PNP-PC chronic conditions: asthma, type 1 diabetes, obesity, and pediatric chronic disease management

Diagnosis: FEV1/FVC ratio <0.85 in children (adjusted for age-specific norms). Spirometry confirmatory; methacholine challenge for indeterminate cases. Evaluate triggers: viral infection (most common in young children), allergens, exercise, cold air, smoke.

NAEPP step therapy for children (modified from adult guidelines):

• Step 1 (mild intermittent): SABA PRN — symptoms <2 days/week, <2 nights/month, FEV1 >80%, no daily medication needed
• Step 2 (mild persistent): Low-dose ICS daily (preferred) OR montelukast (LTRA — second-line for young children unable to use inhalers; FDA black box warning for neuropsychiatric effects — discuss with parents)
• Step 3: Low-dose ICS + LABA (age ≥5) or medium-dose ICS; for <5 years: medium-dose ICS
• Step 4: Medium-dose ICS + LABA
• Step 5–6: High-dose ICS + LABA ± add-ons; refer specialist

Spacer device: Mandatory for MDI in children under 4 years; recommended for all children. With mask for age <4; mouthpiece when able to form adequate seal.

Asthma action plan: Provide written plan at every visit. Green (80–100% PEF, symptoms controlled), Yellow (50–80% PEF, caution, add SABA and step-up), Red (<50% PEF, emergency — oral corticosteroids + SABA + seek care).

Diagnosis: Classic symptoms (polyuria, polydipsia, weight loss) + random glucose ≥200 mg/dL, OR fasting glucose ≥126, OR 2-hour OGTT ≥200, OR A1C ≥6.5% on two separate occasions (or combined with symptoms). DKA at presentation common in T1DM.

ADA pediatric A1C targets: Most children and adolescents with T1DM: A1C <7% (if achievable without excessive hypoglycaemia). Younger children and those with hypoglycaemia unawareness: A1C <7.5% — balance between control and hypoglycaemia safety. Individual target should reflect clinical situation and family engagement.

Insulin regimens: Multiple Daily Injection (MDI) — basal (glargine, detemir, degludec) + rapid-acting (lispro, aspart, glulisine) with each meal. Continuous subcutaneous insulin infusion (CSII/insulin pump) — preferred by many families; requires training and engagement. Continuous glucose monitoring (CGM) is recommended for all children with T1DM (ADA 2024) — reduces A1C and hypoglycaemia; compatible with closed-loop systems (artificial pancreas).

Diabetic ketoacidosis (DKA) recognition: Glucose >250 mg/dL + pH <7.3 + bicarbonate <15 mEq/L + ketonaemia/ketonuria. Management: IV fluid resuscitation (caution — cerebral oedema risk in paediatric DKA; avoid aggressive fluid boluses), insulin infusion (after initial fluid resuscitation), electrolyte replacement (K+ before insulin if hypokalaemic), close monitoring. Refer emergency.

AAP 2023 guidelines represent a significant shift — recommend active treatment rather than watchful waiting for children with obesity.

BMI screening and classification: Overweight: BMI 85th–94th percentile for age/sex. Obesity: ≥95th percentile. Severe obesity: ≥120% of 95th percentile or BMI ≥35 (whichever is lower).

AAP 2023 recommendations:

• Obesity (≥95th percentile): Offer comprehensive, intensive behavioural lifestyle treatment (≥26 hours over 3–12 months) — first-line for all age groups
• Pharmacotherapy: Offer for ages ≥12 with obesity as adjunct to lifestyle treatment. FDA-approved options: orlistat (≥12 years), phentermine/topiramate (≥12 years), GLP-1 agonists — semaglutide (Wegovy — ≥12 years FDA approved 2022), liraglutide (Saxenda — ≥12 years)
• Metabolic and bariatric surgery (MBS): Offer for ages ≥13 with severe obesity + comorbidities when intensive lifestyle + pharmacotherapy fails

Comorbidity screening in pediatric obesity: Blood pressure, fasting lipids, ALT/AST (non-alcoholic fatty liver disease), fasting glucose/A1C, sleep screen for OSA, mental health screening (depression, anxiety, binge eating disorder are common comorbidities).