Presentation on theme: "Top Six Paediatric Picks of 2014"— Presentation transcript:
1Top Six Paediatric Picks of 2014 Prevention is KeyKathryn LecceseSun Peaks Feb 2015
26 picks at sun peaks in paediatrics Antibiotic Stewardship: bacteria gone viral!My brain is fried: cell phone use in kids and teens.PRAM scores; nothing to do with babies.Autism prevalence aka pregnancy is hard enoughCute chubby baby begets pudgy preteenKids having kids(because they don’t respond to antibiotics)
3Objectives Prevention in paediatrics is paramount Review some of the top articles in research that came out in the past year; 2014Prevention of an antibiotic apocalypseDiscuss potential anticipatory guidance for cell phone use in children ; and adultsIntroduce new strategies for asthma stratification in order to hopefully send kids home soonerReview some new literature on autism links in order to better guide your advice to pregnant patientsReview potential age targets for risk of obesity in childrenHelp discussions with teenagers or prevent pregnancy
4Bugs behaving badly Not all bugs need drugs 70-80% of paediatric fevers are due to viruses and not bacteriaAntibiotics in livestock … its not all usAccording to the National Resource Defense Council 80% of antibiotic use in the USA is used to promote livestock useGMOsFew drugs aside from anitmicrobials can lay claim to provide cure for diseaseThis life saving impacts are sill observed everyday but may be in peril in the future
6Resistance for Nine Selected Bacteria/Antibacterial Drug Combinations, 2013 WHOAntimicrobial ResistanceGlobal Report on Surveillance 2014
7Neisseria Gonorrhoeae Detection of decreased susceptibility to 3rd generation cephalosporin and treatment failures up to 2010WHOAntimicrobial ResistanceGlobal Report on Surveillance 2014
8WHO reportHigh proportions of resistance were reported in all regions to common treatments for bacteria causing infections in both healthcare settings and in the communityAntibacterial resistance has a negative effect on patient outcomes and health expendituresTreatment options for common infections are running outDespite limitations, the report demonstrates worldwide magnitude of ABR and surveillance gapsGaps are largest where health systems are weakThere is no agreement on surveillance standards:What samples and information to collectHow to analyze samplesHow to compile and share dataObtained national data was usually based on proportions of resistant bacteria rather than proportions of resistant bacteria causing specific diseases or affecting defined populationsThe report provides a benchmark for future surveillance progress
9Managing Antimicrobial stewardship in daily practice: Managing an important resource CPS 2014 Use clinical judgment and test judiciouslyBased on age, history and physical examIf serious infection suspected (meningitis, bacteremia etc) appropriate cultures should be taken and effective abx BASED on potential pathogensResults of cultures should tailor therapy or stop antimicrobial therapyOffice based difficult; follow up is keyPharyngitis with non viral symptoms:Throat swab for GAS to confirm streptococcal pharyngitis; wait hr for culture is reasonable in a child that is not severely ill.CPS positions statement Antimicrobial steward ship in daily practice. May 2014
10Managing Antimicrobial stewardship in daily practice:Manageing an important resource CPS 2014 AOM: accuracy of diagnosis is paramountFluid behind inflamed tympanic membrane in a child who has acute ear pain is paramountIf older than 6 mo of age, unilateral and uncomplicated with mild symptomsTreatment with analgesics and follow up in hrs is reasonablePersistent symptoms --- bacterial etiology more likelyLobar pneumonia: confirm diagnosis with X-rayRecommended before starting antibioticsIf pneumonic infiltrate Is not observed or consistent with bronchiolitis careful follow up is required; not antimicrobialsIf viral illness suspected; more prudent to have careful follow up than antibioticsCPS positions statement Antimicrobial steward ship in daily practice. May 2014
11Treat infection, not contamination To prevent contamination urine samples collect samples appropriatelyCatheter or clean catch midstreamEven in newborns… bags are badDiagnosis of UTI requires signs AND some laboratory evidence then culture positiveTreatment of positive cultures if there are no signs of infection is incorrectDo not take throat swabs if no signs of infection; will be treating colonized patientsPresence of MRSA in nasal or rectal specimens should not routinely start antibiotic regimens for decolonizationCPS positions statement Antimicrobial steward ship in daily practice. May 2014
12Take a careful history of potential antibiotic side effects and if possible confirm an antimicrobial allergyIgE mediated allergy: urticarial, pruritus, bronchospasm, angioedema or hypotension within 1h of drug administrationConfirmed or disprove allergies by an allergistHistory of Ig E penicillin allergy in a parent is not a reason for avoidance in a childCross reactivity with cepahlosporins is very low (2%)History of SJS or TENS attributed to an antibiotic is a reason to avoid related antibiotics in the futureCPS positions statement Antimicrobial steward ship in daily practice. May 2014
13Most common side effects of using an antibiotic are non urticarial maculopapular rashes of GI symptomsMost are viral or idiosyncratic reactions to the drug NOT an allergyTherefore it can be given to the child in the futureAllowing the use of antibiotics with a narrower spectrum of activity
14Laboratories should produce local, age-specific antibiograms to guide antibiotic choices for selected infectionsLocal antibiogram is compilation of susceptibility patters for common isolated bacteria
17Managing Antimicrobial stewardship in daily practice:Manageing an important resource CPS 2014 Narrow the spectrum of antimicrobials when a causative organism is identifiedOptimize dosing of antimicrobials to obtain maximal benefitUse higher end of the recommended dose range for specific infectionAminoglycosides have “dose dependent killing” maximal effect with high initial dose & less frequent dosing;q24 is recommended over the q8h dosing in all children (not neonates)Oral beta-lactams have short half life and have “time dependent killing”,non serious infection (AOM) twice daily dosing is sufficientmore serious infections (pneumonia) 3-4 times a day dosing is usedThis is for children with normal renal and liver function
18Use the shortest recommended course of therapy for uncomplicated infection Shorter course are associated with fewer adverse events and less development of resistanceThe optimal duration for most infections is not knownGuidelines:Streptococcal pharyngitis: 10 daysAOM: If failed the watch and wait children >2 yrs; 5 daysUncomplicated pneumonia: 7 days should dueCompared with longer coursesUnfortuantley
19Take care not to change or prolong antimicrobial therapy unnecessarily Some infections can 3 days or more to defervesce; not equal to treatment failureCellulits can take over a day to improve on therapy and not a reason to progress to broader coverage.Consider other diagnosis if no evidence of infection or response to antibiotics:Kawasakis, neoplasms, juvenile inflammatory arthris, inflammatory bowel disease and recurrent fever syndromes
20Promote vaccinations !!!!!!!!!!!!!!!!!!!!!Vaccines prevent infections…. Therefore less antibiotic use
21Wrap up: 10 ways to promote antimicrobial stewardship in your paediatric practice Mindful Reflection: Always document a childs vital signs and PE and why you are using antibioticsDetail suspected drug reaction, does history meets true allergy criteria? Consider consultation with an allergist.Ensure minimum diagnostic criteria be met for patients with suspected UTI.Infections caused by GAS are best treated with beta-lactam antibiotics not azithromycin or macrolides. Use cloxacillin or cephalexin for Staphylococcus aureusThere is no need for throat cultures in children with colds & sore throat. A GAS+ culture almost always identifies a carrier and not a true infections1. Schedule clinic follow up instead if patients who are not very ill but may have a bacterial infection2. Consultation with an allergist may be usefule for some patients
22Wrap up: 10 ways to promote antimicrobial stewardship in your paediatric practice ALWAYS use appropriate weight based dose & optimize frequency and duration.Community acquired pneumonia in children is ampicillin IV or oral amoxicillin TID.Prior to prescribing antibiotics for pneumonia a CXR should be obtained for diagnosisChildren with wheezing almost never require antibiotics; asthma in older children or bronchiolitis for infants.Know the bacteria that cause the most common outpatient infections. Minor skin infections can be treated topically. Visble drainiage should be cultured.Managing Antimicrobial stewardship in daily practice:Managing an important resource CPS 2014
23iPHONE to iCHEMOJuly 2015: A review of cell phone exposure from and government documents on microwave radiation (MWR) levels and electronic device manufacturers manuals revealed that there ARE associations between MWR and the development of cancer in childrenThe researchers advocatedmore wide spread implementation of MWR exposure limits on electronic devices,better education about potential risksBANNING MWR emitting toys or devices targeted at childrenMorgan et al. Journal of Microscopy and ultrastructure 2014
24MWR exposure limits have remained unchanged for 19 years, smartphone manufacturers specify the minimum distance from the body that their products must be kept so that legal limits for exposure to MWR are not exceeded.For laptop computers and tablets, the minimum distance from the body is 20 cmPhones are not tested in pants or shirt pockets.Therefore every cellphone manual has warnings that the phone should be kept at various distances from the bodyotherwise the human exposure limits can be exceeded.FCC+FCC requires “For purposes of evaluating compliance with localized SAR guidelines, portable devices should be tested or evaluated based on normal operating positions or conditions”
25iPhone on M’iBody The BlackBerry Torch 9800 Smart Phone “keep the BlackBerry device at least 0.98 in. from your body (including the abdomen of pregnant women and the lower abdomen of teenagers).”The iPhone 5's manualUsers must go to “Settings,” and scroll down to “General,” then scroll to the bottom to “About,” go to “Legal,” scroll down to “RF [MWR] Exposure”To reduce exposure to RF energy, use a hands-free option, such as the built-in speakerphone, the supplied headphones, or other similar accessories.Carry iPhone at least 10 mm away from your body to ensure exposure levels remain at or below the as-tested [exposure limit] levels.”0.98in =(25 mm)“Lower abdomen” is an oblique reference to testicle“abdomen of pregnant women” is an oblique reference to the fetus.
26The rate of absorption is higher in children than adults because their brain tissues are more absorbent, their skulls are thinner, and their relative size is smaller.The fetus is particularly vulnerable because MWR exposure can result in degeneration of the protective myelin sheath that surrounds brain neurons, they report.
27conclusionsThe risk to children and adolescent from exposure to microwave radiating devices is considerable. Adults have a smaller but very real risk, as well.Children absorb greater amount of microwave radiation (MWR) than adultsMWR is a Class 2B (possible) carcinogen.Fetuses are even more vulnerable than children. Therefore pregnant women should avoid exposing their fetus to microwave radiation.This is what the article concludedIt seems clear that we would not expose children to these other carcinogenic agents, so why would we expose children to microwave radiation?
28conclusionsAdolescent girls and women should not place cellphones in their bras or in hijabs.Cellphone manual warnings make clear an overexposure problem exists.Wireless devices are radio transmitters, not toys. Selling toys that use them should be banned.Government warnings have been issued but most of the public are unaware of such warnings.Exposure limits are inadequate and should be revised such that they are adequate.
29Cell phones, kids and cancer Another recent study showed in individuals using a wireless phone for more than 25 years the risk for glioma TRIPLED (Hardell et al. Pathophysiology 2014)Those who begun using a mobile or cordless device prior to 20y old were also at riskCommon sites for glioma were the temporal and overlapping lobes on the side the phone was placedThe International Agency for Research on Cancer classifies the electromagnetic fields produced by mobile phones as possibly carcinogenic. A formal risk assessment to be out in 2016
31Cell phone, kids and cancer No definitive data availableIssues with some of the data, as many of the reports are anecdotal.Public health data is unable to determine if there is one or many environmental concernsIs the perceived increase is simply better recognition at earlier stages based on the availability of MRI? as well as better reporting?At this time continue to use anticipatory guidance such as limiting screen time on MWR emitting devicesLimiting time on the phone and encouraging physical activity and social eventsReassuringly most teens text now and don’t speak to each otherUltimately however it is clear that children are the most at risk population
33PRAM SCOREs; preventing unneeded hospital stays Tool developed in CalgaryHelps asses which children can be dischargedLess time in the ER/clinicAlso a modified score for children admitted to the wardWill be rolling it out at UHNBC paediatric wardUseful for our ED docs too
34Emergent & Urgent Care Asthma Clinical Score (PRAM) Signs123Suprasternal IndrawingAbsentPresentScalene RetractionsWheezingExpiratory onlyInspiratory & expiratoryAudible w/o steth or silent chestAir entryNormalbasesWidespread decreaseAbsent/minimalO2 sat on RA>93%90-93%<90%Severity ClassificationPRAM CLINICAL scoreMILD0-4MODERATE5-8SEVERE9-12IMPENDING RESP FAILURE12+ following lethargy, cyanosis, decreasing resp effort, &/or rising CO2
35For any child over 1 year of age and less than 17 Presenting with wheeze & respiratory distressDiagnosed with asthma2 previous treatment with bronchodialator for asthmaMODERATE4-7SEVERE8-12ORImpending resp failureMILD0-3Sabutamol q20min x3+Ipratropium q 20min x 3In the 1st hrGive steroids after 1st MDI as per MDNotify physician or NPSalbutamol q20min 1-2 dosesIn 1st hour8-12ORImpending resp failureD/CReassess PRAM q min0-3
36Discharge medication/follow up Asthma education GP f/u MODERATE4-7Sabutamol q20min x3+Ipratropium q 20min x 3In the 1st hrGive steroids after 1st MDI as per MDReassess PRAM q min4-7Notify MD/NPSalbutamol q1h0-36hr post oral steroidIf PRAM 0-3Observe 1hr post lastBeta2 agonistYESON0-3NOADMITDischarge medication/follow upAsthma educationGP f/u
37Inpatient Assessment Score (Modified PRAM) Signs123Suprasternal IndrawingabsentPresentScalene RetractionspresentWheezingExpiration onlyInsp. & expiratoryAudible or silent chestAir EntryNormalDecreased at basesWidespread decreaseAbsent minimalPhase Change Criteria: SCORE of <3 at routine assessment or MD order on reassessment in Phase I or Phase IIFor B2 agonist assessment: if SCORE >3 give B2 agonist if <3 no B2 agonistFor any assessment SCORE >6 give B2 agonist and notify MD. If in Phase II or III move back to previous Phase.If in Phase one consider further investigations and reassess therapy (consider ICU, transfer, paediatric consultation)
39Like a fat kid on candy NEJM : obesity is increasing in the USA BMI >95%tile children 6- 11y 4.2%BMI >95%tile children 6- 11y 15.3%How do we identify vulnerable ages?How can we target resources to prevent obesity?Environment? Genetics?Poor choices? Media influence? Lack of exercise?Age???????????????Do not think Canada is insulated from this!
40Cute chubby babyNEJM 2014 article looked at the incidence of childhood obesity in the United States:Followed a cohort of kindergarteners to 8th grade ( )Weight and height were measured 7 timesAge, sex, and socioeconomic factors were collected
41SocioeconomicsAt kindergarten entrance age (~5.6yr) 14.9% were overweight and 12.4% were obeseThe greatest increase in prevalence of obesity was between 1st and 3rd gradeIn black and Hispanic children the prevalence of obesity was higher than in white childrenChildren from the wealthiest 20% of families had a lower prevalence of obesity:7.4% vs 13.8% and 16.5% (the 2 poorest quintiles)These differences increased through to the 8th gradeNEJM 2014
42Incidence AGA or SGA did not affect obesity rates LGA (>4000g) had a higher prevalenceAlthough prevalence increased with age; the incidence declinedKindergarteners : annual incidence 5.4%Grade 5-8: annual incidence 1.9% boys 1.4 % girls45.3% of incident obesity cases between kind and 8th grade occurred from the 14.9% of children who were overweight when they startedThe annual incidence of obesity in kindergarteners who were overweight was 19.7% compared with their normal weight peersOverweight children from the 2 highest socioeconomic groups had 5x the risk of becoming obese as normal weight children in the same groupNEJM 2014
43Main FindingsOverweight children were 4 x as likely to become clinically obeseThe annual incidence of obesity decreased from 5.4% in kindergarten to 1.7% between 5th and 8th gradeThe time to act may have been missed by the time a child enters kindergarten is missed; when 12.4% are obese & an additional 14.9% overweightPoverty is a risk factorThe pool of at risk population is depleted as they get older therefore more likely that thos ewho are normal weight will remain soNEJM 2014
44Timing of adiposity rebound and adiposity in adolescence Pediatrics 2014 Hughes et al Sample BMI of a cohort of children followed from birth at 3 periods of timing until 15 years of age.Adipostiy Rebound: the period in childhood where BMI begins to increase from its nadirVery early AR occurred <43 monEarly AR later AR >61moBMI higher in adolescence with very early ARwas also higher for those with early AR compared with those with later AR (>5 years)Children of obese parents had the greatest risk of early AR43 = 3.5 yrs61=5yr
45ConclusionA component of the course to obesity is established before 5 years of agePreventive interventions should consider targeting modifiable factors in early childhood to delay timing of AR.The overweight children tend to become obese early in schoolInterventions should target the whole family; not just the childrenShould this be discussed at early childhood visits or during pregnancy?; consistent with the depletion of the pool of persons who are more susceptible to becoming obese as time goes on.
46Autism…. AVOID EVERYTHING Last spring CDC calculated the prevalence of autism spectrum disorders in 2010 at 1/68 children aged 8 VS /88.During this time there was no change in diagnostic criteria or data collection methodsSpeculate that children may have been “missed” or “misdiagnosed” Dr. Hyman, MedscapeNot everyone believes the “missed” theoryThere is a genetic link however the increasing incidence has spurred investigations into potential environmental triggers
47As if pregnancy wasn’t hard enough Links of autism risk toMaternal intake of ironParticulate air pollutionPreeclampsiaPregnancy weight gainPesticidesAnd the list goes onThere is some interventions!
48Maternal intake of Supplemental Iron and Risk of Autism Spectrum Disorder Schmidt et al Am J Epidemiol 2014Iron is critical or early neurodevelopmental processes that are dysregulated in ASDIron deficiency affects 40-50% of pregnanciesStudied maternal iron intake in relation to ASD risk in California-born childrenIron intake studied from 3 months before pregnancy through to the end or pregnancy or breastfeeding
49Maternal intake of Supplemental Iron and Risk of Autism Spectrum Disorder Schmidt et al Am J Epidemiol 2014Mothers of cases were less likely to report taking iron-specific supplements vs controlsMothers of cases had a lower mean daily iron intake vs controlsThe highest quintile of iron intake during the index period was associated with a reduced ASD risk compared to the lowestMost notable during breast feedingLow iron combined with advanced maternal age and metabolic conditions; were associated with a 5 fold increase ASD risk
50Autism Risk liked to Particulate Air Pollution Medscape Dec 18 2014 Children whose mothers were exposed to high levels of fine particulate pollution late in pregnancy have a 2 x risk of developing autism vs breathing cleaner air Harvard school of Public HealthIe. Fires, vehicles and industrial smokestacksGreater exposure greater the riskPrevious research 2010: mothers living near highways during their 3rd trimester. Autism risk doubled.
51Autism Risk liked to Particulate Air Pollution Medscape Dec 18 2014 Harvard study:Nurses Health Study II began in 1989Compared prenatal histories of 245 children with ASD to normal developing childrenNo association between fine particulate pollution exposure before or early in pregnancy or after the child was bornHigh levels of exposure during the 3rd trimester DOUBLED the risk of autismNot clear about how the contaminants disrupt brain development
52Preeclampsia Linked to Autism, Developmental Delay Preeclampsia Linked to Autism, Developmental Delay. Medscape DecCHARGE study : compared 517 children with ASD, 194 with DD and 350 typically developing children.Exposure to preeclampsia in utero associated with a greater than 5x vs no exposure for developmental delay and just over 2x for autismPreeclampsia common in obese women or those who have diabetes or chronic hypertensionNB: over half of pregnant women in USA are overweight or obeseInterpret this study with caution; given the multiple factors at play and small numbers
53Pregnancy Weight Gain May influence Autism Risk In 2 separate cohorts from Utah Bilder et al Pediatrics found a positive association between prenatal weight gain; but not pregnancy weight and risk for ASDASD risk was significantly associated with pregnancy weight gain; in two separate groups with an odds ratio of 1.1 and 1.7 for each 5 pounds of weight gainedNote the absolute weight gain difference in the two case and control was only 3 lbsOR very modest increaseI would not tell a mother to not gain weight due to this study
54Pesticides and Autism Spectrum Disorders CHARGE study again486 children with ASD, 168 with delayed development and 316 controlsAssessed timing and extent of pesticides application 1.75km of the mothers residence from 3 mots before conception to time of deliveryStrong association between ASDapplication of nonspecified organophosphate during 3rd trimesterChlorpyrifos during 2nd trimesterSignificant association betweenASD and pyrethroid application during both preconception and 3rd trimesterCarbamate application and developmental delay (smaller number)
55Pesticides and Autism Spectrum Disorders Chlorpyrifos is banned for residential useOften drift into other areasStudy is retrospective and no biological samples were collectedNo account for pesticide use in the home or other exposuresDon’t lick the green green grass; especially when pregnant.
56The study involved 54 families participating in the British Autism Study of Infant Siblings with at least one autistic child.Studies suggest that about 20% of infants with an older sibling with an autism spectrum disorder (ASD) develop ASD themselves.28 families were randomly assigned to a specially adapted Video Interaction for Promoting Positive Parenting Program (iBASIS-VIPP); 26 were randomly assigned to receive no intervention.
57Video Program May Prevent Autism in High Risk Infants Lancet psychiatry: Videotaped parent and child interactions in 1st yr of lifeThe intervention group received at least six home-based visits from a therapistvideo feedback to help parents understand and respond to their infant's style of communicationgoal of improving infant attention, communication, early language development, and social engagement.
58The high-risk infants were assessed at baseline when they were 7 to 10 months old and again 5 months after the intervention or after receiving no intervention.After 5 months, infants in the intervention group showed improvements in several known ASD risk markers, including engagement, attention, and social behavior.The infants also showed improved social behavior with people other than their parents.Intervention infants showed a reduction in autism-risk behaviors, as assessed by the Autism Observation Scale for Infants (effect size 0.50; 95% CI, to 1.08), suggesting that video-based therapy may help modify the emergence of autistic behaviors during early development.Offers the possibility of providing a focused low-intensity intervention on the basis of risk, without the need to identify a specific condition such as Autism Spectrum Disorder.“
59Kids having babies… New guidelines from the AAP this year highlighted: Trend of decreasing teen sexual activity and teen pregnancies since 1991 continuesTeen birth rates at a record low, owing to increased use of contraception at 1st intercourse and use of dual methods of contraception in sexually active teensUnited States still tops all other industrialized countries in terms of teen birth rates.Less than one third of sexually active females (aged years) used contraceptive methods during their most recent engagement in intercourse.700000/yrAbove applies to the USA
60A bit better in CanadaEven with increases in teen pregnancy in parts of Canada, the country still has a much lower rate than the United States.In 2008 Canada’s rate was 30.5, while in the U.S. it was 58.0.Differences include: universal health care, access to contraception and sex education and the lower rate of poverty among young people.
61Teen pregnancy: Who is at risk?? experiencing social and family difficulties;whose mothers were adolescent mothers;undergoing early puberty;who have been sexually abused;with frequent school absenteeism or lacking vocational goals;with siblings who were pregnant during adolescence;who use tobacco, alcohol and other substances; andwho live in group homes, detention centres or are street-involved.It is important to understand who is at riskTo address them in your clinic and counselCPS: Adolescent Pregnancy reaffirmed Feb 2014
62Including information about the emergency contraceptive pill Health care practitioners have an important role in preventing unplanned adolescent pregnancies.Include longitudinal follow-up of at risk teens, provision of a continuum of options from abstinence to contraceptive informationTo discuss decision-making in a manner appropriate to the adolescent’s development.Particularly important for adolescents with a developmental delay, disability or chronic condition.Teens of both sexes who may engage in sexual activity should be counselled in methods of contraception.Including information about the emergency contraceptive pillCPS: Adolescent Pregnancy reaffirmed Feb 2014
63Contraception AAP 2014 statement Counseling about abstinence and postponement of sexual intercourse is an import aspect of adolescent sexual health.Long-acting reversible contraception should be considered first-line contraceptive choices for adolescents.A pelvic exam is NOT required to prescribe contraceptives or refer for IUD placement.Screening for sexually transmitted infections (STIs) can be performed without a pelvic examination and should not delay the initiation of contraception.Encourage the correct and consistent use of condoms "each time, every time" and should take the opportunity to pair this encouragement with a regular update of their patients' sexual histories in a confidential and nonjudgmental setting.Pediatricians and family physicians need to be clinically proficient when discussing the variety of contraceptive options. The significant recommendations are as follows:Long acting including the progestin implant and intrauterine devices (IUDs),
64CPS 2014counsel pregnant adolescents in a nonjudgmental way about their pregnancy options.If they are unable to do so, they should refer to others who can provide this service;attempt to protect adolescents from being coerced into any option against their will;help the adolescent develop a supportive network that may include family members, her partner, trusted friends and other health care providers;provide people in that support network with guidance as to how they can best help the pregnant adolescent;make follow-up appointments;ensure that adolescents referred to another practitioner or service have made and kept their appointment; andrespect the adolescent’s right to privacy and medical confidentiality.
657th heavenCATT in concussionsReturn to playReturn to learn