Juvenile Underwriting

Dr. Jeffrey C. Hoschek, FAAP, MD

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Premature Infants

Asthma

ADHD

Obesity

Juvenile Underwriting

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The number of excess deaths per 1000 predicted by a given mortality ratio is far smaller in children (after the 1st year of life) than in later life.

Because the incidence of life threatening disease is very low after the first year of life, the proportion of screening tests that reveal pertinent information that affects mortality risk is much lower in children.

Aren’t kids just little people?

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Preterm is defined by <37 weeks GA

Higher incidence of Premature Births due to ART and Twin Births

(1/2 twins, 90% triplets)

Account for 1/3 of all infant deaths in USA

<25 WK GA is the highest mortality rate at 50%

<2 grams weight account for >60% of all deaths

Male >>> Females

African Americans are highest ethnic group

Premature Infant Mortality FACTS!

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Maternal- Age, Tobacco, HTN, Anemia, DM, Preeclampsia, Stress, Substance

abuse Cervical and Uterine malformations, ART (in vitro)

Fetal- Twin gestation, Congenital anomalies, Growth Restriction, Fetal infection, Fetal

distress (placental problems)

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INFANT MORTALITY RATES (PER 1000 LIVE BIRTHS) –

WEIGHT/AGE

WEIGHT >2500 GMS - 22000-2499 - 101500-1999 - 251250-1499 - 401000-1249 - 62750-999 - 125500-749 - 394<500 - 853

GESTATIONAL AGE 40 WEEKS GA - 1.7534-39 - 2 to 728-33 - 16-35<28 weeks - 375

The younger, smaller babies have a higher mortality overall.

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Long Term Complications of Preterm Infants

Respiratory Bronchopulmonary

DysplasiaAsthmaRecurrent InfectionsApnea of PrematurityHypoxiaFailure to Thrive

GastrointestinalGERDNECMalrotation (twisted)Enteric InfectionsGastroenteritisFailure to

Thrive/Growth Deficits

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Long Term Complications of Preterm Infants

EnvironmentalSIDSNeglect/AbuseFetal Alcohol

SyndromeDrug WithdrawalPoor Access to

Healthcare needs due to cost $$$

EndocrinologicalGrowth Hormone

DeficiencyAdult DiabetesDecreased Fertility as

AdultsHypertension

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Long Term Complications of Preterm Infants

NeurologicalBlindnessDeafnessHIE/IVH – Brain BleedsSeizuresCerebral Palsy (CP)Developmental Delay

MOST COMMON CAUSE OF CHRONIC PROBLEMS

45% have CP35% have vision issues25% have hearing issues

ALL increase with younger and smaller babies

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Neurological Issues &

Prematurity

Those with HIE (brain bleeds) have the most risk for seizures, CP, developmental delay (both motor and cognitive functioning), and recurrent hospitalizations, compared to premature infants who do not have HIE.

There is an increased risk of low IQ in adolescence (up to 20 points lower), developmental needs and major depressive disorder and ADHD.

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Neurological Issues &

Prematurity

Cerebral Palsy – A primarily neuro-motor abnormality due to an insult to the central nervous system either in utero or shortly after birth. It has a variable presentation and can range from fully functional to profound and severe. There are multiple causes and it requires a multidisciplinary team to care for these children. Their morbidity and mortality depends on severity and the presence of seizures.

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LONG TERM COMPLICATIONS OF

PREMATURE INFANTS – SUMMARY POINTS

Premature infant births are on the rise and you will be seeing more of them

The increase in premature births and improved survival rate have outpaced any concomitant decrease in the rate of long-term neurodevelopmental sequelae.

Premature infants have special needs both in the short term and throughout the adolescent period into adulthood, the most significant being neurodevelopmental.

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Pediatric Asthma

A condition consisting of wheezing, breathlessness and respiratory compromise of varying degree, most often presenting for the first time in children <5 years old (80% of asthma)

The majority of children who present with wheezing under the age of 2 do not go on to develop asthma

THIS LEADS TO A DIAGNOSTIC DILEMMA

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Pediatric Asthma

15% of all children under 2 years old will present as outpatients with wheezing and 3% require hospitalization

RSV and other respiratory viruses are the cause of wheezing in the vast majority of these cases, but there are other risk factors increasing the risk of airway hyper responsiveness and the actual cause of asthma is multifactorial and still not entirely known

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What risk factors predispose a little

wheezer to get asthma?

RISK FACTORS FOR ASTHMA

RSV and Rhino viral infections

Cigarette smoke (major risk)

PreTerm Infants (reduced lung function)

Daycare attendance

Pet exposure

Family History of Asthma/Atopy/Eczema

Environmental (pollution, humidity, grasses)

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Everything that wheezes is not asthma!

Laryngomalacia/Tracheomalacia

Croup Aspiration

Foreign Body Cancers of the airway

GERD PE

Vascular Rings Congenital

malformations

Cystic Fibrosis Bronchiectasis

Vocal Cord Dysfunction and more!!

URI/Bronchiolitis

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How to diagnose Asthma?

History of intermittent or chronic symptoms

typical of asthma PLUS physical examination

findings (present when symptomatic and gone

when not) strongly point toward the diagnosis

of asthma – by definition it is “reversible”.

1. Spirometry to show variable airflow limitation

2. Reversibility of obstruction

3. Exclusion of other causes of wheezing

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How to diagnose Asthma?

Spirometry – Must show obstruction and reversibility, but cannot reliably be done on children under 5 years of age (because it is effort dependent)

An abnormal spirometry rules in Asthma

A normal spirometry does not rule out Asthma

If required a Methacholine Challenge Test or Bronchprovocation Testing is used to confirm the diagnosis.

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Spirometry 101

FEV1 – forced expiratory volume in 1 second

FVC – forced vital capacity

Obstruction is FEV1 <80% of predicted for age, sex, height AND FEV1/FVC <85%

The ratio is a more sensitive measure of impairment and the FEV1 is a useful measure

of risk for future exacerbations.

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Spirometry 101

Reversibility is an improvement of the FEV1 by > 12%

after administration of albuterol.

Peak Inspiratory Flow meters are effort dependent and

we don’t use them for diagnosis but more for monitoring

a patient’s symptoms.

Asthma Severity Index Questionnaires are fairly

predictive of disease state and more reliable.

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What about those children under 5 years

of age?

Spirometry isn’t reliable, and so clinical judgment and a trial of asthma medications helps to establish the diagnosis.

- Allergy Testing is helpful when used selectively

- CXR may help to rule out other causes

- Sweat chloride testing should also be done even if newborn screening is normal

- Clinical judgment is the most important factor

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What about those children under 5 years

of age?

Reactive Airway Disease

Wheezy Bronchitis

Bronchiolitis

Asthmatic Bronchitis

Wheezing-Associated Respiratory Illness

Post infectious Bronchial Hyper reactivity

These all imply a benign process whereas Asthma is a

chronic condition with worse prognosis and spontaneous

resolution.

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Assessing Severity and Control of Asthma

Based on Age, Symptoms and Frequency of Exacerbations

A. 0-4 year olds, 5-11 year olds, >12 years old

B. Symptoms, Nighttime awakening, use of Albuterol, and interference with activity

C. Exacerbations requiring oral steroids

D. Hospitalizations

SEE ASTHMA SEVERITY AND CONTROL HANDOUT

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Asthma- Summary Points

Everything that wheezes is not asthma and not all little wheezers will develop asthma

The diagnostic approach still relies on strong clinical judgment, especially for those children younger than 5.

Most cases are evaluated on a case by case basis and must be in very good control for consideration, especially the younger children.

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Asthma- Summary Points

Unfavorable Asthma Factors

1. Premature Birth or Less than 2 years old

2. Moderate to Severe Control

3. Tobacco Exposure

4. Poor adherence to medical management

5. Hospitalization > 2 times in past year

6. ER visits >3 in past year

7. Life threatening episode (Intubation) less than 2 years ago

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Attention Deficit Hyperactivity

Disorder

Attention deficit disorder (ADD) and Attention deficit hyperactivity disorder (ADHD) present in early childhood with parent and teacher concerns centered upon:

-Short attention span and inattentiveness

-Impulsivity

-Increased motor activity

-Impaired executive function

-Difficulty with response inhibition

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Attention Deficit Hyperactivity

Disorder

Can be diagnosed as early as 3 years old, but most diagnosed by early school years and symptoms MUST be present before 12 years old

Males >>> Females

~9.5% of all children between 4-17 years of age (5.5 million children) have been diagnosed

Symptoms affect cognitive, academic, behavioral, emotional and social functioning

Symptoms MUST be present and cause dysfunction in all settings: school, home, day care

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What causes ADD/ADHD?

Maternal Alcohol, Tobacco and Substance Abuse

Prematurity and Low Birth Weight

Genetic Predisposition

Exposure to toxins (Lead)

Early childhood neglect/abuse

Key: Multifactorial in nature!

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Associated Problems with ADD/ADHD

Learning disabilities (25%)

Language disorders (35%)

Mood disorders (20%)

Anxiety disorders (25%)

–7x more likely to be diagnosed with BPD

–5x more likely to be diagnosed with depression

–4x more likely to be diagnosed with anxiety

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Associated Problems with ADD/ADHD

Young adults with ADHD have 70% increase risk of MVA and “at fault accidents”

Higher rate of injuries as a pedestrian or bicyclists but LOWER rates of sports injuries

50% higher rate of hospitalizations in general

Adolescent substance abuse is higher but treatment with medication DECREASES that risk

Twice the risk of tobacco abuse in these kids

Higher risk of Oppositional Defiant Disorder and Conduct Disorder (Girls and Boys respectively)

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Treatment and Prognosis of ADD/ADHD

Younger children (4-5 yo)- Behavioral Therapy

Children 6-11 yo- Stimulant medication +

therapy (parent and/or teacher) Stimulant medication is particularly helpful

Adolescents 12-18 yo- Stimulant + Behavioral

No laboratory workup nor cardiac workup is necessary before initiating therapy for ADHD

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Treatment and Prognosis of ADD/ADHD

Methylphenidate

Dextroamphetamine

Concerta, Ritalin, Focalin, Adderall, Vyvanse

Daytrana

Atomoxetine

Intuniv

Side Effects

Tachycardia

Elevated BP

Irritability

Insomnia

Weight Loss/Appetite suppression

Unmasking TIC disorders

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Treatment and Prognosis of

ADD/ADHD-Summary Points

Symptoms tend to diminish over time and many children improve significantly by early adulthood and cease to require medications, but others do require ongoing therapy.

The key factor is it’s comorbid association with other psychiatric and behavioral disorders and how it affects their long term morbidity and mortality.

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Childhood Obesity

Obesity is defined as having a BMI >95th%ile

Overweight is having a BMI between 85-95%ile

(SEE HANDOUT FOR SAMPLE BMI CHARTS)

-These conditions are prevalent in up to 35% of today’s youth.

-MULTIPLE ASSOCIATED CHILDHOOD AND ADULT MEDICAL ILLNESSES ASSOCIATED WITH OBESITY

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Childhood Obesity

From 1990 to 2010 the incidence has increased 5 fold

One Obese Parent – 40% chance child will be and Both Obese Parents – 80% chance

Multiple risk factors – maternal DM, maternal obesity, not breast feeding, introducing juice or solid foods too early (<4-6 months), television, media, lack of safe places to play, single parent working families

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Childhood ObesityComplications

1. Hypertension and LVH

2. Hyperlipidemia

3. Early CAD

4. Obstructive Sleep Apnea

5. Asthma

6. Exercise Intolerance

7. Type 2 DM

8. Pubertal Issues

9. PCOS

10.Slipped Capital Femoral Epiphysis

11.Blount’s Disease

12.Fatty Liver and Cirrhosis

13.Gallstones

14.GERD

15.Acne

16.Pseudo tumor cerebri

17.Risk of CVA

18.Risk of Cancers

19.Metabolic Syndrome

20.Risk for Premature Death

21.MORE!!

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Childhood ObesityComplications

Obese children are 3 times more likely to require hospitalization

Odds Ratio for obesity at 35 is high those between 10-18 years old

Current cost of care for obese youth is 14,000,000,000.00 annually

100,000 –Predicted number of new heart disease patients by 2035 due to childhood obesity epidemic

This is the first generation of children that are predicted to have a shorter life span than their parents and grandparents by 3-6 years

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What to look for in Childhood Obesity

Cases-Summary Points

Following BMI trends is very important, because obese children don’t “grow out of it”

Making sure they have been properly screened for blood pressure, diabetes, thyroid disease at least by the age of 5 years old

They are actively being managed to maintain a healthy weight and lifestyle. This includes parent and child education and behavioral modification and close follow up.

Success rates are about 35% for obese children which are much better than the rates for adults.

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QUESTIONS????

THANK YOU!.... and