Susan Millard, MD, Pediatric Pulmonologist
Helen DeVos Children's Hospital
Grand Rapids, Michigan

As if the risks of marijuana, cocaine, prescription pain medication, and other drugs weren't enough, we, as pediatric physicians, also need to worry about another threat: inhalant abuse. Although that's not what the kids doing it call it; to them it's huffing, sniffing, bagging, glading or dusting. 

No matter what you call it, however, it still means inhaling toxic chemicals (think glue, paint thinner, gasoline, spray paint, even the nitrous oxide from whipped cream canisters and the compressed air used to clean keyboards) to get high. It's also a practice that is rampant among pre-teens and adolescents, particularly in hard economic times. As the author of a 2009 article on the topic noted: "A $2.50 container of air freshener is more affordable than a 'dime bag' of marijuana and users get a similar experience."¹

The 2009 National Survey on Drug Use and Health estimated that about 1% of youths ages 12 to 17 have used inhalants, but that it was the first illicit drug 10% of drug users tried. A study evaluating its use among juvenile offenders in Michigan found that nearly 40% reported lifetime inhalant use.² Boys are far more likely to use inhalants than girls.³

I bring this up because, as a pediatric pulmonologist, I don't want to see another kid in the PICU as a result of inhalant abuse. And you, as community pediatricians, are in a position to help prevent it. I recommend you begin talking about the dangers to kids and their parents before they hit adolescence. Tell parents to look for signs their kids are using, such as: 

• Disappearing aerosols
• Sores around or within a child's mouth
• Paint stains on clothing (from spray paint cans)
• Finding paraphernalia like plastic bags in the child's possession (used for bagging)
• Slurred or slow speech
• Mood changes

Clinical signs of inhalant abuse include unexplained coughing up of blood and/or recurrent pneumonia. Although either could be signs of tuberculosis or HIV infection, you should consider inhalant abuse in your differential diagnosis. 

Other signs include:

• throat edema
• changes in kidney and/or liver enzyme levels
• unexplained vomiting
• nausea
• hallucinations
• dizziness
• seizures

Long-term users may demonstrate neuronal damage manifesting as difficulty walking and talking, and loss of hearing and memory.¹ Routine use can also cause arrhythmias, kidney and liver damage, while even a single use can  result in cardiac arrest and death. Children using inhalants also become less inhibited and are more likely to take risks.⁴

So, please, educate yourself on the signs and symptoms of inhalant use and take a few minutes to educate your patients and their parents. 

Are you seeing inhalant abuse in your practice? How do you talk to parents and patients about this threat?

Susan Millard, MD, is a pediatric pulmonologist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

References

1. Criss L. Huffing: prehospital identification & treatment of inhalant abuse. JEMS. 2009 May;34(5):42-3, 45, 47 passim.

Jennifer Hoekstra
Safe Kids Greater Grand Rapids
Helen DeVos Children's Hospital

Of all the things that you, as a primary care physician for young children, have to deal with, car seats might seem relatively innocuous compared to immunizations, respiratory syncytial virus (RSV), and weight/height charts. But nothing kills more children under age 5 than automobiles accidents.¹ In fact, using the appropriate child safety seats can reduce the risk of death for infants by 71 percent; by 54 percent in toddlers ages 1 to 4.

So the new policy statement from the American Academy of Pediatrics on "Child Passenger Safety" is important information to communicate to the families of the infants and young children in your practice.

In a  nutshell:

Rear facing until age 2. Kids need to remain in a rear-facing car seat far longer than we used to recommend. That means until age 2 or until the child reaches the height and weight recommended by the seat manufacturer. This is the biggest change in the AAP recommendations, and comes as a result of data demonstrating that children who ride in a car facing forward before age 2 are far more likely to receive neck and spinal injuries during an accident. Backward-facing car seats protect still-developing neck and spines far more than seats facing forward. Most of these seats today can work for children up to 35 pounds.

Forward facing car seat until booster seat ready. Children 2 and older, or younger children who have outgrown the rear-facing seat, should remain in a forward-facing seat with a harness for as long as possible, up to the highest weight or height allowed by the manufacturer of their child safety seat.

Booster seat until big enough for seatbelts only. Children who no longer meet the height and weight requirements for a child safety seat should be in a booster seat that uses a belt until they are big enough to properly  use the lap-and-shoulder belts in cars. This typically occurs at 4-feet, 9-inches and between 8 and 12 years of age.

Back seat only until age 13 or later. At this point, children should remain in the back seat using the lap and shoulder belt until at least age 13.

Yo might hear parents complain their child simply hates facing backwards. Suggest that they adjust the angle of the car seat rather than turning it around. Newborns should be reclined at a 45-degree incline to protect their airway; but as they get older, the incline can be shifted upwards so the child can see out the windows. 

It is also important that the seats be properly installed. Feel free to refer your parents to their local Safe Kids Coalition, where they can receive hands-on support to make sure that their car seats are properly installed.

Reference:

¹Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System [online]. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer). http://cdc.gov/ncipc/wisqars. Accessed May 11, 2011.

It's time to register for the annual Pediatric Update Conference, sponsored by Helen DeVos Children's Hospital and Grand Rapids Medical Partners in Grand Rapids, Michigan. The conference is designed to increase the knowledge of regional physicians on current trends and treatments in pediatric medicine. Objectives include:

• Provide enhanced care to pediatric patients by increasing the ability to diagnose and manage patients in pediatric and subspecialty areas
• Discuss  and explore current advances and treatments in pediatric medicine
• Serve as an educational resource to regional pediatricians and family practice physicians

This one-day educational conference occurs at the new Helen DeVos Children's Hospital and includes a guided tour and a post-conference reception at the adjacent Van Andel Institute. 

The conference will be held May 25 from 8:30 a.m., to 7:30 p.m.*

Among the speakers:

Daniel Arndt, MD: "Neurology Update: Epileptology"

Who would have thought you could safely remove up to half of the brain and cure a patient from medically refractory epilepsy with a very favorable benefit-to-risk ratio? From the first epilepsy surgery that occurred in 1886 at the National Hospital for the Paralyzed and Epileptic at Queen's Square in London to the epilepsy surgeries that took hold in the 1940s with the invention of electroencephalography (EEG), to the "third wave" of epilepsy surgeries beginning in the 1970s, this talk will focus current efforts to treat epilepsy surgically. It will cover the appropriate identification of surgical candidates who, ideally, would be referred much earlier in the disease than we see today, presurgical evaluation and surgical options, and post-surgical outcomes. 






Chad Afman, MD: "Tonsillectomy and Adenoidectomy: New Guidelines"

This talk will cover the first-ever guidelines for tonsillectomy and adenoidectomy, including indications for and risks and benefits of the procedure. You can read more here about the topic.

 







Brooke Geddie, DO: "Pediatric Ophthalmology Update"

What are the latest recommendations for vision screening in your office? What ocular presentations necessitate immediate versus routine referral to a pediatric ophthalmologist? These questions and more will be addressed during this concise pediatric ophthalmology update. 

Theodore Barber, MD: "Urology Update: Hypospadias and Neurogenic Bladder"

Paradigms of management for both hypospadias and the neurogenic bladder have undergone a dramatic shift. Previously, hypospadias repair was performed using a variety of flap techniques, resulting in suboptimal functional as well as cosmetic outcomes and high complication rates. These techniques are now being replaced by free grafts and the tubularized incised plate (Snodgrass) repair. 

Until recently, deterioration of the neurogenic bladder with the ultimate requirement for bladder augmentation, and its significant associated complications, was viewed as inevitable. However, recent data has challenged this teaching, making a compelling argument for a more conservative approach to these challenging patients.  





William Stratbucker, MD: "Bright Futures: The Front Door to Your Pediatric Medical Home"

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition, provides a model of practice that helps providers prevent dangerous illnesses, manage developmental concerns, educate parents and address the unique needs of children with special health needs in the child's medical home. Information provided will help providers distinguish their services from retail-based clinics, urgent care centers, and the Internet while improving pediatric care. The implementation of Bright Futures Guidelines within a pediatric practice can impact both financial reimbursement for services provided and the provision of best practice, high-quality pediatric medical care. Finding a way to work these recommendations into an already busy practice is challenging but offers the possibility of significant reward.

 

 
You can view the entire agenda here and register for the conference here.

*Grand Rapids Medical Partners is accredited by the Michigan State Medical Society Committee on CME Accreditation to provide continuing medical education for physicians. Grand Rapids Medical Education Partners designates this educational activity for a maximum of 8.25 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.