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Daily Dose

When Tests Should Be Ordered

1:30 to read

The American Academy of Pediatrics has been involved in a series of articles entitled “Choosing Wisely”, as it relates to when and why some tests should be ordered. The latest is related to endocrinology and the myriad of laboratory tests that are often ordered unnecessarily and are overused.

 

The AAP states that it is important to, “avoid ordering Vitamin D concentrations routinely in otherwise healthy children, which includes children who are overweight or obese”.  While a Vitamin D level is the correct screening lab to monitor for Vitamin D deficiency, it should only be ordered in patients with disorders associated with low bone mass (like rickets), some children with liver disease, or in those children who have recurrent low-trauma fractures (not one broken arm).

 

I have seen many patients who have had lab work done by another physician in which they “have a low Vitamin D level” and they are concerned that this is the reason their child is “fatigued”, “depressed”, “not doing well in school”….just to name a few of the statements. Vitamin D levels have not been correlated with any of the above. 

 

Due to the variability of tests available, and unclear cutoffs for deficiency, many children could be misclassified as having Vitamin D deficiency.  The uncertainty around “ normal levels” may lead to over diagnosis, with no clear benefit and may cause undue anxiety. 

 

More important than a Vitamin D level is the assurance that parents are routinely offering their children milk and dairy products high in Vitamin D. Vitamin D is necessary to help the body use calcium, which is the building block for strong bones and teeth.  As many parents have stopped giving their children milk, but are offering more water, the daily recommended intake of Vitamin D and calcium may be difficult to reach.

 

Other foods high in Vitamin D include canned tuna, salmon and some fortified cereals.

 

If you have questions about Vitamin D intake talk to your pediatrician.  

 

 

Daily Dose

Lead Testing

1:30 to read

Lead exposure is young children may lead to long term consequences. Therefore, blood lead level testing has been recommended for all children at their 1 and 2 year check ups. Most doctors offices either prick a child’s finger or heel to draw the blood for testing, and many use an in office machine to perform the test.  

 

Some of the blood testing is performed by Magellan Diagnostics and the F.D.A. just announced that the 3 minute test run in many doctor’s offices could “yield inaccurate results when used on blood drawn from a vein”.  The F.D.A. went on to say “that there was no evidence at this point that the finger and heel prick methods have provided inaccurate results, and for some reason only venous blood has been associated with inaccurate readings”. 

 

I have already been getting some calls and emails from concerned parents wondering if their child needs to have repeat testing performed.  Fortunately, in our office we have routinely used capillary blood from a finger stick. We test that specimen for both lead and also a hemoglobin test to look for anemia.  You would probably remember a “venous blood draw” as it requires finding a vein (usually in the crook of the arm) and actually using a needle and syringe to draw the blood sample…a lot more difficult than a finger stick, especially in a squirming toddler.

 

We are all exposed to some lead in our environment, and lead levels under 5 mcg/dl as being “safe”.  If a child’s screening lead level is higher than 5, then most doctors will draw a venous sample to confirm the elevated levels and to then try to determine if the lead exposure is coming from the home, school, or environment. Infants and young children are especially vulnerable to the effects of long term lead exposure and lead poisoning, especially during periods of rapid brain growth and development. High lead levels may lead to long term effects on IQ and performance as well as affecting other body systems.

 

If your child is under the age of 6 years and you are concerned about the accuracy of their lead testing, you should call your doctor’s office and inquire if they had testing done on venous or capillary blood.  If there are concerns it would be appropriate to draw another sample from capillary blood or sent to an outside lab.  It is estimated that most of the testing performed in a doctor’s office was done on Magellan equipment which is used by about 10,000 pediatricians throughout the country.

 

Daily Dose

Hip Dysplasia In Newborns

1:30 to read

Developmental Hip Dysplasia (DDH) occurs in 1 in 1000 births.  In a normal hip the upper end (ball) of the femur (thigh bone) fits firmly into the hip socket.   DDH refers to different abnormalities of the hip noted in infancy when the hip joint has not formed normally. This may   range from a mildly unstable hip in an infant to an infant that is born with a completely dislocated hip.   DDH is screened for from the time an infant is born until they are walking, in hopes of picking up any abnormality at a young age. 

 

The majority of babies with DDH are female (75%), and it is also more common in infants who are in the breech (butt down) position during the 3rd trimester of a woman’s pregnancy.  Other risk factors for DDH include: a family history of DDH and improper swaddling of an infant. 

 

You may notice that your pediatrician examines your baby’s hips at every visit.  They will perform the Ortolani maneuver and the Barlow test where the doctor is trying to see if they can feel a dislocated or unstable hip. In these tests they are actually putting pressure on the hip to check for a “click or clunk” which suggests a hip problem or instability.

 

For female babies who have been breech it is recommended that they not only have a physical exam checking for DDH, but that they also undergo an ultrasound of the hips after 6 weeks of age and prior to 6 months.  Ultrasound for male babies who have been breech is not “routinely recommended” but may be ordered if the baby has any signs of hip instability.

 

The incidence of hip instability and dysplasia seems to have also increased since parents began routinely swaddling their babies. It is now recommended that babies sleep in a sack rather than having them swaddled with their legs extended. For the hips to develop normally a baby needs to be able to move their legs around which will drive the femur into the hip socket, so that the socket gets deeper. A shallow, flat hip socket may lead to hip dysplasia.

 

In most cases that are detected early the treatment is a brace called a Pavlik harness that will hold the femur into position within the hip socket. A baby stays in the harness for 6-12 weeks in order that the hip joint will develop normally. For babies that may develop hip dysplasia after 6 months of age an orthopedist will probably recommend closed reduction to put the hip back into place. This is done under anesthesia and then the baby is placed in a cast that also pushes the femur into the hip socket.  The baby may have to wear this cast for 4 - 5 months. 

 

Every time your pediatrician takes off your baby’s diaper during their exam it is not really about a diaper change. That hip exam is really important!

 

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