2018-19 TOW #43: Hip dysplasia

Developmental dysplasia of the hip (DDH) is an important newborn-related topic. A 2016 report gave new updates that highlighted the “primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.”

Materials for this week:

Take-home points:

  1. What are the primary risk factors for DDH? Female gender (up to 75% of DDH), family history, and breech position in the 3rd trimester. As of the updated guideline, there is now also a risk factor noted for tight swaddling with legs adducted and extended. As many as one in six newborn babies have mild hip instability at birth, and approximately one per thousand has a dislocated hip.
  2. How do we screen for and prevent DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging. Hip-safe swaddling allows the legs to move into flexed and abducted hip position (i.e., legs not confined to a straight extended position). Safe baby carrying is the “Spread Squat position” – also known as the M-Position, or Jockey Position – with the thighs spread around the mother’s torso and the hips bent so the knees are level with or slightly higher than the buttocks. 
  3. What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy while supine with the hips and knees in straight leg position, and then with the hips and knees in flexed position (*be aware if hip dysplasia is bilateral, we obviously can’t compare sides). Galeazzi sign is unequal knee height when legs are flexed. Use Ortolani maneuver (abduction movement to detect a dislocated femoral head reducing into the acetabulum), which the newest guidelines say has the best predictive value. Barlow manuever may not be necessary and/or harmful if too much pressure is applied. If Barlow is used, it should be gentle pressure applied while adducting the hip after performing Ortolani. The Ortolani and Barlow maneuvers are really most reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds, hip movement, and leg length. Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred.
  4. What imaging do we use to screen? Ultrasound at age 6 weeks to 6 months, or plain x-rays at 4-6 months are considered fairly equivalent according to the data, and are implemented based on local availability of trained sonographers. Note, there are more false positives with early ultrasound, and many children with more subtle findings may be watched and rescreened.
  5. What constitutes a positive screen? Based on consensus, children who have unstable hips on exam (a “clunk” on Ortolani) or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Isolated hip clicks without the sensation of instability usually represent normal laxity and myofascial tissue movement over the bones and do not require referral.

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 #27: Bone Health

As we are in the thick of winter and lacking sun, it’s a good time to review optimizing bone health for children. The AAP updated its statement in 2014 with higher RDA levels for vitamin D for children, due in part to no “safe” sun exposure. Nonetheless, outdoor play time is still recommended, and can help with bone health, as Drs. Pooja Tandon and Kyle Yasuda (UW professor emeritus and current AAP president) wrote about recently in the Seattle Times!

Materials for this week:

Take-home points:

  1. What are the optimum levels for intake of calcium and vitamin D? Recommended daily allowances (RDA) for vitamin D for children are 400 IU 0-12 months, 600 IU >1 year. Calcium RDAs also increase with age: 700mg for 1-3 yo, 1000 mg for 4-8 yo, and 1300mg for 9-18.
  2. Why are we concerned about these nutrients? In addition to rickets, low Vit D and calcium intake is linked to increased fractures later in childhood/adolescence (and adulthood). Despite the many studies linking low vit D to a host of other conditions, we do not have reliable evidence that they are in fact causally linked.
  3. Who is at highest risk for low levels? Children at higher risk for low vit D include youth with darker pigmented skin, overweight youth, inadequate dietary intake, living in northern latitudes (>33 degrees -that’s us!), taking certain medications (anticonvulsants, steroids, antiretrovirals). Those at high risk for low bone density include children who do not do bone-density strengthening exercise, particularly children who require wheelchairs.
  4. Who should be screened with blood tests? Testing for Vit D levels is not routinely indicated; AAP recommends only for conditions associated with reduced bone mass (malabsorption syndromes, CP, taking medications that interfere with absorption), or recurrent low-impact fractures. (*note Endocrine society also recommends for children with dark skin or with obesity).
  5. When should we recommend supplements? It’s better to receive Vit D and calcium in dietary sources, but there are few sources of vit D in the diet: mainly fortified milk (and some orange juice and yogurts). Supplements are indicated for breastfed babies (until drinking at least 1L per day of fortified formula/milk), and those with low dietary sources or high risk for low bone density. Among children who do not drink much milk (including one of my own kids), I recommend a multi-vitamin supplement with calcium and vitamin D.

2018-19 TOW #4: Sports Participation

Summer is primetime for pre-participation sports physicals. There has been much debate as to what should be included in routine testing and screening. Generally, we follow the AAP guidance for screening, and encourage use of the standardized tool adopted by multiple medical organizations, as below. We have a guideline developed for our UW General Peds division as well. Remember to refer to our wonderful local sports meds experts (like our esteemed APD, Dr. Celeste Quitiquit!) if you have questions.

Teaching materials for this week:

Take-home points for sports physicals:

  1. What are the key history questions we should include in sports physicals? Specific questions about key areas should include personal and family history, especially cardiac, bone and joint, asthma (and inhaler use), concussion or seizures, sickle cell, and infectious histories. Review weight and diet including attempted weight loss or gain, supplements to gain weight/muscle, and hydration and eating patterns. With females, review menstrual history.
  2. What are the components of cardiovascular screening? The American Heart Association recommends a 12-element screening tool that encompasses personal history, family history, and physical exam. This tool is incorporated into the Preparticipation Physical Evaluation, Fourth Edition (PPE-4) recommended by the AAP. A positive response or exam finding on any item should prompt referral to cardiology. A goal is to identify risk for and prevent sudden cardiac death, which happens in about 100 young athletes annually in the US. Unlike in other countries, we have not adopted routine ECG due to cost and number needed to screen.
  3. What are the critical parts of the exam? Vision, BP, thorough cardiac exam (murmurs-do valsalva, pulses, Marfan stigmata), musculoskeletal exam (strength, ROM, functional/sport-specific movements), neurologic exam (especially if previous concussion), and skin exam to look for infectious lesions.
  4. What are contraindications to full participation? These include
  • some cardiac diseases (discuss with cardiology)
  • Atlanto-axial instability (especially in Down syndrome or JIA)
  • Infectious diarrhea, conjunctivitis, or actively contagious skin lesions (e.g., HSV, MRSA)
  • Fever–increased risk of heat related illness and hypotension
  • Acute splenic enlargement-increased risk of rupture
  • Poorly controlled seizure disorder-especially for swimming, weight-lifting, sports involving heights
  • Hypertension–if> 5mm Hg above 99th percentile for age, avoid heavy lifting & high-static component sports

TOW #13: Scoliosis

We have a role in screening and diagnosis of scoliosis in primary care, with the AAP recommending screening for teenagers between 12-14 years old. This week we will review this key orthopedic topic.

Materials for this week:

Take-home points for this week:

  1. Epidemiology: Scoliosis is the most common abnormality of the spine. Idiopathic scoliosis is present in 2% of adolescents. There is a genetic basis with first-degree relatives at increased risk (10% prevalence).
  2. Definition: Scoliosis is defined as a lateral curvature of the spine that is 10 degrees or greater on a coronal radiographic image while the patient is in a standing position. It is measured by the Cobb angle.
  3. Types: Most cases are idiopathic and defined by age at recognized onset: before age 3 (infantile), age 3-10 (juvenile) and older than 10 (adolescent). There are also congenital forms due to malformations of the spine in utero that progress with age, and neuromuscular scoliosis associated with neuromuscular diseases.
  4. Work-up: Classic findings of scoliosis on examination are shoulder and scapular asymmetry and rib prominence on forward flexion. We can use an inclinometer tool to help assess the degree of asymmetry. Typically, referral is recommended if >= 7 degrees on inclinometer. Physical exam is also used to help rule out hereditary connective-tissue disorders (e.g., Marfan’s syndrome), neurofibromatosis, or neurologic conditions. Obtain scoliosis spinal radiography in standing position and request measurement of the Cobb angle.
  5. Treatment: Most adolescents can be monitored in primary care for curves <20 degrees. If >20 degree curvature, we would refer to ortho and they may consider bracing when >25 degrees, but data are not conclusive. If >40-45 degree curvature, surgery is usually recommended.

TOW #30: Developmental Dysplasia of the Hip (DDH)

Developmental dysplasia of the hip (DDH) is an important newborn-related topic with some recent updates. The AAP published an updated clinical report on DDH in Dec for the first time in 16 years. The report highlighted the "primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial."

Materials for this week:

Take-home points:

  1. What are the primary risk factors for DDH? Female gender (up to 75% of DDH), family history, and breech presentation. As of the updated guideline, there is now also a risk factor noted for tight swaddling with legs adducted and extended. (Preferred safe swaddling is flexed and abducted hip position).
  2. Who should we screen for DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging.
  3. What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy (*if hip dysplasia is bilateral, we can't compare sides) while supine with the hips and knees in straight-leg position, and then with the hips and knees in flexed position. Galeazzi sign is unequal knee height when legs are flexed. Then we use Ortolani maneuver- newest guidelines say Ortolani has best predictive value and Barlow may not be necessary and/or harmful if too much pressure is applied. If Barlow is used, it should be gentle pressure applied while adducting the hip after performing Ortolani. The Ortolani and Barlow maneuvers are really most reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds and hip movement. Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred.
  4. What imaging do we use to screen? Ultrasound at age 6 weeks-6 months, or plain xrays at 4-6 months. There are more false positives with early ultrasound and many children with more subtle findings may be watched. 
  5. What constitutes a positive screen? Based on consensus, children who have unstable hips on exam, or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Infants who have only hip clicks do not require further imaging or referral.

TOW #14: Bone health

While it's been nice and sunny this week, we are heading into the seasons with less of it, so a good time to review optimizing bone health for children. The AAP updated the statement in 2014 about this topic with newer (and higher) RDA levels for vitamin D established for infants and children, due in part to no "safe" sun exposure being considered optimal to recommend.

Materials for this week:

Take-home points:

  1. What are the optimum levels for intake of calcium and vitamin D? Calcium level RDAs increase with age: 700mg for 1-3 yo, 1000 mg for 4-8 yo, and 1300mg for 9-18. Recommended daily vitamin D for children: 400 IU 0-12 months, 600 IU >1 year.
  2. Why are we concerned about these nutrients? In addition to rickets, low Vit D and calcium intake is linked to increased fractures later in childhood/adolescence (and adulthood). Despite the many studies linking low vit D to a host of other conditions, we do not have reliable evidence that they are in fact causally linked.
  3. Who is at highest risk for low levels? Children at higher risk for low vit D include youth with darker pigmented skin, overweight youth, inadequate dietary intake, living in northern latitudes (>33 degrees -that’s us!), taking certain medications (anticonvulsants, steroids, antiretrovirals). Those at high risk for low bone density include children who do not do bone-density strengthening exercise, particularly children who require wheelchairs.
  4. Who should be screened with blood tests? Testing for Vit D levels is not routinely indicated; AAP recommends* only for conditions associated with reduced bone mass (malabsorption syndromes, CP, or on medications that interfere with absorption), or recurrent low-impact fractures. (*note Endocrine society also recommends for children with dark skin or with obesity)
  5. When should we recommend supplements? It's better to receive Vit D and calcium in dietary sources, but there are few sources of vit D in the diet: mainly fortified milk (and some orange juice and yogurts). Supplements are indicated for breastfed babies (until drinking at least 1L per day of fortified formula/milk) and those with low dietary sources or high risk for low bone density. Among children who do not drink much milk (including one of my own), I recommend a multi-vitamin supplement with calcium and vitamin D.

TOW #11: Scoliosis

Next week is back to school for Seattle schools, so a signal to consider diagnoses that may impact youth in the school setting. Scoliosis (and related conditions) can affect athletics and should be screened for in sports physicals.

Materials for this week:

Take-home points for scoliosis

  1. Epidemiology: Scoliosis is the most common abnormality of the spine. Idiopathic scoliosis is present in 2% of adolescents. There is a genetic basis with first-degree relatives at increased risk (10% prevalence). In about 1/5 of cases, children have either vertebrae that do not develop normally (congenital scoli), an underlying problem in the brain or spinal cord, such as a cyst or a tumor, or a neuromuscular disorder such as cerebral palsy or muscular dystrophy.
  2. Definition: Scoliosis is defined as a lateral curvature of the spine that is 10 degrees or greater on a coronal radiographic image while the patient is in a standing position.
  3. Types: Most cases are idiopathic and defined by age at recognized onset: before age 3 (infantile), age 3-10 (juvenile) and older than 10 (adolescent). There are also congenital forms due to malformations of the spine in utero that progress with age, and neuromuscular scoliosis associated with neuromuscular diseases.
  4. Work-up: Classic findings of scoliosis on examination are shoulder and scapular asymmetry and rib prominence on forward flexion. Use physical exam to help rule out hereditary connective-tissue disorders (e.g., Marfan’s syndrome), neurofibromatosis, or neurologic conditions. Obtain spinal radiography in standing position.
  5. Treatment: Most adolescents can be monitored in primary care. If >25% curvature, may consider bracing but data not conclusive (an RCT is underway). If >45% curvature, surgery is recommended.

TOW #35: Lower extremity disorders

March seemed to come in like a lion this week… but lots of signs of spring are showing! The UW cherry blossoms on the quad are scheduled to be in full bloom March 14th! As children "bloom" and begin walking, we and parents are assessing lower extremity disorders. So, 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.