Brent Smith, PA-C, MMS, NCCPA

 by Dr. Andrew Schuman discussing the COVID-19 pandemic points out many issues and concerns that have been lingering in our medical world for a while. Everyone has a slightly different take on these issues according to their practice, history, and a dozen other factors, but I think that most can agree on the issues addressed in the article. From my perspective as a physician assistant, there are a few other issues that I think we need to address as a country as well.

The rise of social media and the Internet in general has given a voice to all people, for good or bad. This leads to one of the issues Schuman addressed: Much of the advice we are getting is not from people who work the front lines. Many, if not most, have little actual knowledge of what they are discussing. Sifting through the deluge of seemingly credible information to find the few good nuggets is tiresome. To make things worse, little is known about the current pandemic and recommendations change hour to hour. Staying current is a full-time job.

The COVID-19 pandemic reinforces our need to bring our manufacturing and production back home. Our dependence on others has led to huge shortages in medicines and equipment that threaten our ability to treat patients and to protect ourselves. Couple this with overregulation and our problems are multiplied exponentially. These are not new problems but problems that are now brought to the forefront.

Speaking of regulation, it’s time to modernize medicine in America. Outdated and archaic laws and regulations limit the usefulness of our advance practice practitioners. I believe we can have a team concept and still allow a broader scope of practice. We need a national standard to replace our state-to-state laws to provide consistency and allow our providers to utilize their talents to the fullest. Limiting what medications can be prescribed and what tests can be ordered hamstrings providers to a point that patients suffer, especially in rural and underserved areas. Necessity needs to lead to invention so we can fix our broken system.

Mr. Smith, Member-at-Large and Board Member for SPAP, received his Bachelor of Science in Biology from Georgia Southwestern College in Americus, Georgia, next attending the University of Georgia for master’s work in education and later Emory University Physician Assistant school from which he obtained his Master of Medical Science. 

In addition to membership in SPAP, Mr. Smith is also a member of the Georgia Association of Physician Assistants, American Academy of Physician Assistants, and the American Academy of Pediatrics. He is credentialed at Piedmont Columbus Regional Hospital where he chairs the Pediatric Preparedness Committee. He also is a Co-Trainer for the Pediatric Readiness Quality Collaborative, a national program through the Emergency Medical Services for Children.

In December of 2014, Mr. Smith earned a Certificate of Added Qualifications in Pediatrics from the National Commission on Certifications of Physician Assistants (NCCPA). This certification is in addition to his certification from the NCCPA and demonstrates knowledge and skills specific to pediatrics. He is married to Renee Smith, also a Physician Assistant, and they have one child, Emma.

Articles

Everyone has a slightly different take on the issues surrounding COVID-19 according to their practice, history, and a dozen other factors. These issues need to be addressed as a country.

COVID-19: A call to action

% and its correlation with more severe forms of asthma and as a predictor of poorer control of symptoms.

 The premise of the study is that bronchodilator response can be both a diagnostic test and a test to asses severity. Change in lung function test has been used historically as confirmation of a diagnosis of asthma, but the idea of the amount of change in FEV

The study measured both spirometry and fractional exhaled nitric oxide (FeNO) at baseline and then after bronchodilator administration. A change in over or equal to 12% in FEV

 was considered a positive test. Patients with higher reversibility were found to have more severe forms of asthma. Increased FeNO and secondhand smoke also were found to be related to more severe forms of asthma. These numbers are interesting but probably of little help to primary pediatric providers with the possible exception of FeNO testing.

Study is helpful but difficult to replicate

Most primary care providers struggle to obtain baseline spirometry testing due to many factors including lack of staff training, lack of affordable equipment, and time constraints. Testing spirometry after bronchodilators is an even more time-consuming process that most primary pediatric providers do not have time in their schedules to perform. Fractional exhaled nitric oxide testing in the primary care office is quick and relatively easy and can show many of the same things discussed in the article. Spirometry without bronchodilators and nitric oxide testing seem to be the mainstay of asthma testing in most primary care practices.

Pediatric pulmonology practices may find the study more useful and be able to study reversibility with more accuracy and consistency. Both sp

rometry and FeNO testing have an age limit of 6 years and older in this study and usually in practical application. Patients aged younger than 6 years often struggle with spirometry testing. Exhaled nitric oxide testing seems to a little easier for younger patients but still can be a challenge to obtain.

Testing such as spirometry and the nitric oxide test are only part of diagnosing and managing asthma. Thorough history and use of proven questionnaires such as the Asthma Control Test are essential.

Younger patients often are a challenge to diagnosis. Parents can be skeptical of the diagnosis and adherence to medications is often poor. I hope that in the future we will be able to diagnose asthma sooner and increase compliance in all age groups. 

Mr. Smith, Member-at-Large and Board Member for SPAP, received his Bachelor of Science in Biology from Georgia Southwestern College in Americus, Georgia, next attending the University of Georgia for master’s work in education and later Emory University Physician Assistant school from which he obtained his Master of Medical Science.

1. Zimlich R. Bronchodilators can help assess asthma severity. 

A recent study looking at bronchodilator response has potential, but it could prove difficult to perform in most primary care settings.

Practical assessment of asthma severity remains elusive

ooks at depression in preschool aged kids

. For many of us in pediatrics, depression and other related diagnoses can present a challenge. Our counterparts who treat adults see and treat depression more often and are often more comfortable with both diagnosis and treatment. I think this is partially because of something that Dr. Shapiro mentions in the article’s opening, we think of childhood as carefree and happy. Unfortunately, this is not always the case. 

Depression in this age group is a challenging diagnosis to make and often is a diagnosis of exclusion. From my personal experience and what the article mentions, stomach pains and headaches seem to be the most common physical symptoms that children with underlying depression display. These often lead to many office visits and missed preschool or daycare. It is interesting that not eating well is more common in this age group whereas overeating is more prevalent in older children and adults. I also found it very interesting that genetics do not play a bigger role in the younger patients as it seems to in the older children and adults. Age appropriate screening tools should help us with identifying these patients more efficiently. 

Anxiety and depression in this age group share many of the same signs and symptoms and separating 1 diagnosis from the other may be a hard task. Dr. Shapiro suggests that we do not need to know if it is 1 diagnosis or the other and instead concentrate on finding the underlying cause. I think most pediatric providers are watchful for external causes such as abuse, neglect, or other situations that may induce depression and or anxiety in this age. These causes seem to be identified more consistently and treated quicker.

I found it interesting that both the risk of suicide and the genetic expression of depression seem to increase around the age of puberty. Children that come from parents who both have a history of depression risk seem to see the chance go up greatly when they were aged around 12 to 13 years. This is also the timeframe where the risk of suicide increases. In our practice over the past few years, we have seen a significant increase in younger and younger children being referred to us to clear to return to school after making either suicidal or homicidal statements in school. Although I do not think that many of us feel truly comfortable clearing children’s return to school, it is good to know that there is a reduced risk in the younger population. Weeding through which patients can be cleared to return to school and which ones need to be further evaluated by a mental health provider has proven to increase anxiety in providers at my practice and also in myself. 

The author points out that the earlier onset of depression predicts an increase in episodes of depression later in life. I know that in many areas of the United States there is a shortage of mental health providers which makes referrals harder at times. Emergency departments (EDs) are seeing a large increase of children that need inpatient admissions, but an overall shortage of inpatient beds. I have heard of EDs having to board pediatric patients for up to 30 days in the ED before an inpatient bed becomes available. This burden spreads back out to the primary providers to help bridge the gap. In the past few years most of us have started prescribing antidepressant medications more and more. A great chart is included in the article that shows the US Food and Drug Administration-approved range for the most common medications. In the preschool age range, there are very few choices. I agree with the author that starting medications in this range may best be left to psychiatry providers. Referrals to psychology for treatment is probably appropriate in most if not all situations. 

Seeing the chief complaint of depression or anxiety can induce the same reaction in providers, but this article gives some great insight into identifying and treating these patients. Using the mentioned screening tools and an understanding of the risk factors should help us diagnose and treat this population better and hopefully reduce anxiety and depression in the provider as well.       

For many of us in pediatrics, depression and other related diagnoses can present a challenge. Our counterparts who treat adults see and treat depression more often and are often more comfortable with both diagnosis and treatment. It's time to work on this.

Becoming comfortable with diagnosing depression in pediatrics

, Pat F. Bass III, MD, MS, MPH, discusses measles and its hallmark signs and symptoms in his article “

Measles makes a comeback: What to know, what to do

.” For most of us practicing today, we have never seen the disease outside of a textbook or a website. A few years ago at the weekly meeting for providers at our practice, the subject of measles came up. Of the 10 practitioners at the meeting, only 3 had ever seen measles, and of those 3, none had seen it in the past 25 or more years. It made me wonder if I would be able to diagnosis it if the time came. As far as I know, I have never missed a case of measles, nor has anyone else in our office, but with numbers trending up, would that change?

We all probably remember the prodrome for measles consist of the 3 C’s, coryza, cough, and conjunctivitis from boards or school. The problem here is, during flu season, that could look like just about every child. I don’t think there are enough negative pressure rooms to go around. Even during the summer, we get plenty of children who fit this description. Speaking of boards, I think every time I have taken them, I get a question on Koplik spots, the pathognomonic sign for measles-or so we have been told for 50 or more years. Talking to providers who have seen real cases of measles, not one has ever seen a Koplik spot. Were they there and the providers missed them because they are a whopping 1mm to 3mm?  I don’t know, but from what I gather, it’s going to be fairly useless in helping to diagnose measles. 

So, what can we do to improve our odds of correctly diagnosing measles?  I think Ebola helped us out here. We got into the habit of asking about travel, exposures, and immunizations, and that is a habit we can extend to measles. In general, most cases have been in unvaccinated or under-vaccinated individuals. Asking about or checking on immunization status for all visits will remind us about the risk and maybe catch a few patients who have fallen through the cracks. Washington state, Oregon, and New York have all had large outbreaks. Asking about travel to areas of known outbreaks, like we did with Ebola, can help keep measles on our radar. We also need to think about the measles, mumps, and rubella (MMR) vaccine as a travel vaccine for patients who are not fully vaccinated.  The MMR vaccine can be given to an infant as early as 6 months of age (remember you still give the normal dose at 12-15 months).  For travelers aged older than 1 year, a second dose can be given 28 days after the first. Titers can always be drawn when there is a question of immunity, but I would advocate that, when in doubt, give it. 

If you diagnosis a case of measles, you are probably going to have more help than you want. Between public health officials, the infectious disease department, and probably the Centers for Disease Control and Prevention, you will have plenty of people with their fingers in the pie. Dr. Bass’ article brings up many aspects of treatment that would be important if and when the case arises.  A more probable scenario would be if and when to start post-exposure prophylaxis. Do you wait on titers or a confirmatory test to come back? Or go ahead and treat? I would think that input from public health officials and maybe infectious disease specialists would be important in this situation, but there is a time concern to think about. Per the article, you can give the MMR vaccine to children aged 6 months and older when they are under 72 hours post-exposure, and intramuscular immune globulin when under 6 days post-exposure. 

I hope some good will come from the current outbreak and we will see less vaccine resistance, but that is covered in the next article!

In the July 2019 edition of Contemporary Pediatrics, Pat F. Bass III, MD, MS, MPH, discusses measles and its hallmark signs and symptoms. For most of us practicing today, we have never seen the disease outside of a textbook or a website.

Spotting the Unicorn-Measles in 2019

I literally grew up between peanut fields in southwest Georgia and didn’t know anyone who had a peanut allergy.  It was a foreign concept in the area I lived. Granted this was a few years ago, but it does bring up the question about early exposure to peanuts and other allergens. Dust from peanuts being picked blew everywhere not to mention that just about every parent fed their child peanuts in some form. Was this enough exposure early in life to prevent an allergy to peanuts? New guidelines calling for earlier exposure to peanuts and our lack of utilizing these guidelines are discussed this month in an article by Rachael Zimlich, RN, BSN, entitled 

“Paradigm shift on peanut introduction tough to swallow.”

 The guidelines may be new, but the issues related to them are not. Time and understanding seem to be the recurring reasons for lack of implementation for most new guidelines.

Well checks are busy. There is no way around this fact. There are many things that must be accomplished in 20 minutes. I was told recently by a parent that we were killing her with “death by a thousand surveys”. In our office, the 4-month checkup has 5 surveys the parent must complete and the 6-month has 6, all with multiple questions. Adding another survey or guideline is not going to be easy. A provider can easily spend the allotted 20 minutes given for the well check just going over surveys.

The first and third abstracts reviewed in the article addressed the reluctance to implement current allergy guidelines. The main barrier here seems to be time and not reluctance to adopt to new guidelines. However, I think there is a measure of reluctance to take on the responsibility of addressing a topic that the provider is potentially uncomfortable discussing.

The second abstract reviewed discussed a retrospective study of 100 infants aged younger than 11 months who were tested for peanut allergies. This study seems to be of limited use in determining if guidelines are met since the inclusion criteria was only if the patients were tested for peanut allergies without mention of whether the provider who referred the patient was aware of the guidelines.

Only 40% of those referred met the National Institute of Allergy and Infectious Disease screening guidelines, but 100% had mild-to-moderate eczema. Per the addendum, severe eczema is a reason to do skin prick or immunoglobulin E testing. Determining moderate from severe eczema is a very subjective thing. Also, many primary care providers are not set up to do skin prick testing and parents are reluctant to have blood drawn for any reason. I think most providers would refer patients who have significant eczema and a concern about peanut allergies to their local allergist. The abstract also mentions that 52% were referred for a family history of peanut allergies which seems to be logical. Referrals in these patients do not seem out of place and are probably to allay parental concerns.

Change is often slow, and these new guidelines are a significant shift from previous recommendations. The strains and time constraints placed on providers are not going away and new recommendations and requirements, such as fluoride varnish that I discussed in 

, will need to be incorporated into our visits. Change will happen, but probably not as fast as many would like. I do find it ironic that, looking back, the rise in peanut allergies in the public may be because we told parents not to give their children peanuts until later in life, which is the opposite from the findings of the 

Learning Early About Peanut Allergy (LEAP) study

. So now, we need to work on fixing our mistakes.  

What's the reason behind the lack of following the newest peanut introduction guidelines? Brent Smith, PA-C, MMS, NCCPA, argues that the recurring reasons come back to a lack of time and understanding.

The new guidelines time squeeze

This is the first in a series of commentaries penned each month by leaders from Contemporary Pediatrics’ new content partner, the Society for Physician Assistants in Pediatrics (SPAP). 

Mr. Smith, Member-at-Large and Board Member for SPAP, received his Bachelor of Science in Biology from Georgia Southwestern College in Americus, Georgia, next attending the University of Georgia for master’s work in education and later Emory University Physician Assistant school from which he obtained his Master of Medical Science. 

“Pediatric oral health: Fluoride use recommendation”

 discusses current recommendations and best practices in oral health for the primary provider. I think we have all encountered patients with caries and other dental issues and discussed with the patients and caregiver the importance of dental visits and brushing their teeth. What else should we be doing?  In this article and 

, the authors,  Michelle Dalal, MD, Melinda Clark, MD, and Rocio B QuiÃ±onez, DMD, MS, MPH, help us to understand where we fit in with regard to dental care.

The American Academy of Pediatrics (AAP) recommends that all patients see a dentist by 12 months of age, but in reality, this does not happen. Very few dentists in the area where I work will see kids at 12 months, and most say they will start seeing the patients only after they turn 3 years old. This leaves a long timeframe without dental care and primary care can help fill the void.

Recently, the office I work in started applying fluoride varnish to patients that have not been to the dentist. We start applying varnish at the 12-month or 15-month well check if the patient has 4 upper teeth.  We will then reapply in 6 months until they see a dentist.

In short, this practice can be a challenge. These visits can be hard enough without trying to dry and paint the patient’s teeth. I have found that enlisting the caregiver in assisting with holding and applying the varnish serves 2 purposes. First, you just need extra hands. Providers are accustomed to finding ways to check ears and such, but applying something to teeth is a new adventure and we can use all the help we can get. Secondly, it gives you a good chance to interact with the caregiver and educate on the importance of dental visits and brushing.

Dietary fluoride supplementation is something I think that we as providers often forget to discuss. We often assume that patients live in an area where the water is fluorinated and forget that some of our patients have well water at home, which  can also be a risk factor for lead, but that is another article.  It is recommended by AAP to start supplementing with fluoride by age 6 months if the patient does not have a fluorinated source of water. This also can be tough to sell to caregiver when the child does not have teeth. For the reluctant caregiver, I will often tell them we can readdress when the child breaks the first teeth. 

On occasion, you will have a caregiver who has concerns about fluorosis.  The article authors touch on this and discuss giving only a small amount of toothpaste to children aged younger than 3 years and not allowing them to brush unsupervised, as well as checking patients’ water sources to be sure they do not contain fluoride before we prescribe supplements. Reassure the caregiver that, if any discoloration occurs, it is minor when compared to the destruction dental caries can cause and that the discoloration does not carry over to their child’s permanent teeth.

Primary care pediatric providers have a lot on their plates. Surveys, checklists, immunizations, sports forms, and a myriad of other things make up what we need to get done in that 10 to 20 minute well check. Dental health has to be a part of what we address at every well check with attention to dental visits, brushing their teeth, and ascertaining if they have fluorinated water sources. Per the article, dental caries may be reduced by up to 59% with the addition of fluoride varnish and its application needs to become part of our very busy well check. 

We have all encountered patients with caries and other dental issues and discussed with the patients and caregiver the importance of dental visits and brushing their teeth. What else should we be doing?

Brent Smith, PA-C, MMS, NCCPA

Articles

COVID-19: A call to action

Practical assessment of asthma severity remains elusive

Becoming comfortable with diagnosing depression in pediatrics

Spotting the Unicorn-Measles in 2019

The new guidelines time squeeze

Dental care in primary practice: Where we fit in