Chapters Transcript Video Panel Discussion 1 Hi, it's Jennifer Shaw from touchpoint Pediatrics. I have two very different and both distinct questions um that come up weekly. At least for us, one is on the precise supplements, especially the ones with caffeine that a lot of the adolescents are taking. Now we've had multiple kids that I've had new episodes of palpitations and chest pain sometimes after a viral illness, but often it's so there's deconditioning involved, but often it's related to taking these supplements and what your thoughts are, what your recommendations are. We're having these conversations even daily. And the second very different one is about the COVID clearance and how you guys respond to parent concerns about post COVID clearance, about myocarditis for the vaccine, hesitant for COVID shots. Um And both of those things are things that have to do with clearance. So I thought this might be the right form Lauren. Do you want to take the first part of that? Um Yes. So, I mean, with regard to the caffeine supplements, uh certainly those symptoms can be seen with excessive caffeine intake. Um uh the chest pain and, and heart racing just related to hypertension and tachycardia as effects of the caffeine. Um furthermore, they dehydrate you which will exacerbate those symptoms. So, uh if you know, we don't recommend them at all and certainly if they're having symptoms, that should be the first thing that should be excluded. And we say that reg that's part of our history, um especially in our patients that present with a questionable pots um scenario we ask um about intake of those substances. So, no, we don't recommend them and yes, they can explain those symptoms um without underlying cardiac pathology. And I must say for when we talk about the sports drinks for our pots patients, I specifically make it clear, you really have to go through what the ingredients are in the sports drinks. We have specific ones that we recommend that we know have no caffeine and low amounts of sugar. Gatorade, for example, has excessive sugar in it. Gatorade, 00 sugar. Um So sometimes we can't just make the blanket statement of the sports drinks because the social media out there with the prime and all those other various sports drinks that are attracting the kids many times have those unnecessary additives to them. And the sec the second part about the COVID, um you know, I screen them in the same way. Uh What if they have the history of COVID? Um I still just focus on the history as well as the physical examination. Um We all do the additional testing if they've had documentation of myocarditis. And so, you know, the question they may have for us is, well, how do you know, I didn't have myocarditis and the, how I pose it back to them is any virus can cause myocarditis and kids get viruses all the time. So the fact that they didn't have the symptomatology at that time that brought us to their presentation gives them a low likelihood that we would do any testing in order to clear them. Um And there are cases where we've seen cardiomyopathies in older kids and we get this distant history of a viral infection and symptomatology at that time that maybe it was subclinical. So that's why it's not a zero risk, but it doesn't change how I clear them. And I'll just say one thing in terms of the patients who are or parents who are resistant to the vaccine. We do emphasize that the cases that we've seen of myocarditis related to COVID are so much worse than the cases of vaccine associated myocarditis. Those Children really recover very well with the vaccine related myocarditis versus we know the other ones who've had long term complications. Hm Yes. Doctor mcphillips said that uh uh Dan K advocate participant in pediatrics, um I have a ECG screening question. So, um back in the days when I was considered a young athlete, uh um I, I was shocked that uh when I was living in Europe, I had to have a mandatory ECG test uh while I was in Italy. And uh then I realized I learned about how shockingly lower the rates of sudden cardiac death for athletes were in Italy because they did this screening. Uh So here's my question. I, I understand that the US has decided that this is too expensive to do it for 10 million athletes a year and too many false positives. I think you said uh 50,000 to 300,000, 1 and one in 50,000 to 1 300,000 cardiac deaths per year that um uh happened. So, so I understand there's some cost benefit ratio concerns. But you've also highlighted on your screens that non-hispanic African Americans are at higher risk and we're doing a bad job of screening that population. And you've also had um uh on your slides uh about how family history, every, every male in Italy dying twenties and thirties sounds like Brugada Center like you're showing risk factors. So why not the adopted kids who we don't know the history and maybe they're adopted because they have lost family from these things. So, so I feel like there are real risk factors that can show us entire segments of the population that would have a much higher benefit ratio in the cost-benefit analysis. Um And yes, there's some false positives and that has to be sorted out and yes, those kids may wind up having higher um costs of echoes and, and further studies. But you know, at what point do we say? Ok, maybe not for every athlete, but we already know who we should be doing much more ecg screening on. Yeah. No, I agree. And there's a lot of articles out there. It's saying exactly what you're saying right now. Um, and that's why as of recently the A H A is starting to hedge on that topic. They're not fully recommending it yet. Um, but they're not opposing it for the physician to order it. Um, here at our institution, you do not need to be seen by cardiology to get an echo uh just to get an EKG. So we do EKG appointments only and you can get those same day if not within a couple of days if that helps, um, the screening process. Um But yeah, your opinion is one of many and it may be in our future where that does change. It's just EKG has a higher false positive rate than what would be acceptable for any screening. And that's why at this point they oppose it. But you have that family, if it cost $1 billion to have this program by having it added to the screening, the family who lost their kid would pay that $1 billion. So to talk just about cost is unfortunate. Um But the A H A does heavily discuss the economic burden and that's largely the reason of why they're not including it as well as the infrastructure we have right now in the United States, you have it readily available with us, but other parts of the country don't. And so they take that into account of how they're going to apply that recommendation across all states. I would just add the reason why uh it's more effective in Europe. Um And why they've had success is because the population is much more homogeneous. And so you can apply more standardized uh interpretations of the EKG S and get less false positives. Um And with the diversity here, that's been argued as one of, one of the problems is that we're gonna get why we're gonna get so many false positives as opposed to some of these smaller countries with less diversity. There's also the A H A is not opposed at all to grassroots efforts and school efforts, high school efforts in terms of including EKG S as part of their own specific um re um qualifications, you know, for uh engaging in sports but not as a general screen. And you, you know, you had mentioned some ethnic um differences in terms of EK in terms of risk factors. There's also a lot of ethnic differences, particularly in the black population in terms of EKG. So it also raises questions of interpretation of EKG S in the black population with a lot of students potentially being disqualified for EKG S that are absolutely normal in that population. So it's a, it's a little bit more complicated in the United States because of the, um, as Lauren was saying, the home of the heterogeneous of, of the population here compared to other countries. And it's also interesting. It's actually on the P pe s are only recommended for non-professional athletes in three countries, the United States, Italy and Israel everywhere else. It's at the discretion of the schools. It's not universal. So I also found that interesting too, but you can't not talk about sports clearance and hear about all the Italian um studies that are out there because of the program they've initiated, I think since the 19 seventies is when they started that universally. And although the Italian study, which is, you know, usually what everyone quotes in terms of the, um, the reason why EKG S are included, the Italian study showed that the, um A RBD um, was picked up more readily in the Italian population where the incident may be actually higher compared to other parts of the world. Um, and it has decreased the incidence of sudden death in that population. However, the Israeli study in, in Israel, EKG S are also part of the requirement for preparticipation screening, um, did not show any difference before the EKG was incorporated into the protocol in reference to sudden death in athletes um compared to including EKG. So it's, it's controversial still and you know, to really sum up the preparticipation screening no matter how much screening you do, how much testing you do there as Lindsay was saying, there's zero, there's nothing where there's zero risk and the most important part of participation, scr uh parti participation in sports is really making sure that um, there is an emergency plan in place in the schools and uh each of the sporting events, unfortunately, with Janet's law that takes place in New Jersey, the other thing that's very interesting is in terms of, um, the high schools in New Jersey, New Jersey is one of the states that requires uh high school students to have CPR training before they can graduate in the United States. Now, 40 states require that. So, you know, it's a step in the right direction. Do we have any more questions? Good morning, Susan, chair from AM G pediatrics. I just have a question about stethoscopes. Do you recommend those enhanced digital stethoscopes or do you have a recommendation for a good stethoscope you use, I'm due for a new one. So that's why I asked. I do not have one. I, I do not have the stethoscope but I know doctor Chea has one. So and Cyrus and take you over there has one too. I um you know, it's funny because so my dad was a neonatologist and he was hard of hearing in his later years and he always said bone conduction is better than air conduction. And so, you know, these stethoscopes, they do augment sounds, but they augment breath sounds, they augment static, they augment everything and I don't know about you CIA, but I feel like mine always gets turned on in my bag and then it gets that it loses its charge. And it's actually, I find that as an analog stethoscope, it's not as good. So I've dispensed. I, I don't use it anymore. Yusuf Abdul Meir from Totowa pediatrics. Quick question uh outside the newborn period. Uh What percentage of patients you see the end for heart murmur? They end by having EKG and or echocardiogram outside the newborn period. Is that what you said? I, I'd say, I mean, I don't want to speak for everyone, but I'd say under a year if they come to us and they have a murmur, um The majority of of us will, will do uh everybody gets an EKG when they come to us and the majority of us will add on an echo. Um uh I think between one and two, it's, it's variable in our practice over two. If they have a classic murmur of a stills murmur, a normal EKG uh or a classic venus hum. Um uh and a normal EKG and no, concerning personal or family history. Um I think I could speak for the for us that we do not uh for all of us that we do not get echocardiograms. I can't give you a percentage but um I don't know if that answers your question but mhm OK. Um Up to what age do you feel comfortable seeing a patient for the first time? What was the question there up to? What age do you feel comfortable seeing a patient for the first time? We do have a policy on this. What somebody, what's the guard? It's, it's between 18 and 20. Um, I don't know. We've aged Colleen, I believe it's 21. Right? 20 down. So, yeah. And the thing is, it's not, it's not so much. Yeah, it's not so much the idea that we're not comfortable taking care of adults. I actually find that pediatric cardiologists are comfortable taking care of everybody from fetuses to the adults, which can't be said about the adult cardiologists. But it's more about the idea that you don't want to establish care with a patient who's then going to be transitioned pretty quickly. But. Mhm. I need to go over time. So thought. Yes. Correct. And which is better? Awesome. Not sure. Yeah. And so that, you know, I, I do find that if it is kind of something that is easily managed by adult specialists that I think and again, and it's hypertension is going to be a long, an ongoing issue. In that case, it would certainly make sense to send them to adult cardiology. But there's some, there, there are some considerations like you said, with, with Down Syndrome, developmentally delayed or I think they would be better served by a pediatric cardiologist. And as you were referring to. Um we have an adult congenital heart disease transition program started by Doctor Donnelly years ago, um in which our congenital heart disease and complex pediatric patients, those with developmental delay, et cetera get um have a formal transition curriculum that culminates in an uh being formally transitioned to an adult congenital heart disease specialist who's trained in both pediatric and adult cardiology. We have uh a really great program here and um actually, and now we've just partnered with Ny U's Adult congenital specialists as well who now come here as well. And um it culminates in their final appointment with us is the same as their first appointment with the new specialist. Any other questions or we can take a short break before I start our next session. Thank you guys. Published Created by
