Clinical Pearls

• Always remember your differential related to a history, especially when it comes to highly stigmatized diagnosis, such as Autism.  My pearl however is:  evaluate speech delay very closely, just because autism is diagnosed much more frequently now, there are other differentials behind speech delay.

• If parents are using an incentive-style method of potty training or bladder retraining for their child, remind them to reward the child for things within the child's control, such as going to the potty when they are told to, rather than things they cannot yet control, such as being dry.

• The role of supplemental fiber in a constipated child's diet is not well studied.  Some constipated children do not respond well to fiber, because they tend not to drink as much water as they need to.  Without enough fluid, the additional fiber may simply worsen the constipation

• Here are some tips from swallowing pills:  Practice with balled up pieces of white bread, from tiny to large, and have your child work their way up.  Have them place the bread, a tic-tac, a mini M&M, or the pill itself at the back or side of their tongue, then drink from a straw.  The straw helps it go down without stressing as much.  Most capsules float, so lean forward when swallowing.  Pills sink, so leaning back can help make this easier.

• In patients with liver transplant:  When portion of liver is taken from the donor (in this case, her father) and placed in the patient (the operation took place at age 1), the liver does not always grow in the normal shape/location.  While it is placed in the correct location during the surgery, it sometimes grows in an odd shape/size/location.  This is an important thing to know when palpating the abdomen of a liver transplant patient.  In this case, her liver was located more centrally, was oblong in shape, and coud be felt several centimeters below the ribs.  It is important to communicate with specialists about what is normal for patients with not so normal histories.  This way you have the ability to determine when there is a problem versus what is in the normal for that patient.

• In starting birth control, once the pregnancy test is negative.  Quick start is initiating birth control the same day your pregrnancy test shows up negative and teaching girls to use a back up method the first week as the pills are not effective as of yet.  This method has only been in use the last two years at this school and some concerns practitioners have with this method is the increased incidence of breakthrough bleeding related to starting OCP in teh middle ofa cycle.  However in a study comparing the Quick Start method to the traditional Sunday start method there was no difference in side effects, most commonly breakthrough bleeding and nausea/vomiting, and the 1-year compliance rate in adolescent females was the same in both methods.  In fact findings suggested taht there was better compliance in adolescents at 3 months with the Quick Start approach.