#124: AAP Conference Recap 2024

November 6, 2024 | By Sam Masur

Audio

Summary:

Get ready for an influx of practice-changing pearls as the Cribsiders team shares what we learned at the AAP 2024 conference in Orlando, FL. Learn how to diagnose and manage GERD, common gynecologic disorders, murmurs, and hypertriglyceridemia. Find out what’s new in the newborn nursery and how to counsel on marijuana use.

AAP 2024 Highlights: Speakers, Resources, & References

GERD: A Burning Topic (Phyllis Bishop, MD)

1. Check out our GERD episode with Dr. Carlo DiLorenzo. 
2. First step in management is always positioning and small, frequent feeds. 
3. Then can trial thicken feeds. Use at least 2-3 teaspoons of low arsenic rice cereal per ounce to get the right viscosity! If you’re worried about hydration, give it every other feed when less than 3 months of age. Once they are over 3 months old, you can start spacing out the thickened bottles because reflux should be getting better. 
4. Milk protein allergy is difficult to differentiate between GERD and so guidelines recommend 2 week trial of hydrolyzed formula after trialing thicker feeds
5. There is no evidence for diagnostic testing in absence of red flags. Endoscopy is reserved to look other diagnosis (congenital abnormalities and pyloric stenosis) and complications of GERD (esophagitis)
6. Red vocal cords DO NOTE EQUAL GERD 
7. There is insufficient evidence for PPI trial in infants for diagnosis or treatment. If you’re at the point of trying PPI, involve your local GI doctor. (Note: there is evidence for doing a 4-8 week PPI trial in school age kids.)
8. When turning to acid suppression, PPI is recommended over a H2 blocker. If using for more than 8 weeks, you must remember to taper. 
9. Although spitting does not equal GERD, spitty babies are 4 times more likely to have reflux as preteens.

Marijuana and High-Potency THC Products: What Pediatricians Need to Know (Kevin Osterhoudt, MD)

1. There has been an increase in accidental ingestions after marijuana legalization. This is thought to be secondary to increased availability, increased THC content in products, and rise in edibles that are attractive to children 
2. Common toxidromes include unresponsiveness, elevated HR, large pupils. 
3. Severe toxicity can lead to seizures vs myoclonus and respiratory depression
4. Rocky Mountain Poison and Drug Safety 2023 found that in children < 6 years old, >1.7 mg/kg predicted prolonged (greater than 6 hours) and severe toxicity (defined by neurological toxicity, CV, respiratory toxicity).
5. 2015 study in New Zealand showed that marijuana dependence in adolescence can decrease IQ 
6. Remember that marijuana is legal, but not always standardized. In some states, packages may not accurately depict the amount of THC per serving. Some states do not yet have regulations around other THC isomers such as delta8 and THC0. 

Recognition, Evaluation, Treatment, and Referral of Common Gynecological Disorders (Elizabeth Alderman, MD)

1. Check out our Heavy Menstural Bleeding with Dr. Angela Weyand
2. Only 67% have regular periods 2 years post menarche 
3. How to manage heavy menstrual bleeding and moderate anemia:
   1. OCP with 35 mcg ethinyl estradiol (EE) twice daily until bleeding decreases significantly or stops. Continue for 3 months to rebuild iron stores.
   2. If OCP is contraindicated, use progesterone only
      1. Norethindrone acetate 10 mg daily until bleeding stops, THEN go down to 5 mg
      2. Medroxyprogesterone acetate (MPA) pill 10 mg daily for 14 days, then go to the progestin only pill 
   3. If not using NSAIDS already,
      1. Ibuprofen 600 mg three times a day OR naproxen 500 mg twice daily for 3-5 days. 
   4. Call in 3 days to see if bleeding has stopped
4. To rebuild iron studies, supplement with iron. Wait till bleeding stops because GI symptoms from iron may lead to stopping all medications! Then start ferrous gluconate 650 mg daily with stool softener. Any ferritin <50, consider as iron deficiency and treat 
5. Potentially helpful supplements for primary dysmenorrhea include vitamin B1, magnesium, vitamin E, and omega 3s.
6. Center for Young Womens Health is a great resources for patients on common GYN disorders 

Heart Sounds and Murmurs: How to Listen (Peter Sambatakos, MD) 

1. When listening to murmurs, palpate the radial/brachial pulse to identify S1. 
2. Murmurs are present in 1% of newborns, but 31-86% of who have structural heart disease (Rein, 2000)
3. AFP recommends that family physicians should order echocardiography or consider referral to a pediatric cardiologist for newborns (< 1 year of age) with a heart murmur, even if the child is asymptomatic. This is because of the higher prevalence of structural heart lesions in this population.
4. When talking to parents consider phrases like: 
   • “I hear a heart murmur. It may be nothing but it also may be something. I want to refer your child to someone who knows more about the heart to help look into this.” 
   • “As children grow, their heart goes through lots of changes and so murmurs can come and go. It doesn’t mean that the previous doctor missed something.”
5. Some complex congenital heart disease do not have murmurs.
6. Look out for an upcoming Cribsiders episode on murmurs! 

Intranasal Epinephrine 

1. August 9th, FDA approved intra-nasal epinephrine for type 1 hypersensitivity allergic reactions similar to intramuscular epinephrine. 
2. Only approved for weight ≥ 30kg
3. Given via the same nasal actuator as intra-nasal naloxone.
4. Ordered in a 2 pack, similar to intramuscular epinephrine. Give 1 dose and wait 5 minutes and then readminister (can be in the same nostril). 
5. Can be stored anywhere and lasts for 30 months from manufacturing, which is usually 24 months after its dispensed by a pharmacy. 
6. Pharmacies will begin to stock at approximately $200 for a two-pack, but will be discounted through the company’s partnering pharmacies for as low as $25. 

What’s Trending in the Newborn Nursery: Controversies and Evidence (Allison Markowsky, MD MSHS FAAP, Arun Gupta, MD FAAP) 

1. Hyperbilirubinema
   • Check out our bilirubin episodes! Part 1 and Part 2.
   • The 2022 Hyperbilirubinemia Guidelines have higher thresholds for intervention, separated by gestation age and neurotoxicity risk factors. 
2. Car Seat Challenges 
   • Preterm infants are at increased risk of apnea. AAP’s official recommendation is to do car seat testing (CSTS) for all babies less than 37 wga. However, there is a wide variety on how hospitals perform and interpret car seat testing. 
   • 2023 retrospective cohort study down in Kaiser, who discontinued CSTS in 2016, found that there was no increase in death, 911 calls, readmission, apnea, BRUE within 30 days of discharge.
3. 3. RSV 
   • Check out the RSV Immunization episode!
   • All infants should be protected by either maternal RSV vaccination or Nirsevimab administration in the 2024-2025 RSV season. 
   • Give nirsevimab for infants <8 months old whose moms’ aren’t vaccinated or were vaccinated <14 days before birth. 
4. NOWS 
   • Check out our NOWS episode! 
   • There’s a rising number of mothers using opioids in pregnancy 
   • 2023 multicentered RCT found that Eat, Sleep, Console (ESC) method decreased length of stay compared to Finnegan.
   • 2024 study found ESC decreased mean opioid exposure and length of stay
5. Ankyloglossia
   • There has been increased frequency of frenotomy being performed. Most breastfeeding issues aren’t related to ankyloglossia. 
   • Symptomatic ankyloglossia: a tight lingual frenulum that restricts the tongues range of motion, causes breastfeeding difficulties, and is not improved by lactation support. 
   • Frenotomy can be reasonably offered for symptomatic ankloglossia after other cases of breastfeeding have been evaluated and treated. It does NOT help with speech articulation or OSA. 

Diagnosis and Treatment of High Triglycerides (Justin Zachariah, MD MPH) 

1. Increased percentage of overweight and obese children, but decrease in percentage low HDL-C and decrease in percentage of high non-HDL (Zachariah et al. 2021)
2. AAP recommends universal screening. 
3. Significant portion (30-40%) of children with high TG are NOT overweight/obese (Zachariah et al. 2021)
4. A fasting lipid panel is ideal, though non-fasting is useful, depending on clinical context and/or difficulty obtaining a fasting sample at a later date
5. If there is a high index of suspicion, children as young as two can be screened in a targeted approach. If normal, repeat every 3-5 years. If abnormal, consider lifestyle changes first. 
6. Helpful dietary changes in dyslipidemia include increasing whole grains (focusing on “brown” foods) and fish rather than dietary supplements. Eliminating sugar sweetened beverages often provides a good yield.
7. Cumulative hazard for cardiovascular disease events are similar for those persistently within guideline range and with resolution of prior dyslipidemia. (Wu et al. 2024)
8. There is a paucity of data on effect childhood dyslipidemia on adult CVD outcomes, but it probably does matter

Goal

Listeners will recall key pearls from topics presented at the AAP 2024 conference. 

Learning Objectives

After listening to this episode listeners will…  

1. Be familiar with latest topics in pediatric hospital and outpatient medicine
2. Consider how these pearls and studies will change their current clinical practice.

Disclosures

The Cribsiders report no relevant financial disclosures. 

Citation

Park J, Engel S, Rago A, Berk J, Chiu C, Masur S. “#124: AAP Conference Recap 2024”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ November 6, 2024.