The Art of Differential Diagnosis Objectives for …...2/15/2020 1 The Art of Differential Diagnosis for Lactation Consultants: What, Why, and How Christina M. Smillie, MD, FAAP, IBCLC,

2/15/2020

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The Art of Differential Diagnosis for Lactation Consultants:

What, Why, and How

Christina M. Smillie, MD, FAAP, IBCLC, FABM, Stratford, Connecticut, USA

(and why it’s within the LC’s scope of practice!)

1. The participant will describe how and why the lactation consultant’s scope of practice distinguishes a “lactation assessment” from a “medical diagnosis”

2. The participant will describe what a differential diagnosis is, differentiate it from a medical diagnosis, and explain why this is a key part of a lactation assessment

3. The participant will describe how to make a differential diagnosis, giving examples from recent families s/he has seen

4. The participant will explain why the art of differential diagnosis is not only within the LCs scope of practice, but key to better assessments, better outcomes, and better communication with other health care providers

Objectives

© 2020 CM Smillie MD

1. A couple brief clinical scenarios

2. A little background• IBLCE’s rules and statements about scope of practice• A look at some definitions, why’s and wherefores…• Why a differential diagnosis is OK for LCs to do.

3. What a Diff Dx is and how to create one.• How doctors use differential diagnoses.• The lactation adaptation. • The process.

4. Using a Diff Dx in your clinical practice. • A look at those scenarios first described. • Benefits to you and your clients.

Structure of this talk


1. 28 you mother comes in with her 3rd child, now 6 weeks old, for help with pumping because….

• Pediatrician has put her on an elimination diet, and for 2 weeks she has to pump and dump and formula feed, because...

• Pediatrician says the baby is allergic to mom’s milk or else perhaps “silent” reflux.

A couple brief clinical scenarios


• Baby latches shallowly and has a visible type III frenulum.

• The LC who works in the hospital saw the frenulum too but this doctor has forbidden LCs to tell the mother if a baby needs a frenotomy.

A couple brief clinical scenarios2. A 21 yo mother comes in with sore cracked nipples, exclusively breastfeeding her 1st child, 8 days old, despite severe pain…


Diagnose


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Clinical Competencies


III. IBCLC certificants have the duty to provide competent services for clients and families by: 2. Performing

comprehensive maternal, child and feeding

ASSESSMENTSrelated to breastfeeding and human lactation.


III. The IBCLC has the duty to provide competent services for clients and will perform a comprehensive maternal, child and feeding ASSESSMENTS related to lactation, such as….

Total of 63 skills listed


From IBCLC Clinical Competencies, Sec III, “History & Assessment Skills”

2. Ascertain the client’s goals for breastfeeding/child-feeding. 5. Obtain a lactation history.6. Identify events that occurred, before and during the pregnancy, labour and birth process that may adversely affect breastfeeding and human lactation9. Assess the impact of physical, mental and psychological states of the breastfeeding parent on breastfeeding.10. Obtain child’s health history and assess the impact of the child’s medical condition on breastfeeding. 11. Assess social support and possible challenges.

From Clinical Competencies, Sec III, “Skills to Assist Breastfeeding Dyad”

10. Assess the child’s stooling and voiding.

An IBCLC takes a historyUSDA Public domain


From Clinical Competencies, Sec III, “History & Assessment Skills”

8. Assess the breasts to determine if changes are consistent with adequate function/lactation.


3. Assess oral anatomy, neurological responses and reflexes of the infant. 4. Assess infant behaviour and development as it relates to breastfeeding. 7. Identify effective latch/attachment.8. Assess for effective milk transfer.9. Assess milk intake of the infant.

And looks at other data22. Calculate an infant’s caloric/Kilojoule and volume requirements. 24. Assess the child’s growth using World Health Organization Child Growth Standards.

And does an exam

USDA Public domain


And an IBCLC Makes Clinical DecisionsAssessments

Some are simply observationsMany involve judgments,

explicit or implicit, whether normal or problematic.


23. Assess milk production and provide information regarding increasing or decreasing milk volume as needed.

From Clinical Competencies, Sec III, “General Problem-solving Skills”

3. Evaluate potential or existing challenges and factors that may impact meeting a client’s breastfeeding goals.4. Assist and support the client to develop, implement and evaluate an appropriate,

acceptable and achievable breastfeeding plan utilising all resources available. 7. Assess and provide strategies to initiate and continue breastfeeding when challenging

situations exist/occur.

USAID


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Background

IBLCE® has received several inquiries regarding the diagnosis of disease and disease processes including, among others, "tongue tie," thrush, and mastitis.


The IBCLC certificant neither practices medicine nor diagnoses a disease or disease process unless the certificant is separately licensed or authorised to perform such procedures.

An IBCLC certificant does: carefully ASSESS,document findings, and refer appropriately as needed, to obtain a medical diagnosis and possible treatment.


So what’s the difference? If I see that the baby has tongue tie, that’s my Assessment!

I’m not trying to play doctor. I’m just assessing the infant’s oral structures per the IBLCE Clinical Competencies!


So what’s the difference? Definitions– From IBLCE Advisory Opinion

A medical diagnosis is based upon a medical history and physical examination and may include additional testing which then leads to identifying a disease or disease process.

The IBCLC assessmentisn’t defined in IBLCE’s Advisory Opinion, but the verb assess is used in multiple ways in IBLCE’s Clinical Competencies–

• for gathering history, • observations or exam,• and for some judgment calls.


Advisory Opinion:Assessment, Diagnosis, and Referral

22 March 2017

Advisory Opinion

The IBCLC certificant neither practices medicine nor diagnoses a disease or disease process unless the certificant is separately licensed or authorised to perform such procedures.

An IBCLC certificant does: carefully ASSESS,document findings, and refer appropriately as needed, to obtain a medical diagnosis and possible treatment.


So an LC assessment involves…

✓ History

✓ Exam

❑ Medical tests

✓ Decisions

✓ whether the situation is normal or abnormal,

❑ Diseases processes

✓ A management plan

And a medical diagnoses involves…

✓ History

✓ Exam

? (Sometimes) medical tests

✓ Decisions

✓ whether the situation is normal or abnormal,

? (Sometimes) disease processes

✓ A treatment plan


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So if there’s no disease, and no tests,

what’s the difference between an

LC’s assessment and an MD’s diagnosis??

© 2020 CM Smillie MD © 2020 CM Smillie MD

Medical diagnosisis the

PROCESSof

DETERMINING WHICHdisease or condition

EXPLAINSa person’s symptoms and signs


Diagnosis is often challenging, because many signs and symptoms are nonspecific.


Medical diagnosisis the

PROCESSof

DETERMINING WHICHdisease or condition

EXPLAINSa person’s symptoms and signs


There are a number of methods or techniques that can be used in a diagnostic procedure, including performing a differential diagnosis or following medical algorithms.[7] In reality, a diagnostic procedure may involve components of multiple methods.[8]

Differential diagnosisMain article: Differential diagnosis


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https://en.wikipedia.org/wiki/Sensitivity_and_specificity

https://en.wikipedia.org/wiki/Differential_diagnosis

https://en.wikipedia.org/wiki/Medical_algorithm

https://en.wikipedia.org/wiki/Medical_diagnosis#cite_note-Langlois-p198-7

https://en.wikipedia.org/wiki/Medical_diagnosis#cite_note-Langlois-p204-8

https://en.wikipedia.org/wiki/Differential_diagnosis

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A systematic and methodical PROCESS for reaching a decision about what might explain the patient’s signs and symptoms.

Physicians are taught

Before you can make a diagnosis,

FIRST you have to consider ALTERNATIVE explanations for what you are seeing.

Considering the alternatives is a crucial part, an important step, in making the diagnosis.

Differential diagnosis


Helps you

Sort out confusing situations.

Avoid missing a dangerous situation.

Avoid missing a less likely or less obvious explanation that could turn out to be the real problem.

Avoid unnecessary delays and interventions.



Differential diagnosis For doctors, all sorts of mnemonics to remind us to think of all possibilities


Differential diagnosis Mnemonics

*PHARYNGITIS: "THROAT PAIN"

T - Thyroiditis

H - Herpangina ,Hodgkin's

R - Retropharyngeal abscess

O - Oral ulcers: Aphthous, Syphilis,TB, Herpes

A - Angioneurotic edema

T - Toothache/abscess

P - Peritonsillar abscess

A - Angina: Vincent's, Ludwigs

I – Infection

N – Neoplasm


Differential diagnosis Mnemonics

Acute Abdominal Pain: "Bad Gut Pain"

Females Acute With Pelvic Pain: "Ectopic"

Amylase elevation – “Parotid”

Anemia: Macrocytic = "Big Fat Red Cells"

Normocytic = "Normal Size"

Microcytic = "Tics”

Hemolytic = "Hematologists"

Arthritis – “ Arthritics”

Arthritis Autoimmune – “Suppress”

Atrial Fibrillation – “Irregular P Waves”

Back Pain : "Disk Mass"

Bradycardia – “Bradycardias” Chest Pain: "An Aching Heart Can Play A Part"


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Dozens of books on Differential Diagnosis


A systematic and methodical PROCESS for reaching a decision about what might explain the patient’s signs and symptoms.

• Helps sort out a confusing situation.

• Helps avoid missing the real diagnosis when a single obvious (but wrong!) diagnosis jumps out at you.

• Helps avoid unnecessary interventions.

• Helps you communicate with physicians (more about that later)




I don’t get it.It’s even more about doctor kind of diagnosis

And how does this apply to my work as a lactation consultant??


Not for every dyad you see


Useful when:

You aren’t sure what’s going on

You’re considering a painful, expensive, controversial or otherwise difficult intervention

You want to refer out.

You want a doctor to hear your assessment.


1. Collect information (Mother/baby history and exams, watch a feed)

2. Make a list. All possible causes of this picture.

3. Prioritize the possibilitiesBy most serious, or most likely, or most in need of quick treatment

4. Narrow down to 2 or 3 top choices.(NOT just one!)

5. Make a plan for the familyTo confirm or refute your choicesTo help family in meantime, even without definitive answer

The PROCESS of differential diagnosisIn a nutshell


1. Collect information (Mother/baby history and exams, watch a feed)

2. Make a list. All possible causes of this picture. Think outside the box

The PROCESS of differential diagnosis

Mother causes Baby causes Both-their interaction

Neither—Family, friends, doctor, hospital, employer…

Mood

Underweight, no reserves for learning, feeding well


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3. Prioritize the possibilities

✓ By most urgently dangerous possible causes at the top of the list.

✓ AND/OR by most urgent to treat early, even if not dangerous

✓ AND/OR by most common and/or most likely



4. Narrow down to 2 or 3 top choices.(NOT just one!)

RULE OUT those that really don’t fit.What’s left is your differential


HOW do you narrow down the list?

METHODICAL PROCESS to Rule Out most of them,Starting with the most serious to miss, or the most likely,

What fits? What doesn’t fit?

What’s missing? What’s still unexplained?

What do you still need to find out?

Now to the next on your priority list, same questions


5. Make a plan for the familyTo confirm or refute your 2 or 3 choicesTo help family in meantime, even without definitive answer

Tentative plan, “First do no harm”

Feeding plan, given what’s going on. Expressing?

Trial of this or that…. What might make a difference?

Or answer a question?

Refer out, and/or talk with the doctor.



What can we do for this family RIGHT NOW?

What other questions do you have?

What can we suggest to the pediatrician?


Refer out, and/or talk with the doctor.

Now you speak the doc’s language…

Instead of a single “assessment,”You have a “differential”

PLUS, you have

• Pros and cons for why you are leaning this or that way,

• Pros and cons for the alternative possibilities

• And a plan for sorting it out.



For EACH of these possible diagnoses, Allergy, Reflux, or Hyperlactation, each with choices explaining the blood

1. The facts: Say what you see, the history and exam that supports each of these possibilities, as well as the various reasons for blood in the stool. What facts go with and against each possibility?

2. Your educated opinion: The factual reasons why you think each of these is more or less likely be the explanation for the distress or the stool blood. Hedge a little. Allow for a difference of opinion.

3. Ask pedi to evaluate, and decide if referral necessary.

4. Gives you the opportunity to educate re how each of these situations affects feeding.

Using your differential diagnosis to make the referral and improve communication.


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From IBLCE’s Advisory Opinion

The IBCLC certificant neither practices medicine nor diagnoses…. An IBCLC certificant does: carefullyASSESS, document findings, and refer appropriately as needed, to obtain a medical diagnosis and possible treatment.

From Wikipedia

Medical diagnosis is the PROCESS of determining WHICH disease or condition explains a person’s symptoms and signs.


1. Creating a differential diagnosis is totally within the LC’s scope of practice and part of a good lactation assessment.

2. Creating a differential diagnosis can help you when you’re pretty confused about what’s going on, and help you decide what to do for the family while you’re still figuring it out.

3. Creating a differential diagnosis is fun, intellectually challenging and can help you avoid jumping to the wrong conclusion when you are absolutely certain what the problem is and exactly what to do about it.

4. Presenting your assessment as a differential diagnosis can improve your communication with physicians and other health care providers, and allow teaching without preaching.

Take Home Messages


Questions? [email protected]

We need Lactation Diff Dx Mnemonics!

• For the broad possibilities covering all mother baby issues

• For common and confusing problems like apparent tethered oral tissues.

Let’s share ideas!


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mailto:[email protected]

Documents

The Art of Differential Diagnosis Objectives for …...2/15/2020 1 The Art of Differential Diagnosis for Lactation Consultants: What, Why, and How Christina M. Smillie, MD, FAAP, IBCLC,