation, 64 Pediatric allergy, update in diagnosis, 63 food allergy, 61 diagnosis, 62 pathophysiology and clinical presentation, 61, 62 prevention and management, 63, 64 Pediatric cardiology congenital heart disease, 79, 80 cardiac imaging, 86–89 dyslipidemia, 98, 99 exercise in, 83, 84 fetal cardiology, 85, 86 genetic testing in, 90–98 Turner syndrome, 95, 96 interventional cardiology, 89, 90 late outcomes, 80 neurodevelopmental outcomes, 80, 81 psychosocial outcomes and quality of life, 81–83 Pediatric Confusion Assessment Method (pCAM-ICU), 156 Pediatric critical care, 149 education courses, 170 electronic learning, 171 future directions in, 171 simulation, 170 healthcare inequities, 171, 172 organ systems cardiology, 159–161 gastroenterology/nutrition, 161, 162 hematology, 162, 163 infectious disease/immunology, 163–166 neurology, 153–158 respiratory, 158, 159 palliative care, 169, 170 patient monitoring and technology, 149 bioinformatics, 151, 152 capnography, 150, 151 continuous electroencephalogram monitoring, 151, 152 near-infrared spectroscopy, 149, 150 point-of-care bedside ultrasound, 152, 153 video laryngoscopy, 153 quality improvement patient care bundles, 168 pediatric early warning scores, 167, 168 standardized handover tools, 167 rehabilitation, 168, 169

Index Pediatric early warning scores (PEWS), 167, 168 Pediatric Endocrine Society, 345 Pediatric Gait Arms Legs and Spine (pGALS), 702 Pediatric hospital medicine acute hematogenous osteomyelitis (AHO), 464 antibiotic treatment, 466 diagnosis, 465 diagnostic testing, 465 laboratory analysis, 465 microbiologic etiology, 465 oral antibiotic therapy, 466 serial monitoring, 466 acute viral bronchiolitis, 449 cardiorespiratory, 450 high-flow nasal canula (HFNC), 449 management, 449 post-hospitalization follow-up, 450 pulse oximetry monitoring, 450 brief resolved unexplained event (BRUE), 458 AAP guidelines, 459 clinical guidelines, 458 initial evaluation, 459 risk assessment and outcomes, 458 subspecialist consultations, 459 COVID-19 pneumonia, 459–462 anticoagulation, 461 dexamethasone, 461 diagnostic evaluation, 460 discharge criteria, 462 immunomodulators, 461 laboratory monitoring, 462 remdesivir, 461 febrile urinary tract infection (UTI), 451 age 22-28 days, 455 age 29 to 60 days old, 456 clinical practice guidelines, 453 imaging, 451 oral antibiotic, 452 procalcitonin, 457 time to discharge, 457 high-value-care (HVC), 470 hyperbilirubinemia adequate feeding, 467 discharge recommendations, 469 escalation of care, 469 hour of life (HOL) phototherapy, 469 intensive phototherapy, 468 jaundice, 468 overview, 467 phototherapy discontinuation, 469 prevention of, 467 reliable follow-up, 470 risk assessment and monitoring, 468 multisystem inflammatory syndrome in children (MIS-C), 462 cardiac involvement, 463 case definitions, 462 diagnostic evaluation, 463 treatment, 464 Pediatric infectious diseases, 481

Index antibiotic management, 486 CAP in children, 488 encountered infections, 487 SSTI in children, 489 UTI in children, 488 Covid-19 pandemic, 489 acute flaccid myelitis (AFM), 491, 492 enterovirus D68 (EV-D68), 491 prevention and control, 490 respiratory syncytial virus (RSV), 490 febrile infant, 481–486 vaccine hesitancy, 493 causes, 495 communication framework, 497 Covid-19 pandemic, 496 definition, 493 multi-prong approach, 498 practical actions, 496 state of affairs, 493–495 Pediatric nephrology acute kidney injury (AKI) definition, 532, 533 epidemiology, 534 etiology, 534 indication and timings, 535 overview, 532 prevention and treatment, 534 prognosis, 535 childhood hypertension diagnosis, 538 epidemiology, 538 organ damage, 539 overview, 538 treatment, 539 chronic kidney disease (CKD) classification, 536 definition, 536 GFR estimating formulas, 537 hypertension, 537 overview, 536 ciliopathies, 541 glomerular diseases, 540 glomerulonephritis clinical applications, 530 diagnosis, 530 epidemiology, 530 in children, 529 management, 531 overview, 528 prognosis, 531 nephrolithiasis, 543 nephrotic syndrome, 531 overview, 523 renal tubular disorders, 541 UTI, children, 524 clinical representation, 525 diagnosis, 525 imaging technology, 526 pathogenesis, 524 treatment, 525

733 vesicoureteral reflux antibiotic prophylaxis, 527 defined, 526 diagnosis, 527 surgical intervention, 528 Pediatric Research in Inpatient Settings (PRIS) Network, 450 Pediatric rheumatology, 701 PFAPA, 715 pGALS musculoskeletal screen, 703 tests and treatments, 716 Pegylated liposomes, 438 Penile size, 41 Periodic fever aphthous stomatitis, pharyngitis, cervical adenitis, (PFAPA), 715 Peripherally inserted central catheters (PICC), 152 Pharmacogenomics, 91 Phenobarbitone, 568 Photo sharing, 24 Physical abuse, 112, 117, 118 abdominal trauma, 130–132 bruising, 118, 119 differential diagnosis, 119, 120 history, 120 medical testing for, 120, 121 occult injuries, testing for, 121 physical examination, 120 physical findings, documentation of, 120 burns, 132–134 fractures, 122–125 head and spine injuries, 125–130 red flags, 119 Physical neglect, 134 Physiologic discharge, 42 Physiologic leukorrhea, 37 Playing games, 24 Point-of-care bedside ultrasound, pediatric critical care, 152, 153 Political action committees (PACs), 496 Pollen-food allergy syndrome (PFAS), 62 Polycystic ovarian syndrome (PCOS), 44–46 Positive end expiratory pressure (PEEP), 165 Post cardiac arrest care, 310 Post-exposure prophylaxis (PEP), 140 Post intensive care syndrome (PICS), 169 Post-intensive care syndrome in pediatrics (PICS-P), 168 Post-traumatic stress disorder (PTSD), 679 Postural orthostatic tachycardia syndrome (POTS), 597 Pre-hospital triage, 332 Prematurity, 569–572 childhood vaccinations, 571 delivery room resuscitation, 571 dental eruption, 572 extremely preterm infants (EPT), 569 incidence and risk factors, 569–570 initial stabilization, 570 limit of viability, 570 neurodevelopmental follow up, 571 NICU graduates, 571 short-term complications, 570

Index

734 Premenstrual dysphoric disorder (PMDD), 45–47 Prenatal drug exposure, 258 Prenatal genetic testing, 290 Pre-oxygenation, 307 Preschooler’s development at 36–48 months, 238 between 36–48 months, 238–243 between 48–60 months, 243–247 Prescribing controlled substances, 30 Primary survey, 332, 335, 336 Procedural pain, 302 Procedural sedation, 301, 303, 304 Prone positioning, 165 Propofol, 303 Proton pump inhibitor (PPI), 370 Psychiatric disability, 81 Psychiatric illness ADHD clinical presentation, 674 diagnosis, 672 prevalence, 672 treatment, 673 anxiety diagnosis, 678 heritability, 679 OCD, 680 prevalence, 678 treatment, 679 bipolar disorder diagnosis, 681 mood dysregulation, 682 prevalence, 680 safety, 682 treatment, 682 childhood and adolescent age, 669, 670 depression diagnosis, 675 prevalence, 674 safety, 677 SSRIs, 677 suicide, 676 treatment, 676 DSMV, 670 ARFID, 671 defiant disorder (ODD), 671 DMDD, 671 neurodevelopmental disorders, 670 research and delineation, 672 trauma and stressor-related disorders, 671 inflammatory Disease, 691 mental illness in youth, 665 psychotic spectrum disorders, 682 antipsychotics and aggressive behavior, 685 atypical antipsychotics, 684 diagnosis, 683 DSMV disorders, 683 SGAs profile, 686 treatment, 683 SARS-CoV-2, 667, 688 anxiety disorders, 667

BDI, 689 CDI, 689 in children and youth, 668 CPSS, 690 depression, 667 eating disorder (ED), 667 EDE-Q, 690 MASC questionnaire, 689 PHQ-9, 690 SACRED questionnaire, 689 sleep disorders, 668 social media use, 667 schizophrenia, 682 diagnosis, 683 treatment, 683 substance use disorders (SUD) cannabis and psychosis, 688 clinical presentation, 688 diagnosis, 687 prevalence, 687 treatment, 687 Psychosocial and risk behavior assessment adolescence, 6 additional interview tips, 8 breaking confidentiality, 8, 9, 11 caregivers, interacting with, 7 indications for use, 6 order of topics, 6 psychosocial assessment, navigating, 7 PTEN sequencing, 291 Puberty control, 353 definition, 353 environmental exposures, 356 GNRHa therapy, 355 phalates, 356 precocious puberty, 354 pubertal delay, 355 testosterone formulations, 356 Pulmonary valve replacement, 89, 90 Push-pull technique, 317 Pyelonephritis, 525 Q Quality improvement, pediatric critical care patient care bundles, 168 pediatric early warning scores, 167, 168 standardized handover tools, 167 Quality of life (QoL), 81–83 R Rapid sequence intubation (RSI), 308 Reactive attachment disorder (RAD), 262 RECSS trial, 433 Rehabilitation, pediatric critical care, 168, 169 Respiratory acute respiratory distress syndrome, 158, 159

Index e-cigarette and vaping product use associated lung injury, 159 Respiratory quotient (R/Q), 162 Respiratory syncytial virus (RSV), 449 Resuscitation airway, 307, 308 cardiopulmonary, 309, 310 intubation, equipment for, 307 medications, 308, 309 post cardiac arrest care, 310 Retinal hemorrhages, 127 Retinoblastoma, 650 Return of spontaneous circulation (ROSC), 160 Ringers’ lactate, 334 RNA sequencing (RNAseq), 288 Rocuronium, 309 Romiplostim, 434 S SAPIEN valve, 90 Sarcomas, 639–645 bone tumors, 639–642 central tumors, 640 Ewing sarcoma, 639 needle tract placement, 640 osteosarcoma, 639 outcomes, 641 presenting symptoms, 639 staging approach, 641 surface tumors, 640 treatment response, 642 Sarnat scoring staging system, 565 SARS-CoV-2, 688 depression BDI, 689 CDI, 689 CPSS, 690 EDE-Q, 690 PHQ-9, 690 MASC questionnaire, 689 mental health care provision, 690 SACRED questionnaire, 689 SARS-CoV-2 (covid) epidemic, 411 SARS-CoV-2 pandemic level of distress in youth, 669 mental health concerns in youth, 668 Scalds, 132 Screening Brief Intervention Referral and Treatment (SBIRT), 25, 26 Secondary survey, traumatic injuries, 336, 337 Sedation, 303 Selective serotonin reuptake inhibitors (SSRI), 258 long term effects, 677 NSSI, 677 during pregnancy, 569 suicide related events, 677 Sentinel injuries, 117 Sentinel node biopsy, 644 Sepsis, 163, 164, 313

735 definitions, 313 diagnosis, 315 epidemiology and risk factors, 314 etiology and microbiology, 314 management, 317, 319 pathophysiology, 314, 315 Sepsis-associated organ dysfunction, 313 Septic shock, 163 Serial transverse enteroplasty procedure (STEP), 391 Serum aminotransferase levels, 405 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) accountability and apology, 513 case-fatality-rate, 507 children protection, 504, 506 emergency management process, 508 hyper-inflammatory syndrome, 506 infection fatality rate, 505, 507 infection hospitalization rate, 505 lockdowns, 504 pandemic plans, 512 precautionary principle, 512 vaccines, 510, 511 Severe sepsis, 313 Sexual abuse/assault, 112 child maltreatment, 135, 136 discharge and follow-up, 140 documentation, 138, 139 emergency contraception, 140 forensic evidence collection, 139 history, 136, 137 interpretation of findings, 138 physical examination, 137 psychosocial support, 140 sexually transmitted infections, testing for, 139, 140 timing of examination, 136 Sexual dysfunction, 41–42 Sexual health, adolescent, 40 dysmenorrhea, 44 female-bodied reproductive health, 42, 43 male-bodied reproductive health, 41 menstrual cycle irregularities, 43, 44 polycystic ovarian syndrome, 44–46 premenstrual dysphoric disorder, 45–47 Sexually associated infections, 36 Sexually transmitted infections, 31 assessing STI risk, 31 multiple national medical organizations, 32–34 safe sex practices and prevention, 37 STI-related consent and confidentiality, 31 treatment guidelines, 34–36 vaginal discharge, evaluation of, 34, 35, 37 Sexual satisfaction, 41–42 SHADES assessment, 9–11 Shock Index, 332 Shock Index Pediatric Age-Adjusted (SIPA) score, 332 Sickle cell disease (SCD), 431 Simulation, pediatric critical care, 170 Single nucleotide variants, 254

Index

736 Skeletal immaturity, 336 Skeletal injury, 121 Skin prick test (SPT), 62 Sleep disturbances, treatment for, 269 Sleep problems, 268, 269 Small for gestational age (SGA) profile diabetes, 686 dyslipidemia, 686 movement disorders, 686 weight gain and obesity, 686 Smegma, 41, 42 SOARS Model, 12 Social anxiety, 263 Social (Pragmatic) Communication Disorder (SCD), 262 Social development, 189 Social emotional development, 185, 186 Social emotional milestones 0–3 months, 186 4–6 months, 186, 187 7–12 months, 187 13–18 months, 187, 188 19–24 months, 188 25–36 months, 188, 189 Social media, risks, 23, 24 Social play skills, 188, 189 Society for Critical Care Medicine (SCCM), 169 Sodium bicarbonate, 160 Soft tissue sarcomas, 643 diagnosis, 643 histology, 643 molecular profile, 643 non-RMS tumors, 643 outcomes, 645 presenting symptoms, 643 RMS tumors, 643 staging, 644 treatment, 645 Solid tumors, 629 biopsy, 630 delivery of bad news, 630 future aspects, 654 genetic alterations, 640 goals of therapy, 629 kidney tumor, 635 epidemiology, 635 genetic predisposition, 635 loss of heterozygozity (LOH), 636 molecular profiling, 636 outcomes, 637 pathophysiology, 635 presenting symptoms, 636 renal cell carcinoma (RCC), 638 rhabdoid tumors, 639 staging, 637 treatment, 637 long-term toxicities, 653 neuroblastoma chemotherapy, 634 epidemiology, 630 genetic predisposition, 630

histology, 631 molecular profile, 631 outcomes, 634 pathophysiology, 630 presenting symptoms, 630 radiation, 635 staging, 631 treatment strategies, 634 post-treatment care, 652 psychological impact, 652 sodium thiosulfate (STS), 652 treatment-related toxicities, 652 radiographic findings, 632 surgical approach, 630 tumor imaging, 629 Sophia Observation withdrawal Symptoms (SOS), 155 Spectrum disorders, 273 Speech/language disorder, 261 Splenectomy, 434 Standardized handover tools, 167 Staphylococcus aureus, 443 State Behavioral Scale (SBS), 155 Status epilepticus, 156, 157 Streptococcus pneumoniae, 488 Stress ulcer prophylaxis, 161, 162 Stroke, 157, 158 Subdural hemorrhages, 127 Sublingual immunotherapy (SLIT), 63 Suboptimal communication, 167 Substance Abuse and Mental Health Services Administration (SAMHSA), 25 Substance use, 24 alcohol, 30 inhalant use, 30 marijuana, 29 nicotine and tobacco use, 29 prescribing controlled substances, 30 referral to treatment, 27–29 SBIRT, 25, 26 Substance use disorders (SUD) cannabis and psychosis, 688 clinical presentation, 688 diagnosis, 687 prevalence, 687 treatment, 687 Succinylcholine, 309 Sucrose, 302 Sudden cardiac death (SCD), 97, 98 Sudden deceleration, 127 Surviving Sepsis Campaign, 164 Syphilis, screening and testing recommendations for, 33 T T-cell receptor gamma delta (TCRγδ), 376 Team composition, interfacility transport, pediatric patient, 323, 324 Technology and social media changing technological landscape, 19, 20 electronic health record privacy, 22, 23

Index emerging social media risks, 23, 24 medical and developmental health concerns, 20 mental, emotional, and social challenges, 20, 22 Tension pneumothorax, 333 Thalassemia syndromes, 432 Thoracic trauma, 338 Thoracostomy, 333 Thrombopoietin (TPO) receptor, 434 Thromboprophylaxis, 163 Thyroid disease acquired hyperthyroidism, 359 acquired hypothyroidism, 358 congenital hypothyroidism, 357 Congenital Hypothyroidism, 358 methimazole dosing, 359 overview, 357 Tics and Tourette syndrome, 270 Tissue transglutaminase (TTG), 375 Tobacco use, 29 Toddler’s development at 19–24 months, 225 at 25–36 months, 229 between 19 and 24 months, 225, 227–229 between 25 and 30 months, 229, 231–233 between 31 and 36 months, 234–236, 238 Toddler’s diarrhea, 377 Tolerance, 26 Topical calcineurin inhibitors (TCIs), 65 Topical corticosteroids (TCS), 65 Total iron binding capacity (TIBC), 430 Toxic stress derails healthy development, 247, 248 Tranexamic acid (TXA), 335 Transcutaneous CO2 monitoring devices, 151 Transfusion and Anemia Expertise Initiative (TAXI), 162 Transfusion medicine, 433 age of blood, 433 red cell transfusion, 433 Transfusion strategies, 162, 163 Transition Readiness Assessment Questionnaire (TRAQ), 50 Transport Pediatric Early Warning Score (T-PEWS), 168 Transport Risk Assessment in Pediatrics (TRAP), 168 Trauma, 117 panel, 336 team, 332 Traumatic brain injury (TBI), 153, 154, 337, 338 Traumatic injuries, 331 abdominal trauma, 338 airway, 332, 333 breathing, 333, 334 circulation, 334 disability, 335 exposure and temperature control, 335 fluid resuscitation and hemorrhage, 334, 335 pediatric, scope of, 331 pre-hospital care, 331, 332 primary survey, 332 adjuncts to, 335, 336 secondary survey, 336, 337

737 thoracic trauma, 338 trauma team, 332 traumatic brain injury, 337, 338 Treponema pallidum, 33 TRICC trial, 433 Triceps skin fold (TSF), 387 Trichomonas vaginalis (TV), 33, 37 TRIPICU trial, 433 Tube thoracostomy, 327 Turner syndrome, 95, 96 U Urinary tract infections (UTI), children, 524 clinical representation, 525 diagnosis, 525 imaging technology, 526 pathogenesis, 524 treatment, 525 Ursodeoxycholic acid (UDCA), 402 V Vaccine preventable diseases (VPD), 493, 494 Vaccine unsure vs. vaccine very hesitant, 496 Vaginal discharge, 34, 37 Valproic acid, 258 Vapocoolant sprays, 302 Variceal bleeding, 393 Vasoactive agent, 319 Ventilator-associated pneumonias (VAP), 168 Ventricular septal defects (VSDs), 79 Verbal Numerical Rating Scale (NSR-11), 300 Vesicoureteral reflux (VUR), 526 antibiotic prophylaxis, 527 defined, 526 diagnosis, 527 surgical intervention, 528 Video-feeds, 24 Video laryngoscopy, 308 pediatric critical care, 153 Video sharing, 24 Viral hepatitis, 408 chronic hepatitis B breastfeeding, 408 definition, 408 monitoring and therapy, 408–409 vaccination, 408 cirrhosis, 408 hepatitis C virus (HCV), 409 monitoring, 409 screening, 409 hepatocellular carcinoma (HCC), 408 Virginity, 42 Virtual autism assessments, 260 Visceromegaly, 589 Vision impairment (VI), 262 Vitamin D deficiency, 257 Vlogs, 24

Index

738 Volume resuscitation, 317 Volumetric capnography, 151 Vulvodynia, 43 W Walls, social media, 24 Withdrawal, 26 Withdrawal Assessment Tool-1 (WAT-1), 155

Y Yolk sac tumors, 646 Youth-driven communication, 50 Youth readiness, 50 Z Zellweger syndrome, 586