Choosing Wisely: 5 things doctors & patients should question about tests or treatment for rheumatologic diseases

Dr KK Aggarwal

The American Academy of Pediatrics (AAP) - Section on Rheumatology, as part of the national “Choosing Wisely” campaign, has released a list of tests and procedures commonly used to treat rheumatologic diseases that should be questioned by patients and physicians to ensure they are evidence-based and necessary.

The five list items are

1.     Do not prescribe opioids for chronic pain management in patients with autoimmune disease.

2.     Antinuclear antibody (ANA) and other autoantibody testing should not be ordered on a child unless there is strong suspicion or specific signs of autoimmune disease.

3.     Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history or appropriate exam findings.

4.     Do not send periodic fever syndrome genetic panels prior to infectious and oncologic workup or in a patient without clear evidence of recurrent fever.

5.     Do not order rheumatoid factor alone, or as part of a "panel" or "cascade" in children to evaluate for rheumatologic disease such as juvenile idiopathic arthritis due to musculoskeletal complaints. Do not let laboratory results guide referral.

(Source: American Academy of Pediatrics)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

American Academy of Pediatrics urges all families to learn to swim

Dr KK Aggarwal

With the advent of summer, the American Academy of Pediatrics (AAP) has urged all communities to make water safety a No. 1 priority, which includes making swim lessons accessible for everyone.

"This is an essential life skill for children, teens and adults. It's an important part of the 'layers of protection' that families and communities can put in place to protect children and teens around water", says AAP President Kyle Yasuda, MD, FAAP.

The AAP published updated recommendations on drowning prevention in March 2019. It recommends 'layers of protection' including:

·           All children and adults should learn to swim. Most children will be developmentally ready for formal swim lessons between ages 1 and 4. Talk with your pediatrician about when your child will be ready.

·           Not all swimming lessons are created equal. Choose a program that meets your family and child's needs and skills, and one that will ensure they have basic water safety skills.

·           Close, constant, attentive supervision around water is important. Assign an adult 'water watcher,' who should not be distracted by a cell phone, socializing, chores, or drinking alcohol. With young children or poor swimmers, the adult should be within an arm's length, providing constant 'touch supervision.'

·           Empty wading pools immediately after use.

·           Pools should be surrounded by a four-sided fence, with a self-closing and self-latching gate. Research shows pool fencing can reduce drowning risk by 50%.

·           Adults and older children should learn CPR. 

·           Everyone, children and adults, should wear US Coast Guard-approved life jackets whenever they are in open water, or on watercraft. Small children and non-swimmers should wear life jackets when they are near water and when swimming. Inflatable "floaties" can't be relied upon to protect kids. 

·           Parents and teens should understand how using alcohol and drugs increases the risk of drowning while swimming or boating.  

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

High risk infantile hemangiomas should be promptly evaluated by hemangioma specialist

The American Academy of Pediatrics (AAP) has published new clinical practice guideline for the management of infantile hemangiomas.

Published online Dec. 24, 2018 in Pediatrics, the guideline says that “unlike many diseases, management of IHs is not limited to one medical or surgical specialty. A hemangioma specialist may have expertise in dermatology, hematologyoncology, pediatrics, facial plastic and reconstructive surgery, ophthalmology, otolaryngology, pediatric surgery, and/or plastic surgery, and his or her practice is often focused primarily or exclusively on the pediatric age group.”

Some key recommendations include:

·         Infantile hemangioma associated with life-threatening complications, functional impairment or ulceration or risk thereof, structural anomalies (e.g., in PHACE syndrome or LUMBAR syndrome), or permanent disfigurement is high risk. Once the hemangioma is classified as high risk, the patient should be evaluated by a hemangioma specialist as soon as possible.

·         Imaging should be done only when the diagnosis is uncertain, there are ≥5 cutaneous hemangiomas, or associated anatomic abnormalities are suspected. Ultrasonography is recommended as the initial imaging modality when the diagnosis of IH is uncertain. MRI may be done if associated structural abnormalities (e.g., PHACE syndrome or LUMBAR syndrome)

·         Oral propranolol (2-3 mg/kg/day) is the first-line agent for hemagiomas requiring systemic treatment; but, in the presence of comorbidities or adverse effects, a lower dose is recommended.

·         Propranolol is to be administered with or after feeding and doses be held at times of diminished oral intake or vomiting to reduce the risk of hypoglycemia.

·         Clinicians should evaluate patients for and educate caregivers about potential adverse effects of propranolol, including sleep disturbances, bronchial irritation, and clinically symptomatic bradycardia and hypotension.

·         When propranolol is contraindicated or response to propranolol is poor, oral prednisolone or prednisone may be used.

·         Intralesional injection of triamcinolone and/or betamethasone can be given to treat focal, bulky hemangiomas during proliferation or if they are located in  certain critical anatomic areas such as the lip.

·         In cases of thin and/ or superficial hemangiomas, topical timolol maleate may be prescribed.

·         Surgery and laser therapy may be indicated if the lesion has failed to improve with local wound care and/or pharmacotherapy; the lesion is well localized, and early surgery will simplify later reconstruction (e.g., a prominent hemangioma involving the ear or eyelid); the lesion is well localized in an anatomically favorable area or resection is likely to be necessary in the future, and the resultant scar would be the same

·         Clinicians should educate parents of infants with the hemangioma about the condition, including the expected natural history, and its potential for causing complications or disfigurement.

(Source: Krowchak DP, et al; Subcommittee on the Management of Infantile Hemangiomas. Pediatrics Dec 2018, e20183475; DOI: 10.1542/peds.2018-3475)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA