2022-23 TOW #46: Toilet training

In this spring season, a topic of toddler “blooming,” so to speak, is toilet training! In the process of going through it with our daughters, I learned how different approaches work for different children, as described below. Below are the case and discussion, thanks to our own fabulous Dr. Heather McPhillips, and several summary articles.

Materials for this week:

Take home points on toilet training:

  1. Why has the age of toilet training changed in the US? Toilet training in the US has moved later in toddler years (combination of factors including availability of better disposable diaper options, children in child care settings, and cultural norms/approach to training). Average age at which toilet training begins has increased from earlier than 18 months to between 21 and 36 months. Worldwide in countries without access to diapers or machine washing, infants as young as 4-6 months can be taught through “elimination communication” or “assisted infant toilet training” where parents watch facial cues and hold children over a toilet, often training with a specific sound,, with minimal to no diapers. I’ve had a number of families toilet train children earlier and support that approach if the family chooses, especially given the cost and environmental impact of diapers.
  2. How does starting earlier affect the length of time to potty train? Generally the earlier that children start, the earlier they complete it, though it may take longer to fully potty train. On average, female children usually begin and complete toilet training about 2-3 months before male children in the US.
  3. What is the most commonly used approach in the US? The child-centered toilet-training approach is most common. As described by Dr. Barry Brazelton and recommended by the AAP, this approach suggests that children are more likely to be developmentally ready after 18-24 months. This approach follows the child’s lead, looks for developmental readiness cues and provides positive encouragement for attempts at toilet training but avoids forcing / coercing or any negative comments. Studies highlighted above have shown that children raised in other countries potty train much earlier, like France, where 2 years old is more normative. We in the US probably have among the latest age for potty training (and also a bigger environmental impact, as many now acknowledge).
  4. What’s the “train in a day” type approach? As described by Azrin and Foxx, this potty training “bootcamp” is often done in a dedicated day/weekend using an operant conditioning model with positive reinforcement and negative reinforcement for accidents. One element of the “bootcamp” we found helpful at our house was to set a “potty timer” to remind when to go make an attempt-about every 30-60 minutes to avoid accidents (families can start with more frequent then gradually spread them out).
  5. What’s the evidence behind different approaches? Both of the most common approaches have been shown to work in practice to effectively teach typically developing children how to potty train. As above, given the different approaches used around the world, clearly all can be effective in context. Pediatricians who have experience with elimination communication are now advocating for more broad discussion and adoption of this approach, as well as those exploring options for reducing environmental impact. We can help explore with families what they are comfortable with trying in their home.

2022-23 TOW #45: Firearm injury prevention

For us as pediatricians, we recognize the tragedy of ongoing violence and lives lost to firearms. May is National Trauma Awareness, and coming up June 2-4 is national Gun Violence Awareness Day with Wear Orange for Gun Safety events in Seattle including at Othello Park, Sat June 3 11 – 2pm. We are fortunate that our local general pediatrician hero, Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention, founded the Harborview Injury Prevention and Research Center (HIPRC) Firearm Injury and Policy Program (FIPRP), now co-directed by Dr. Ali Rowhani-Rahbar (Sahar’s husband!). Materials for this week:

Take-home points for firearm safety:

  1. What are some key statistics on firearms and children? Firearm injuries became the leading cause of death in U.S. children in 2020. 1 in 3 homes in the US with children have firearms. 80% of unintentional firearm deaths of kids under 15 occur in a home. In classic studies, Rivara and his colleagues found in a home with a firearm, the odds ratio of suicide was 4.8; Kellerman found a firearm was 43 times more likely to be used to kill a family member or friend rather than be used in self-defense. Fowler and colleagues found that Black youth aged 15 to 24 years were 19 times as likely to be victims of firearm homicide than White peers. We  must acknowledge the deep inequities in urban firearm injuries disproportionately harming Black youth and seek to eliminate poverty and racism that are key factors in those disparities.
  2. Who should we prioritize for firearm screening? If you are tight for time and cannot screen for firearms in every clinic wellness visit, be sure to include specific counseling in visits with depressed teenagers. In a case-control study done by Grossman et al., storing firearms locked, unloaded, or separate from the ammunition was associated with significantly lower risk of unintentional and self-inflicted firearm injuries and deaths among adolescents and children. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline and the 3 Interventions Toolkit from the FIPRP.
  3. What can we recommend for firearm storage? The safest thing is not to have a firearm in your home. For families that have one, advise that the safest way to store them is unloaded, locked, and out of reach of young children and teenagers. There are 5 main types of locking devices to improve safe storage: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Generally avoid devices with keys. Visit King County’s Lock it Up program website for information about how to store firearms. Consider using a statement like: “Having a loaded or unlocked firearm in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store firearms unloaded in a locked drawer or cabinet, out of reach of children.”
  4. How do we advise parents to ask about firearm safety? Research shows that 93% of parents, including parents who choose to own firearms, would be comfortable with being asked about a firearm in their home. Present your concerns with respect. Suggested wording includes:  “Knowing how curious my child can be, I hope you don’t mind me asking if you have a firearm in your home and if it is properly stored…” For family members, this might include: “[Mom, Dad] this is awkward for me and I mean no disrespect. I am concerned Alex will find one of the firearms in your home when we visit, and I want to make sure we keep her safe. Do you keep them locked up with the ammunition stored separately?”
  5. Does counseling work? Several studies have found counseling in office visits to be associated with improved safe storage of firearms. A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Likewise, Barkin et al. found that brief office-based counseling increased the use of safe storage.

2022-23 TOW #44: Substance use

We are wrapping up the annual National Prevention Week so a good time to review this topic. For adolescent substance use, pediatric primary care roles include universal screening, brief intervention, and referral to treatment (known as SBIRT in the literature), as well as providing access to life-saving reversal agents like Naloxone. As states legalize marijuana (which Washington did in 2012), societal messages are changing. These are confusing and often erroneous for teens, so it’s important for us to help provide accurate information and support, and access to resources including Naloxone.

Materials for this week:

Take-home points for substance use problems:

  1. What’s the epidemiology of youth substance use? Among US teens, average first use of alcohol is 13.1 years, ~50% have tried alcohol by 8th grade, and almost 80% have tried it by high school graduation. >50% have tried other drugs by the end of high school, most often marijuana, and ~20% have used prescription drugs non-medically (a BIG increase in recent decades). Data have shown that those who drink prior to age 15 years are 4 times more likely to develop alcohol use disorder than those who start at age 21.
  2. What are the risk factors and protective factors for substance use disorder? Parents with substance use disorder, history of physical or sexual abuse or neglect, depression or learning disabilities (especially ADHD), family conflict, friend use, and living in a rural area. Youth getting Ds and Fs in school are 3x more likely to be using alcohol than those getting As, so lower grades can be a red flag for youth substance use. Protective factors include a stable, supportive home environment with clear parental expectation and rules, friends not involved with substances, and personal, academic and social success.
  3. What are the problems associated with adolescent substance use? These include deaths due to overdoses, school drop-out, violence including homicide and suicide, unprotected sexual activity, unwanted pregnancy, rape, motor vehicle accidents, and permanent decrease in IQ with prolonged use.
  4. How should we screen? Use the HEADSSS assessment (D=drugs) to screen all youth, emphasizing confidentiality-in Washington State, youth 13 and above can access substance use treatment without parent involvement. It’s helpful to frame this as a message of support: “we care about you, teenage years can be hard, and we want to help.” Some recommend asking teens their attitude towards tobacco, alcohol, and drugs as a neutral way to broach, and/or consider first asking parents and teens together what they have talked about and their attitudes. If concerned, follow-up with the CRAFFT assessment: 2 or more positive responses are predictive of problem use.
  5. Where can we refer? Options to address problem use include mental health counseling and specific substance use treatment. Local resources: Adolescent medicine at SCH, and community programs such as Therapeutic Health Services. UW Addictions, Drug, and Alcohol Institute (ADAI) has a compiled list of resources in Washington.

2022-23 TOW #43: Celiac disease

May is Celiac awareness month. Huge thanks to the excellent team of Drs. Pooja Tandon in General Pediatrics and Dr. Dale Lee in GI, who collaborated to provide the materials for this topic. 

Materials for this week

Take home points:

  1. What is celiac disease and what is the epidemiology of this condition? Celiac disease (CD) is an autoimmune enteropathy triggered by ingestion of gluten (a protein found in wheat, barley, and rye) in genetically susceptible individuals. As gluten can’t be digested, the body’s immune reaction leads to an inflammatory cascade, and eventually B cells produce antibodies against gliadin, endomysium & tTG which lead to small intestinal mucosa damage. Celiac affects approximately 1% of the population and occurs throughout the world. About 50% is undiagnosed, which is particularly high in non-white populations, in part due to bias and lack of knowledge about who to consider for testing. First-degree relatives of people with celiac disease – parents, siblings and children have a 1 in 10 risk compared to 1 in 100 in the general population. Lifelong withdrawal of all gluten from the diet reverses the intestinal damage and relieves signs and symptoms.

  2. What are the clinical manifestations of celiac disease in children? We used to think that CD was only a gastrointestinal (GI) disease. Although many patients do have GI symptoms, non-GI symptoms frequently occur simultaneously, may be extremely diverse, and may be the only initial patient complaint. Isolated short stature has been identified as the initial presentation for CD in up to 10% of those referred to an endocrine clinic for evaluation. However, many patients with CD are within the normal growth parameters for age and >10% of CD patients may be overweight. Anemia is one of the most common extraintestinal manifestations of CD. Other symptoms include chronic fatigue, amenorrhea, dental enamel defects, dermatitis herpetiformis, aphthous stomatitis, pubertal delay, headaches, and behavioral problems.

  3. What workup in the primary care setting would be helpful for diagnosing celiac disease? Serum immunoglobulin A (IgA)–tissue transglutaminase (tTG) is recommended as the most cost effective, sensitive, and specific test (the sensitivity and specificity >97%) for CD. Because this is an IgA-based antibody test, a serum IgA level should be checked to ensure that the child does not have IgA insufficiency. If deficient, choose alternative IgG-based testing, such as deamidated gliadin peptide IgG (DGP IgG). Of note, low or high IgA levels do NOT suggest celiac disease or need for GI referral.

  4. At what age can you screen for and diagnose CD? Generally, children at risk for CD are screened at age 2 or 3 unless symptoms are seen beforehand. In children younger than 3 with symptoms, antibody testing may not always be accurate. Children must be eating gluten-containing food products for some time, usually at least 2-3 months, but sometimes up to one year, before they can generate an autoimmune response to gluten that shows up in testing. 

  5. How is the diagnosis of celiac disease confirmed? Guidelines recommend that when serum testing is suggestive of CD, or if there is a strong clinical suspicion even without indicative laboratory data, an upper GI endoscopy with small intestinal biopsies is required to confirm the diagnosis. A child should remain on a normal, gluten-containing diet until the endoscopy has been completed. 

2023-24 TOW #42: Climate change and children’s health

Honoring yesterday’s official celebration of Earth Day 4/22, with special gratitude to many residents’ awesome work addressing climate change and children’s health. Dr. Mary Beth Bennett, R2, drafted this TOW and was a co-author with me on the Case discussion chapter for the Yale Primary Care Curriculum. R3 Dr. Alee Perkins launched Pediatricians for Climate Action, partnered with R3s Drs. Allie Obremskey and Blair Perkins to bring more advocacy and a dedicated focused curriculum to our residency. R3s Drs. Sruti Pisharody, Julia Hadley, and R2s Drs. Alex Arvanitakis and Angela Zhang presented an inspiring Health Equity Rounds on Climate Change and Social Justice (Children’s log-in required). Many others have joined the efforts to do ecological restoration, testify on legislation, and help with research. THANK YOU ALL!

Spring is the perfect time to give thanks for the natural beauty that surrounds us (especially here in the Pacific Northwest!) and to reflect on how we care for planetary health as we care for our patients and each other. It’s compelling to realize how these intersect and how we can address equity, justice, and children’s health in the process. 

 
Materials:
 
Key points:
  1. How is our changing climate disproportionately affects kids’ health? Climate change contributes to increasingly severe (and more common) extreme weather events that are directly and indirectly associated with greater child illness and mortality, including heat waves, wildfires, hurricanes, floods, and droughts. Vulnerability to these extreme events is a combination of exposure risk, physiologic susceptibility, and adaptive capacity. All children have increased vulnerability because they depend on caregivers and communities to buffer them from exposures, and their bodies, organs, and immune system are still maturing and developing. Climate change is an equity concern given that children and communities negatively affected by structural racism are further disadvantaged due to pollution, urban heat islands, contamination, and other factors.
  2. How can we screen and prepare families? General pediatricians need to know how to screen for environmental risk factors and advise families on preparedness for emergencies. Information about disaster preparedness for multiple weather events is provided in many languages at https://www.ready.gov including Ready Kids. Families can sign up for local disaster preparedness alerts and create a disaster preparedness plan.
  3. What’s the effect of climate change on youth mental health? Growing numbers of young people acknowledge the existential threats of climate change and how this affects their mental health. A 2021 survey study with ten thousand 16-25 year-olds across ten countries found that 84% expressed moderate worry about climate change, and 59% were very or extremely worried. Climate grief, closely related to eco-anxiety, represents psychological sadness in response to awareness of changing natural areas, biodiversity loss, and other ecological impacts of climate change. Youth need support and opportunities to talk about and address climate concerns. 
  4. How do climate solutions have immediate beneficial effects on children’s health? The actions needed to reduce climate change can improve individual child health including: (1) sustainable and healthy food systems and adopting diets that emphasize fresh and local plant-forward nutrition sources, as well as efforts to reduce food waste, (2) healthy transportation systems with active (walking and biking) transportation, carpooling, and public transit options, (3) clean, renewable energy sources that decrease air pollution and greenhouse gases in our homes, building, and health care settings, (4) weatherization to reduce energy use, save on energy bills and adapt to changing weather patterns, (5) supply chains that factor in environmental impact for all purchases and choices–from health care, to cars, appliances, clothing, etc, and (6) support for organizations working towards environmental sustainability and conservation, which also helps people take collective action and maintain hope.
 
We hope this Earth Day inspires reflection on how we can all be better stewards of our environment. As a program, we look forward to continuing our work in this area and welcome feedback on the best ways we can incorporate climate change into our practices. We will be launching a Department-wide Climate Change CARE committee this year – all are welcome to join! Stay tuned for more information. 

2022-23 TOW #41: Circumcision

According to the AAP, newborn male circumcision has adequate benefits compared to risks to “justify access to the procedure for families who choose it.” In line with this being considered an elective procedure, in Washington State, families who choose circumcision may have to pay for the procedure out of pocket. Some insurance plans have a circumcision benefit, and some Medicaid plans will cover up to $200. At the UW Northgate Clinic, one of the available local sites, it costs about $300. If desired, families need to schedule for circumcision within 3 weeks of birth, so it’s helpful to provide information before discharge from newborn nursery, or at the first follow-up. Providers locally include UW Northgate and Kent Des Moines clinics.

Materials for this week:

Key take-home points:

  1. What are the main benefits and risks of circumcision? Benefits include decreased risk of UTI before age 2, and decreased risk of transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, webbed penis, and buried penis.
  2. What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
  3. What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw from lysing foreskin adhesions, which can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
  4. When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, pathologic phimosis (foreskin that does not retract and causes complications such as repeated infection) or paraphimosis (retracted foreskin that gets stuck behind the head of the penis), or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves).
  5. What advice do we give about care for the uncircumcised penis? The basic care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding, and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractable foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 5-7, and by teenage years in almost all boys. Topical steroids (e.g., triamcinolone 0.1% ointment twice daily) applied to the foreskin for 1-2 months can speed resolution of physiologic phimosis.

2022-23 TOW #40: Adolescent Contraception

This week we will review contraception, with thanks to adolescent specialists Sarah Golub MD MPH and Taraneh Shafii MD MPH for sharing their terrific expertise in this topic.

Materials for next week:

Take-home points:

  1. Epidemiology: Whereas rates of teen sexual activity between ages of 15-19 have been relatively stable, the rates of teen pregnancy, birth, and abortion have all been declining thanks to more appropriate condom and birth control use. About 47% of 9-12 graders report having had sex in national surveys, with 59% having used a condom before last sex, 19% having used birth control pills, and 5% using other forms. Even with decreasing rates, rates of teen pregnancy in the US have been about twice the rates in Europe, and the CDC reports disparities persist by racial/ethnic groups and geographical regions. Now more than ever, advocacy to ensure reproductive justice and access to reproductive rights for adolescents in the US and worldwide continues through many efforts and organizations.
  2. What are the most common birth control choices among adolescents? Condoms are the most commonly used form by teens, with 90% reporting using at least once. Condoms have a failure rate up to 25%. Next most common are combined oral contraceptive pills (COCs); the failure rate is 8-9% for typical use and up to 25% for teens. Other combined hormonal forms including the transdermal patch and vaginal ring, which may be more effective among teens as they don’t require daily dosing. Injectable progestin-only hormonal method (Depo-provera) lasts for 12 weeks and is more effective, though is associated with weight gain and some bone density loss with longer term use.
  3. What’s the most effective birth control? Ideal is DUAL USE: CONDOMS + another form. The long-acting reversible contraceptives (LARCs) including implantable (e.g., Nexplanon) and intrauterine devices (IUDs) are most effective pregnancy prevention (less than 1% failure rate). Nexplanon is inserted into the subcutaneous tissue of the upper arm and lasts 3 years; the main side effect is irregular menstrual bleeding, and 15% of individuals amenorrheic at one year. IUDs last longest, but require a pelvic exam to insert. The hormonal IUDs (Mirena-up to 7 years, Kyleena- up to 5 years, Liletta -up to 7, Skyla – up to 3 years) are better for decreasing bleeding overall. The copper IUD (ParaGard) has no hormones, lasts up to 12 years, can be inserted as emergency contraception, yet is associated with more bleeding and cramping.
  4. What needs to happen in a visit to start combined oral contraceptives? Brief medical and sexual hx, including date of last unprotected sex and current meds.
    • Rule out absolute contraindications to estrogen-containing contraceptives including migraines with aura, history of DVT/PE, personal or family history of clotting disorder, uncontrolled hypertension, and relative contraindications such as anti-epileptic drugs (see the US Medical Eligibility Criteria for Contraceptive Use -USMEC including an app available)
    • Blood pressure and weight. Pelvic exams are no longer needed
    • Negative pregnancy test
    • Provide affirmation and education, as well as condoms and advance emergency contraception

2022-23 TOW #39: Child abuse recognition

April is child abuse prevention month, an important reminder to discuss this always challenging but critical topic. Our role in primary care encompasses strategies to build resilience, promote strong relationships, link families to resources, and screen and refer for concerns as mandated reporters. SCH’s Protection, Advocacy and Outreach team has 3 prevention programs: Period of PURPLE crying, Medical-Legal Partnership, and Positive Parenting (which funds our Promoting First Relationships (PFR) training and offers resources for a lot of parenting classes).

Materials for this week:

Take-home points for child abuse recognition:

  1. How many children are affected by maltreatment? We are likely to encounter child maltreatment in our practices: 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. How are physical abuse, neglect and verbal abuse defined? Physical abuse is the intentional use of physical force that results in or could result in physical injury to a child. Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child; it includes lack of adequate nutrition, hygiene, shelter, and safety. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. Verbal abuse refers to nonphysical forms of punishment intended to cause shame and humiliation.
  3. What is the AAP stance on corporal punishment and why? Making a distinction between corporal punishment (CP) and maltreatment can be challenging. As of fall 2018, the AAP opposes any form of corporal punishment, including spanking, as it is not effective for changing long-term behavior and is associated with many adverse outcomes, including aggressive behavior and mental health problems. Here’s a very informative infographic on the psychology of spanking. Dr. Sege, who co-authored the AAP statement, discusses how you can talk to parents who were spanked themselves in this podcast (here’s the interview transcript).
  4. Which children are at highest risk for child abuse? Children in all SES levels are at risk, and in ~80% of cases, parents are perpetrators. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired or multiple gestation pregnancy. Parent-level risk factors include poverty, multiple children under 5, substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for development.
  5. What is the most overlooked form of abuse? Bruising is the most frequently missed form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger. Those bruises should prompt more work-up and referral to CPS. Before being diagnosed with child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury.

2022-23 TOW #38: Childhood nutrition

This is a topic close to my heart, and it’s really a rich, packed one. Please try to digest (pun intended!) whatever element is most helpful for you to learn/review.

Materials for this week:

Take-home points:

  1. What should we recommend for children to eat? The American Heart Association and AAP and the Dietary Guidelines say diets should focus on fruits and vegetables, whole grains, low-fat dairy, beans, fish, and lean meat. (I like Michael Pollen’s 7-word summary: “Eat food, not too much, mostly plants.”) Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars (in everything from bread to yogurt to drinks), and eating less processed foods. Some people are more susceptible to lipid changes with animal fats, even when maintaining a healthy weight, but for others, animal fats in moderation may be okay, and is certainly preferable to added sugars. If we are eating with sustainability in mind, we will naturally limit animal fats. 
  2. How we eat not just what we eat matters. There’s certainly some truth to the adage “we are what we eat,” but it’s also “we are HOW we eat.” Our society has emphasized food on the go, and there’s been a growing interest in teaching children a more balanced message: mindful eating (which our own amazing Dr. Lenna Liu teaches), preparing our own food at home, raising our own food through gardening, and creating a positive environment for eating without distractions. I love engaging young kids in cooking – one of my favorite first cookbooks is “Cooking Class” by Deanna Cook (such a perfect chef name!), and Cooking Class-Global Feast. These got my own kids to expand their palates, and we still make recipes from them!
  3. What is the Division of Responsibility for feeding? “The parent is responsible for what, where, and when food is served, and the child is responsible for how much to eat”. I like the short and sweet AAP version: “parent provides, child decides.” Ellyn Satter, a child dietitian who developed this model, reminds us of key elements: make eating times pleasant (no pressuring, battles, cajoling, etc.), only offer water between snacks and meals, acknowledge lack of experience with a food while not catering to likes and dislikes. When giving new foods, offer along with ones kids already know. At our house, we call trying a new food “adventure bites.” Children can self-regulate and recognize when they are full or hungry.
  4. How does appetite and portion size fit in? It’s typical to taper off food intake between 15 months and 3 years as growth rate slows, termed “physiologic anorexia.” I like to show parents how the BMI chart goes DOWN during these times, and that it is expected they will look skinnier (and will seem much pickier!). Appetite matters but so does portion size as a cue to eat. There’s more evidence for portion size effects in toddlers/preschoolers and up, but even some evidence for infants. One study found that 2 month old babies who were formula fed using large bottles (holding >=6 oz.) gained more weight by 6 months than babies fed with bottles <6 oz.
  5. How can we promote interaction rather than distraction during meals? Sitting together for meals has many positive effects, and doesn’t just have to be at dinner, but can be any meal. I start the idea of family meals and eating together when I first talk about introducing solid foods. To spur interaction, we have found it helpful to start our family dinners with a gratitude practice. We recommend screen-free meal times for several reasons: media has a pervasive influence on children’s food choices, and even young children are heavily marketed to by the food industry. Watching TV during meals is associated with kids’ poorer food choices in multiple studies. Also screen media definitely interfere with mindful eating.

This is a topic close to my heart, and it’s really a rich, packed one. Please try to digest (pun intended!) whatever element is most helpful for you to learn/review.

Materials for this week:

Take-home points:

  1. What should we recommend for children to eat? The American Heart Association and AAP and the Dietary Guidelines say diets should focus on fruits and vegetables, whole grains, low-fat dairy, beans, fish, and lean meat. (I like Michael Pollen’s 7-word summary: “Eat food, not too much, mostly plants.”) Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars (in everything from bread to yogurt to drinks), and eating less processed foods, which is good for people and the planet. Some people are more susceptible to lipid changes with animal fats, even when maintaining a healthy weight, but for others, animal fats in moderation may be okay, and is certainly preferable to added sugars. If we are eating with sustainability in mind, we will naturally limit animal proteins and fats. 
  2. How we eat not just what we eat matters. There’s certainly some truth to the adage “we are what we eat,” but it’s also “we are HOW we eat.” Our society has emphasized food on the go, and there’s been a growing interest in teaching children a more balanced message: mindful eating (which our own amazing Dr. Lenna Liu teaches), preparing our own food at home, raising our own food through gardening, and creating a positive environment for eating without distractions. I love engaging young kids in cooking – one of my favorite first cookbooks is “Cooking Class” by Deanna Cook (such a perfect chef name!), and Cooking Class-Global Feast. These got my own kids to expand their palates, and we still make recipes from them!
  3. What is the Division of Responsibility for feeding? “The parent is responsible for what, where, and when food is served, and the child is responsible for how much to eat”. I like the short and sweet AAP version: “parent provides, child decides.” Ellyn Satter, a child dietitian who developed this model, reminds us of key elements: make eating times pleasant (no pressuring, battles, cajoling, etc.), only offer water between snacks and meals, acknowledge lack of experience with a food while not catering to likes and dislikes. When giving new foods, offer along with ones kids already know. At our house, we call trying a new food “adventure bites.” Children can self-regulate and recognize when they are full or hungry.
  4. How does appetite and portion size fit in? It’s typical to taper off food intake between 15 months and 3 years as growth rate slows, termed “physiologic anorexia.” I like to show parents how the BMI chart goes DOWN during these times, and that it is expected they will look skinnier (and will seem much pickier!). Appetite matters but so does portion size as a cue to eat. There’s more evidence for portion size effects in toddlers/preschoolers and up, but even some evidence for infants. One study found that 2 month old babies who were formula fed using large bottles (holding >=6 oz.) gained more weight by 6 months than babies fed with bottles <6 oz.
  5. How can we promote interaction rather than distraction during meals? Sitting together for meals has many positive effects, and doesn’t just have to be at dinner, but can be any meal. I start the idea of family meals and eating together when I first talk about introducing solid foods. To spur interaction, we have found it helpful to start our family dinners with a gratitude practice. We recommend screen-free meal times for several reasons: media has a pervasive influence on children’s food choices, and even young children are heavily marketed to by the food industry. Watching TV during meals is associated with kids’ poorer food choices in multiple studies. Also screen media definitely interfere with mindful eating.

2022-23 TOW #37: Head size and shape

An important aspect of evaluating infant growth is head size and shape. Positional plagiocephaly has increased with back to sleep recommendations, and treatment continues to evolve, in part thanks to research by some of our wonderful local craniofacial experts.

Materials for this week:

Take-home points for assessing abnormal head size and shape, especially plagiocephaly:

  1. What are the relevant bones/growth plates and growth patterns of the head? Newborns have 7 skull bones (2 frontal, 2 parietal, 2 temporal, and 1 occipital) separated by 6 major sutures important to skull growth: 1 metopic, 2 coronal, 1 sagittal, and 2 lambdoid. During the first two years of life, 75% of head growth occurs; only 25% occurs after age two. Craniosynostosis is premature fusion at one or more of the cranial sutures, resulting in restriction of skull growth at that site.
  2. How common is plagiocephaly? Plagiocephaly (Greek derivative that means “oblique head” referring to unilateral flattening over the occiput) is due to either positional causes (the most common) or lambdoid suture craniosynostosis (much more rare). About 20% of infants have positional plagiocephaly in the first 4 months, which increased after the 1992 “back to sleep” guidelines. Craniosynostosis affects 1 in 1800. Lambdoid synostosis affects 3 in 100,000.
  3. What should we look for on physical exam? Look at the head from multiple angles, especially from the top. Positional plagiocephaly has a “parallelogram” shape with the ipsilateral ear pushed forward and ipsilateral bossing with no palpable ridge. Lambdoid synostosis is distinguished by a trapezoid shape with ipsilateral ear pulled back and contralateral bossing with a palpable ridge over the suture. Another tip to remember is the metopic suture closes first, in the first year of life, and can cause some normal ridging on forehead as it closes (abnormal closure leads to a triangular shape of the head-“trigonocephaly”).
  4. What work-up should be done? Generally clinical exam is most important to follow head size and shape closely. A concerning size would be rapid increase crossing multiple percentiles (specially if above a z-score of 3.0). If concerned for head shape not improving by 6 months, refer locally to craniofacial clinic to decide on imaging. In more remote areas, where referral access is more limited, imaging may need to be done first; typically starting with a skull x-ray and/or cranial ultrasound (depending on availability of technicians skilled in ultrasound).
  5. How should we manage? Provide patient education about position, including changing direction baby is facing in the crib, keeping babies out of “containers” (carseats, swings, etc.) and promoting tummy time starting in the newborn period (goal is 30-60 min/day). I show parents how this looks in the newborn nursery or first exam at clinic (and ooh and ahh at how their baby is already lifting up their head!). Refer to PT for any concerns of decreased mobility or torticollis. Refer to craniofacial around 5-6 months if not improving. Helmet therapy costs several thousand dollars and may not be covered by insurance. It is usually implemented between 6-9 months. Developmental outcomes for otherwise typically developing children is unrelated to positional plagiocephaly. More severe plagiocephaly associated with developmental delays likely reflects co-morbid conditions.