Chapter 20: Pediatric Disorders 263
• Spacer or aerochamber: A chamber is attached
directlytotheMDI,oritcanbeusedwithanattached
mask.Thiseliminatestheneedtocoordinateinhala-
tionwithMDIactivation.Theaerosolmedicationis
dispensedintothechamberorspacer,andthechild
cantheninhalethemedicationfromthespacer.
• Drypowderinhaler(DPI):DPIsareusedforachil-
drenolderthanage4or5years.Theydonotneed
spacers or shaking before use. After inhalation the
childshouldrinsehisorhermouthwithwaterand
thenspit.
Lifestyle Changes: Practical Tips for Your
Patients
Participatinginusualchildhoodactivitiesastolerated,
minimizingexposuretoenvironmentalirritants,using
medications,andmonitoringasthmacontrolarethecor-
nerstonesoftreatment.Thechildshouldparticipatein
thetreatmentofhisorherillnessascompletelyaspos-
sible, including measurement of peak ow readings,
monitoringtimesfordosages,andidentifyingsymp-
tomsearly.Thechildshouldbeencouragedtopartici-
pate in activities as much as possible. Every effort
shouldbe takento make the child’s environment as
irritantfreeas possible.For example,if the child is
oldenoughtoassumedutiesaroundthehouse,clean-
ingresponsibilities(e.g.,dusting,sweeping,orvacu-
uming)shouldnotbegiventohimorher.Thechild
canassumeotherdutieswheredustexposureislim-
ited(e.g.,foldinglaundry,washingdishes).
Thetreatmentofasthmaisbasedonearlyprimary
prevention,reductionofexposuretoallergentriggers,
and medication. Primary prevention includes issues
suchasbreastfeeding,delayingintroductionofsolid
foodsuntilafterage4months,usinghypoallergenic
formulasforallergy-pronechildren,avoidingpassive
smokeexposure,maintaininglowindoorallergenlev-
els,avoidingasthmatriggers,administeringanannual
inactivated inuenza injection and a pneumococcal
vaccine, and beginning early pharmacotherapy for
allergicrhinitis.
Homeorself-monitoringforthechildwithasthma
providesobjectivedatathatcanbeusedbythechild,
parent,and clinician to follow the clinical course of
asthma.Peak owis measuredtwice dailyuntil the
normalorbestlevelisestablished.Onanygivenday,
a reading that is 70 percent or greater is considered a
goodresponsetotherapy.Valuesthatfallbetween70
and 50 percent require increasing treatment (e.g.,
nebulizationfourtimesperdayinsteadofthreetimes).
Areadingbelow50percentrequiresacalltothedoc-
torandwillprobablyresultinanadditional doseof
medication or the addition of systemic steroids. An
acute asthma attack is life threatening. Parents and
caregivers should be educated and prepared to take
appropriate action, including when to initiate and
increaseSABAsandwhentocall911.
Indicationsforreferralorconsultationincludethe
following:
• Alife-threateningexacerbation
• Patientisnotmeetingthegoalsofasthmatherapy
after3–6monthsoftreatment
• Signsandsymptomsareatypical
• Otherconditionscomplicatethediagnosis(e.g.,
sinusitis, nasal polyps, vocal cord dysfunction,
GERD)
• Additionaldiagnostictestingisindicated
• Patient requires additional education and
guidance
Cardiovascular Risk Factors
General Characteristics
Theincreaseofchildhoodobesityduringthepast2decades
hasbeenwelldocumentedandisconsideredtobeamajor
risk factor in the development of cardiovascular disease
(CVD).ManyriskfactorsforCVDarerelatedtolifestyle
Figure 20–2 Asthma treatment using an inhaler.
Source:
©
David Davis/Dreamstime.com
264 PART II: PRIMARY CARE DISORDERS
issuesandcanbemodied.Lifestyleissuesthatcontribute
toheartdiseaseincludesmoking,dietwithhighsugarand
fatcontent,andsedentarylifestyle.
OneriskfactorforCVDthatisnotmodiableisafamily
history of premature CVD, cerebrovascular disease, and
occlusive peripheral vascular disease at age 55 years or
youngerin
a parent, grandparent, sibling, sibling of a parent,
oraparent withatotal cholesterollevelof240mg/dLor
higher. Selective screening is recommended for children
withthistype of familyhistoryand also for childrenwith
incompleteorabsentfamilyhistorydata,suchasinthecase
ofadoption.
The following conditions contribute to the develop-
mentofCVD:obesity,Type2diabetes,cancers(endome-
trial,breast,andcolon),hypertension(HTN),dyslipidemia,
stroke,liverandgallbladderdisease,sleepapnea,asthma,
gynecologicproblems(abnormalmenses,infertility,poly-
cysticovarydisease),andmusculoskeletalproblemsrelated
toweightbearing.
PediatricmeasurementsrelatedtoCVDandmetabolic
syndromeincludebodymassindex(BMI),bloodpressure
(BP),andcholesterollipidlevels.HTNoccursin30percent
of overweightchildren.Obesity and metabolicsyndrome
arehighlylinkedtolipidabnormalities.Indicatorsformet-
abolicsyndromeincludeobesity,truncalobesity,HTN,high
total cholesterol, elevated low-density lipoprotein (LDL),
decreased high-density lipoprotein, high triglycerides, and
hyperinsulinemia(insulinresistance).
7,8
BMI can be used to screen for obesity, overweight,
healthyweight,orunderweight.Itisanumericcalculation
basedonthechild’s weightandheight,anditisusedto
assessriskforhealthproblems.AlthoughtheBMIdoesnot
measurefatdirectly,itcorrelatestodirectmeasuresofbody
fat.Inchildrenandteens,theappropriateBMIisageand
sex specic, and it is reported in percentiles similar to
percentilesusedonstandardizedgrowthcharts.Thishelps
to account for body changes during the growth period.
BMItrendingchartsareincludedwithheightandweight
charts that are recommended by the Centers for Disease
ControlandPrevention.TheBMIcanbecalculatedmath-
ematically,usingametricorstandardversion:
Metricsystem(kg/cm)BMI:weight(kg)÷height(cm)
÷height(cm)×10,000
Englishsystem(lb/in)BMI:weight (lb) ÷ height (in)
÷height(in)×705
BMI can also be calculated using Web-based or elec-
tronicprogramsorBMIplottingtables(Table 20–3).
7,8
BPstandardsarebasedongender,age,andheightand
providespecicclassicationsthatprovideguidelinesfor
treatmentofHTN.TheNationalHeart,Lung,andBlood
Institutepublishedextensivetablesthatincludethe50th,
90th, 95th, and 99th percentilesfor each gender by age,
height,systolicBP(SBP)anddiastolicBP(Table 20–4).
9
RoutineBPmeasurementsbeginatage3years.Select-
ing the correct cuff size is important for accuracy; the
largestcuffthattsontheupperarmwithenoughroom
below for the stethoscope diaphragm should be used.
ElevatedBPshouldberepeatedatleasttwiceatthatsame
visit and conrmed on repeatedvisitsbeforediagnosing
thechildashavingHTN.
Therearenoconsistentoruniversalrecommendationsfor
screeningchildrenandadolescents for lipidabnormalities.
Childrenwithahigh-riskfamilyhistoryandotherriskfac-
tors, such as diabetes, HTN, overweight or obesity, and a
historyofsmoking,shouldbescreenedforlipidabnormalities.
Itisrecommendedthatat-riskchildrenbescreenednotlater
thanage10yearsandnoearlier thanage2years. Gender
affects cholesterol, with girls having higher cholesterol levels
thanboys.Lipidlevelsmayvaryduringthegrowthstageof
childhood,andvaluescouldbe referencedintermsofper-
centages,muchlikeBMIandBP(
Table 20–5).
8
Management
TheprimaryrecommendationsforreducingCVDfactors
inchildrenincludelifestylechanges,suchasaerobicactiv-
ityseveraldaysaweek;adietthatislowinfat,salt,and
sugar;fewersedentaryactivities;andnotsmoking.Aerobic
exerciseshouldbeanactivitythatthechildoradolescent
enjoys and should include 30 to 60 minutes of aerobic
exercisewithwarm-upandcool-downperiodsbeforeand
after.The clinicianshould providethe patient withspe-
cicinformation,suchasanexerciseplanthatbeginswith
1to3weeksofmildexerciseandthenincreasestomore
strenuousexerciseuntilthechildoradolescentcando30
Table 20–3
BMI Percentiles
Weight Status Percentile Range
Underweight < 5th percentile
Healthy weight 5th to < 85th percentile
Overweight 85th to < 95th percentile
Obese 95th percentile
Source: Centers for Disease Control and Prevention. Healthy weight—it’s
not a diet, it’s a lifestyle. http://www.cdc.gov/healthyweight/
assessing/. Accessed March 10, 2010.
Table 20–4
Classication of HTN in Children
Status SBP or DBP Percentile
Normal < 90th percentile
Pre-HTN 90–95th percentile or if BP > 120/80
Stage 1 HTN 95–99th percentile plus 5 mm Hg
Stage 2 HTN > 99th percentile plus 5 mm Hg
Source: National Heart, Lung, and Blood Institute. The Fourth Report on
the Diagnosis and Treatment of High Blood Pressure in Children and
Adolescents. Bethesda, MD: National Institutes of Health; 2005. NIH
publication 05-5267.
Chapter 20: Pediatric Disorders 265
to60minutesofactivity.Itisimportanttoemphasizethe
improvement in well-being and general health and to
encouragesupportfromfamilyandfriends.
The most important dietary change is reducing the
amount of fat to 30 percent or less of total calories for
childrenaged3yearsandolder.Fatprovidestherichtaste
tomanyfoods,anditrequirescommitmenttoreducefat
intake (Figure 20–3).Examplesincluderedmeats,pastries,
and desserts. Most of the calories consumed should be
fromcomplexcarbohydrates(50to60percent),andpro-
teinshouldbeonly10to20percentofachild’sorteenager’s
diet. Including more fruits and vegetables (such as ve
servingsaday)andcalcium-richfoods,anddiscouraging
highlysweetenedjuicesandsodas,canhelpwithweight
management.Eatingtogetherasafamilyatleastonceaday
helpspromotehelpfulcommunicationandsocialaspects
of eating. If the parents are also at risk for CVD, these
activitiescanbeadoptedbythewholefamily.Justaswith
the exercise regimen, the child or adolescent needs the
supportoffamilyorfriends.Theamountoftimechildren
spend watching television should be limited. Watching
television is associated with a sedentary lifestyle, obesity,
andahigh-fatdiet.
Indications for antihypertensive medication include
symptomatic HTN, secondary HTN, hypertensive target
organ damage, diabetes mellitus, and persistent HTN in
spiteofnonpharmacologicmeasures.BPclassicationsare
usedtoguideBPmonitoringandinitiatelifestylechanges
orpharmacotherapytreatment:
• NormalBP:Recheckin1year
• Prehypertension:Recheckin6months;weightman-
agement;nomedication
• Stage 1 HTN: Recheck in 1–2 weeks; begin further
evaluation;weightmanagement;medicationifneeded
forconditionspreviouslylisted
• Stage2HTN:Evaluateorrefertoprimarycarepro-
viderwithin1weekorimmediatelyifthepatientis
symptomatic;initiatemedication
Pharmacologictherapy,
whenindicated,shouldbeiniti-
ated in children aged 1 to 17 years with
asingledrug.The
majoracceptable
drugclassesforuseinchildreninclude
Table 20–5
Cholesterol Risk Assessment
Risk Assessment Total Cholesterol LDL Cholesterol
Acceptable < 170 mg/dL < 110 mg/dL
Borderline 170–199 mg/dL 110–129 mg/dL
High > 200 mg/dL 130 mg/dL
Note: HDL levels below the 5th percentile (35–40 mg/dL) are abnormal.
Triglyceride levels in children vary considerably (adult normal level
< 150 mg/dL).
Figure 20–3 Example of high fat food.
Source:
©
Jones and Bartlett Publishers. Photographed by Kimberly Potvin.

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