2019-20 TOW #12: Working with Limited English Proficiency (LEP) families

As we work with our increasingly wonderfully diverse families in Seattle, we have an imperative to be knowledgeable in navigating visits with families who do not speak English as their primary language. One of our very talented gen peds faculty, Casey Lion MD MPH, has developed this TOW to share her expertise and research in working with families with Limited English Proficiency (LEP). Here are the resources for this week:

Take-home points in working with LEP families:

  1. How many children have an LEP parents? In the US 15% of children live with at least 1 parent who has LEP; it’s much higher in some areas, and growing everywhere.
  2. How do language barriers affect care? Language barriers are associated with decreased adherence, comprehension, and satisfaction with care, as well as poorer outcomes and increased adverse events. Research by Dr. Lion and team has found that interpreter use improves discharge communication in our own institution. Families with LEP are at risk for inequity. It is our responsibility to try to decrease that risk and prevent errors by using certified interpreters.
  3. What is the legal requirement for interpretation in medical care? Under Title VI of the Civil Rights Act of 1964, federal law requires providers or institutions that receive any federal dollars (including Medicaid, Medicare) to provide medical care in a language patients understand. The rule applies to nearly every hospital and private group in the country. Under the Culturally and Linguistically Appropriate Care (CLAS) Standards, we are legally required to provide professional interpretation.
  4. How do we know when an interpreter is needed? To determine if a patient or caregiver needs an interpreter, ask what language they prefer for discussing medical information. If they want to use a family member or friend to interpret, one way to approach this is to say: “I am so sorry—hospital policy requires me to use a professional interpreter.” Teach-back is an excellent strategy to use to assess for parent or patient understanding.
  5. What type of interpreter form is best? Patients and families tend to report similar satisfaction with in-person, telephone, and video interpretation, while providers tend to prefer in-person and video interpretation. Dr. Lion’s research found video interpreting  in the ED was associated with parents’ improved understanding of the diagnosis and fewer lapses in communication, though there were higher costs for video use. The bottom line is that all modalities can be effective; most important is that we use them.

Enjoy getting to work with families from all over the world!

2019-20 TOW #11: The Medical Home & Children with Special Needs

Among the most fulfilling aspects of primary care is longitudinal relationships with families and addressing comprehensive, holistic needs over time. There is a growing body of data on the health benefits of medical homes, especially for children with special health care needs, and also for typically developing children.

Materials for this week:

Take-home points:

  1. What are the principles and goals of a “medical home”? The “medical home” (or  “health care home” to encompass health maintenance and health promotion) is a model promoted by national agencies including the AAP to provide comprehensive, family-centered, community-based care for patients, especially Children with Special Health Care Needs (CSHCN). The medical home model seeks to provide care that is accessiblefamily-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. A key part is to overcome barriers of fragmented services and provide care that is proactive, not always reactive.
  2. How many qualify as “Children with Special Health Care Needs (CSHCN)? Large population-based surveys estimate that 13% to 20% of children and youth meet the definition of CSHCN, as defined by parent report. This is probably an underestimate, and many children have two or more conditions.
  3. How does socioeconomic status affect prevalence of CSHCN? Unfortunately, there remain large inequities in chronic health conditions, access to health care services, and unmet specialty care needs based on social determinants of health. National data indicate higher odds for special needs among children living in poverty.
  4. Who should be involved within a medical home? Being an effective medical home requires a team approach. The primary care physician often develops the plan of care, with implementation and coordination managed by nurses, care coordinators, social workers, and the family. Collaboration with school nurses, visiting nurses, and home health aides is also crucial.
  5. What does a care plan include? One of the recommended strategies to help coordinate services for CSHCN is to develop care plans. Suggested care plan components include diagnoses/problem list, care team contact information, patient and family strengths and challenges, prior surgeries and/or procedures, recent lab and other diagnostic studies, assistive technology, and patient and family goals.

2019-20 TOW #10: Literacy Promotion/ Reach Out and Read (ROR)

Image result for literacy month 2015As we head into September (!), it’s back to school time and National Literacy Month. It’s the perfect time to review how to promote literacy in our practices. We have a terrific Reach Out and Read (ROR) program in Washington thanks to Dr. Jill Sells, an alum of our residency program. In addition to clinic, residents can also promote literacy in the hospital, thanks to our inpatient ROR program (contact me if you’re interested to be involved with this team!). Keep delivering those books to patients!

Here are this week’s materials:

Take-home points for literacy promotion:

  1. Educate yourself: ROR is an evidence-based, nationally recommended program started by pediatricians that improves literacy outcomes. The #1 thing you can do to effectively use Reach Out and Read (ROR) is to complete the online training and additional ROR training resources.
  2. Support parents with positive feedback about reading: When children reach for the book and start interacting with it, we can highlight the child’s natural interest in books. We can provide positive instructive feedback for parents about how reading aloud with their young children enriches their relationships and enhances their children’s social-emotional development. This builds brain circuits to prepare children to learn language and early literacy skills.
  3. Describe dialogic reading: Share with parents how to do interactive reading through “dialogic reading”. Parents prompt the child to have “a dialogue” or conversation about the pictures and story as they read together. This interactive technique helps the child become the storyteller and promotes language development more quickly. 
  4. Provide books: ROR is founded on providing developmentally, culturally, and linguistically appropriate books at health supervision visits for all high-risk, low-income children. Also we can provide books in the waiting room, and educational materials including info on local libraries.
  5. Review the 5 R’s of early education: These are the foundation of healthy early brain development: 1. Reading together as a daily, fun, family activity; 2. Rhyming, playing, talking, and singing; 3. Routines with regular times for meals, play, and sleep; 4. Recognition (praise) for everyday successes, particularly for effort toward worthwhile goals such as helping; and 5. Relationships that are reciprocal, nurturing, purposeful, and enduring.

2019-20 TOW #9: School Readiness & Challenges

As pediatricians, we have a special role in helping promote and assess school readiness and addressing issues when challenges occur. We hope everyone has a great school experience, yet the literature tells us ~1 in 6 children experience school challenges or failure. (I prefer using the term “challenges” as it conveys more of a growth mindset; “school failure” is used in the literature on this topic, usually to signify failing a grade). Hopefully we can recognize and address issues early on through regular visits and monitoring in the medical home.

Materials for this week:

Take-home points:

  1. What is meant by “school readiness”? As written in the article above by the AAP Councils on Early Childhood and School Health, “school readiness includes not only the early academic skills of children but also their physical health, language skills, social and emotional development, motivation to learn, creativity, and general knowledge.” We have a lot of domains to consider when evaluating children’s readiness for school! In essence, it’s a very holistic approach to recognizing the broad influences on participation and performance in school, much more than knowing the alphabet and how to count to 10.
  2. How we can promote school readiness? In the medical home, we will naturally assess and address physical health needs. Beyond that, we can promote social-emotional health through nurturing strong, connected relationships (see last week’s topic on Promoting First Relationships). We can help families promote early cognitive growth by discussing early brain development and how families support this through reading (using Reach Out and Read), interacting, and enrolling in early learning programs like Head Start. We can also identify children with developmental delays and learning difficulties at an early stage by using appropriate screening tools.
  3. Epidemiology of school challenges: About 10% to 15% of school-age children repeat or fail a grade in school. Grade failure is more likely among males, minorities, children living in poverty, and those in single-parent homes. Children who have disabilities are nearly 3x as likely to repeat at least one grade as are children without disabilities. Similarly, children who were small for gestational age (SGA) are nearly 2x as likely to experience school failure. Children who fail in school are more likely to engage in subsequent health-impairing behaviors as adolescents. Failing students also are more likely to drop out of school and have adverse adult health outcomes.
  4. Differential diagnosis for school difficulties: Possible causes of school challenges should include evaluating exogenous and endogenous factors. Exogenous factors include stressors in the home, poverty, and negative peer influence or school environment. Endogenous factors include learning disabilities, ADHD, chronic illness, perinatal conditions (e.g., prematurity, fetal exposures) and mental health disorders.
  5. How can we help families facing school difficulties? Clinicians can help families identify the causes of school challenges and advocate for resources to improve a child’s academic trajectory. It can be very important for a child’s doctor to get involved with a child’s school to ask questions, discuss resources, and advocate for services. The law protects students’ rights to have their educational needs addressed through the Individuals with Disabilities Education Act (IDEA). Under IDEA, schools must identify children with disabilities, evaluate their needs, provide services, and guarantee due process, including the provision of Individual Education Plans, or IEPs. We can utilize the resources of school family advocates, omsbudsman, counselors, social workers, and medical-legal partners to advocate for children and their access to services.

2019-20 TOW #8: Promoting First Relationships in Pediatric Primary Care (PFR-PPC)

We’ve been fortunate to offer training to residents in a relationship-based parenting approach called Promoting First Relationships (PFR). PFR was developed at UW and has been shown to improve caregiver responsiveness and child outcomes, especially for children in foster care. Huge thanks to the team who helped adapt PFR for our residency training.

Materials for this week:

Take-home points:

  1. Why are early relationships so important to children’s development? Research in neurodevelopment, toxic stress, adverse childhood experiences, early child and brain development, and infant mental health continues to demonstrate the critical nature of the early caregiver-child relationships as a driver of physical, social, and emotional wellbeing.
  2. What are the fundamental infant and early childhood mental health concepts that inform the PFR approach? 1) Importance of early attachment and parental attunement and reciprocity, 2) responsive caregiving including noticing and understanding child cues and how they help children regulate, 3) need for caregivers to provide co-regulation for children’s big emotions, especially those emerging at 9-24 months of life, 4) reframing challenging behavior as stemming from unmet physical, social or emotional needs
  3. How can we as pediatricians help with developing children’s primary caregiver relationships? We are uniquely positioned to influence early relationships from our knowledge of child development, our trusted relationship with families, and the frequency of wellness visits during early childhood. Pediatric care providers are often the only service provider that sees new families in the first year of life. We can observe attachment and relationships in the office and provide positive feedback to parents about how they are helping their children through attunement, response, understanding, and co-regulation.
  4. What are the PFR strategies and why are they used? PFR strategies include Joining, Positive Feedback, Positive Instructive Feedback, and Supportive Reflective Capacity. These strategies are designed to help medical providers increase parent or caregiver’s feelings of competence, confidence and joy, so they are better able to support their child’s social emotional development. One of the reasons I really appreciate this program is the focus on developing parents’ strengths and joy in their parenting. I have noticed I enjoy visits more when I am attuned to the relationships and “catching them doing well” in modeling effective approaches with their children.

2019-20 TOW #7: Immunizations

A huge thanks to our amazing immunization experts Drs. Doug Opel and Annika Hofstetter for developing materials for next weeks’ TOW on immunizations. This is a timely topic given the measles outbreaks and back-to-school visits, and the relatively lower immunization rates for WA state compared to national rates. Hopefully, thanks to our colleagues here, we will continue to make inroads to protect our children.

Teaching materials for immunizations:

Take-home points:

  1. Why are issues around immunizations so important to know well as pediatricians? Immunizations are arguably the biggest success story of public health in the 20th century and the most important component of the recommended well child visit schedule. While vaccine safety has been extensively studied, no vaccine is 100% safe or 100% effective. This has contributed to the controversies around vaccines. Yet, we know vaccines are overwhelmingly effective to decrease morbidity and mortality from vaccine-preventable diseases.
  2. How many parents are vaccine hesitant? While only about 1% of parents are anti-vaccine (choosing no vaccines), about 1/3 are considered vaccine hesitant, and the vast majority (about 2/3) are vaccine accepters. Vaccine-hesitant parents are the ones where we may have the most influence to change their approach/decision.
  3. How is it best to bring up the topic of vaccines in clinic? As Doug Opel and team identified in a study in Pediatrics (see above), choosing a “presumptive stance” (i.e., “today your child is due for these vaccines”) rather than a more collaborative approach (e.g. “what vaccines did you want to give today?”) was associated with more likelihood of vaccines being accepted by parents. It’s always important to use good general communication skills including being open to questions, honest, respectful of parents, and not coming across as offended or defensive. The CHOP vaccine app has helpful info for parents as well.
  4. Why have vaccines developed such a negative reputation? Partly it’s because there are many more of them and that’s been worrisome to some parents. But mostly it’s been related to vaccines, especially MMR, being wrongly associated with causing autism. The study that first suggested this association was published in the Lancet and was eventually retracted as people recognized the poor study design and even falsified data. The lead author had his medical license revoked. Unfortunately, the repercussions of this unethical study were incredibly detrimental, and we are still dealing with them.
  5. What are the most controversial ingredients in vaccines? Those that have specifically raised concerns are thimerosol (a preservative that was taken out of most vaccines despite lack of evidence that it could cause neurological problems), aluminum (an adjuvant that helps vaccines work better – concentrations are less than what a baby ingests in breastmilk by age 6 months), animal-derived gelatin (used as a stabilizer in some vaccines – objectionable to some people in Muslim faith though there have been statements from imams that they can be given) and aborted fetal material (used as cell strains to grow MMR, varicella – of special concern to devout Christians or Catholics – the Vatican has said parents could accept these vaccines).

2019-20 TOW #6: Formula feeding

As a companion topic to last week’s review on breastfeeding, we are taking some time to learn about formula feeding. While breastfeeding is recommended as the optimal nutrition for babies, there are families for whom this is not an option (see commentary below from a pediatrician who was not able to breastfeed her baby); parents rely on us to have expertise on formula feeding as well.

Teaching materials for this week:

Take-home points about formula feeding:

  1. How much formula to provide? after the first few weeks of life, for every 1 kg (or 2 pounds) babies drink ~1 ounce of formula, up to about 7-8 ounces (I usually say closer to 6 ounces is optimal), every 3-4 hours. This amount approximates the baby’s stomach capacity and will meet metabolic needs of an otherwise healthy infant (which is ~100kcal/kg/day in babies <10 kg). Babies should be gaining 25-30g/day through 3 months, then 15-20g/day from 3-6 months (see helpful table in case discussion). Total intake in the day should be no more than 32oz. There is some evidence that using larger bottles (>=6 oz) at 2 months may be associated with feeding too much at one time, and with more rapid weight gain/overweight at 6 months.
  2. Parents often ask about how to choose a formula-what should we say?: Although claiming unique properties, all of the major standard formulas commercially available are essentially similar and contain enough vitamins and minerals to meet babies’ needs. If fully formula-fed, vitamin D should be adequate to meet 400 IU daily. There should never be an indication to use “low-iron” formulations. There is mixed evidence on whether adding long-chain fatty acids DHA and ARA to formulas has benefit for vision and cognition; nonetheless, these are now routinely added to most formulas in the US. Check out info for parents on choosing a formula from the AAP healthychildren website on choosing a formula
  3. What are recommendations for preparing formula? This is important to know and families should follow labels carefully. (I will always remember a baby brought to us at clinic seizing and hypoxic from hyponatremia due to inproperly mixed formula.) For powdered formula, it is typically 1 scoop for every 2 ounces. Fill the water first, then add the powder. In places with safe drinking water, standard tap water can be used without boiling (heavy boiling may increase concentrations of lead, in fact). Be cautious about well water – this should be tested for lead and other heavy metals. There is some concern about mild fluorosis if formula is mixed with fluoride-containing water – in which case you can sometimes mix with bottled water. At room temperature, discard formula not used within 2 hours. Refrigerated formula should be discarded after 24 hours.
  4. When should we consider switching formulas? Most infants tolerate standard formulas and do not require switching. Parents often ask about switching formulas when babies have irritability and colic, which are unlikely to improve because of a formula change. Infants with specific GI symptoms, such as diarrhea, constipation, blood in the stool, and excessive gas are more likely to benefit from a formula switch.
  5. When should infants have special formulas? Soy-based formulas can treat some cow-milk formula intolerance, whether from lactose intolerance or cow milk protein allergy. Infants that have an IgE-mediated cow milk allergy may switch to soy-based formula, though up to half of infants allergic to cow’s milk may also not tolerate soy. In these cases, hydrolyzed formulas are required (such as Alimentum, Nutramigen, Pregestamil, and Neocate). These formulas are 3-4 times more expensive and may require prescriptions to be covered by insurance/WIC, though most are available over the counter. (See the helpful table to review these in the article above).

2019-20 TOW #5: Breastfeeding

Promoting breastfeeding in infants represents our earliest opportunities to influence nutrition and health for the lifetime. Among the many reasons to promote breastfeeding, the emerging data on how breastfeeding affects the microbiome for infants is pretty amazing. This data may help us better understand why breastfed babies get fewer infections and have other health benefits. Another benefit of breastfeeding: babies get exposed to flavors of healthy foods, and are more likely to eat them later.

Take-home points on breastfeeding challenges:

  1. What are the indicators of successful lactation to assess at initial well visits? Mother: milk is in, not too engorged, minimal nipple soreness with latching (should be improving, get better after first few sucks each feeding); starting to adjust to her newborn and has social support; Baby: feeding on both breasts 8-12 times in 24 hours, satisfied after 30-40 minutes of nursing; gaining 25-30 grams a day.
  2. What are the main problems with breastfeeding that often lead to early cessation? Primary breastfeeding challenges include poor latch, nipple pain, and problems with milk supply. While nearly all mothers try breastfeeding, almost half stop after a few weeks due to these challenges (and many others due to having to return to work without adequate support for breastfeeding). Most challenges are treatable with support from us, lactation specialists, and family/social support. Only about 5% of moms actually have physiologic problems that lead to inadequate supply.
  3. How can we help with these challenges? We need to know a few basics: observe feeds so we can help with latch in different positions, assess nipple pain (should improve with better latch and with time. but if not think of fungal and bacterial infections and vasospasm as causes), and help with milk supply. If milk supply is an issue, recommended strategies include rest, hydration, breast compression, and increased stimulation through feeding and pumping, and galactogogues including Reglan, fenugreek and oxytocin nasal spray.
  4. Why are late preterm infants at special risk for difficulty breastfeeding? Some appear large (6-7 pounds) but can be breastfeeding “imposters”; appear to be feeding well but are not transferring enough milk and not gaining weight well. They need extra attention, clear feeding plan, and benefit from early and ongoing lactation support to help them get there.
  5. How do we decide if a mom’s medication is compatible with breastfeeding? Look it up on LactMed, the NIH sponsored website to provide information about drugs and other chemicals while breastfeeding.

2019-20 TOW #4: Early adolescence well care

We move into the land of adolescents and the fun and challenge that can bring in well visits for ages 11-14 years. Perhaps invoking memories of our own experience at that age helps us be more empathetic to what early adolescents and their parents are experiencing as the tidal wave of hormonal changes hit the body! Let’s review some key approaches and resources for this age group.

Materials for this week:

Take-home points

  1. What are the priorities for well child visits in early adolescence (ages 11-14)? We will be addressing patient and parent concerns first, though may have a harder time eliciting them from patients at this age. That’s why it’s important to allow time 1:1 with the adolescent and to set the tone by explicitly reviewing confidentiality, discussing their strengths and then HEADSSS questions. Some adolescent docs have adopted “SSHADESS” as an alternative to HEADSSS as it reviews strengths and school first before other more challenging topics. As long as we ask more personal/intimate questions later in the interview, either approach can work.
  2. What are the Bright Futures priority areas for these ages? 1) Physical growth and development (puberty, body image, healthy eating, activity), 2) social and academic competence (connections with family and peers, relationships, school performance), 3) emotional well-being (coping, mood regulation, mental health, sexuality), 4) risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs), and 5) violence and injury prevention (seatbelts, helmets, firearms, personal violence).
  3. What are the most evidence-based aspects of our care? Vaccines for adolescents are again a bigger evidence-based aspect of our care at this age. In addition, using strengths-based interviewing and a motivational interviewing approach has been shown to be effective. MI has been applied successfully in adolescent care to address cigarette smoking, alcohol and marijuana use, chronic disease management, and adoption of safety behaviors.
  4. What are the recommended screenings? In addition to measuring weight, height, BMI, and BP, we should screen for vision once in early adolescence. The AAP recommends universal lipid screening for kids in this age group, which has been one of the more controversial recommendations; many opt for a risk-based screening. All other screenings would be considered selective: vision, anemia, TB, STIs, pregnancy, alcohol and drug use.
  5. How do we establish rapport with our patients at this age? What are some clinical pearls? As with children, we try to enter the kids’ world by asking about things they are enjoying, new activities, or their favorite subject. Particularly at this age we want to hear about patients’ strengths (see Dr. Ginsberg’s article above) – we can ask them to describe themselves, or ask how their family or friends describe them. Since parents and young teens are often not having great opportunities to converse, drawing this out during the visits by asking parents what they appreciate about their kids can lead to some amazingly reflective and positive dialogue.

2019-20 TOW #3: Middle Childhood Well Checks

We continue our journey through the land of well visits and review middle childhood (ages 5-10). Speaking from personal experience as a parent of kids this age, it’s a wonderful time to see children growing and developing as their personhood emerges. In primary care at this stage, we get to interact more directly with our patients and begin to develop more of a doctor-patient relationship. I’ve had the joy of attending a patients’ 5th grade graduation ceremony-just one example of the experiences that make primary care amazing!

Materials for next week:

Key take-home points:

  1. What are the priorities for well child visits in middle childhood (ages 5-10)? As always, we are addressing parent concerns first. During these years we discuss school readiness and school performance to help us assess how children are doing. Mental health becomes a bigger area to address including issues like bullying and body image; as well as limit setting and safety, as children become more independent including around strangers, using media, and walking and riding on streets.
  2. What are the Bright Futures priority areas for these ages? 1) School readiness/ school performance, 2) development and mental health, 3) nutrition and physical activity including limits/rules about screen time, 4) oral health, and 5) safety.
  3. What are the most evidence-based aspects of our care? There are not quite as many areas that are as well studied for this age group, but we do know that we should not try to cover too many topics – less is more and probably not more than 5. We know studies have shown parents value primary care and want us to discuss topics likes behavior, eating habits, and safety. Some studies have shown we can augment our verbal advice with approaches like safety-focused children’s books and parent videos and other tangible tools. One study looking at violence-prevention strategies in primary care using office-based counseling and free tools like timers and firearm locks demonstrated parent-reported changes in media use and firearm storage after the intervention.
  4. What are the recommended screenings? In addition to measuring weight, height, BMI, and BP, we should screen for vision and hearing. Anemia, TB, and dyslipidemia should be selectively screened based on risk factors.
  5. How do we establish rapport with our patients at this age? What are some clinical pearls? We can begin to interact first with the patients in these visits, then their parents. Entering the kids’ world by commenting on how much they have grown, something they are wearing, or reading or watching can be a fun starting point. For younger kids in this age range, I have found it really helpful to use the ROR books to assess school readiness/ reading/ counting, as well as their drawings of people and how they write their name. A strategy to learn about kids’ self-perception is to ask them what they like/are proud of about themselves and to ask parents what they appreciate about their kids to draw out more about their strengths and relationships.