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health as it happens

From watches to apps: Connected tech for better health care - Contemporary Pediatrics

A look at the latest apps, smart watches, and more for better health.

In 2007, Steve Jobs changed the world—and medical care—by introducing the iPhone. The iPad followed in 2010, and the Apple Watch in 2015.1 We now have hundreds of smartphone-based medical applications; we can dictate into the medical record using our phones, and can utilize “connected” devices, such as digital stethoscopes, pulse oximeters, continuous glucose monitors, and others to improve patient care. Here’s a look at some of the most useful connected devices/wearables, and smart applications for pediatric practice.

The Apple Watch: Implications for personal health

Although the Apple Watch followed the introduction of the iPhone by 8 years, it has had an enormous impact on health care. The current version of the Apple Watch, Series 6, can detect and monitor a patient’s heart rate, and alert if atrial fibrillation or an unusually fast heart rate is detected.2 With numerous patients, the Apple Watch has documented episodes of tachycardia that resulted in an evaluation by a pediatric cardiologist. Moreover, pediatric cardiologists are now advising patients to use their Apple Watch (or similar smart watch) to monitor their heart rate. Additionally, this series of the Apple Watch includes a pulse oximeter, which correlates surprisingly well with home fingertip oximeters. Therefore, the Apple Watch can be used to monitor asthma exacerbations or monitor the condition of children with respiratory infections. With watch OS 8 installed, the watch will be able to monitor sleep respiratory rate. The watch can be configured to detect falls from syncope or seizures and can auto dial 911 to summon help.2

The next version of the Apple Watch is reported to include a body temperature sensor, and many speculate that, at some point, the device will be able to monitor blood pressure and continuously monitor blood sugars.3

Connected spirometry for improved asthma management

As we all know, many children with asthma do not take their medications as prescribed. Therefore, many patients may have exacerbations or may be unaware that they are not optimally managed. When such patients begin to wheeze, patients may not seek care from their primary care physicians, preferring to be seen at more convenient urgent care clinics or, all too often, at an emergency room. VitalFlo is a company that will enable physicians to better care for their asthmatic patients. The VitalFlo system consists of a high-tech spirometer that communicates with an application on a smartphone. The application is easy to use, includes a tutorial for using the spirometer, a brief survey of symptoms, and directs the patient to produce 3 good blows into the device.4 Patient results are transmitted to a portal that can be viewed by the patient or clinician, and recommendations can be discussed with patients via office or telehealth visits. Depending on disease severity, the provider makes recommendations regarding the frequency of testing. The VitalFlo system is a prescription-based service that costs a practice $35 per patient per month (less if the patient purchases the spirometer). The provider can generate revenue by charging for monitoring a patient using the VitalFlo system.4

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VitalFlo

An application for ADHD and anxious patients

A parent recently informed me about Mightier, a smart tablet–based system for treating children with attention-deficit/hyperactivity disorder (ADHD) or anxiety.5 It is a biofeedback program that teaches children coping and calming skills that can yield tangible results in a matter of months. It is appropriate for children with ADHD, oppositional defiant disorder, and anxiety disorders. Once a parent subscribes to the Mightier program, their child is provided with a gaming tablet and a heart rate monitor that is worn on the arm. The child plays video games while wearing the heart rate monitor, and as the heart rate increases, the difficulty of the games increases as well. When the heart rate reaches a certain level, the game is interrupted and the child is taught a variety of coping skills from a cartoon character. Mightier teaches children to implement coping strategies when they recognize the physiologic consequence of negative thoughts and emotions, ie, an elevated heart rate, associated with dysregulation. An integrated award system reinforces the adoption of coping strategies, and children look forward to participating in the program.5

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Mightier Tablet

The program was developed at Boston Children’s Hospital and has been used by thousands of children since its release 7 years ago.5 The system is affordable at $40 per month, with discounts offered for prepayment. It is directed at children aged 6 to 12 years, and a child should commit to at least 45 minutes of play time per week to see results from the program.5

Continuous glucose monitors

Although our diabetic patients are usually managed by pediatric endocrinologists, pediatricians should be aware that there are 2 connected systems now available for monitoring patients’ sugars continuously. The FreeStyle Libre 2 system from Abbott Diabetes Care is approved for use in children 4 years of age and older.6 A 14-day sensor is inserted on the back of the arm. The sensor has a thin filament that sits under the skin and tracks glucose measurements every minute. A handheld monitor/reader is used to scan the sensor and displays the glucose measurement as well as a trend indicator graph that depicts the latest 8 hours of glucose history.6 Measurements are also uploaded to a smartphone-based FreeStyle LibreLink application, which displays information like that of the reader and stores data for 90 days.6

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FreeStyle Libre 2

The Dexcom G6 Continuous Glucose Monitoring System is indicated for children 2 years and older.7 In contrast to the FreeStyle Libre, the Dexcom subcutaneous sensor lasts for 10 days and uses a Bluetooth transmitter attached to the sensor to communicate with either a handheld monitor or a smartphone application.7

Connected pulse oximeters and more

Masimo has also produced several devices for use by patients. The $300 MightySat has been a reliable medical-grade fingertip oximeter that is used for monitoring a pulse, pulse oximeter readings, and perfusion indexes.8 It has been upgraded and is now the only fingertip pulse oximeter that can report a patient’s respiratory rate. The MightySat integrates with a Masimo Personal Health application to track all readings.8 Masimo also sells an $80 sleep monitoring application that monitors a patient’s heart rate, oxygen level, and respiratory rate during sleep and integrates with a sleep monitoring application on smart devices. Each sensor can be used for 10 nights, and low oxygen readings suggest the patient may be experiencing sleep apnea, indicating that the patient should be referred for a formal sleep study.8 Additionally, the Masimo Radius-T sensor is applied to the chest of a child 5 years and older and can monitor temperatures for as long as 8 days, and temperatures are recorded on a smart- phone application. For $50, Masimo provides 3 Radius-T sensors.8

Furthermore, Withings will soon start selling a ScanWatch, which will enable users to screen for sleep apnea by recording electrocardiogram, pulse oximeter measures, and heart rates.9

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Public health research via Apple Watch

Best smartphone applications for pediatric practice in 2021

Over the years, I have installed a select few applications on my smartphone. Here is a quick look at my current top recommendations:

Epocrates. This application facilitates rapid look-up of pediatric drug dosages for most frequently prescribed medications and has a terrific web-based version that can be accessed from a desktop. Epocrates provides extensive features beyond just drug dosages. It provides free continuing medical education online courses, a disease compendium, a drug interaction checker, a pill identifier, a comprehensive list of medical calculators, and a library of current medical guidelines. The basic version is free, but users can subscribe to upgrade and access Epocrates’ additional features.10

GoodRx. This platform enables me to help patients determine the lowest cost medications in our local area, listing all area pharmacies. In many circumstances, GoodRx prices are lower than insurance company co-pays.11

Pediatric Symptom MD. I always recommend this application to all new—and old—parents to provide guidance regarding symptoms, when to call the doctor or seek medical assistance, as well as medication dosages for antipyretics and other commonly prescribed OTC medications, including acetaminophen, ibuprofen, and diphenhydramine. It also provides handy parenting advice and first aid measures that discuss common injuries, and even what to do in life-threatening emergencies.12

Pedi QuikCalc. Version 5 of this application is now in beta testing. This has always been at the top of my best applications list for pediatricians. Its appearance has improved substantially and, as in the past, it provides a quick way to convert pounds to kilograms, a bilirubin risk calculator, and a formulary of commonly prescribed medications. It also includes useful calculators, including an age calculator based on date of birth, a body mass calculator, an adjusted midparental height calculator, as well as growth charts, recommendations for intravenous fluid administration, tables of topical steroids, and links to useful websites for pediatricians. It was created by W. Kent Bonney, MD, in 2010 and continues to be the first application I place on the front screen of my new smartphone whenever I upgrade!13

Conclusion

The above are but a few of the devices and applications that will revolutionize health care over the next few years. Smart devices were once only an idea we saw in science fiction movies and television shows. Now they are an integral part of our high-tech practices and enable physicians to improve the health of patients.

References

1. Kheit J. Apple innovation timeline — revolutions keep on turning. The Mac Observer. July 12, 2016. Accessed August 2, 2021. https://www.macobserver.com/columns-opinions/editorial/apple-innovation-timeline-revolutions-keep-turning/

2. Apple Watch Series 6. Apple. Accessed August 2, 2021. https://www.apple.com/apple-watch-series-6/

3. Gallagher W. Apple Watch body temperature sensor research underway since at least 2019. Apple Insider. June 17, 2021. Accessed August 2, 2021. https://appleinsider.com/articles/21/06/17/apple-watch-body-temperature-sensor-research-underway-since-at-least-2019

4. Unsurpassed remote respiratory monitoring. VitalFlo. Accessed August 2, 2021. https://www.vitalflohealth.com/healthcare-providers

5. Mightier is a fun, proven way for kids to manage their emotions. Mightier. Accessed August 2, 2021. https://www.mightier.com/hiwage/

6. FreeStyle Libre. Abbott. Accessed August 2, 2021. https://www.freestyle.abbott/us-en/home.html

7. The Dexcom G6 CGM System. Dexcom. Accessed August 2, 2021. https://www.dexcom.com

8. Masimo. Accessed August 2, 2021. https://www.masimopersonalhealth.com

9. Wearable health you’ll want to wear. Withings. Accessed August 2, 2021. https://www.withings.com/us/en/watches

10. Epocrates. Accessed August 2, 2021. https://www.epocrates.com

11. GoodRx. Accessed August 2, 2021. https://www.goodrx.com

12. Self Care Decisions. Accessed August 3, 2021. https://www.selfcare.info/

13. Pedi QuikCalc. Accessed August 2, 2021. http://www.pediquikcalc.com/PediQuikCalc/Welcome.html

14. Apple heart study launches to identify irregular heart rhythms. News release. Apple. November 30, 2017. Accessed August 2, 2021. https://www.apple.com/newsroom/2017/11/apple-heart-study-launches-to-identify-irregular-heart-rhythms/

15. Miller C. Apple Watch and other wearables can detect long-term effects of COVID-19, early research suggests. 9 to 5 Mac. July 7, 2021. Accessed August 2, 2021. https://9to5mac.com/2021/07/07/apple-watch-long-covid-effects/

16. Mishra T, Wang M, Metwally AA, et al. Pre-symptomatic detection of COVID-19 from smartwatch data. Nat Biomed Eng. 2020;4(12);1208–1220. doi:10.1038/s41551-020-00640-6

17. Radin JM, Quer G, Ramos E, et al. Assessment of prolonged physiological and behavioral changes associated with COVID-19 infection. JAMA Netw Open. 2021;4(7):e2115959. doi:10.1001/jamanetworkopen.2021.15959