2022-23 TOW #30: Childhood Obesity – prevention & treatment

There have been many ways that COVID compromised access to health for children, including restricting access to physical activity and nutritious foods. We have lots of work ahead to open up more equitable ways for us to promote healthy behaviors for all children. As this is a topic close to my heart with my prior research in this area, I am always excited to highlight our great local resources. We have many wonderful obesity clinicians and researchers including Drs. Thelben Mullett and Seja Abudiab who staff the SCH Child Wellness Clinic, and Drs. Lenna Liu, Jay Mendoza, and Pooja Tandon who engage in prevention research. Feel free to send questions to any of them!

Teaching materials for this week:

Take-home points for this week:

  1. What’s the epidemiology of child obesity? While some progress was being made pre-pandemic, with promising data on declines among preschool youth, obesity rates have risen to 1 in 5 children with a BMI >=95th percentile, 1 in 3 including overweight (BMI>=85th percentile). Unfortunately, the CDC reported the rate of BMI increase nearly doubled among youth during COVID. Etiology of obesity is multifactorial including important genetic and environmental contributors that are affected by social determinants, which were exacerbated by COVID. We must acknowledge the equity issues reflected in higher rates of obesity among those affected by racism and social disadvantages including low-income families, and Hispanic, African American and American Indian youth.
  2. What focused messages can we share in clinic? Focusing on behaviors/ environments that support healthy weight starts from infancy. Teach responsive feeding with the Division of Responsibility for feeding; or “parents provide, and child decides.” The parent is responsible for what, where, and when food is served, and the child is responsible for how much to eat. We can use Let’s Go! 5210 goals to help guide healthy behaviors: 5 fruits and veggies per day, watch no more than 2 hours of screen time, get 1 hour or more of physical activity, and have 0 sugary drinks. Limiting processed foods and having family meals are 2 other important nutrition approaches families can take. Families should choose their own goals through motivational interviewing, which has been shown in randomized trials in pediatrics to work in improving weight trajectories.
  3. How can we address this sensitive topic and avoid weight stigma in our practice? Bias about weight is among the strongest biases, even among children, and bullying and stigma are major problems for those living in larger bodies. We must be aware of our own biases as we treat patients and adopt inclusive, non-judgmental language, as recommended by Health at Every Size (HAES), which seeks to promote health-affirming behaviors and diversity of size, and to decrease weight stigma and emphasis. It’s helpful to acknowledge there are a lot of things outside the control of families (genes, community environment, societal stigma, etc), while also supporting specific behaviors to promote well-being and health (and advocating for changes at the societal level). I like to hold these concepts as a dialectic of both/and: acknowledging that obesity/high BMI can be (though not always) an individual and public health challenge associated with medical complications, and also that an over-focus on weight/BMI is highly problematic, may contribute to unhealthy behaviors such as disordered eating, increased weight bias, and other harms.
  4. What are the approaches for overweight and obese? The clinical practice guidelines algorithm and Key Action Statements recommends BMI screening and blood pressure for all youth. Starting at age 10, all youth with BMI >85th percentile (overweight) who have risk factors, and BMI> 95th percentile (obese) should have screening labs for metabolic risk factors (lipid panel, liver enzymes and A1c and/or glucose). Labs may be considered in ages 2-9 if severe obesity and/or risk factors. To promote healthy behaviors, the guidelines recommend intensive health behavior and lifestyle treatment (IHBLT). In our area, this would include referral to resources like the YMCA ACT! program, the SCH Wellness Clinic for multidisciplinary weight management from age 2 through 11. When metabolic problems are identified, see this article on treating comorbidities.
  5. What is the role of physical activity? For children of all body sizes, regular physical activity reduces the likelihood of comorbidities, including psychological ones, with or without changes in BMI. It’s important for us to emphasize helping kids and parents find ways to be active and enjoy movement, no matter their body type.

2022-23 TOW #29: Constipation

Next week we are reviewing constipation. Discussing poop can be a squirmy topic for our patients, yet we know how important it is for us to be comfortable addressing this issue.

Materials for this week:

Review on constipation in pediatrics:

  1. How common is constipation in children? Constipation accounts for 3–10% of visits to general pediatric clinics and up to 25% of referrals to pediatric gastroenterologists worldwide. Genetics plays a role, and social/ environment risk factors include low consumption of fiber, low levels of physical activity, living in a highly-populated community, and low parental education. Functional constipation (without another cause) accounts for more than 90% of all childhood constipation. 
  2. What’s the clinical definition? Constipation symptoms are most commonly hard stools, painful stools, and/or stools that are difficult to pass, infrequent, incomplete, dry, very large, or hardened. More specific ROME criteria defines pediatric functional constipation are also used (see table in case discussion). A related issue, “infant dyschezia,” occurs among ~2.5% of babies <9 months of age who have >10 minutes of straining and crying before passage of soft stools (or sometimes no stool). This self-resolving diagnosis occurs due to immature coordination of pelvic floor relaxation with increased intra-abdominal pressure.
  3. How does physical exam contribute? Many children have normal exams. 30-50% have a palpable abdominal mass. 5-25% have anal fissures or hemorrhoids. 3% have anal prolapse. >40% have fecal impaction. Rectal exam should be considered if the diagnosis is uncertain or other causes need to be excluded.
  4. What is the recommended work-up? Diagnosis can be made with history and exam and rarely requires additional work-up, except for more severe, persistent cases. Concerning history / red flags to prompt work-up would include passage of meconium >48 h after birth, abnormal findings on exam of spine, sacrum or anus, bloody diarrhea, ribbon stools (anatomical narrowing), poor weight gain, low energy/fatigue (e.g, hypothyroidism), and vomiting. Also think about genetic risks such as CF and autoimmune diseases.
  5. How should we manage constipation? A 4-step approach is recommended with 1) education, 2) disimpaction, 3) preventing stool reaccumulation (through medication and dietary/behavioral changes), and 4) behavioral therapy. Oral laxatives with Polyethylene glycol (PEG) (1-1.5g/kg/day) or rectal enema are considered equivalent first-line therapy for disimpaction. Maintenance laxatives are needed for most children for months to years. In my experience, it may be helpful to increase fiber through supplements, such as products like Benefiber, especially for more minor constipation, or when laxatives lead to incontinence. The most common foods that constipate are dairy, bananas, and apples, and lower-fiber processed foods/grains. Protocols and education are provided through our GI division including a constipation protocol.

2022-23 TOW #28: Promoting mental well-being

As we continue to experience anxiety-provoking societal changes, promoting mental well-being among our patients (and ourselves) is increasingly important. While teens may be notorious narcissists in focusing on themselves, they need guidance and support in how to actually care for themselves. We also get to practice walking the talk with this topic as we discuss these strategies with our patients. 

Materials/Resources for this week:

Take-home points for promoting mental wellness and self-care among our patients:

  1. How do concerns about teen stress and mental health affect primary care peds practice? 1 in 5 children experience mental health disorders in a given year. Pediatricians must be comfortable diagnosing, discussing, and treating these conditions, as well as helping prevent them. Many teens take time to warm up to the idea of seeing a therapist or another provider for mental health, so we may be their first stop, and sometimes the only one.
  2. What are key factors for promoting mental well-being? Most importantly, we can focus on doing the basics well for overall health: sleep, nutrition, physical activity, and appropriate sedentary/screen time (especially a healthy social media “diet”). Beyond that, we also need positive experiences to thrive / flourish. A good model of this from positive psychology is PERMA –  Positive Emotions, Engagement, Relationships, Meaning, Accomplishment (originally described by psychologist Martin Seligman). Increasingly, tools like mindfulness, relaxation skills (e.g. breathing techniques, stretching), biofeedback, mindful eating, and positive psychology practices like offering gratitude have shown success among youth. 
  3. How are wellness skills learned and practiced? Long before the frontal lobe is fully developed, youth can learn and practice self-care and wellness. These skills are not necessarily innate, so we get better with practice: think of them like exercises for the mind. I often remind patients that even professional athletes get a lot of help to manage stress, find flow, and build skills to perform at the top levels.
  4. What are parents’ roles in supporting their children/teens? Parents offer guidance, resources, and role modeling and may need help themselves in navigating challenges. We can support parents’ self care and stress reduction and offer mental health resources.
  5. How do we walk the talk? Just like the age-old expression, “Doctor, heal thyself,” as we personally become familiar with self-care approaches and resources, we can also help patients. Teens appreciate knowing that the adults around them are human and have to keep learning too. We can be deliberate about acknowledging the need for and benefit of self-care/wellness amidst the daily stressors of life. I often share with teens and families about the meditation app I use (Insight Timer), practicing “3 good things” with my kids, why I spend time in nature and bike to work, and how I cope with struggles with sleep, as a few examples.  

2022-23 TOW #27: Atopic dermatitis

This cold weather season brings dry skin and flares of atopic dermatitis (AD). Many of us are extra grateful for lip balms and skin creams this time of year! This is a great time to review some tools of the trade for skin care and recent data on AD.

Key points to review:

  1. How common is atopic dermatitis? Atopic dermatitis (AD) is one of the most common skin disorders in young children, with a prevalence of 10% to 20% in the first decade of life. Almost half of children with AD develop it before 1 year of age, and the majority by age 5.
  2. What is the pathophysiology? AD represents a chronic illness with defects in the epidermal barrier function as well as cutaneous inflammation. Skin with and without lesions have shown defects in transepidermal water loss, even measured at 2 days of age. Mutations in filaggrin, an important protein in skin barrier function, are predictive of multiple forms of atopy, including atopic dermatitis, food allergies, and asthma.
  3. How do topical steroids work and how should they be dosed? Steroids reduce inflammation in the skin by causing vasoconstriction and preventing inflammatory cells from entering the affected area, so they also have an anti-pruritic effect. Potency is actually determined by the degree of vasoconstriction they cause. For children with rapid flares, use short-term bursts of mid- to high-potency topical steroids (our dermatologists usually recommend triamcinolone 0.1% for the body and desonide 0.5% or hydrocortisone 2.5% for the face). Typical frequency is twice daily for 7 to 10 days, then tapering to once daily or to lower potency daily (such as hydrocortisone 2.5%), then to intermittent application, 2-3 times per week (see below).
  4. What is the role of emollients? Emollients are important treatment to prevent skin drying-they are designed to retain water on the skin surface in the stratum corneum. Ointments contain little or no water, creams contain 20% to 50% water, and lotions contain >50% water. Patients should use a dye-free, fragrance-free moisturizer and apply it at least twice per day and after bathing. Generic ones are more affordable. In practice (and personal experience with my kids), my go-to has been white petrolatum (e.g., petroleum jelly/Vaseline or brand products like Aquaphor, which are ointment based). Lotions often have alcohol so more stinging than ointments or lotions. Creams in tubs (like Eucerin or Cerave products), are thicker and can be especially helpful if white petrolatum is too greasy. For kids prone to skin infection, it’s recommended to avoid contaminating the container by scooping with a clean spoon or tongue depressor.
  5. How to avoid side effects of topical steroids? Steroid side effects are most problematic when applied to skin without inflammation. Steroids should be applied to affected skin until 3 days after resolution. For those with more severe AD, treatment may continue weekly (or more often) to prevent flares symptoms. Use lower potency especially in the face and groin area where the skin is thinner / more susceptible to damage. Topical calcineurin inhibitors provide another treatment option to avoid steroids. They are considered second line therapy for short term and noncontinuous chronic treatment, with improving evidence for safety since the 2006 FDA black box warning.

2022-23 TOW #26: Bone Health

As we are in the thick of winter and lacking sun, it’s a good time to review optimizing bone health for children. The AAP statement in 2014 raised the RDA levels for vitamin D for children, due in part to no “safe” sun exposure. Nonetheless, outdoor play time is still recommended, and can help with bone health, as Drs. Pooja Tandon and Kyle Yasuda (UW professor emeritus and former AAP president) wrote about in the Seattle Times.

Materials for this week:

Take-home points:

  1. What are the optimum levels for intake of calcium and vitamin D? Recommended daily allowances (RDA) for calcium increase with age: 700 mg for 1-3 yo, 1000 mg for 4-8 yo, and 1300 mg for ages 9-18, as do RDAs for vitamin D: 400 IU for 0-12 months and 600 IU >1 year. The blood level of vitamin D recommended is >20 ng/ml to prevent rickets and osteomalacia.
  2. Why are we concerned about these nutrients? Calcium and vitamin D are important throughout life; the years between age 9 and 14 are the most important for developing the skeleton. By age 18, children have 80% of the bone density for their lives. In addition to rickets, low Vit D and calcium intake is linked to increased fractures later in childhood/adolescence (and adulthood). Despite the many studies linking low vit D to a host of other conditions, we do not have reliable evidence that they are in fact causally linked.
  3. Who is at highest risk for low levels of vitamin D and low bone density? Children at higher risk for low vit D include youth with inadequate dietary intake, living in northern latitudes (>33 degrees -that’s us!), more richly pigmented skin (especially in less sunny climates), overweight youth, and those taking certain medications (anticonvulsants, steroids, antiretrovirals). Those at high risk for low bone density include children who do not do bone-strengthening exercise, particularly children who use wheelchairs.
  4. Who should be screened with blood tests? Testing for Vit D levels is not routinely indicated; AAP recommends only for conditions associated with reduced bone mass (malabsorption syndromes like CF, IBD, celiac; cerebral palsy, and/or taking medications that interfere with absorption), or recurrent low-impact fractures, or for children with poor growth. (*note the Endocrine Society guidelines also recommend for children with darker skin pigment or with obesity).
  5. When should we recommend supplements? Calcium is in more foods, so easier to obtain in dietary sources; however, there are few sources of vit D in the diet: mainly fortified milk (and some orange juice and yogurts). Humans evolved with more sun exposure than we have now; given we have reduced sun exposure to prevent skin cancer, essentially, vit D supplements are indicated for most people especially for breastfed babies (unless drinking at least 1L per day of fortified formula/milk), and those with low dietary sources or high risk for low bone density. Drinking 3 8 oz cups of milk gets you to about 300 IU vit D, which is half of the RDA, so I usually recommend a multi-vitamin supplement with vitamin D for all kids living in Seattle, and also calcium supplements for those not drinking much milk (including my own kids!).

2022-23 TOW #25: Media guidelines

Parents pretty much threw up our hands surrendering to screen time for youth in COVID (myself included!). It’s a pervasive challenge, now more than ever. National media expert and general pediatrics faculty at UW, Dr. Dimitri Christakis, served on the committee that wrote the national AAP media policy below. It’s an ever-evolving landscape, yet we need to keep managing the screen time guidance, as Dr. Christakis and others assert.

Materials to review:

Take-home points to review on media for youth:

  1. How significant is media exposure for youth? Screen media is THE WAY that most children interact with the world outside of family and school connections; quantity and quality are both important. The explosion of devices that contribute to media exposure for youth is frankly astounding. Most babies are exposed to TV by 4 months old (and at birth for their parents’ phones/devices)! According to a 2020 survey, watching online videos has now surpassed all forms of other viewing for children under 8.
  2. What are the most important questions to ask our families in clinic? 1) How much screen media is your child exposed to every day? 2) Does your child have a TV or internet-connected device in the bedroom? 3) What guidelines have you set for media use at home? 4) How are you monitoring your child’s media use?
  3. What are the top tips for parents? Start early with setting and enforcing limits-and keep enforcing them! It is so much easier to prevent problematic use than to rein it in later (and it does take constant vigilance, speaking from experience. Examples are smart phone contracts, daily screen-free time, digital holidays, and monitoring. Parents need to develop mindfulness around our own use, and be good role models. Parents should be “media mentors” who teach children how to use media appropriately. Experts encourage thinking of media use like having a driver’s license to demonstrate effective, safe use, and that media access, particularly through tablets and phones, is an earned privilege.
  4. Why recommend no screen time for children under 2? It disrupts language development and time for interactions with caregivers. In the 2016 guidelines, educational apps are acceptable at 18 months, and videochatting with family is allowable. For older children screen time does not include school use or homework. If parents do allow more, at least help them select more educational/prosocial media (like PBS, or shows recommended by Commonsense Media (which, as above, we rely on all of the time at our house!)
  5. When do most families put a TV/device in the bedroom? By age 2-4 years, particularly among low-income families, over 50% have bedroom TVs. We want to counsel really early about media to help prevent the use of media and TV’s in the bedroom, associated with many concerning negative effects on health such as disrupted sleep. Parents should limit media time 1 hour before bed to support sleep. I like the guidance, “put the device / phone to bed in a separate sleeping area before bedtime.”

2022-23 TOW #24: Primary Care of Premature Infant

We love our babies in pediatrics, and we have the privilege to care for increasing numbers of babies that survive very premature birth thanks to the expertise of our amazing neonatologists and the many breakthroughs they have had in care in recent decades. Once babies graduate from the NICU, we can offer ongoing specialized care, reviewed here.

Materials for this week:

Take-home points

  1. How do we support families after graduation from the NICU? We can help families transition by assessing their social support and emotional health, sharing what to expect, and offering more frequent visits. We should explain how we use corrected age (subtract number of weeks of prematurity from their chronological age) to assess growth and development so they know what to expect.
  2. How long do we adjust growth parameters based on gestational age? Other additions for follow-up tracking? Until infants reach a chronological age of 2 years, we should adjust height, weight, and head circumference for prematurity. Blood pressures should be assessed initially for all NICU grads, and followed regularly for babies with extra complications, such as BPD.
  3. To support adequate growth, how do we typically adjust feedings and supplements for premies? Babies under 2 kg or <28 weeks at birth typically receive a transitional formula of 22-24kcal/oz at discharge from the NICU. As infants demonstrate consistently good growth, and self-regulation of intake, they can be switched to term formula – often between 4-9 months, though may be longer for some. Premature formula provides extra calcium and phosphorus to prevent osteopenia of prematurity. Some recommend extra vit D (up to 1000 IU) for premies (compared to 400 IU for term infants). To prevent anemia, a multi-vitamin with iron should be provided for breastfed infants until 1 year to ensure the recommended 2mg/kg/day of elemental iron. Preterm babies typically start solids at 4-6 months adjusted age when showing appropriate cues.
  4. How should the vaccine schedule be adjusted? We give vaccines on the chronological age schedule. All family members should have Tdap, flu, and COVID vaccines to “cocoon” infants and protect them from illnesses.
  5. What is the recommended neurodevelopmental follow-up? All high-risk neonates should be referred to early intervention (our state’s birth to three program). Premature infants should be monitored for development using standardized screening such as the ASQ. All infants who were in the NICU for 5 or more days should have formal audiologic screening done by 24-30 months, even if they passed the initial screen. Given the higher incidence of vision problems including ROP, amblyopia, strabismus and cataracts, vision should be evaluated by an ophthalmologist, typically around 8-10 months.

2022-23 TOW #23: Lipid screening

Lipid screening and dyslipidemia treatment remains controversial in pediatrics. Nationally, variation in recommendations reflects the debate: the AAP has sided with universal screening, while others, including the US Preventive Services Task Force and the AAFP find insufficient evidence to recommend screening before age 20. Dr. Perri Klass summarized the debate in her NYT blog, quoting Dr. Fred Rivara, MD MPH about his statement against universal screening. The goal this week is to be familiar with some of the recs and the evidence to inform your understanding and decision-making.

Materials for this week:

Take-home points:

  1. Who should be recommended for lipid testing? It depends on if you follow targeted screening vs universal screening. The 2011 NHLBI guidelines recommend targeted screening for children 2-8 years old and adolescents 12-16 years old and universal screening for children 9-11 years old and adolescents 17-21 years old. The repeat is done at age 17-21 to assess after puberty which can alter levels. These same recommendations are endorsed by the AAP. In the targeted approach, screening is indicated in children or adolescents with a positive family history of dyslipidemia or premature cardiovascular disease (CVD) (including parent or 2nd degree relative <55 male, <65 female), an unknown family history, or children with other risk factors for CVD, like obesity, hypertension and diabetes.
  2. If you are screening, what tests would you do? In the NHLBI guidelines, the recommendation for universal screening was to use non-fasting lipids and calculate the non-HDL-C as follows: Non-HDL-C = total cholesterol (TC) – HDL-C. If the non-HDL-C was >=145, then do follow-up with fasting lipid panel. If elevated, average 2 sets of fasting lipid profiles (FLP) separated by 2 weeks to 3 months (as the individual levels can vary by up to 30mg/dl). With a non-fasting draw, total and non-HDL levels are considered more reliable, but triglycerides (TG) are much more likely to be overestimated. In practice, most pediatricians may only obtain one measurement.
  3. What is the first-line treatment for elevated lipids? Initially, we recommend lifestyle intervention, including more fruits, vegetables, fish, wholegrains and low-fat dairy products, with reduced intake of fruit-juice, added sugars, and decreased salt. We also recommend physical activity and losing weight, if appropriate. The fact that we essentially recommend this diet for all children is partly why many advocate not testing lipids because it does not change recs unless you have serious disease, which is rare. To treat overall elevated cholesterol or LDL, we focus more on dietary fat intake, but to treat elevated TG, we focus more on sugar and carbohydrate intake.
  4. If children have higher lipid levels that don’t respond to diet or have familiar hypercholesterolemia (FH), what is the treatment? There is more controversy here as well! There is minimal data on the long-term safety of statins for children. The NHLBI guidelines do not recommend medication for children under 10 unless they have severe primary hyperlipidemia or a high-risk condition associated with serious morbidity. For children with FH, statin treatment in childhood is associated with improved carotid thickness. For children ≥10 years, starting a statin is recommended for those who have persistent elevated LDL (range from 130-190 based on family history and risk factors) after 6 months of lifestyle changes, to lower LDL below the 95th percentile (≤130 mg/dl). While on statins, children should be monitored for muscle and hepatic toxicity with CPK and transaminase levels.
  5. When do we refer to a specialist and which one? Consider consulting a specialist before starting statins. Referral has been recommended for those with LDL ≥250 mg/dl and TG ≥500 mg/dl even before a trial of lifestyle management, or when more than one lipid-lowering medication may be needed (such as a bile acid sequestrant or cholesterol absorption inhibitor). Around the country, different specialists manage lipids; in our region, the Endocrine Division runs the lipid clinic so patients would be referred there when needed.

2022-23 TOW #22: Hip dysplasia

Developmental dysplasia of the hip (DDH) is an important newborn-related topic. A 2016 report highlighted the “primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.”

Materials for this week:

Take-home points:

  1. What are the primary risk factors for DDH? Female sex (up to 75% of DDH, 4-5 times the rate of males), family history, breech position in the 3rd trimester, and tight swaddling with legs adducted are the primary risk factors, and these are thought to be additive. As many as one in six newborn babies have mild hip instability at birth, and approximately one per thousand has developmental dislocation of the hip.
  2. How do we screen for and prevent DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging. Hip-safe swaddling allows the legs to move into flexed and abducted hip position (i.e., legs not confined to a straight extended position). Safe baby carrying is the “Spread Squat position” – also known as the M-Position, or Jockey Position – with the thighs spread around the parents’ torso and the hips bent so the knees are level with or slightly higher than the buttocks. 
  3. What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy while supine with the hips and knees in straight leg position, and then with the hips and knees in flexed position (*be aware if hip dysplasia is bilateral, we obviously can’t compare sides). Galeazzi sign is unequal knee height when legs are flexed. Use Ortolani “O=out” maneuver (abduction movement to detect a dislocated femoral head reducing into the acetabulum), which the newest guidelines say has the best predictive value. Barlow “B=back” maneuver identifies instability and subluxation/dislocation of the femoral head out of the acetabulum. The Barlow may be harmful with repeated forced pressure, so no posteriorly directed pressure should be applied, only apply gentle anterior pressure while adducting the hips “back” after performing Ortolani. The Ortolani and Barlow maneuvers are only reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds, hip movement, and leg length. After 3 months, the most important exam finding is limited hip abduction (<70 degrees) or asymmetric hip abduction, which should prompt evaluation.
  4. What imaging do we use to screen? Selective ultrasound should be done for clinical findings on exam between 3-6 weeks of age and for risk factors without exam findings (i.e., breech or family history) at age 6 weeks to 6 months. Plain x-rays at 4-6 months are considered fairly equivalent according to the data, and are implemented based on lack of local availability of trained sonographers. Note, there are more false positives with early ultrasound, and many children with more subtle findings may be watched and rescreened.
  5. What constitutes a positive screen? Based on consensus, children who have unstable hips on exam (a “clunk” on Ortolani) or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Isolated hip clicks without the sensation of instability usually represent normal laxity and myofascial tissue movement over the bones and do not require referral according to the 2016 guidelines. Thankfully, studies show that the natural history of mild dysplasia and instability noted in the first few weeks of life is typically benign.

2022-23 TOW #21: Faltering growth (Failure to thrive)

Next up in TOW-land: faltering growth (previously known as “failure to thrive”). The approach has evolved, including starting with less medicalization/work-up and reserving hospitalization to limited situations. The pathway at Seattle Children’s adopted the more approachable term “faltering growth,” which I appreciate so parents don’t feel like they or their child are “failing”. Unfortunately, it’s not an ICD-10 term, so we have to use “failure to thrive”, “poor weight gain” or “underweight.”

Materials for next week:

Faltering Growth/Failure to Thrive (FG/FTT) take-home points to review:

  1. How do we measure growth appropriately? FG can be missed or misdiagnosed due to incorrect measurement/ data input (I have learned this the hard way multiple times!). In children less than 2 years of age, we use recumbent length (not height). Measure head circumference until age 3. Use the World Health Organization (WHO) charts for children aged 0 to 2, Centers for Disease Control and Prevention (CDC) charts for children over 2, or a need-specific growth curve (e.g., premature infants, Down syndrome) available from the CDC. Always re-measure when a child plots below the 5th percentile (or any measurement not tracking) to ensure accuracy.
  2. What is the definition of FG? FG is a physical sign of inadequate nutrition to maintain growth. It has several definitions: most common being less than 3rd percentile weight-for-age on more than one occasion OR crossing two major percentiles (90th, 75th, 50th, 25th, 10th, and 5th) downward. Shifts in percentiles can be normal in healthy developing children. In one study, between birth and 6 months of age, 39% of healthy children crossed two major percentile lines (up or down), as did 6% to 15% of children between 6 and 24 months of age.
  3. What are the different broad categories of etiology for FG and how do they correlate with growth patterns? 1) inadequate caloric intake, 2) inadequate absorption, 3) excess demand or 4) inadequate utilization (or some combination). FG due to low caloric intake will result in decreased weight followed by decreased height (stunting), and finally, if severe, decreased head circumference. Head circumference tends to be spared when there is inadequate intake. Systemic disease will more typically lead to concurrent decrease of all three growth parameters.
  4. How do history, PE and lab work-up help us determine etiology for FG? Only 1-2% of diagnostic tests ordered in the hospital for FG evaluation help to establish an etiology. We need to gather detailed history about feeding, development, social and family history, and also be aware of social determinants including poverty in how they may affect risk for lack of food access. If no obvious concerns on history or physical suggest medical disease, we can start nutritional and social therapy before obtaining more work-up. If determined to be appropriate, initial labs might include CBC, electrolytes, LFTs, total protein/albumin, urinalysis, and lead levels.
  5. When is hospitalization for FG appropriate? Hospitalization should be limited to more severe cases not responding to intervention or for concerns of abuse/neglect. The admit criteria for our Pathway includes: concern for underlying disorder requiring urgent workup (e.g, CHF, inborn error of metabolism); failure to respond to outpatient feeding plan; severe malnutrition, or suspected abuse/neglect.