#developmental pediatrics

Hi anon!

That is a pretty comprehensive list! I’m impressed someone put all that time and effort into writing this all in…

In my humble opinion, I’d add in a few more subspecs that were not covered:

Peds emergency medicine: fever, minor head injuries and headaches, abdo pain, foreign bodies in various orifices, seizures, (usually minor) lacerations/punctures, and some random orthopedic stuff (usually soft tissue strains/sprains and fractures); the really, really acute patients are actually less common but are the main reason most of us want to do PEM (i.e. trauma, resuscitation of critically ill neonates and children)The ugly: the stuff that either didn’t need to come to ER at all or comes to ER WAY LATER AND WAY WORSE THAN IT SHOULD HAVE BEEN because parental anxiety is HUGELY out of proportion with the patient’s presenting symptoms (e.g. the otherwise healthy toddler with fever x1 hour versus the known type 1 diabetic that’s been in DKA for days that parents brought in “not knowing why he won’t wake up”), any and all forms of child maltreatment, the inorganic symptoms (e.g. conversion disorder), the mental health crises for whom there just aren’t enough resources (so they stay teetering in crisis mode until they are suicidal enough or just successful enough in self-harming that they finally get admitted), the chronic non-urgent complaints that for some reason just have to be assessed in the ER TODAY at 4AM, and the things that really should have gone to the primary care docs but the family couldn’t get an appointment/couldn’t wait a few hours until morning/don’t have a primary care provider/weren’t satisfied with the wait time for their specialist appointment and for some reason think that presenting to the ER will expedite things for them even though nothing has changed

Peds rheumatology: arthritis +/- arthralgia, the weird inflammatory processes that no one knows how to deal with (that sometimes end up being autoimmune disorders and sometimes… aren’t…; closely related to the strange constellations of wtf symptoms that also happen to be accompanied by elevated CRPs and/or ESRs), the “query periodic fever syndrome”, and lupusThe ugly: hypermobility syndromes which you unfortunately can’t actually do anything for, the “undifferentiated inflammatory condition” that is really hard to treat since you don’t actually know what to treat, the referrals for “joint pain” that are clearly non-inflammatory and MSK in origin but the referring provider didn’t actually take a history or do a physical exam…

Allergy/Immunology: asthma that no one else has gotten under control, allergies (of course) + desensitization + exposure trials, anaphylaxis, and immunodeficienciesThe ugly: debunking the “penicillin allergy” which was really just a rash that a kiddo had a gazillion years ago but may or may not have been right after a dose of amox

Adolescent medicine: eating disorders, substance use disorder, mood disorders, anxiety disorders, poor adherence to management of chronic diseases, conversion disorderThe ugly: …some of these kids are going through more awful stuff than anyone should ever go through and it breaks your heart; also some of them are belligerent and they just DGAF and it makes you want to tear your hair out because please just take your meds?!

Developmental peds: the really complex/low-functioning global developmental delay/intellectual disability/autism spectrum disorders, behavioural disorders, and sometimes not-so-low-functioning developmental delaysThe ugly: the fact that most of these kiddos need a lot more than the system can provide, fetal alcohol spectrum disorder (because that diagnosis doesn’t actually help kids access more services/resources and it is kind of just a mother-blaming, socioeconomically-segregating label that neither guides management nor aids in patient care) and the GIANT DISCONNECT between the educational system and the healthcare system that leads to many of these kids lacking services that actually are available but they “don’t qualify for” because their family can’t afford the ridiculous expenses associated with psychoeducational testing

Musculoskeletal function is tightly linked to quality and quantity of life in cerebral palsy. For instance, someone with spastic diplegia or hemiplegia usually has normal intelligence and can often ambulate independently; 98% survive to age 20. However, someone with spastic quadriplegia is likely to have intellectual disability but only 85% reach age 20. A significant percentage survive to 50, but loss of ambulation can herald general decline. There are about 500,000 adults living with cerebral palsy in the United States. By age 30, 60% live independently from their parents, 25% are partnered, and employment ranges from 10-50%.

Conditions associated with cerebral palsy include - intellectual disability 50% - seizures 50% - communication difficulties 40% - dysphagia and sialorrhea - gastric reflux and constipation - urinary dysfunction and UTIs - scoliosis and chronic MSK pain - low bone mineral density - vision and hearing disabilities 50% and 10%

In addition to the number of limbs affected (see Monday's post), cerebral palsy can be defined by the individual's muscle tone and movement. Most infants with congenital cerebral palsy go through an early stage of hypotonia. Hypertonicity then develops at 6-18 months, except for those with dyskinetic or dystonic CP*, who have fluctuating tone. *Injury to extra-pyrimidal, subcortical areas of the brain such as the basal ganglia and thalamus, causes dyskinesia (aka choreoathetosis), with excess movement (either slow writing or quick jerks), whereas dystonia consists of involuntary muscular spasms. Individuals with ataxic CP have low tone and trouble balancing due to an insult to the developing cerebellum.

Source: Cerebral Palsy, StatPearls, https://www.ncbi.nlm.nih.gov/books/NBK538147/

This week's topic is cerebral palsy, a life-long neurological condition that occurs in 2-3 of every 1,000 live births. It's an umbrella concept that includes diplegia (primarily legs), hemiplegia (one side or the other), and quadriplegia (all four limbs) as long as the insult occurred during development (in utero up to age 2). For a long time hypoxic injury was assumed to be the major cause, but now we now that it's responsible for a minority of cases, which are more likely to be due to genetic condition, infection, neonatal stroke, or environmental factors (such as prematurity) that disrupt brain development. Although considered a "static encephalopathy" in that the neurological injury doesn't progress, the downstream effects of CP such as spasticity, neurogenic bowel or bowel, and dysphagia leading to failure to thrive may worsen due to age, lack of therapy, or intercurrent illness.