Transcription:
Illness, Illness, Everywhere Illness.

Trisha Williams: Hi guys. Welcome to the second season of the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien: And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. Our goal is to provide you with education and some inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look at the Practice roles at Children's Mercy.

Host 1: We are so glad that you're joining us today. So sit back, tune in and let's get started. Today we are blessed to sit down with not only one, but two experts. Brenda Snyder is an APRN, in Asthma Allergy Immunology Clinic, and Christy Dejmal is an APRN in Infectious Diseases. Today, we are going to chat about the overlap of pediatric infectious diseases and immunology concerns. Welcome to the podcast ladies.

Brenda Snyder, RN, APRN, CPNP (Guest): Thank you so much.

Christy Dejmal, RN MSN CPNP (Guest): Yeah. Thanks for having us.

Host 1: You are so welcome. Christy, do you want to start off and tell us a little bit about yourself?

Christy Dejmal, RN MSN CPNP (Guest): Sure. Yeah. So I grew up in Kansas City and completed my undergraduate degrees at K State and at KU, then I finished my masters in nursing at UMKC, a few years later. I started working at Children's Mercy in 1999 and have had the pleasure of working in Infectious Disease for my entire career here.

I've been a nurse practitioner here now for a little over 16 years. I currently follow our outpatients in clinic at both our Adele Hall and at our College Boulevard locations on the Kansas side. And I primarily provide hospital follow-up care for those who were recently admitted with a serious infection.

I see a variety of referrals from our community providers, including evaluations, for things like congenital infections or tuberculosis. And I also provide care for our HIV infected youth. So I see a pretty big variety and every day is something different.

Host 1: You definitely do. Well, welcome so much to the podcast. We appreciate your time today. Brenda, tell us a little bit about yourself.

Brenda Snyder, RN, APRN, CPNP (Guest): Hi, I'm Brenda Snyder and I have been a Kansas City native my entire life. Go Chiefs that's for sure.

Host 2: Go Chiefs. Yeah.

Brenda Snyder, RN, APRN, CPNP (Guest): I my undergrad at University of Missouri Kansas City and became a nurse practitioner back in 2014 from UMKC. Most of my career has been involved with the NICU and worked at North Kansas City Hospital for several years.

I've done a lot of mother baby, also a lactation consultant. So, I knew that I always wanted in the back of my mind to be a Pediatric Nurse Practitioner. So, I ended up back at Children's Mercy in 2010 as a staff nurse in the Asthma Allergy and Immunology Clinic. And I loved it so well that as I was continuing on to get my masters, I was able to, they created a position for me to be the first nurse practitioner for Immunology. And I love it. I've been there 11 years now and it's been a great experience. And I just enjoy taking care of the children.

Host 2: Welcome Christy and Brenda, you guys thanks so much for joining us. We have a lot to cover in a really short time. So let's just jump right in with Christy, I know you see so many different kinds of things, as you already mentioned, in infectious diseases, but for today's purposes, let's focus on recurrent illnesses and recurrent fevers and when to refer to infectious diseases. So tell us a little bit about the kinds of kids that get referred to you for those concerns of those recurrent illnesses or recurrent fevers.

Christy: Absolutely well referrals for recurrent illness and recurrent fevers are one of the most common referrals that we receive in ID clinic. Most of these referrals, they're in the toddler preschool or young school aged child. Referrals for recurrent illness are typically what the name implies. The patient is having a lot of recurrent illnesses.

And while the presentation for these patients varies, most are concerned about the frequency of these illnesses. Some of these children are having recurrent upper respiratory infections where symptoms can last for a few weeks with a brief period of wellness and then symptoms start right back up again, where others are having illnesses so close together that there sometimes isn't even a perceived period of wellness between those symptoms.

Some patients come to us and they've been on multiple courses of antibiotics over the previous year and they just don't feel that it has helped. And they're concerned about their child being on frequent antibiotics. Whereas others come in with stories of these illnesses being spread through numerous family members, which causes significant absenteeism from school and work, which is a huge challenge for families.

Now, the recurrent fever evaluations can also fall into a few different areas. Sometimes we receive referrals for patients who have intermittent fevers, where the height and the interval between those fevers really varies. They may have temperature one month up to 103 for a few days. And then a month later have another temperature of around 100 for even just a few hours. Most of these patients will have symptoms with these episodes and they may include mild upper respiratory symptoms or GI symptoms, or they may even be more vague where they have complaints of fatigue, decreased appetite or activity level, along with their fever. And sometimes they just have a fever and no other noticeable symptoms.

But then we have other referrals for patients who have fevers in a much more predictable pattern. And these patients will report fevers as high as 104 for three to four days a month, every four to five weeks. And some of these parents for these patients can look at their calendar and predict in advance even, when these fevers might occur.

They can tell me, yep. The first week of every month I can plan on my child coming down with this high fever. Some have symptoms with their fevers, like sore throat or swollen lymph nodes, or they may also have complaints of headache or abdominal pain where others, again, they just report a high fever without any other noticeable symptoms. Some of these patients come to us with a year long history or more even of these cyclical fevers. And some of them have had extensive workups completed during these various fever episodes in an attempt to identify a cause, as some of them don't appear to have an easily identifiable source. So with the heightened awareness, if you will, to illness and body temperatures that we've had during the pandemic, the number of referrals that our clinic has seen in the past year and a half or so for recurrent illness and recurrent fevers have greatly increased. We're constantly screening our kids, right. I mean, every day before they, before they head off to school or daycare, we've been asked to look very closely for any symptoms. And also for a lot of these kiddos, they're having daily temperatures taken or temperatures taken multiple times a day. So, for many of these families, these fever episodes have meant lots of visits to doctor's offices and, you know, again, a significant amount of time missed at school or work.

So by the time these families land in our clinic, some are just, they're frustrated and they're just looking for ways to keep their kids and their families healthy.

Host 1: Yeah. I could only imagine the impact that the pandemic has had just because we're monitoring our children more closely. Right? It's just like you said, so the increase of referrals I bet has definitely happened. Brenda, I know that there's a lot of crossover between immunology and infectious diseases when it comes to this recurrent illnesses and recurrant fevers. Can you talk a little bit about the kiddos that get referred to Immunology for kind of the similar reasons of these recurrent illnesses and recurrent fevers?

Brenda: Yes, our children that come to the immunology clinic, they typically will have infections that are recurring that sometimes might be on a monthly basis, or they might have two or three infections a year. Some of our referrals our young ones say like, preschool to like five years and under, and a lot of those infections, these children will have a cough and cold symptoms typically, and will go to their primary and be placed on antibiotics for upper respiratory infections, and several will also be placed on oral steroids courses for upper respiratory infections. And a lot of those times, they will come to our clinic and we'll do workup with labs and things, but with a more thorough history, we'll find out that they basically are having asthma symptoms. So, we'll put them on an asthma plan and have them come back within six weeks. A lot of those infections that they were treated with antibiotics is really just asthma.

And so then we will continue to follow them in the Asthma clinic and they will have no immunodeficiencies whatsoever. Which is great because we calm the parents down and they find out what's going on with their child. Then the other ones we will see there actually is a primary immune deficiency.

There's 10 warning signs that was created by the Jeffrey Modell Foundation. And those 10 warning signs are family history of immunodeficiencies or any unexplained early deaths before the age of 30, failure to gain weight or grow normally like failure to thrive, the need for intravenous antibiotics and or hospitalizations to clear infections, six or more ear or respiratory tract infections within a year, two or more serious sinus infections or pneumonias within a year, four or more new ear infections within one year, two or more episodes of sepsis or meningitis in a lifetime, two or more months of antibiotics that have no or little effect, recurrent oral or cutaneous candidiasis or deep skin or organ abscesses.

And that's what we will end up, coming to our immunology clinic. And so we'll do a workup and you know, hopefully rule things out, but those are the warning signs that will typically bring children to our clinic. As far as recurrent fevers, we can pretty good overlap between infectious disease, like Christy said, and ourselves with those with recurrent fevers and pretty much just what Christy was talking about.

They will have fever sometimes up to a 104, 105 and no other symptoms. And then on the other hand, they might have these random fevers that pretty much like Christy said, the parents will know every month here comes that fever and they could have a fever up to seven days and there's really no labs to figure that part out. But that's pretty much what we see in our clinic. And that's it for that part.

Host 2: Sure it sounds like there really are a lot of overlapping, you know, recurrent upper respiratory infection type symptoms that do get referred to both of you guys. I mean, it sounds like there's definitely lots of things such as this cyclical fevers that seems completely appropriate to come see you guys.

But whenever you mentioned the 10 warning signs, I was curious because it does sound like six or more upper respiratory infections in a year. I feel like that's pretty common though. So, I guess we have to also consider, do they have the other things that you mentioned in those 10 reasons to be concerned there would be an immunodeficiency as far as who really should come see you, which families, because most preschoolers have six colds a year. So how do you know the difference?

Brenda: So what we would do is because, like I said, a lot of them are diagnosed with asthma, but we will do a complete immune workup. A lot of times we might just put them on an asthma plan and if that works, then we will hold off on doing any type of labs, some parents want to, you know, very aggressive and they want to kind of, you know, know now, okay is there any labs that are abnormal as to why they're having these recurrent upper respiratory infections and some will say, great, let's start this asthma plan. Let's see if that works. So, if the asthma plan works, then we typically won't go in and dig in and do the immune workup. But if there is any other suggestions that we think, well, you know, sometimes you kind of have that hunch.

And as being a nurse, we all know that we have pretty darn good assessment skills and you can kind of almost tell the ones that are going to have maybe that immune deficiency. So our immune workup is what we would do and we would go into getting a complete blood count. We would look at immunoglobulins, which we typically look at the total IgG, the IgM and the IGA and those immunoglobulins are sometimes could be low. And and if they're low, then depending on what's going on, sometimes we might start on prophylactic antibiotics, or we might have to do an immunoglobulin infusions. We also look at vaccine titers to see if the kids are responding to their vaccines that they have received.

And if those titers are low, then what we would do is do a repeat, we would give them a booster vaccine, particularly for tetanus and pneumococcal and give them a booster and then check those counts again in four to six weeks. And if those numbers are normal, then we can say, hey right at this point, there's not an immune deficiency, but we'll continue to monitor.

We typically will continue watching our children in the Immunology Clinic for a few years sometimes just to make sure things don't kind of go up and down. Cause a lot of times, you know, things can go in waves. So we do look at labs and if there's anything abnormal, then possibly they do have an immune deficiency.

Host 1: I could see how there is so much crossover with these patients with infectious diseases and immunology, like we talked about and the workup like Brenda, I think in Immunology, your workup is very extensive for these patients, but I'm also wondering on the infectious diseases side, like, does the workup that you guys do in infectious diseases kind of overlap. Do you guys ever collaborate with each other for these workup, for these patients? Or do they start? I have so many questions or do they start in one department and move to the other department? Like Christy, can you kind of shed a little light on what you guys start off with in infectious diseases and then kind of expand on, do you ever refer to immunology or how does that work?

Christy: Sure. Yeah, kind of like Brenda said, it sounds like we do, you know, we'll see a lot of the similar initial presentations as they can both, you know, both, kiddo re presenting with recurrent infections may have just that, they may be having a lot of minor viral infections due to their age or exposure from school or daycare, or there may be something else going on.

So there, there are a couple of key differences. Children who do present with recurrent minor infections that are typical for their age. Or like I said, maybe related to exposure at daycare or school, they tend to be pretty healthy in between their illnesses and have normal growth and development.

I do tell parents that it's, it is normal for a healthy child to have upwards of 10, even a little bit more of those very minor viral types of processes a year, especially if they are a kiddo in daycare or preschool. So even for those, if we have patients that are hitting that 10 to 12 recurrent minor infections in a year's time period, we are going to kind of have in the back of our minds, okay, what else could be going on here? Is, like Brenda said is as there a history of some atopic disease or is what is going on in between these illnesses? If I see a child who presents with a number of abnormalities on their exam for instance, if they have generalized lymphadenopathy or if we're noticing failure to thrive, and these kiddos just don't seem to fully recover in between these illnesses or if they've got history an unusual infection or some type of serious infection, or lots of recurrent pneumonias or sinusitis in a very young child; those are some red flags that would likely prompt me to refer to our colleagues in immunology. That would kind of go, that would be a little bit different than just your typical toddler preschool or young school aged child that's having lots of colds.

Host 1: I think what I found fascinating too, is those warning signs. I didn't know that those existed. So as our community providers are listening, I'm sure that they're probably making note of what those warning signs are. And so, Brenda, can you tell us again what those, just the name of those warning signs?

Brenda: Yes, it is the 10 warning signs of primary immune deficiency by the Jeffrey Modell Foundation.

Host 1: Fantastic. So it sounds like if they have those warning signs and please correct me if I'm wrong, if they have those warning signs, that would be a good reason to refer to immunology, but then if they don't and there are still concerns about recurrent illness, then those patients or those children would go to infectious diseases.

Brenda: Yes. Correct.

Host 2: Nice. I think that this helps a lot, Trisha. Don't you think so?

Host 1: Absolutely. Absolutely.

Host 2: Well, thank you guys so much for joining us today. We really appreciate both of you guys and sharing your expertise with us.

We like to end each episode, this is sort of my favorite part, but we like to end each episode with the same question. What is your best overall piece of advice you've received or read lately that you'd like to share with us? And we could start with Brenda.

Brenda: My best advice is especially in past couple years, is that we need to always be upbeat and kind to others. And we never know what that other person is going through in their life. And so, you know, smile, say good morning, just, you know, be courteous to others and stop the negativity. I am just really wanting to be positive in the world today.

Host 1: I love it. Let's be positive. Christy, what about you? What's your piece of advice?

Christy: I'm going to kind of echo along a little bit what Brenda just said, because that's something also that I've found in the past year and a half with everything going on in life to just maybe pause and take a breath and give ourselves some grace with everything that's been going on, you know, both on, everything that's happened has impacted everyone so much on both personal and professional levels, right? Especially for us in the healthcare sector. So, just pause, take a breath, take some time for yourself. And yeah, like Brenda said, just be kind and and courteous to others and respectful to every, everyone that you come in contact with.

Host 2: I love it. Well, thank you guys for both sharing your Saturday with us today. So, we appreciate you guys so much. Listeners, thank you for tuning in.

Host 1: If you have a topic that you would like to hear about, or you're interested in being a guest, you can email us at tdo'brien@cmh.edu or twilliams@cmh.edu. Once again, thank you so much for listening to the Advanced Practice Perspectives Podcast.