2018-19 TOW #41: Temperament in the pediatric visit

Temperament is a great topic to integrate discussion about parenting approaches, and recognizing child needs/preferences. This is a good time to review with colleagues how the Promoting First Relationships (PFR) approaches might help teach parents to recognize child needs, including temperament. Remember that PFR handouts are available for each of the well visits on the TOW blog page. I’ve found them really helpful in anticipatory guidance and addressing parents’ behavior/development concerns.


Take-home Points

  1. What is the definition of temperament and its underlying theory? Temperament is a little challenging conceptually, but can be generally thought of as the ways we self-regulate and react in different situations. Temperament is associated with both emotions and behavior. It emerges early in life, is largely influenced by genetics, and mostly stable over our lifetime. We know temperament can affect developmental pathways and be associated with future psychopathology, but it has been difficult to agree on a consistent definition and exactly how this influences children’s behavior and future.
  2. How many different temperament types are there? There are 10 main temperament traits generally assessed in childhood (adaptabillity, approach, sensory sensitivity, reactivity, distractibility, persistence, mood, regularity and emotional sensitivity). There are 3 main temperament clusters in childhood: “easy” children, “slow to warm up” and “difficult,” based on combinations of traits. Easy children are, well, easy. “Slow to warm up” kids tend to be more careful, to have low adaptability to new situations, and to have difficulty separating from parents. “Difficult” children may be more irritable or fearful, have low adaptability and short attention span, have disordered sleep-wake-eat cycles, and may respond more intensely. I really love framing this more positively as “spirited” to characterize the “difficult” temperament clusters. The book “Raising Your Spirited Child” by Mary Sheedy is a classic and so helpful when parenting a child that is more temperamentally challenging.
  3. How does parenting interact with temperament? We want to use labels carefully to help parents recognize that some children are more prone to having certain behavior/difficult reactions. This is not because they want to make life hard, but may just be how they are wired. Having parented a “slow to warm up” child through toddler years, I can say that it really did help me to learn about temperaments to be more empathic. We can help parents understand it’s not necessarily their fault when their child is easily upset, and also that sometimes a temperament mismatch between parents and children affects their interactions.
  4. How can we use concepts of temperament to discuss parental concerns? It’s helpful to use open-ended questions to explore concerns and give parents a “pause” moment to understand their child’s perspective, such as “What do you think may be going on with her/him when you see this behavior? How do you think s/he is feeling?” Also exploring how parents may be reacting/ feeling to help you understand their perspective / temperament. Simply pausing before offering advice may allow parents insight into their child’s and their own reactions, and help us provide better guidance and reflections.

2018-19 TOW #40: Head 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. Clinical definitions: Newborns have 7 skull bones separated by 6 major sutures important to skull growth: 1 metopic, 2 coronal, 1 sagittal, and 2 lambdoid. Craniosynostosis is defined as premature fusion at one or more of the cranial sutures, resulting in restriction of skull growth at that site. Unilateral flattening over the occiput is due to either positional plagiocephaly or lambdoid suture craniosynostosis (much more rare).
  2. Epidemiology: During the first two years of life, 75% of head growth occurs; only 25% occurs after age two. About 20% of infants have positional plagiocephaly in the first 4 months, which increased with 1992 “back to sleep” guidelines. Craniosynostosis affects 1 in 1800. Lambdoid synostosis affects 3 in 100,000.
  3. 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 metopic suture closes in the first year of life and can cause some normal ridging on forehead (abnormal closure leads to a triangular shape of the head).
  4. Work-up: Generally clinical exam is most important so follow head size and shape closely. If concerned, 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, which would typically start with skull x-ray and/or cranial ultrasound (depending on availability of technicians skilled in ultrasound).
  5. Management: 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. Refer to PT for any concerns of decreased mobility or torticollis. Refer to craniofacial around 5-6 months if not improving. Helmet therapy costs about $2000 and may not be covered by insurance. It is usually implemented between 6-9 months. Follow developmental status closely as plagiocephaly is associated with higher rates of developmental delay at 36 months.

2018-19 TOW #39: Nutrition and picky 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 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. As the daughter of a cardiologist, I’ve watched with interest the debates over fat and animal fats in our diets. As in many health-related issues, the answer seems to be “it depends”: 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.
  2. How we eat not just what we eat matters. There’s certainly some truth to the adage “we are what we eat,” (best dramatized by the movie Super Size Me), 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 about), raising our own food through gardening, and creating a positive environment for eating without distractions.
  3. Review with families the Division of Responsibility for feeding, especially for picky eaters (“parent is responsible for what, where, when and child is responsible for how much”). 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, be aware of lack of food experience while not catering to likes and dislikes. When giving new foods, offer along with ones kids already know. Children can self-regulate and recognize when they are full or hungry. 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!)
  4. Portion size matters as a cue to eating/hunger, with more evidence for effects in toddlers/preschoolers and up, but some evidence this may even be true 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. Promote interaction not distraction during meals. 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. Sitting together for meals has many positive effects, and doesn’t just have to be at dinner, but can be any meal. To spur interaction, we have found it helpful to start our family dinners with a gratitude practice.

2018-19 TOW #38: 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).

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 “neglect” and “verbal abuse” defined? 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? 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.

2018-19 TOW #36: Learning disabilities

Our role in addressing child development extends into the school years as we help children when there are concerns about school performance. I had a long discussion with a school psychologist this week who helped identify important needs for one of my patients. This is a really important topic for us to be knowledgeable about to support families and partner effectively with schools.

Materials for this week:

Take-home points:

  1. How many children are affected by learning disabilities? The lifetime prevalence of learning disabilities in US children is 5-10%, so should be considered when children are having school difficulties. Learning disabilities are heritable, but specific genes are still being identified. fMRI studies show children’s brains with learning disabilities differ in structure and  function.
  2. How do we define a learning disability and what are the types? A learning disability is a disorder that affects a child’s ability to read, use and understand language, write, or do mathematical calculations. Learning disabilities have been described as a significant discrepancy between academic achievement and intellectual potential, despite receiving appropriate instruction. Two main types are verbal/language (affecting ~80% of those with learning disabilities including dyslexia, i.e., difficulty reading and dysgraphia, i.e., difficulty writing) and non-verbal (dyscalculia, including problems with visual-spatial relations, math, and problem solving). There is a lot of overlap, and children often have both types.
  3. What’s the pediatrician’s role in diagnosis? Usually, behavior problems are the first presenting symptoms. Children may act out or withdraw because they cannot meet the demands or may have difficulty paying attention to material they don’t understand. We should first identify or exclude other causes that impact academic performance such as psychosocial (e.g., abuse, neglect), medical (e.g., prematurity, drug exposure, hearing/vision problems) and developmental issues (e.g., ADHD). Formal testing required to confirm a specific diagnosis is typically the school’s role. We can refer the child to the school’s committee on special education for evaluation. The request should be in made in writing by the parent, and we can often be helpful by including a note outlining specific concerns. We can also refer for advanced evaluation by a psychologist or developmental-behavioral pediatrician.
  4. What’s our role in monitoring? Our role includes being an advocate for the child in interfacing with school personnel, assisting the family in understanding the diagnosis, and monitoring progress. We should routinely screen for associated problems that can arise such as new behavioral difficulties, anxiety, and depression.
  5. How should we interface with schools? First, we have to obtain permission with a signed Release of Information form from the parents. An important law to be aware of is the Individuals with Disabilities Education Improvement Act (IDEA) part B, a federal law ensuring that all students ages 3-21 receive a free and appropriate public education under the least restrictive environment, regardless of disability. If a child is found to qualify for special education services under IDEA laws, an individualized education program (IEP) is created, outlining the plan for special education service. We can access the Medical-Legal Partnership if we feel that children are not receiving services for which they qualify under the law.

2018-19 TOW #35: Menstrual disorders

As we help with the process of puberty, addressing the challenges that arise with menarche and menstrual disorders in adolescents is a common issue we see in primary care. This is a great topic for seniors who have done their adolescent rotation to facilitate.

Materials for this week:

Take-home points for this week:

  1. How is the menstrual cycle different for adolescents than fully mature females? In adolescents the hypothalamic-pituitary-ovarian (HPO) axis feedback loops are not yet mature. For the first 1-2 years after menarche, steroid hormones do not yet regularly have coordinated negative and positive feedback loops to cause ovulation, so menstrual cycles may be anovulatory or infrequent /irregular (oligoovulation). In the first year after menstruation, ~50% of cycles are anovulatory. One of the most difficult aspects of these cycles for teens is that they can cause prolonged and/or unpredictable bleeding.
  2. What’s considered a “normal” cycle for a teen? AAP and ACOG define normal menstrual cycles for adolescents as having an interval of 21–45 days with the duration of flow lasting <=7 days, and average product use of 3-6 pads/tampons per day. We should be concerned when there’s heavier bleeding (soaking through products after 1-2 hours), cycles >90 days apart for even one cycle, or a change from regular to very irregular.
  3. What defines “abnormal uterine bleeding (AUB)”? Bleeding that’s heavy or prolonged or occurs outside normal menstrual cycles. Ovulatory AUB, or heavy menstrual bleeding, occuring as part of the usual cycle, is most commonly caused by uterine problems (i.e., endometrial polyps, leiomyomas, malignancy) or bleeding disorders. Ovulatory dysfunction is AUB that presents as irregular, heavy, or frequent episodes of bleeding without a clear pattern. While this is usually from anovulatory cycles, it’s considered a diagnosis of exclusion; other causes to consider would be endocrine disorders, pregnancy and infection.
  4. When working up AUB, what are key parts of the history and physical? In addition to regular elements of H&P, we should obtain 1) Menstrual history: timing of menarche, usual frequency, duration, and volume of bleeding, presence of menstrual cramps, when/how did menstrual bleeding change, and any medical problems or lifestyle changes or other events that coincided with the change; 2) confidential HEADSSS review of substance use, sexuality, sexual activity, exposure to STIs, contraception, and any history of sexual abuse; 3) related ROS including symptoms of PCOS, thyroid disease, bleeding disorders, pelvic infection, anemia, psychosocial disorders like eating disorders/female athlete triad; and 4) physical exam including external genitalia; consider a full pelvic exam in sexually active females.
  5. What tests would you obtain? Depending on the presentation, appropriate lab testing could include a urine pregnancy test or quantitative hCG level, CBC, TSH, and iron studies. If there’s heavy bleeding, check coagulation studies including von Willebrand panel and possibly platelet function. An androgen panel would be useful if a patient is hirsute or has significant acne. An ultrasound would be done to help evaluate pelvic anatomy, uterine abnormalities and endometrial thickness – usually it could be done transabdominally, but transvaginal can provide better anatomy if patient is sexually active and more detail is needed.

2018-19 TOW #34: Lower extremity disorders

March seems to have come in like a lamb today with signs of spring showing-birds chirping, buds emerging, and longer days of sunshine! The UW cherry blossoms on the quad are scheduled to be in full bloom in 3 weeks. As children “bloom” and begin walking, we and parents are assessing lower extremity disorders. Here are materials to review about lower extremity / gait problems:

Take home points on lower extremity disorders to review:

  1. Lower extremity disorders of children are common: including clubfoot, flat foot, in-toeing, and toe-walking. They present commonly to pediatric offices and are a source of significant parental concern, but most are benign and resolve with time.
  2. The causes of in-toeing vary with age based on the different bones affected in the lower extremity. In babies, in-toeing is most often caused by metatarsus adductus, which is a flexible bending of the forefoot relative to the hindfoot, usually caused by intrauterine positioning. It is distinguished from clubfoot by passive flexibility to a neutral position and full mobility at the ankle. In toddlers, in-toeing is most often caused by internal tibial torsion. In children older than 3-4, in-toeing is most often femoral anteversion, and is sometimes exacerbated by sitting in a “W” position.
  3. Toe-walking carries a risk of Achilles contracture so flexibility of the Achilles should be evaluated and parents should be taught stretching exercises. Rule out muscular dystrophy (tire easily with running) and CP (usually can’t heel walk).
  4. A careful history and physical examination often yield the diagnosis. In most cases, imaging is not needed. Use a prone exam with knees bent at 90 degrees to evaluate hip internal and external rotation (which should be symmetric). Use thigh-foot angle to evaluate tibial position. Also evaluate for any leg-length discrepancy or hip misalignment. Be aware of Vitamin D deficiency as a possible cause of tibial bowing, especially after 18-24 months when physiologic bowing should be improving.
  5. Most of these disorders can be monitored and resolve with growth. Flat foot, in-toeing, and out-toeing, usually only require observation and reassurance for parents. In comparison, clubfoot has a non-rigid curvature of the lateral foot and prompts referral for serial casting and occasionally surgical correction. For out-toeing, referral to ortho should be done at age 3-4 years in case casting is necessary, which is ideally completed before the start of kindergarten.

2018-19 TOW #33: Adolescent Contraception

This week we will review contraception, with a big thank you to adolescent specialists Taraneh Shafii MD MPH and Emily Ruedinger 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 are about twice rates in Europe, with the CDC reporting 1 in 4 adolescent girls will become pregnant by age 20.
  2. What’s the most common birth control 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, but is associated with weight gain and some bone density loss with longer term use.
  3. What’s the most effective birth control? Remember, 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), and are now recommended as first-line for adolescents. 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 myths about IUDs do we need to dispel? 1) IUDs do not increase a woman’s risk of pelvic inflammatory disease (PID), as long as she’s not infected at time of insertion. 2) If exposed to gonorrhea or chlamydia post-insertion, treatment can occur without IUD removal. 3) IUDs can be used in females who have not yet conceived and do not increase the risk of infertility; fertility returns to baseline within 1-2 months post-removal.
  5. What needs to happen in a visit to start COCs?
  • Brief medical and sexual hx, including date of last unprotected sex and current meds.
  • 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

2018-19 TOW #32: Primary Care of Premature Infant

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

Materials for this week:

Take-home points

  1. How do we support families after graduation from the NICU? We can help families transition by assessing their social support and emotional health, sharing what to expect, and offering more frequent visits. We should explain how we use corrected age (subtract number of weeks of prematurity from their chronological age) to assess growth and development so they know what to expect.
  2. How long do we adjust growth parameters based on gestational age? Until infants reach a chronological age of 2 years, we should adjust height, weight, and head circumference for prematurity. Blood pressures should be assessed initially for all NICU grads, and followed regularly for babies with extra complications, such as BPD.
  3. To support adequate growth, how do we typically fortify feedings for premies? Babies under 2 kg or <28 weeks at birth typically receive a transitional formula of 22-24kcal/oz at discharge from the NICU. As infants demonstrate consistently good growth, and self-regulation of intake, they can be switched to term formula – often between 4-9 months, though may be longer for some. Premature formula provides extra calcium and phosphorus to prevent osteopenia of prematurity. Some recommend extra vit D (up to 1000 IU) for premies (compared to 400 IU for term infants). To prevent anemia, a MVI with iron should be provided for breastfed infants until 1 year to ensure the recommended 2mg/kg/day of elemental iron. Preterm babies typically start solids at 4-6 months adjusted age when showing appropriate cues.
  4. How should the vaccine schedule be adjusted? We give vaccines on the chronological age schedule. The only routine vaccine not given to premies in the hospital is the rotavirus vaccine as it is a live virus vaccine that can be shed. All family members should have Tdap and flu vaccines to “cocoon” infants and protect them from illnesses.
  5. What is the recommended neurodevelopmental follow-up? All high-risk neonates should be referred to early intervention or the state birth to three program. Premature infants should be monitored for development using standardized screening such as the ASQ. All infants who were in the NICU for 5 or more days should have formal audiologic screening done by 24-30 months, even if they passed the initial screen. Given the higher incidence of vision problems including ROP, amblyopia, strabismus and cataracts, vision should be evaluated by an ophthalmologist, typically around 8-10 months.

2018-19 TOW #31: Promoting wellness & self-care

As we head into the Valentine’s week, we will discuss some ways to teach how to love and care for ourselves and how to promote wellness among our patients. While teens may be notorious narcissists, they need to be given support in how to actually care for themselves.

Materials/Resources for this week:

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

  1. Rising concerns about teen stress and mental health: As rates of depression and anxiety have risen for kids and teens, pediatricians are called upon to become more comfortable discussing these conditions, and what we can do to prevent and treat them. Many teens may take some time to warm up to the idea of seeing a therapist or another provider, so we will be their first stop, and sometimes the only one.
  2. Priorities for wellness promotion: Most importantly, we can focus on basics: sleep, nutrition, and physical activity. Increasingly tools like mindfulness, relaxation skills (e.g. breathing techniques, stretching), biofeedback, mindful eating, and positive psychology practices like offering gratitude have shown success among youth.
  3. Wellness skills can be learned and practiced: long before the frontal lobe is fully developed, youth can learn and practice self-care and wellness. These skills are not necessarily innate, so we get better with practice: think of them like exercises for the mind. I often remind patients that even professional athletes get a lot of help to manage stress and build skills to perform at the top levels.
  4. Offer resources for parents to support their children/teens: Parents offer guidance, resources, and role modeling and may need help themselves in navigating challenges. We can support parents’ self care and offer resources, like those here.
  5. Walk the talk: “Doctor, heal thyself” is a well known expression in medicine. As we become familiar with self-care approaches and resources, we can use this to help patients. Teens appreciate knowing that the adults around them are human and have to keep learning too. We can be deliberate about acknowledging the need for and benefit of self-care/wellness amidst the daily stressors of life.