pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Back To School Health Issues for Physicians and Parents

Kids aren’t the only ones going back to school! Parents need to endure the yearly cycle too. It seems that every year there’s more and more to think about, fill out, arrange, make appointments for, explain, buy….

Gone are the days of merely buying one size largerKindergarten boy and mom buying school clothes school clothes and giving them lunch money!

These days a parent’s back-to-school agenda is greatly more complicated than attenuated haberdashery and nutritional procurement; there’s legal attestments, secure transportation, computational aids, arrangements for ever swelling convolutions of teaching schedules, legislation compliance… and, unfortunately, medical issues.

Sympathetically I’ll keep this short and concise. Here is a short list of back to school health issues. A quick reminder quiz that pediatricians begin thinking about in August and September.

Immunization Mandates

There are health requirements for kindergarten

Which of the following would prevent an incoming kindergartner from school admission, according to most state requirements?

There are health requirements for kindergarten

  • Failure to receive Haemophilus influenzae type B (Hib) vaccine
  • Incomplete information about pneumococcal conjugate vaccination
  • Lack of a second dose of the measles, mumps, rubella (MMR) vaccine
  • None of the above

In order to achieve adequate immunity a second “booster” dose of the Measles-Mumps-Rubella vaccine is needed and a child’s risk of becoming infected becomes much more critical when they begin attending school. That’s why nearly all states require a second MMR dose prior to admission.

The actual mechanism for providing proof of the immunization is what varies from state to state; but, a parents “word” that “he’s had all his shots” isn’t accepted anywhere any more.

The MMR vaccine given at 12-15 months of age is really very effective, as vaccines go, in producing immunity – about 95% achieve immunity. The problem is that the measles virus is not only one of the deadly and debilitating “vintage” diseases it is extremely contagious as well!

The mere 5% of children who didn’t get immunity from one dose is enough to keep the disease going around the community and causing epidemics. A second (“booster”) dose between 4 and 6 years of age gives immunity to 95% of the remaining 5% and that covers enough to likely stop the spread to even those who don’t have immunity

If a child is late for even his first MMR shot you don’t have to wait 4 years for the second. A minimum of 4 weeks between doses is required and states have made provision in the school acceptance rules for that.

The evidence we have that this works is supplied by the data from the Center for Disease Control (CDC). Data shows that 1.8% of kindergartners over all have a vaccine exemption for any reason. Localities in which refusal rates climbs higher than that have definite links to outbreaks – like THIS year (2014) in Ohio and New York.

School “Phobia” (Refusal)

Which of the following are the most common ages for children to demonstrate school refusal?

  • 5-6 years
  • 8-10 years
  • 10-11 years
  • Both 5-6 years and 10-11 years

Kindergarten boy with separation anxiety, school refusalWe used to call this “school phobia” and I didn’t much like the name. Now it’s known as: “School refusal behavior” and refers to a child-motivated refusal to attend school – I don’t like that name much either.

It’s not a “phobia” in the true sense because there may be a good, albeit undisclosed, reason for the child to be afraid of attending school; and it may not have anything to do with school at all and be more attachment to a parent.

Even the term “School refusal behavior” sounds like a “diagnosis” and it’s not – it’s a symptom not a psychiatric diagnosis.

It occurs in about 2 or so percent of school-aged children; and, surprise, occurs in peaks at the transition times (i.e. switching schools) so when children are 5-6 years and 10-11 years old. There’s also a smaller “bump” in teens entering high school.

It occurs equally in boys and girls of any socioeconomic class and can indicate an emotional disorder in which anxiety or depression plays a predominant role – Separation Anxiety Disorder (SAD); OR, like I said, result from external factors like bullying or intimidation.

About 22% of children with the school refusal symptom actually have Separation anxiety disorder. Other diagnoses might include generalized anxiety disorder, major depressive disorder, and oppositional defiant disorder.

Clinical manifestations of SAD, along with school refusal, may include the following:

Separation Anxiety Disorder (SAD)

  • Reluctance to fall asleep without being near the primary attachment figure;
  • Excessive distress (eg, tantrums) when separation is imminent;
  • Nightmares about separation-related themes;
  • Homesickness (ie, a desire to return home or make contact with the primary caregiver when separated); and
  • Frequent physical or somatic symptoms, such as headache, palpitations, and abdominal pain.

Head Lice

Head lice - but boys are not the most affected

Which of the following characteristics increases risk for pediculosis capitis (head lice) infestation among children attending middle school?

Head lice – but boys are not the most affected

  • African American race
  • Male sex
  • Female sex
  • Rural location

Not everything that itches on their heads is caused by lice; but, a lot of it is. Pediculus Humanus Capitus, or to you and me the head louse, infests children of all socioeconomic groups, does NOT reflect poor hygiene habits, is seen most often in urban areas, does not spread disease and seems to prefer the late summer and fall.

Full infestations occur in child-care settings and schools and transmission is quite easy. It does require direct contact with the hair of infested persons, hats, headbands, combs, shared pillows or the like.

The social behavior of girls, e.g. acceptance of close physical contact and sharing of articles, makes them a higher risk for infestation than boys – hair length is not a factor.

And, it’s interesting that African-American children living in North America seem to have a lower incidence of head lice – probably due to the use of pomades (waxy hair-styling products) and because the louse’s claw is more able to attach to round-shaped hair shafts than flattend-elliptical shafts.

A big problem of late is that the head louse has developed resistance to both of the medications we’ve used for years to treat it! That just leaves parents with those ultra-fine-toothed combs to repeatedly pick off the nits until the last one’s gone.

There is a promising new lotion that perhaps will be useful; but, it cannot be used as first-line treatment. Butch Wax wasn’t such a bad idea after all.

Sore Throat Testing

Old-fashioned throat culture

Which of the following is the criterion standard  in assessing a high school student with suspected group A streptococcal (GAS) throat infection?

Old-fashioned throat culture

  • Rapid antigen detection test
  • Throat culture
  • Blood culture
  • Anti-streptolysin O titer

The invention of the “Rapid strep” test for use in physicians offices has made dealing with sore throats a lot easier and quicker in many ways. However, it also has introduced some complexities all on its own.

Pediatricians used to need to rely on their diagnostic acumen to decide upon whether or not to begin antibiotics for possible “Group A Strep throat” (GAS) prior to the 24-72 hour turn-around time the throat culture would take. A culture done that way is highly specific for GAS and highly sensitive – only misses less than 10% of true cases which is why an old-fashioned throat culture is still the gold standard test.

The rapid-antigen detection tests can be done in minutes right in the office – and they are also very specific to GAS. The problem is that they are much less sensitive and can miss up to 30% of true cases.

If the rapid-antigen test is positive the doctor can rely on it; but, if it’s negative he cannot. If the patient’s illness really “looks” like GAS another “real” throat culture should be performed for verification.

Neither of these test are any good IF the person doing the swabbing doesn’t do a good job however. A “swabber” doing a namby-pamby “touch quick so you don’t gag” throat swab is NOT doing you any favors! The sterile cotton swab should rub along both the tonsils and the posterior pharynx in order to obtain an adequate sample.

Furthermore, guidelines don’t recommend even doing a culture if the doctor’s exam shows the diagnosis is likely a virus; AND, children diagnosed with a viral illness should NOT be prescribed antibiotics.

There are so many practioners and generalists caring for children these days who still like to have it both ways – namely, tell you that it is a virus but prescribe antibiotics none-the-less just-in-case – that if you are prescribed an antibiotic without a culture being performed you should start asking very pointed questions.

Sexually Active Screening

During summer break, many teenagers become sexually active. Which of the following sexually transmitted infections (STIs) should be screened for in female high school students who report unprotected sexual activity?

  • Chlamydia
  • Syphilis
  • Chancroid
  • Trichomoniasis

Chlamydia trachomatis infects over 1.4 million persons a year in the US according to the CDC. It is by far the most commonly reported sexually transmitted infection (STI) and most of them occur in females between 15 and 24 years old.

A tremendous problem with Chlamydia is that many of those infected remain asymptomatic and “carriage rate” is about 20% of women. Infections can persist for months to years, and reinfection is common therefore screening for this STI is important.

left untreated, as is common, a girl will develop urethritis or cervicitis and progress to acute or chronic pelvic inflammatory disease, ectopic pregnancy, or infertility.

There are screening tests which can be done from vaginal swabs and urine specimens. Guidelines from the US Preventive Services Task Force calls for screening all sexually active, non-pregnant women 24 years old and younger. (Evidence does not suggest screening for chlamydia in men.)


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