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

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

Materials for this week:

Take-home points:

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

2019-20 TOW #7: Immunizations

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

Teaching materials for immunizations:

Take-home points:

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

2019-20 TOW #6: Formula feeding

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

Teaching materials for this week:

Take-home points about formula feeding:

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

2019-20 TOW #5: Breastfeeding

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

Take-home points on breastfeeding challenges:

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

2019-20 TOW #4: Early adolescence well care

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

Materials for this week:

Take-home points

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

2019-20 TOW #3: Middle Childhood Well Checks

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

Materials for next week:

Key take-home points:

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

2019-20 TOW #2: Early Childhood Well Child Care

We are moving on to the fun and challenge of early childhood WCC (ages 1-4). I’ve attached some cases to stimulate discussion, the link to the Bright Futures materials, and a review article that has some helpful tables about incorporating development-behavioral teaching in primary care. The cases are a way to introduce resources/concepts, and I’ve noted that we will also have more on several topics later in the year.

Materials for next week:

Key take-home points

  1. How do we prioritize what to cover in early childhood well child checks? Again, the most important element in providing patient-centered care is to ask about the parents’ concerns and priorities first. We hone in on the ongoing dramatic developmental and behavioral changes of these years, and the challenges those can bring for caregivers. There is a critical influence that environment plays in nurturing children’s development that affects their behavior, communication, nutrition and activity.
  2. What are the Bright Futures anticipatory guidance topics for early childhood? For toddlers/preschoolers, the major 5 areas vary somewhat by age, but general priorities are family support, routine (including sleep and nutrition), development (with discipline and response to tantrums important in year 2, and school readiness becoming a bigger emphasis for preschool years), oral health, and safety.
  3. What are the most important evidence-based components of early childhood visits? In addition to immunizations, there’s a bigger role for developmental screening and appropriate referral in this age group. There is great evidence for the benefit of literacy programs like Reach Out and Read and early childhood education programs like Head Start, so we have an important role in promoting these. Evidence also shows that our efforts to provide continuity and have ongoing relationships with parents helps with early child outcomes and lowers use of emergency care.
  4. What are the recommended screenings for early childhood visits? It varies some by age, but during this time we should screen for anemia and lead screening in year 2, vision starting at age 3, and hearing at age 4. In addition, we should do formal autism screening (at age 18 months-2 years). We continue to screen for social determinants of health (poverty, education, legal issues, housing and food security).
  5. How can we build rapport with parents and children for early childhood visits?  Again, we can acknowledge the really hard work parents are doing and how exhausting it can be to care for toddlers. Children at this age are also amazing in their rapid change and new skills, so we can help parents connect with that joy and wonder. In our family we joked that this required “advanced parenting,” as you’re trying to negotiate with little ones that can behave like demanding tyrants. It requires a ton of patience and awareness of the child’s experience to be empathic. As always, noticing parent strengths and the qualities they bring helps build those relationships.

2019-20 TOW #1: Infant Well Child Care

It’s exciting to kick off another year of continuity clinic teaching and our TOW series.

We are starting with a review of well child care at different ages in the first 4 weeks. This is a great opportunity to highlight recommended screening and priorities for these visits, and your clinical pearls. For interns not in clinic this month, please refer back to them later!!

Materials for this week:

Key take-home points:

  1. How do we prioritize what to cover in infant well child checks? There is widespread acknowledgement that providing comprehensive WCC is difficult in a typical ~20 minute visit, and it’s impossible to cover everything. National organizations like the AAP and pediatric research have helped define key priorities. And, others, including one of our own faculty, Tumaini Coker MD MPH, have highlighted the need to do more to address social determinants of health in WCC. One critical element in providing patient-centered care is to first ask about the parents’ concerns and priorities, e.g., “What do you want to make sure we talk about today? What are your questions and concerns?”
  2. How can Bright Futures resources be used? Bright Futures is the AAP-endorsed and supported guidance for primary care practices to prioritize components to include in comprehensive well-child and adolescent care. For each recommended well child check from newborn to age 21, there are guidelines for screening and 5 key recommended areas to discuss. For infants, the major 5 areas to prioritize are family functioning, development, growth and nutrition, oral health, and safety. Many sites use Bright Futures patient education handouts, which are great to review briefly when preparing for visits.
  3. What are the most important evidence-based components of infant visits? Providing immunizations and helping families stay up to date (more on this in a future topic!) is the most evidence-based. There is also evidence for programs that help parents thrive in parenting roles. We want to identify untreated mental illness or substance abuse, and if parents understand normal infant behavior, such as crying, and how to connect with and comfort their infants. Strategies like those taught in Promoting First Relationships (PFR) are effective (more on that to come as well). Questions to help explore include: “How are you doing? How are things going for your family?” To explore the relationship, perception of infant, we can ask “Tell me about your baby. What do you like best about him/her?” or “What has been difficult? What has surprised you?” These help us identify red flags for high-risk social interactions that may warrant more support.
  4. What are the recommended screenings for infant visits? It varies by age, but after the newborn hearing and metabolic screenings, most screenings (including blood pressure, vision, hearing, and anemia screenings) are selective for at-risk infants, such as for preterm infants or those who have abnormal findings on exam or by parent report. It is recommended to do a formal development screening at 9 months. In addition, we can make the case for the benefit of routine screening for social determinants of health (poverty, education, legal issues, housing and food security-more on these to come).
  5. What ways can we build rapport with parents for infant visits? Acknowledge how hard parents are working, and normalize how difficult it can be caring for infants. Also notice their strengths as a parent. It’s helpful to note out loud the positives about their interactions with their babies, e.g., “Wow, look at how your baby gazes at you – it’s so clear how much they want to see and hear you. It’s amazing how she already knows you. When you respond with comforting like that, this helps her feel safe and secure and know she’s loved.”

2018-19 TOW #49: LGBTQ+ Health

This week’s topic comes to us thanks to Dr. David Inwards-Breland, one of our fabulous adolescent medicine docs, who provided the materials. If you are interested in more on adolescent health, check out the Teenology 101 blog by Dr. Yolanda Evans and specifically the LGBTQ articles.

Materials for this week:

Take home points for LGBTQ youth health:

  1. What are some particular health care needs for LGBQT+ youth? Most people who identify as LGBQT+ are healthy, however, there is a disproportionate number of LGBTQ+ youth who face barriers to health care and mental health problems, usually as a result of sexual prejudice and lack of family/community support.
  2. How many teenagers identify as LGBTQ+? Recent studies estimate that somewhere between 3 and 10% of the adult population is LGBTQ+. Estimates in teenage years are difficult because the sexual identity is evolving. Around 25% of 12 year olds feel uncertain about their sexual orientation.
  3. How should we approach sexual health discussions? Begin to talk to patients separately from their parents by age 11 or 12 to allow them to speak with you confidentially. In visits with adolescents, we should explicitly remind them of confidentiality and use non-judgmental, gender-neutral language. Tailor the HEADSSS assessment to their age and development. In the study on LGBTQ+ youth health care preferences linked above, youth felt that provider qualities and interpersonal skills were just as important as provider knowledge and experience, and they placed little importance on a provider’s gender and sexual orientation.
  4. What are ways to ask about sexual attraction and sexual identity? We can explain to patients we ask about their sexual health as part of routine visits because it’s an important part of life, and we want all youth to feel comfortable and supported. We should ask adolescent patients about who they feel attracted to: “Do you feel attracted to girls, boys, both or neither?” Asking about gender identity can be done as: “do you identify with being male, female, both or neither?”
  5. What are risks for STIs among LGBTQ+ patients? We should provide counseling about safe sex and birth control to all adolescents. Female patients that identify as lesbian may still have male partners, so may be at risk for STIs and pregnancy and should have PAP smears. Male patients have higher rates of STI exposure (in King Co in 2015 exposure rate was 44% among 15-19 yo men who have sex with men). Patients with high risk for HIV infection should be considered for pre-exposure prophylaxis (PrEP).

2018-19 TOW #48: Injury prevention

Next up in TOW-land is reviewing injury prevention, a timely topic for summer months, which are known as “trauma season” to all those at Harborview. Please offer appreciation to your colleagues taking care of injured children this summer at HMC. We also offer gratitude to our injury prevention experts including Drs. Beth Ebel, Brian Johnston, and Fred Rivara, who dedicate their time to making kids safer across our nation/globe.

Materials for review:

Take-homes points:

  1. How big a problem are childhood injuries? About 1 in 4 children has an unintentional injury that requires medical care each year. Injury is the leading cause of death among children and adolescents > 1yr in the US. Injuries cause 42% of deaths in children ages 1-4 and 65% of deaths ages 4-18.  Injury peaks during the toddler years (ages 1 to 4) and again during adolescence and young adulthood (ages 15 to 24). The problem is even more profound in developing countries.
  2. Have childhood injury rates changed over time? Thankfully, injury rates have decreased due to multiple public health and health care efforts. Between 2000 to 2009, the unintentional injury death rate for US children <19 declined by 29%. This is attributed to seat belts and carseats, reduced drunk driving, increased use of child-resistant packaging, as well as better awareness and improved medical care. The highest deaths remain due to motor vehicle accidents, drownings, and firearms, so we cover those more in-depth in other topics.
  3. How do we best prevent Injuries? Mace and colleagues describe the “four E’s of injury prevention”-education, engineering (modifying environmental or product design), enforcement (mandating appropriate laws), and economics (creating financial incentives and disincentives). In general passive interventions that don’t require someone to act (like air bags, road design) work better than active ones that require users to choose them (like seatbelts, helmets), and certainly better than education alone (as Kat Bonsmith recently reviewed for us in her informative RCP on baby-proofing).
  4. What’s the pediatrician’s role in education (and advocacy)? In the primary care setting, education is the main way we provide anticipatory guidance, and the AAP recommends every well-child visit include age-appropriate injury prevention counseling. However, only approximately 50% of pediatric residents and practitioners provide injury prevention counseling at well-child visits. We have to be strategic because we can’t cover every topic every time. Bright Futures helps guide which injury prevention topics to cover at each age. Extending our role to advocacy addresses the even more important “E’s” that produce system improvements to protect thousands of children.
  5. Are there “teachable moments” after an injury? Due to the lack of data, there is some controversy that the “teachable moment” has an added effect after an injury, but its reasonable to ensure people have the information and tools they need to prevent future injuries. At Harborview, the peds team distributes injury-specific information and resources as often as possible, such as bicycle safety and helmets after an unhelmeted bicycle injury, a new carseat after an MVA, or window guards after a fall.