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Region 8 EMS

Continuing Education

April 2009

Pediatric Disorders of Today

Let’s face it—EMS is a perfect fit for those of us who have a short attention span (Hey!

I’m talking here!) and need immediate gratification for our actions. We can honestly

say that we like helping people, and eagerly await the results of our interventions.

Knowing how to secure spider straps, start an IV, terminate some abnormal heart

rhythm…all of these (and many more) are skills which enable us to care for our

patients. It is equally as important to be current on events, disease conditions and

trends because sooner or later, these things will affect how we deliver patient care.

The focus of this month’s C.E. will be on two disorders affecting the pediatric

population: Autism and Obesity.

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OBJECTIVES:

I. Autism1. Define Autism and list distinctive behaviors and other symptoms

which typically characterize this disorder.

2. List developmental milestones of children, and how they relate to

assessing overall wellness of the pediatric patient.

3. State prehospital considerations when assessing/caring for and

interacting with autistic individuals.

II. Childhood Obesity1. List factors which contribute to childhood obesity.

2. State physiologic and psychological consequences of obesity in the

pediatric patient.

3. List actions for resolution of childhood obesity.

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AUTISM

APRIL IS NATIONAL AUTISM AWARENESS

MONTH

For many, the movie “Rainman” provided the first exposure of what we know now as

autism. Certainly, the past decade has seen a rise in autism awareness. This disorder

has gotten much attention from the media, parents and the medical community. A

complex disorder affecting so many, we have seen parents and some of the world’s

most respected professionals working tirelessly to find the cause(s) of autism, and a

cure for all.

STATISTICS

Current studies suggest the incidence of autism is 1:150 children ages 10 andyounger.

Males are affected 4x more than females Autism is 5x as common as Down Syndrome, and 3x as common as juvenile

diabetes

WHAT EXACTLY IS AUTISM?Autism is a general term used to describe a spectrum of developmental disorders.These are also referred to as Autism Spectrum Disorders (ASD). Autism is classified as

a “spectrum” disorder, because there is a wide range not only of the symptoms andbehaviors, but also differences in their severity. These disorders affect the child’s ability

to interact and communicate with others, and can also interfere with their ability tolearn and play. The signs and symptoms of autism typically present during the firstthree years of life.

Autism is characterized by three distinctive behaviors, which can range from mild tocompletely disabling. These behaviors are:

Impaired social interaction Problems with verbal and non-verbal communication Unusual, repetitive or severely limited activities and interests

IMPAIRED SOCIAL INTERACTION

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The hallmark feature of autism is impaired social interaction, and is usually one of the

first symptoms noticed first by the parents. The onset of this symptom differs fromchild to child.

Some children demonstrate impaired social interaction from infancy. These behaviorsinclude failure to respond to their name, or not smiling in recognition of their parents’faces. When this occurs, many parents suspect that the child has a hearing deficit and

seek a medical evaluation. Other behaviors include fixation on one object, and

resistance to being cuddled or hugged.

Other autistic children begin to withdraw from social interaction after a seeminglynormal developmental period. Imagine what this must be like for these parents. Manyparents will comment that their normally happy, and interactive child “disappeared.”

These children prefer to play alone, do not make eye contact with others, and seem tolive in a world of their own.

PROBLEMS WITH VERBAL AND NON-VERBAL COMMUNICATIONCommunication skills in children with autism develop much differently than in other

children. And, as previously mentioned, symptom severity differs from child to child.

Verbal CommunicationSome children will remain mute, whereas others will speak in a sort of sing-song voice.If you grew up in a household with other children (or perhaps are raising your own

family), does this sound familiar?...”MOM! Tell (insert name of sibling here)

__________ to stop copying what I say!!” Echolalia is the term used to describe this

“copying” or “echoing” of word(s), and is another feature observed in those individualsaffected by autism. Speech tends to develop later in children with autism, and manytimes the child will refer to themselves by name (rather than “I” or “me”). The topics ofconversation are usually limited to very narrow areas or interests; and there is littleregard to another’s participation in the conversation.

Non-verbal communicationThese children also avoid eye contact with others. They are unable to interpret non-verbal and social cues, such as reading facial expressions and body language, while also

A thorough hearing exam is necessary prior to diagnosing achild with autism.

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having difficulties interpreting what others think or feel. To many, these children

appear to lack empathy.

UNUSUAL, REPETITVE OR SEVERELY LIMITED ACTIVITIES AND INTERESTSAutistic children are extremely resistant to change. They prefer to maintain setenvironments and schedules. Many times, they engage in ritualistic and/or repetitivebehaviors, such as rocking, spinning/twirling, and arm flapping. Disruption of these

routines or rituals can lead to tantrums, and/or inconsolable crying spells.

Many autistic children also demonstrate decreased sensitivity to pain. They mayengage in self-injurious activities, such as biting and head-banging, especially whenthey are frustrated or exposed to a stressor. Despite this apparent heightened painthreshold, children with autism can be very sensitive to sensory stimulation, such as

sound and touch. Loud noises, bright lights, and even hugging or cuddling thesechildren appears to be very painful for them, and may provoke crisis. These childrenmay also exhibit unpredictable behaviors such as tantrums and hyperactivity.Remember some of these children lack the verbal skills to communicate their distress.They then “act out” as a means of communication.

An area of major concern is that autistic children tend to have poor judgment skills,such as running into a busy street without fear. Consequently, they are perpetually atrisk for danger; and require close supervision.

WHAT CAUSES AUTISM?There are no certain causes for autism. In the “olden days,” maternal behaviors were

blamed for the social withdrawal associated with autistic children. These moms werelabeled as “refrigerator mothers” and it was supposedly due to their cold and unfeelingrelationship with their children that caused these kids to become socially withdrawn.

This has since been disproved, yet it wasn’t until the 1970’s that other possibilitiescausing the disorder were investigated.

Since then, many theories have been proposed, and research has investigated possibleunderlying neurologic, genetic, physiologic and environmental causes of autism. It is acomplex and puzzling disorder, with its spectrum of symptoms, and varying time ofonset amongst individuals. Several studies point to the role of genetics in causing

Sometimes these children will run away from people or things which theyperceive as stressful. These “runners” also tend to be very attracted to water.

First responders should always check nearby swimming pools or bodies ofwater in the event you are dispatched to a scene involving such an individual

who is missing.

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autism. Researchers have identified a number of genes associated with the disorder,

but have not isolated which gene(s) are directly responsible for causing the symptoms.

Epidemiology, the study of factors affecting health and illness of populations(Wikipedia.com), is what flags many areas in need of research. Consequently, the fuelfor a huge chunk of research stems from the incidence of autistic symptoms developing12-15 months after birth. Prior to 1990, approximately 2/3 of autistic children were

autistic from birth. After the 1980’s, the trend actually reversed; and 2/3 of autistic

children became autistic in their second year of life. (Adams, et. al, 2008)

Due to this shift in the onset of autistic symptoms, many scientists believe that while

genetics appear to play a large role, it is the exposure to certain environmental toxins(such as mercury and pesticides) that causes the onset of symptoms.YouTube contains several clips filmed by the parents of autistic children. Many of themshow images of the “normal, joyous, and interactive” child; and in the next frame, showthe progression of the autistic symptoms.

OTHER INTERESTING RESEARCH FINDINGS: Blood from umbilical cords has been examined. Results revealed that certain

pollutants and chemicals are able to pass through the placental barrier. Studies have found irregularities in several regions of the brain in people with

autism.

Studies suggest that people with autism have abnormal levels of serotonin orother neurotransmitters in the brain.

Studies of identical twins show there is a much greater probability of them beingautistic than fraternal twins.

Parents with an autistic child have an increased likelihood that their futurechildren will also develop autism.

HOW IS AUTISM DIAGNOSED?

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Diagnosing a child with autism doesn’t come about from one single trip to the

pediatrician. Typically, parents are the first link in identifying behaviors demonstrated

by autistic children. Most parents/caregivers have a general knowledge of what

developmental tasks children should be capable of by a certain age. This knowledge

comes from previous experience with children, or by observing how other babies

behave in comparison to their own. These tasks/behaviors are also known as

developmental milestones. Failure to reach developmental milestones (such as social

smiling, cooing, and babbling) or regression from these milestones indicates the need

for further investigation.

DEVELOPMENTAL MILESTONES AND YOU

Anyone caring for pediatric patients

must know important developmental

milestones because they influence

both the assessment and treatment of

these patients. But it doesn’t stop

there. Our knowledge and

responsibilities as pre-hospital

providers/health care workers

extend into our personal lives as well.

How many times have you been

asked by various friends and family

members to “take a look” at

something? How ‘bout when you’re

out to dinner? The elderly guy at the

next table is having a coughing fit,

and you’re thinking about what size ET tube you could stick down his throat. Or when

you’re sitting in a movie theatre, you’re scanning the room for the emergency exits. We

are always assessing and planning our interventions. Most of us don’t even realize

we’re doing it because it’s become automatic!

Every piece of knowledge we learn has to do with PEOPLE. People who become our

patients by calling us to help them. People who become our patients by default: i.e.

the coughing guy in the restaurant, and by sheer closeness, our neighbors, parents,

nieces, nephews and even our own children. While noting abnormal or delayed

development may not bring about the adrenaline rush you may feel after a structure fire

or successful resuscitation, its importance should not be overlooked. Think about the

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impact that reporting your observations could have not only on an individual, but on

an entire family!

(For more details go to www.cdc.gov/ncbddd/autism/actearly/milestones)

Just because an individual is diagnosed as autistic, does not infer that they have mental

disability. Mental retardation can be found in autistic individuals, as it can in any other.

Autism does not mean that these children are incapable of learning. They simply

process information differently. Sometimes, autistic children will be especially (and

surprisingly) brilliant at some skill or task, such as: playing a piece of music on the

piano after hearing it one time, painting/drawing, or other skills involving memory.

“Autistic savant” is another way of referring to such a child.

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DEVELOPMENTAL MILESTONES

By the end of 3 Months,

children:

Begin to develop a

social smile

Watch faces intently

Follow moving objects

Smile at the sound of

your voice

Begin to babble and

imitate some sounds

Turn their head towards

the direction of sound

By the end of 7 Months,

children:

Enjoy social play

Respond to their own

name

Use their voice to

express joy and

displeasure

Respond to other

people’s expressions of

emotions

Appear joyful often

Babble chains of sounds

By the end of 12

Months, children:

Cry when mom or dad

leave

May be fearful in some

situations

Develop “stranger

danger”

Respond to simple

verbal requests

Babble with inflection

(changing tones)

Try to imitate words

By the end of 24 Months,

children:

Get excited about

company of other

children

Imitate behavior of

others

Use simple phrases and

2-4 word sentences

Follow simple

instructions

Repeat words overheard

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Screening tools have been developed to assist in the initial phases of diagnosing autism.

While some details contained in these screening tools may slightly differ, included are:

a series of questions to ask the parents/caregivers, and/or areas for direct observation

of the individual regarding social interaction of the child and their communication

skills. Based on this information, referrals to a multi-disciplinary team (including, but

not limited to: psychologists, neurologists, other specialists) is instituted.

Autism’s symptoms can overlap with those of other diseases/disorders. Consequently,

diagnosing an individual with autism requires ruling out other possible causes, such as

brain tumors, metabolic disorders, hearing deficits and seizures.

TREATMENTS FOR AUTISM

There are no known cures for autism. Treatment for this disorder is based on the type

and severity of symptoms the child shows. The most effective treatment plans are

pointed at treating the three primary symptoms of autism.

EDUCATIONAL AND BEHAVIORAL TREATMENTS

Educational and Behavioral Treatments are key ingredients in maximizing these

children’s potential. Sessions are very structured and aimed at helping the child to

develop skills in socialization and language. More and more, specialized schools and

treatment programs for autistic individuals have come into existence in our

communities.

PREHOSPITAL CONSIDERATIONS

Education for first responders/prehospital personnel has become an important focus

for autism advocacy groups. Included in the live C.E. sessions is a pamphlet designed

for paramedics and ER staff by the Autism Society of America . It briefly defines

autism, and some common characteristics/behaviors of the autistic individual. Most

importantly, the pamphlet lists some effective measures to implement when responding

to an individual with autism. (For those on-line C.E.-ers, log onto http://www.autism-

society.org/site/DocServer/Paramedics_and_Emergency_Room_Staff.pdf?docID=1094

2 and you will be able to print a copy of the PDF file for this pamphlet)

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Families of autistic children, much like those of chronically ill or other special needs

children are a wonderful resource to utilize during your assessment/treatments. They

tend to be very detail oriented, and are extremely knowledgeable about their child’s

symptoms, and behavior. Remember that many autistic individuals are highly resistant

to change, touch and loud noises…all things that are common elements of emergency

care. Obviously if there’s a life or death situation, all bets are off; but if time permits,

follow the suggestions offered by the caregiver. They know the most effective ways to

calm their child, and allow you to do your job.

In addition to the previously mentioned symptoms, children with autism often suffer

other maladies. These include: ADHD, Obsessive-compulsive disorders, food allergies,

pica, seizures and depression. Treatment varies, according to practitioner and the

severity of symptoms.

MEDICATIONS

Autistic individuals may be prescribed medications by their physician to alleviate some

of their symptoms.

Anti-depressants help with depressive symptoms, and sometimes with

obsessive-compulsive behaviors

o Prozac, Zoloft

Anti-psychotics may also be used to help with anxiety, impulsiveness or

aggression

o Risperidone(Risperdal), Zyprexa

Stimulant drugs for treating hyperactivity disorders

o Ritalin, Adderall, Concerta

Anti-convulsants for treating seizures

o Dilantin, Tegretol, Depakene

SEIZURES AND AUTISM

PicaWhen a person eats non-food items, it is called pica. Chalk,

dirt, sand and paint are some examples. 30% of autistic

children have moderate to severe pica.

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For reasons not yet fully understood, seizure disorders are present in 20-35% of autistic

individuals. The incidence of the seizures increase as the child gets older, so one

thought is that hormones contribute to the onset of the seizures. (Epilepsy Ontario.org)

As with other symptoms observed in children with autism, the severity of seizures

differs as well. Some individuals do suffer grand mal seizures; those types of seizures

we frequently encounter in EMS. They are preceded by an aura, and usually have that

post-ictal phase; where the child is unresponsive to others, or does not immediately

resume their normal activity. On the opposite end of the spectrum are those children

who suffer milder forms of seizures; and they demonstrate a variety of different actions

or behaviors. Some symptoms seen in these milder seizures include staring off into

space, a sort of absence seizure. Still others demonstrate what are classified as

subclinical seizures, and are associated with symptoms such as: tantrums, aggression,

and/or losing some behavioral and/or cognitive gains.

Stop. Rewind. That’s no typo. Subclinical seizures can present as just like some of the

behaviors which are commonly observed in the autistic individual. A thorough history

is needed to distinguish these behaviors from subclinical seizures. Seizures do not

necessarily require a trigger event; they can just suddenly occur. If these behaviors are

thought to result from fear or frustration, they are not seizures. Again, the child’s

caregiver will be of great value in deciphering such information.

OTHER PROMISING TREATMENTS

A group of physicians, many of whom are parents to autistic children are investigating

methods (biomedical treatments) for treating autism, such as special diets and

supplements. This program is called the Defeat Autism Now! (DAN!®) program.

One of the methodologies utilized include chelation therapy, which removes heavy

metals from the body. Many physicians in the (DAN!®) program strongly suggest that

the bodies of autistic children are not able to rid themselves of metals, and this is what

predisposes them to developing autism.

Other promising treatments include supplements such as Vitamin B₁, Vitamin B₁₁,

Cod Liver Oil, Melatonin, and Zinc. Additionally, special diets which address food

allergies, and specific carbohydrate diets, and gluten-free/casein-free diets have shown

to improve autistic symptoms.

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A listing of doctors who utilize the DAN!® approach can be found on the website for

the Autism Research Institute (www.autism.com). There you will also find the

Summary for Biomedical Treatments for Autism, written by James B. Adams, Ph.D.

PROGNOSIS

Prognosis for autistic individuals, while dependent on language ability and intelligence,

is largely influenced by early diagnosis and treatments. This includes family

involvement in the treatment process. Each member of the family needs to be educated

and involved in order to ensure continuity of the treatment plan. Many autistic

individuals can be taught job skills, and how to live in community-based housing (with

adult supervision). There are many great resources to help educate, motivate, and

encourage those dealing with the challenges of autism.

SUPPORT GROUPS/RESOURCES:

Autism Society of America( www.autism-society.org) provides education, current

events and links to finding a local chapter in your area.

The Autism Research Institute (ARI) (www.autism.com), is a non-profit organization,

was established in 1967. For more than 40 years, ARI has devoted its work toconducting research, and to disseminating the results of research, on the trigger ofautism and on methods of diagnosing and treating autism. They provide research-

based information to parents and professionals around the world.ARI's Autism Resource Call Center: 1-866-366-3361

National Autism Association (ANA) (www.nationalautismassociation.org) The

mission of the ANA is to educate and empower families affected by autism and other

neurological disorders, while advocating on behalf of those who cannot fight for their

own rights. There are several links to local events and groups, as well as to current

research and treatment modalities

One Place for Special Needs (www.oneplaceforspecialneeds.com) links for all special

needs families to services, support groups, organizations and events in your local area.

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Childhood Obesity

Another issue of growing concern is that of childhood obesity, especially in

the United States. In this country, “We want everything hot, fresh, andnow!” (Dr. Mark Cichon, 2008)

Statistics

The National Health and Nutrition Examination Survey (NHANES)determined the obesity rates among children. The increase in obesityrates are made by comparing the results of the surveys conductedduring 1976-1980, and 2003-2006. In children and adolescents:

ages 2-5, obesity rates increased from 5% to 12.4%ages 6-11, obesity rates increased from 6.5% to 17%ages 12-19, obesity rates increased from 5% to 17.6%

Obesity-related hospital costs for our youth has increased from $35million (1979-1981) to $127 million (1997-1999).

Approximately 60% of obese children ages 5-10 years old have atleast one cardiovascular disease risk factor (i.e. elevated totalcholesterol, insulin, blood pressure, etc.; and 25% had two or morerisk factors.

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Obesity is defined in the American Heritage Dictionary as “…increased bodyweight caused by excessive accumulation of fat.” Conduct any sort of

engine search on obesity or weight-related topic, and most likely you will bedirected to a location where you can calculate your BMI.

A Recipe for Disaster

1. Take our expectation of immediate gratification and add

to it the increasing costs of food, gas and energy.

2. Mix in parent/caregiver’s working 60-80 hours per week;

or as of late, the many people who have lost their jobs.

3. Sprinkle in a little ignorance regarding healthy living.

4. Remove any remaining physical education from the school

systems.

5. Top with your choice of: TV, internet, and/or video

games.

Serves: the entire American public.

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What is BMI?

BMI, or body mass index, is a calculation of body fatness using a person’sheight and weight. The CDC (Centers for Disease Control and Prevention)has published recommendations for acceptable BMI in both adult andpediatric populations. While BMI does not directly measure body fat, itsresults have proven to correlate with results of other body fat measures,such as underwater weighing.

1Mei Z, Grummer-Strawn LM, Pietrobelli A, Goulding A, Goran MI, Dietz WH. Validity of body mass index comparedwith other body-composition screening indexes for the assessment of body fatness in children and adolescents.American Journal of Clinical Nutrition 2002;7597–985.

What’s a “good” BMI?

The general scale for interpretation is as follows: Healthy Weight is having a BMI between 18.5 and 24.9 Overweight is having a BMI between 25 and 29.9 Obese is having a BMI over 30

Screening our Children

In the 2003 mission statement of the American Academy of Pediatrics,Prevention of Pediatric Overweight and Obesity, pediatricians were calledupon to calculate their patients’ body mass index (BMI) as a tool to aid inthe early recognition of obesity. You might be saying to yourself, how cansomeone, namely a parent or a doctor, not be able to just look at a child andtell if they are obese?!? Before casting any hasty judgment, doctors andresearchers investigated that very question. Studies have been conductedto survey people’s views on what they consider to be obese and/oroverweight. Know what they found? There were major discrepanciesamongst various ethnic groups in regards to what is “normal”bodyweight…hence the reason why BMI screening was implemented!

The BMI results only comprise a portion of what is involved in the screeningprocess. A thorough patient and parent/caregiver history of both the child’sactivity level and diet are important components as well. These piecesprovide a foundation for recognizing obesity, and also key in on thosechildren who, because of poor habits, are at risk for becoming obese adults.

BMI is calculated differently in pediatric populations than it is in adultpopulations. This is due to the fact that normal fat deposits differ between

age groups and also between boys and girls.

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In order to realize the urgency in addressing childhood obesity, it is important tounderstand the general consequences of obesity. These consequences are both

physical and psychological.That being said, the concern regarding overweight/obese individuals is one of

health, not physical appearance.

Cardiovascular Risks:

High blood pressure (twice as common in obese individuals) Elevated triglycerides, with low levels of the “good cholesterol” (HDL) Increased risk of heart disease…arrhythmias, sudden cardiac death,

CHF, MI…

Respiratory Problems:

Sleep apnea Higher incidence of asthma

Reproductive Complications

Increased risk of maternal high blood pressure (reference Region 8C.E. “OB Emergencies”, April 2008)

Increased risk of birth defects (i.e. spina bifida) Increased risk of gestational diabetes Increased risk of complications during labor and delivery

Diabetes

Over 80% of people with diabetes are overweight or obese. A weight gain of 11 to 18 pounds increases a person’s risk of

developing Type 2 diabetes twice over those who haven’t gained thatweight.

Diabetes in Children

Recall what you have learned about diabetes (Reference Region 8 C.E.,

February 2009 on diabetes. Building blocks of knowledge we are here! )

In the past, most children have been diagnosed with Type I diabetes

(juvenile diabetes). Remember with Type I diabetes, the pancreas (for a

number of reasons) doesn’t produce the insulin needed. Regular insulin

supplementation (via injections, insulin pumps, etc.) is required.

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Type II diabetes had previously been considered mostly an “adult disease.”

It has been associated with many causes and risk factors. Insulin resistance

and obesity are highlighted specifically as to their roles in the development

of Type II diabetes.

Insulin resistance comes about when people’s muscles, liver and fat cells do

not respond properly to insulin. The body doesn’t know exactly what to do,

so it signals the pancreas to produce more insulin. As the lonely little

pancreas just churns out insulin to keep up with this workload, two things

happen. First, the body is unable to use this insulin to shuttle glucose into

the cells. That’s where “insulin resistance” gets its name. Secondly, when

the need for more insulin arises, the pancreas is unable to produce more.

When a person carries more weight in their abdominal area, this is called

central obesity. The fat tends to accumulate around vital organs (visceral

fat), and is known to predispose people to developing insulin resistance.

Central obesity and lack of physical activity are two major (and preventable)

causes of insulin resistance. Over the past decade, Type II diabetes has

been diagnosed in the pediatric population at an alarming rate. What’s the

link? Increased obesity rates contribute to increased incidence of diabetes.

If you could, would you relive your adolescence? That “awkward” phase that

seemed to take forever to get through? (Admit it, you have at least one

school picture you refuse to show ANYONE.) Remember what it was like?

The insecurities? Getting picked on because you weren’t good at sports, or

because you didn’t have the latest fashion accessories, or because you made

the honor roll, or because your next door neighbor was the social outcast of

the school…kids can be so cruel, can’t they? For most, body image plays a

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major role in our mental well-being. It’s a part of growing up. What’s even

tougher, is growing up in American society, where we have created a

ridiculous standard for men and women to live up to, especially when it

comes to physical appearance.

For the average individual, pre-occupation with this standard is enough to

make you want to pull your hair out. For anyone who has ever been

overweight or obese, or knows a loved one who suffers because of obesity,

the consequences run much deeper. Many individuals who struggle with

weight concerns also suffer from depression, low self-esteem and anxiety.

Think about how that might affect an adult, and superimpose it into the

mindset of an adolescent.

Of course no two children react the same way, but how do these children

respond to their insecurities and self-consciousness when it comes to

weight? Well, some eat more; food is a source of comfort for them. Others

may develop eating disorders such as anorexia and/or bulimia. In fact,

some adolescents who have been diagnosed with Type I diabetes have taken

this a step further. Prior to diagnosis, many diabetics lose weight. This is

because the body needs insulin to shuttle glucose into the cells. As

mentioned, Type I diabetics lack this insulin, and require regular doses of

insulin to properly utilize that glucose. There have been several cases of

Type I diabetic adolescents who don’t take their insulin on purpose, in order

to lose weight. Kudos to their creativity, but this is dangerous! Even

potentially life-threatening behavior!

Are these issues starting to unfold in your brain? One thing leads to

another…short-term problems cause long-term maladies. When it comes to

health, those long-term maladies are chronic, and sometimes irreversible.

Again, diabetes lends itself to a wealth of complications, and increases the

risk for so many other disease processes. Not only does the quality of life

Diabetes and Depression

9% of adolescents with diabetes have moderately or severelydepressed mood symptoms.

Females are affected more so than males. Depressed mood is associated with poor blood sugar control,

and leads to an increased likelihood of ER visits(Pediatrics, 2006, 117: 1348-58)

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potentially suffer as these children grow older, but think about the amount

of economic strain caused on an individual, a family and society from all of

the medical costs associated with this disease process!

Armed with the knowledge that obesity-related diabetes may bepreventable, don’t you think it would be prudent to focus some effort onpreventing obesity?

Other

Obese individuals are at increased risk for developing some types of cancer,arthritis, and gall bladder disease.

Food for Thought…

What is the #1 cause of death in the United States?Coronary Artery Disease (CAD)

What are some of the risk factors for developing CAD?

High blood pressure (hypertension)High cholesterol (hyperlipidemia)DiabetesObesity

What did we just learn about obesity and cardiovascular risk?Obesity contributes to the development of these riskfactors!!

To sum it all up, individuals who are obese (BMI >30) have a 50 to100% increased risk of premature death from all causes,

compared to those of a healthy weight.

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All of these problems have previously been associated with ADULTS. Wehold them responsible for the choices they have made and continue tomake, and the consequences they suffer. But now, our babies, our two yearolds, who are fully dependent on us, have a 12.4% obesity rate? What isgoing on?

PHYSICAL ACTIVITY

Most of us have common knowledge as to how our body ends up storingmore fat. The number of calories consumed is greater than the number ofcalories needed to fuel the body’s activities. Fine. But kids usually runaround, they ride their bikes, and play all day, right? Come on, is this reallywhat today’s children are doing? Do they have physical education at school?(Some states do not require P.E. in school) Do they play tag? What arethey doing after school? Maybe some sports, but the amount of time spenttexting, or in front of the TV, computer and video games has increasedexponentially! “Mom don’t shut it off! I just got to level 7!” Our children are not

addicted to these modern electronics because of their novelty, but rather,because they have become a part of our culture. Therein lies the first ofmany causes contributing to our obesity rates: Lack of physical activity.

NUTRITION

Long gone are the days when families ate all three home-cooked meals (with

a healthy after-school snack) at the table, served by a smiling mom in anapron. How have American family dynamics changed over the past 4decades? Working moms. Single parent homes. Both parents working.Who makes dinner now? Many children are responsible for feedingthemselves these days. What’s for dinner? Fast food, microwavedsomething…all washed down with some sugar-laden drink (pop, fruit-juicedrink, etc.). Fresh fruits and vegetables? Nope. Milk? Not so much.

“All my kid will eat is macaroni-and-cheese and french fries!” (Some parents actuallylaugh when they say that) We are teaching our children that it is ok to insertfast food to accommodate our fast lifestyle. And now, like the electronics,fast food/junk food is an addiction because it is a part of our culture. Inaddition to the amount of calories that we feed our children/our children eat,we must also look at the nutritional sources of those calories as well.

Let’s throw back to Old School…

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Remember the food pyramid?How many of us as adultsactually follow those guidelines?We are the first models for ourchildren’s behaviors. If we don’tfollow healthy guidelines, whywould our children?

How about Popeye? “…Strong to thefinish, ‘cuz I eats me spinach!”

SPINACH! Not stuffed pizza withspinach!

“An apple a day keeps the doctor away.” Amazing…with all of the advances intechnology, medicine and overall know-how, why is it that the oldergenerations understood health and nutrition better than we do?Hmmm.

Another problem of nutrition is that healthy food can be more expensivethan not-so-healthy-foods. This leads us to a rather interesting discussionregarding the patterns of obesity amongst various socioeconomic groups.

SOCIOECONOMICS:

Obesity can be found amongst all socioeconomic groups. However, thereasons for why they exist are different.

In wealthier socioeconomic classes, some factors which contribute to theoverweight/obesity incidence are:

Divorce guilt—Parents give their children whatever they want to earntheir love/trust or to “make up” for the divorce.

Children have easier access to technology-computers, video games,cell phones… this lends itself to a more sedentary lifestyle.

There’s more food in the home to eat. These children may have easier access to buying whatever food they

want, especially if they are given an allowance to spend.

In lower socioeconomic classes other factors contribute to the incidence ofoverweight/obesity:

Many healthy foods are more expensive than fast food/junk food. Many children have working parent(s), and are responsible for feeding

themselves. The solution? Fast food/junk food/microwaveable food.

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Healthy food costs more. Neither thesefamilies nor the school systems may beable to afford healthy, fresh food.

Ignorance as to healthy choices. Fewer playgrounds in the neighborhoods

where they live Less access to extra-curricular

activities/sports

The rise in childhood obesity is not unique tothe United States. The overall obesity rate is

increasing across the world. Global studies ofcountries/areas of the Western Hemispherehave shown that the relationship betweensocioeconomics and obesity depends on thestage of economic transition. Early in the transition, the more wealthy an

area is, the greater the obesity rate. Later in the transition, the less wealthyan area is, the greater the obesity rate.

WHAT DO WE DO NOW?

As with anything, identifying that there is a problem is the first step. Aswith every facet of life, we need to be accountable for ourselves first. WEare responsible for our children. Not the school systems, not thegovernment, but us as parents and adults. Children model behaviors thatthey see. Treating obesity and implementing a healthy lifestyle for ourchildren will only be successful if we are motivated to actually practice whatwe preach!

WHERE DO WE BEGIN?

Several governmental bodies have been developed to educate the public andhave taken initiatives encouraging healthy lifestyles. The Surgeon General’sCall to Action to Prevent and Decrease Overweight and Obesity, and ThePresident’s Council on Physical Fitness and Sports are two examples.

GET MOVING!One of the most important things we can do for our children is to get themphysically active. The U.S. Department of Health and Human Servicesreleased the 2008 Physical Activity Guidelines for Americans(www.health.gov/paguidelines) which discuss all aspects of the “how’s” and“why’s” as they pertain to physical activity for Americans ages 6 and older.

The President’s Challenge

is a program which

promotes an active

lifestyle.

(www.fitness.gov) Here,

kids may earn medals for

their fitness efforts. It’s a

fun way to get children

and their families

involved.

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There’s TONS of information here! These recommendations are for health-related fitness; NOT performance-related fitness. Chapter 3, Active Childrenand Adolescents, provides the guidelines for physical activity in our youth.

Key Guidelines for Children and Adolescents

Children and adolescents should do 60 minutes (1 hour) or more of physical

activity daily.o Aerobic: Most of the 60 or more minutes a day should be either moderate- or

vigorous-intensity aerobic physical activity, and should include vigorous-intensity

physical activity at least 3 days a week.

o Muscle-strengthening: As part of their 60 or more minutes of daily physical

activity, children and adolescents should include muscle-strengthening physical

activity on at least 3 days of the week.

o Bone-strengthening: As part of their 60 or more minutes of daily physical activity,

children and adolescents should include bone-strengthening physical activity on at

least 3 days of the week.

It is important to encourage young people to participate in physical activities

that are appropriate for their age, that are enjoyable, and that offer

variety.

YOU ARE WHAT YOU EATAnother area to improve is nutrition. Again, we must set the example.Providing healthy foods for our children to eat. Here’s a tip when groceryshopping: avoid the middle aisles! The healthy foods are usually around theperimeter of the store (barring the bakery section).

What are the two most common reasons people give as to why they cannotdo something? Lack of time, and lack of money.

“But I don’t have time to cook…” Don’t sell yourself

short! Americans are creative and full ofingenuity!!

Get a slow-cooker.

Pack lunches before going to sleep at night.

Prepare meals ahead of time and freeze them.

Engage your family to help come up with some

solutions.

Currently, the Acting SurgeonGeneral, Steven K. Galson is on a

nation-wide tour promoting the

Healthy Youth for a Healthy Futureproject. This is to recognize several

communities throughout our countrywho have taken measures to promote

healthy lifestyles, and decrease

childhood obesity.

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Even though they may complain, roll their eyes, and make all sorts ofhuffing sounds of disgust, engaging our children in these activities will helptheir self-esteem! How? They are directly involved in tasks which keep thefamily healthy. There is one caveat: we must explain WHY theirparticipation is important, AND express our appreciation for thatparticipation. It’s not what you say, it’s how you say it!

“It’s too expensive…”

Another great resource is from The National Heart Lung and Blood Institute,entitled: WeCan! Ways to Enhance Children’s Activity & Nutrition(www.wecan.nhlbi.gov). There are all sorts of money-saving tips whileeating healthily.

Don’t forget to utilize the resources your pediatrician may have access to,such as a nutritionist. Weight loss, especially in the pediatric populationneeds to be monitored by a physician. Children are not tiny adults;

remember their bodies are still growing. They have unique nutritionalrequirements that must be adhered to, to promote things such as healthybones, to last long into adulthood.

We can come up with excuses from now until eternity. This is about ourchildren and teaching them good habits. This is about arresting the increasein childhood obesity, and preventing further complications of this disorder.

If your “why” is great enough, you’ll find a way.

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Drug of the month - Versed

(A.K.A. Midazolam)

Short-acting benzodiazepine with CNS depressant, muscle relaxant, amnestic and

anti-convulsant effects.

Dosage depends on age group and indication

o Pediatrics: (IV/IO route) 0.05mg/kg up to 0.2mg/kg maximum

o Adults

o Drug Assisted Intubation

o Sedation

o Intranasal

o Side Effects:

o Drowsiness

o Respiratory depression

o Amnesia

o Hypotension

o Dizziness

o Agitation

o Contraindications: Hypersensitivity, pregnancy, narrow-angle glaucoma. Caution in

COPD, renal failure, CHF, elderly, concomitant alcohol or CNS depressant medication

use.

27

Rhythm of the Month

Sinus Bradycardia and Pediatric Bradydysrhythmias

Causes:

Hypoxia, hypothermia, increased vagal tone, increased intracranial pressure, drug

toxicity, sedation

Findings:

Regular rhythm

HR < 60

P-wave : QRS = 1:1

PRI = < 0.20 sec, does not change

QRS < 0.12 sec

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Illinois Region 8 Emergency Medical ServicesCentral DuPage, Edward, Good Samaritan, Loyola EMS Systems

Standard Operating ProceduresIllinois Region 8 EMS Systems - Revised 2006

Page 16

PEDIATRIC BRADYDYSRHYTHMIAS

ALS1. Assess for causative factors, such as hypoxemia, acidosis and hypothermia.Initiate corrective resuscitative measures as necessary

2. Initial Medical Care Adequate airway and ventilation is essential Initiate CPR if, after adequate ventilation, the heart rate remains < 60 per minute If signs of hypovolemia: NORMAL SALINE 20 ml/kg IV push

3. EPINEPHRINE 1:1000 0.1 mg/kg (0.1 ml/kg) ET orEPINEPHRINE 1:10,000 0.01 mg/kg (0.1 ml/kg) IV/IO. Repeat q 3 minutes aslong as dysrhythmia with hypoperfusion persists.

4. ATROPINE 0.02 mg/kg rapid IV/IO or 0.03 mg/kg ET. Minimum dose 0.1 mg.Repeat q 3 minutes until maximum total dose admin.

Maximum single IV/IO dose is 0.5 mg ≤8 years, 1 mg > 8 years. Maximum total IV/IO dose is 1 mg ≤8 years, 3 mg > 8 years.

5. External Transcutaneous Pacing: Contact Medical Control.

Notes:

Flush all IV/IO drugs with 5 ml NS Flush or dilute all ET drugs with 5 ml NS Attempt to keep child warm with protected hot packs and blankets as a

29

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Parents of Young Autistic Children. Autism Research Institute, San Diego.

American Heritage Dictionary of the English Language, 4th edition. (2006). Houghton Mifflin

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dyn/content/article/2008/05/17

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