2021-22 TOW #23: Hypertension

Updated guidelines for hypertension were released by the AAP in 2017 with the lead author our own nephrologist, Dr. Joseph Flynn. Next week we will review this topic and familiarize ourselves with the recommendations. This is a dense one, so try to at least review some of the key tables and summarized recommendations in the practice guidelines.

Materials for this week:

Take-home points:

  1. How do we define “hypertension” in the pediatric patient? What’s the difference between elevated BP (previously “prehypertension”), stage 1 hypertension, and stage 2 hypertension? There is no known cut-off for elevated BP in childhood that affects cardiovascular (CV) outcomes, so HTN definition in children and adolescents is based on the normative distribution of BP in healthy children (excluding those with overweight/obesity) based on age, sex and height. Height was incorporated in 1996 since it affects BP measures. Persistently elevated BP (formerly “prehypertension,”) is defined as BP values from the 90th to 94th percentiles or between 120/80 and 130/80 mmHg in adolescents. Stage 1 HTN is defined as auscultatory-confirmed BP readings at 3 different visits ≥95th percentile (but less than 95th percentile +12 mmHg) or 130/80 to 139/89 mmHg (whichever is lower). Stage 2 HTN is ≥95th percentile + 12 mmHg, or ≥140/90 mmHg (whichever is lower). Stage 1 and 2 for adolescents align with adults, so it’s easier to remember (130/80 to 139/89 mmHg or ≥140/90 mmHg, respectively).
  2. What’s the prevalence of clinical HTN in children and adolescents? Prevalence of HTN is ∼3.5%.‍ Persistently elevated BP is also ∼2.2% to 3.5%. The rates are higher among children and adolescents who have overweight and obesity, so these children’s data were removed from the new tables in the updated guidelines (cut-points are therefore lower than they used to be).‍
  3. Which children and adolescents need regular BP monitoring and how should BP be obtained? We should be checking BP annually at all well visits for ages 3+. We should do it at all visits for children <3 who have an underlying risk factor (e.g., prematurity <32 weeks, congenital heart disease, renal disease, UTIs, transplant, etc). We can use automated devices for measuring BP if they are validated for pediatrics. If BP is elevated, confirm with auscultation. If the initial BP is elevated, obtain 2 additional BP measurements at the same visit and average them (throw out the automated one), to determine the patient’s BP category. If HTN is suspected/ diagnosed, we should do ambulatory blood pressure monitoring to rule out white coat hypertension and determine persistence/severity of HTN.
  4. What work-up should evaluate for secondary causes, comorbidities, and end-organ damage in the pediatric hypertensive patient? Use the history and PE to identify possible underlying causes of HTN, such as heart disease, kidney disease, renovascular disease, endocrine-related, drug-induced, and sleep apnea-associated HTN. Recommended work-up for all patients includes: BP of both upper extremities and at least 1 leg BP, urinalysis, chemistry panel (including electrolytes, BUN/Cr), lipid profile (fasting or nonfasting). Add renal ultrasound in those <6 y of age, or those with abnormal urinalysis or renal function. Youth ≥6 y of age do not require an extensive work-up for secondary causes of HTN if they have a positive family history of HTN, or are overweight or obese. If starting pharmacologic treatment, echocardiography is recommended to assess for cardiac organ damage.
  5. How do we treat hypertension in children? The treatment goal is reduction in SBP and DBP to <90th percentile and <130/80 mmHg in adolescents ≥ 13yo. At the time of diagnosis of elevated BP or HTN, we should provide advice on the DASH diet (which has evidence of benefit for youth) and recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) (evidence level C). We should also consider subspecialty referral. If lifestyle modifications are not successful, and especially if there is LV hypertrophy on echo, symptomatic HTN, or stage 2 HTN, clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic.

2021-22 TOW #22: Community Acquired Pneumonia

Next week’s topic is community acquired pneumonia (CAP), always relevant topic as we enter the winter months. There are some features to distinguish compared to inpatient treatment.

Materials for this week

A few take home points to review:

  1. What is the global burden of pneumonia? The WHO reports pneumonia is the single highest cause of death in children worldwide under 5, accounting for 18% of deaths. Fortunately it has become much less of a problem for us in an era of widespread access to vaccines against pneumococcal and HIB. In the US, pneumonia occurs in an estimated ~2.6% of children under age 17.
  2. How do we diagnose pneumonia? Pneumonia is a clinical diagnosis that can be challenging to confirm, and no single definition is used in pediatrics. In diagnosing it, we look for the most common symptoms of cough, fever, and/or tachypnea in the setting of findings of parenchymal disease by either physical exam or chest x-ray. Crackles (rales) are the most common exam finding, but we should also look for decreased breath sounds, egophany, tactile fremitus, and/or dullness to percussion. X-rays are not needed to confirm diagnosis or resolution of pneumonia, but should be obtained when diagnosis is less certain and/or patient symptoms are more severe. Labs such as blood cultures are not routinely indicated for children treated as outpatients.
  3. What is the recommended treatment? Treatment is based on age and severity. Viral pneumonia is much more common in preschool age children, so observation and supportive care is often appropriate, especially here in the US where we have widespread access to the vaccines. Older children are more likely to have bacterial pneumonia and are treated as appropriate with high-dose amoxicillin as first line therapy for lobar disease. Use azithromycin for suspected atypical pneumonia, or both amox and a macrolide, especially if they are sicker.
  4. Who can be managed as an outpatient? Outpatient management of pneumonia is appropriate for mild-to-moderate disease for children who are not hypoxic or in distress who can tolerate oral antibiotics. The Pediatric Infectious Diseases Society guidelines recommend hospitalization for children with moderate to severe CAP including respiratory distress and/or hypoxemia (pulse ox <= 90%).

2021-22 TOW #21: Sore throat

As we continue viral respiratory season, we will be treating a lot of URIs, especially with COVID added to the mix.  When we see children with a sore throat, one consideration is distinguishing between viral infections and strep throat (Group A Strep Pharyngitis or GASP). Thanks to our knowledgeable emeritus general pediatrics guru Dr. Jeff Wright, we have a brief algorithm to help guide our decisions.

This week’s materials:

Take-home points for evaluating a possible diagnosis of strep throat:

  1. Which children with sore throat should we test for strep infection? We can use the Centor/McIsaac criteria to help. Positive criteria include age 3-14, exudate or swelling on tonsils, tender/swollen anterior lymph nodes, temp >38.0, and absence of cough. (See this PedsEM Podcast on strep throat and importance of considering pre-test probability.) We should not test children who have symptoms strongly suggesting a viral infection such as cough, rhinorrhea, hoarseness, or oral ulcers. Presence of either a scarlitiniform rash or palatal petechiae are also predictors of GASP, but not foolproof, so testing is recommended for these symptoms as well. Only test children under 3 who have a known contact or highly concerning exam.
  2. When should we initiate antibiotics for strep pharyngitis? Contrary to prior practices, it’s now recommended all children have a confirmed positive rapid strep or strep culture before being treated with antibiotics. This is due to a larger concern about overuse of antibiotics, and a persistent decline in rates of rheumatic fever.
  3. What should we use to treat GASP? Treat confirmed strep throat with oral penicillin, amoxicillin, or cephalexin given for 10 days, a single injection of Benzathine G penicillin, or 5 days of oral azithromycin (reserved for penicillin allergic patients). (I prefer amox for the BID dosing and the slightly higher rate of eradication compared to penicillin, which is probably mostly based on compliance.)
  4. Should we treat sick contacts without testing? It is no longer recommended to presumptively treat sick contacts – clinical guidelines now recommend that everyone treated have testing that confirms the presence of GAS. (We had an example of this in clinic for a sibling sick contact who had concerning symptoms, but did not test positive, even on culture. That sibling then infected the first one with the virus!)
  5. How many kids are GAS carriers? There is a fairly high normal carriage rate for Group A streptococcus in children – as high as 15%. This really reinforces we do not test unless we have a higher concern for strep throat.

2021-22 TOW #20: Asthma diagnosis and management

REACH Pathway R2s will share some asthma tips and tricks for case crunch tomorrow (Monday). The sneak preview I saw was awesome –  reminding us how we can recognize and address social needs through screening, referral, and partners like Community Health Workers and the Medical-Legal Partnership. To provide effective care for children of all backgrounds, we must recognize and address the powerful influence of structural, economic, climate, and equity factors on asthma.

A big thank you to Dr. Jim Stout, our local expert, who participated in the 2020 updates for the national asthma management guidelines and shared slides below.

Materials:

Asthma Diagnosis and Management take-home points:

  1. What is the epidemiology of asthma? Asthma affects about 1 in 12 children in the US, and rates are higher among Black and Hispanic children, due to environmental and structural racism factors affecting exposures and air quality. Every year, 1 in 6 children with asthma visits the ED, with about 1 in 20 children hospitalized. Climate change is leading to more severe weather patterns and risk for exacerbations, particularly for lower-income and BIPOC youth. The recent fantastic Health Equity Rounds on Climate Justice led by R1s Angela Zhang and Alex Arvantiakis and R2s Sruti Pisharody and Julia Hadley, highlighted the climate effects on respiratory illness like asthma.
  2. How is asthma diagnosis and management affected by age, severity, and level of control? “Severity” is the intrinsic intensity of the disease process, which is based on impairment and risk. Severity is classified as “intermittent” or as “persistent” with mild, moderate, or severe levels. “Control” refers to the degree to which manifestations of asthma are minimized and the goals of therapy are met. This is classified as “well controlled,” “not well controlled”, or “very poorly controlled.” To help make this diagnostic process easier, please refer to NHLBI guidelines for age groups, as above: 0-4 yo, 5-11 yo and 12 and older.
  3. What are some of the key components of managing asthma? The National Asthma Control Initiative outlined 6 priority messages for clinicians to help control asthma:
    • Use inhaled corticosteroids to control asthma. Inhaler videos can be helpful teaching tools: CDC version and a longer one from CHOP that includes going over the asthma action plan
    • Use written asthma action plans to guide patient self-management.
    • Assess asthma severity at the initial visit to determine initial treatment (as above)
    • Assess and monitor asthma control and adjust treatment if needed. One note: the new guidelines had a new step-up plan called Single Maintenance and Reliever Therapy (SMART): 1 to 2 puffs of ICSformoterol (e.g., Symbicort) once to twice daily, with additional use every four hours prn (not to exceed 12 puffs of formoterol daily). This step was a change from prior treatment strategies of daily combination ICS+LABA inhaler with as needed SABA. However, if the current regimen is working, then stick with it.
    • Schedule follow-up visits at periodic intervals.
    • Control environmental exposures that worsen a patient’s asthma.
  4. What are resources to help reduce environmental exposures for children? Key resources locally include the American Lung Association home health assessment program that we can refer families to that helps identify environmental triggers through home visits. The Medical-Legal Partnership is also helpful to access the legal system to ensure environmental triggers are minimized in rental properties where children live.
  5. What are the local EMR and clinic options? Review your clinic’s management approaches and tools including action plans, EMR tools, screening questionnaires, and spirometry options. For clinics using EPIC, there is a smartset for asthma that Dr. Sheryl Morelli helped champion based on the outpt guidelines.

2021-22 TOW #19: Child poverty

The effects of COVID on poverty, particularly disproportionate for BIPOC families, puts the crushing effects of poverty, and how it is intertwined with structural racism and the effects of climate change, into stark reality. Globally, efforts to eliminate extreme poverty faced huge setbacks with COVID, rising for the first time in 20 years. As much as ever, we need advocacy to serve our most vulnerable children, here and around the globe.

Materials for this week:

Take-home points:

  1. How many children live in poverty? Unfortunately, children represent the group with the highest poverty rates in the US, with 22% living below the federal poverty level (FPL). In 2021, the FPL is $26,500 in annual income for a family of 4. If you include those living at 200% of the FPL, or “near poor,” that represents 43% of children – almost half. It’s a shocking statistic, yet it’s persisted. Since 2013, the majority of children enrolled in public school live in poverty. The FPL method was developed in the 1960s, and many argue that it is outdated and understates the true scope of poverty in the nation. There are major inequities in poverty rates, with children of color who are Black, Latinx, and/or American Indian/Alaska Native experiencing 3 times higher rates of poverty due to embedded structural racism factors.
  2. What are the effects of poverty on health? Poverty represents one of the biggest threats to children’s health, with far-reaching effects. The PBS series “America by the Numbers” highlighted striking disparities in health related to poverty, and Frontline covered child poverty in 2020. Bauman et al. (Pediatrics 2006) summarized key data on the multitude of poverty’s health effects: “Poor children are almost twice as likely to be in fair or poor health, are 1.7 times more likely to be born low birth weight, are 3.5 times more likely to suffer from lead poisoning, are twice as likely to experience stunting, and are more likely to be diagnosed with severe chronic health conditions. Poor children are 1.7 times more likely to die in infancy and 1.5 times more likely to die in childhood.”
  3. Where can we learn more about the science of poverty and its effects on children? The Academic Pediatric Association (APA) Task Force on Child Poverty developed the U.S. Child Poverty Curriculum​, a series of 4 stand-alone modules to promote understanding of the impact of poverty and other social determinants of health on child well-being, the biomedical influences of poverty, and advocacy. The AAP has many resources for pediatricians to learn about and address poverty through advocacy.
  4. How do we tackle poverty in the office? Dr. Benard Dreyer, past president of the AAP, helped develop the AAP’s first policy statement on poverty and recommended that pediatricians screen for poverty risk factors. As we reviewed recently, I-HELP is a screening tool to remember ways we can address concrete needs by asking and linking to resources for Income, Housing, Education, Legal (immigration), Personal & Family stability. Other screening tools including for food insecurity are reviewed here. We can also help parents develop positive relationships with their children that are protective and build resilience, such as those approaches taught in the Promoting First Relationships curriculum. It’s also hopeful to consider more sweeping structural changes including revamping primary care delivery, providing home visitation, care coordination, and parenting programs, all described by Drs. Beck et. al (see above).
  5. What can we do to address poverty at a policy level? We can advocate with our national organizations for policies that benefit families including benefits and tax support. Many possibilities were outlined by Dr. Dreyer in his Case For Ending Childhood Poverty. PBS highlighted the ways that Canada and New Zealand are tackling child poverty, providing inspiration for future policy changes here, too.

2021-22 TOW #18: Lead screening

We are continuing our advocacy-related theme topics during the October Health Equity Track and REACH Pathway block. There has been tremendous advocacy done by pediatricians to help prevent and address lead toxicity. This has included the inspiring work by pediatrician Dr. Mona Hanna-Attisha in Flint MI who was one of the first people to raise awareness about dangerous lead levels in the water supply. We are fortunate to have two prominent environmental health pediatricians, Drs. Catherine Karr and Sheela Sathyanarayana, who do research and advocacy to keep children safe from toxins, and contributed to this teaching topic.

Materials for this week:

Take-home points for lead screening

  1. What is a safe blood lead level (BLL)? Based on strong research evidence, no measurable BLL is considered safe. Neurotoxicity associated with lower BLLs has been established by overwhelmingly consistent evidence from meta-analysis, so primary prevention of lead exposure is paramount. All detectable BLLs are reportable in WA State and the health department follows up with all BLLs > 5 mcg/dL.
  2. Why screen for lead? While lead is toxic to multiple body systems, the developing brain is particularly vulnerable. Most lead toxicity in the US is sub-clinical, only found on blood testing. Even low levels (<10mcg/dL) may be associated with behavioral problems (such as attention, aggression) and learning difficulties. Children aged 9-24 months are highest risk due to normal exploratory behavior – crawling, teething, putting non food objects in the mouth. Absorption across the gut is greater in children than adults.
  3. What are the sources of elevated lead levels? Ingestion of lead-containing dust or soil is the highest source, usually from old paint in homes built before 1950, but up through 1978, and homes from these eras being remodeled. As we have learned from Flint MI, lead is also in water sources, from contaminated water and old pipes. There are also newer sources of lead in imported products including candies, food, spices, make-up, and ceramics. Globally, leaded gas was finally eliminated in August 2021 in the last remaining country, Algeria, after one hundred years of use. A pioneer in environmental and occupational health, Dr. Alice Hamilton MD, led efforts to raise awareness of lead’s toxic effects.
  4. Who should receive blood lead testing? In WA state, the 2016 guidelines identify children with these risk factors: 1) Lives in or regularly visits any house built before 1950 or built before 1978 with recent or ongoing renovations or remodeling, 2) From a low income family (<130% of the poverty level). (Federal law mandates screening for all children covered by Medicaid), 3) Known to have a sibling or frequent playmate with an elevated blood lead level, 4) Is a recent immigrant, refugee, foreign adoptee, or child in foster care, 5) Has a parent or principal caregiver who works professionally or recreationally with lead, 6) Uses traditional, folk, or ethnic remedies or cosmetics. Unfortunately, screening questionnaires have not reliably identified kids, as one of our residents found for a topic review at Harborview, so when in doubt, screen.
  5. What do you do with an elevated level? The PEHSU provides a summary of key next steps based on BLL results on their website. Next steps will include evaluation for anemia/low calcium and Vit D, since these may impact lead absorption, as well as determining the need for imaging or medical management.

2021-22 TOW #17: Medical-legal partnership

This week’s topic is the Medical –Legal Partnership model, a collaboration to provide patients/families access to legal support. We are fortunate to have our own MLP in Washington originally formed as a partnership which included Harborview, Odessa Brown and local attorneys. Washington MLP directors have included our own amazing Drs. Ben Danielson and Brian Johnston and SCH director Annette Quayle. Scott Crain JD was the first attorney with MLP in WA and now supports statewide advocacy through NW Justice Project.

Materials for this week:

Take-home points regarding Medical-Legal Partnerships (MLP):

  1. What was the origin of the MLP model? The MLP model was first started in the Dept of Pediatrics at Boston Medical Center in 1993. Due to its success, the model has now spread to 49 states and >450 health care settings. MLPs provide a holistic and preventive approach to identifying and addressing the social determinants of health and equity. Health care providers and MLP attorneys partner to provide a warm handoff for legal needs affecting health. MLP attorneys are also trained in identification of additional concerns that could be addressed
  2. Why are MLPs so useful? Approximately 50% of all low to moderate- income households are estimated to have at least one unmet legal need (e.g., public benefit denial or unsafe housing, access to education services, etc). Given that 15-20% of children live in poverty in the US and close to 40% live in near poverty, pediatricians can best address the needs of the whole child by engaging with multi-disciplinary teams including legal professionals and social work to advocate for patients. While we cannot know all of the intricacies of benefit eligibility and legal rights, we can screen for needs and refer to specialists who do. MLPs also work on class-action lawsuits that address population-level inequities.
  3. What is a useful screening tool to assess need? We can use the I-HELP mnemonic (Income, Housing, Education/ Employment, Legal Status, and Personal and Family Stability and Safety) to help screen for needs. I-HELP was developed by the National Center for Medical-Legal Partnership to describe common health-related social and legal needs.
  4. Which legal needs does our local MLP address? In one study, families referred to an MLP showed increased access to health care, food, and income resources; two- thirds reported improved child health and well- being. An important note about legal services provided by the Washington MLP: it does not handle malpractice, criminal issues, personal injury or other fee-generating cases, or other civil legal cases where a referral for services is readily available elsewhere. They do not handle immigration-related legal issues, but do work closely with and refer to the Northwest Immigrant Rights Project.
  5. How do residents use our MLP? In addition to the partner clinics currently involved (OBCC, HMC), all patients that residents serve at Seattle Children’s are eligible to have referral to the MLP. MLP is also willing to discuss cases in consultation via residents roles at SCH. Remember to complete a Release of Information (ROI) form which is required before referral. You can also refer to the Washington Legal Help resource for legal needs not addressed by MLP or for families not eligible for MLP.

Here’s to advocating and teaching others to advocate!

2021-22 TOW #16: Positive Discipline

This week’s topic comes courtesy of the expertise of our wonderful Dr. Heather McPhillips. We have certainly been the beneficiary of her sage advice in our household.

Materials for this week:

Take-home points for discipline:

  1. How to define positive discipline? Discipline means “to teach” and should not be confused with “punishment.” Fundamentally, we want children to know that we love them and care about them, and that’s why we set age-appropriate limits. We promote “positive discipline” in pediatrics: having a loving relationship, teaching and modeling what we want them to do (and setting up their environment for them to be successful), and reinforcing limits by decreasing unwanted behaviors without shaming or corporal punishment.
  2. Why are extremes in discipline a problem? Authoritarian parenting tends to be overly restrictive, demanding, and “doing it because I say so,” which leads to compliance with resentment and poorer relationships. Permissive parenting is too loose and sets few limits, allowing a child too much leeway in deciding the rules. The best outcomes are with an authoritative approach: being firm AND loving, setting limits and providing boundaries, and opportunities to make decisions within those boundaries.
  3. Why are all forms of corporal punishment (including spanking) explicitly discouraged? While spanking (or other corporal punishment) historically were considered acceptable, at home and at school, the AAP unequivocally stated in 2018 that children should not be spanked given many negative outcomes including increased aggression, emotional distress, escalation to abuse, and lack of effectiveness over time – see this compelling infographic about spanking). This is in alignment with the UN Committee on the Rights of the Child to prevent all forms of corporal punishment. While seeking to prevent children’s physical harm, we must also acknowledge the context of corporal punishment, and the trauma and physical violence experienced among BIPOC, especially Black, children and families due to racism, including disproportionate racist applications of corporal punishment in school settings. We can guide families to more effective strategies and highlight that corporal punishment overall is a less effective strategy. Stacey Patton PhD wrote a book Spare the Kids, about understanding the racial trauma of spanking.
  4. How do we best use time-outs? Time-outs are one strategy used to remove children from a situation where they may be harming themselves or others and to reinforce calming themselves down before re-joining activity. Time-outs have generated some controversy among discipline experts and alternatives are offered, especially parent time-outs! Advocates of child time-outs remind us they should not be viewed as punishment, and are especially preferred to physical punishment. To be effective, time-outs need to be consistent, kept short, and clear. Parents need to be calm and use few words and to convey that they are not leaving or abandoning their child.
  5. Help parents recognize triggers and build positive connections. We want to help parents recognize their child’s needs, especially for love and connection, and know their child’s triggers for negative behavior. One great trigger acronym I’ve learned from my husband (a clinical psychologist) is HALT: Hungry, Angry, Lonely, Tired. These triggers are true for all of us but especially for young children. Recognizing meltdowns/ misbehavior as a sign of unmet need in a little one can help us be more empathic and calm in our responses as adults. The PFR approach offers some strategies to help us prompt this dialogue like hitting the “pause” button and asking “wondering questions” that allow parents to tune in to what children may be feeling and experiencing.

2021-22 TOW #15: Telehealth

A big thanks to Dr. Tom Courtney MD, one of our faculty at UW Neighborhood Clinic – Kent Des Moines who provided this TOW! Telehealth stepped from relative obscurity into the main stream during COVID-19 as we shifted to help patients and practices cope with the “new normal.” This TOW gives a brief background, followed by a detailed, practical discussion of evidence-based practices to help you become more comfortable. It’s clear telemedicine will  continue as a key tool to provide medical care and medical homes.   

Resources for this week:

Take-home points:

  1. How can we stay up to date with changes in virtual care and implement it into my practice? Telehealth is a rapidly evolving area that will likely play a prominent role in medical care going forward. Experience in the current COVID pandemic has rapidly accelerated interest and use in many fields of medicine. The challenge going forward is to stay current with new resources while we integrate this useful tool. The AAP and numerous telehealth groups and companies have tools and resources for navigating this evolving area (see links).   
  2. How do we avoid further widening the digital divide between families with different levels of resources? The digital divide is a term used to refer to the gap between socioeconomic groups and those who have more reliable access to Internet and better hardware, in contrast to lower resource groups for whom these may be unaffordable. It can also refer to the difference between rural access and city/suburban access or more broadly to more resourced and less resourced countries. Currently there are many initiatives to help try to close the gap and provide better infrastructure both nationally and globally. Be aware that some families have limits on their cellular data plans that can easily be used up by even basic telehealth visits through platforms like Zoom. When uncertain, standard phone calls may be preferable to video calls.  
  3. Should well child care be done via telehealth? There has been great debate about well child care via telemedicine, but the consensus and the recent AAP recommendation is that if WCC visits are done, they should be split into two parts. The first part could be done by telemedicine including development screening, basic exam, and anticipatory guidance, and the second part would have to be an in-office visit later to include vaccinations, growth, vision and hearing checks and a more complete physical exam.  There is consensus that routine vaccination should not be deferred and every effort should be made to ensure all children receive normal vaccinations on time. 
  4. What are some unique factors for telehealth with teens? Adolescent specialist at SCH, Dr. Yolanda Evans highlighted the potential benefits and application for telemedicine for teens including access to contraception, gender-affirming care, behavioral health, substance use, eating disorder treatment. Many teens and young adults prefer telehealth visits to office visits to support their independence and allow them to talk to their doctor on their own in the comfort of home where they may be more relaxed. Just as with in-person visits, it is critical we ensure confidentiality when starting telehealth visits. Options for privacy include having the patient move to a different room, using a headset, and/or using the chat function.

2021-22 TOW #14: Language Other than English (LOE) visits

As we work with our increasingly wonderfully diverse families in Seattle, we have an imperative to be knowledgeable in navigating visits with families who speak another 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 who use a language other than English (LOE) for medical care.* Here are the resources for this week:

*A quick note about terminology: Limited English proficiency (LEP) is the term used by the US Census and in many research studies, based on an individual’s self-reported ability to speak English; any response less than “very well” is classified as LEP. In most healthcare settings, we ask about language for medical care or preferred language, which Seattle Children’s now refers to as having LOE (a language other than English). LOE is also preferred because it is not deficit-based. This TOW will use LOE other than when required for accuracy (e.g., LEP in census results).

Take-home points in working with families who have a language for care other than English:

  1. How many children have a parent with LEP? Based on census information, 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 who use a language other than English are at risk for inequity. It is our responsibility to decrease that risk and prevent errors by using certified interpreters for every medical communication.
  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 would like to use to discuss 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 interpretation 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 (compared to telephone). The bottom line is that all modalities can be effective; most important is that we use them consistently! Enjoy getting to work with families from all over the world!