Initial Paediatric Medical Letter

14 May 2024

Dr Sarah Jenkins Adelaide Hills Family Practice, 42 Mount Barker Road Stirling, SA, 5152

Dear Dr Jenkins,

Re: Leo DAVIES DOB: 14/01/2018 (6 years and 4 months) Address: 18 Wattle Street, Bridgewater, SA 5155

Issues

1. Attention Deficit Hyperactivity Disorder (ADHD) - combined presentation
2. Mild intermittent asthma

Medications

• salbutamol (Ventolin®) 100 mcg INH PRN
• melatonin 2 mg PO nocte

Services

• Ms Chloe Vance, Paediatric Occupational Therapist (Hills Allied Health)

Growth Parameters

• Weight: 21.5 kg (50th centile)
• Height: 118 cm (50th centile)
• Head Circumference: 52 cm (50th centile)

Consultation Summary

Thank you for referring Leo for assessment of his inattention, hyperactivity, and emotional dysregulation. I was pleased to review him, together with his parents, Mark and Emma, in my paediatric clinic today.

Leo has a two-year history of significant restlessness, impulsivity, and difficulty sustaining attention, which has become increasingly problematic since commencing Year 1 this year. Vanderbilt rating scales completed by both his parents and classroom teacher strongly support a diagnosis of combined-type ADHD, with minimal oppositional or anxiety features. His teacher notes he struggles to remain seated during mat time, frequently interrupts peers, and requires 1:1 prompting to complete tasks, though his foundational literacy and numeracy skills are age-appropriate. He has been seeing an occupational therapist fortnightly for sensory regulation strategies with modest benefit.

Mark and Emma also raised mild concerns regarding episodic nocturnal cough during winter viral illnesses, though this responds well to inhaled bronchodilators and does not limit his daytime physical activity.

Regarding his medical background, Leo was born at term via normal vaginal delivery following an uncomplicated pregnancy, with no neonatal issues. He has a history of mild viral-induced wheeze, managed with PRN salbutamol, and underwent bilateral grommet insertion at age 3 for recurrent otitis media; subsequent audiometry was normal. His immunisations are fully up to date according to the National Immunisation Program schedule, and he has no known drug allergies.

Leo lives with his parents and 4-year-old sister, Maya, in a supportive home environment. He attends Bridgewater Primary School and enjoys playing soccer, though he struggles with waiting his turn during games. Family history is notable for paternal ADHD and maternal childhood asthma.

Leo has a robust appetite and consumes a varied diet including meats, dairy, and selected fruits and vegetables, with adequate fluid intake throughout the day.

Sleep onset has historically been delayed by up to two hours due to bedtime resistance and restlessness, though the recent introduction of melatonin 2 mg nocte has reduced his sleep latency to approximately 30 minutes, with no overnight awakenings or snoring.

Physical Examination

On examination today, Leo was an active, cooperative boy who required frequent redirection and was constantly fidgeting with toys in the room. His blood pressure was 96/60 mmHg and heart rate was 84 bpm. Cardiovascular examination revealed dual heart sounds with no murmurs, and femoral pulses were normal. His chest was clear to auscultation bilaterally with no wheeze or increased work of breathing, and his abdomen was soft and non-tender. Brief neurological and dysmorphology screening was unremarkable.

Discussion with Family

I discussed with Mark and Emma that Leo meets the DSM-5 criteria for Attention Deficit Hyperactivity Disorder (ADHD), combined presentation. We reviewed multimodal management strategies, including classroom accommodations, ongoing occupational therapy, and pharmacological options. We discussed the mechanism, expected benefits, and potential side effects of stimulant medication, specifically methylphenidate, including appetite suppression, sleep disturbance, and rare cardiovascular or mood effects. Mark and Emma are keen to trial stimulant therapy to support Leo's learning and social integration at school.

Recommendations

1. Commence methylphenidate hydrochloride (Ritalin®) 5 mg PO BD (morning and midday), starting this weekend; titrate to 10 mg PO BD after 1 week if tolerated.
2. Provide ADHD school support letter to Bridgewater Primary School recommending preferential seating, movement breaks, and chunked instructions.
3. Continue fortnightly occupational therapy with Ms Chloe Vance focusing on executive functioning and emotional regulation.
4. Continue melatonin 2 mg PO nocte as required for sleep onset.
5. Arrange clinic review with me in 6 weeks to assess medication efficacy, side effects, height, weight, and blood pressure.

• However, if any further concerns arise in the meantime, I would be happy to review Leo sooner.

If you have any further questions about Leo, please do not hesitate to contact me.