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).

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 #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 #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 #26: Childhood Obesity

As the new year begins, we can harness the season’s focus on wellness to offer families encouragement with healthy behaviors. Obesity prevention and intervention is a topic close to my heart, so I am excited to highlight our great local resources. We have many wonderful obesity research experts in our clinics, including Drs. Lenna Liu, Jay Mendoza, and Pooja Tandon. A big thanks to Dr. Allison LaRoche for her help updating materials for this topic. Feel free to email any of us with questions!

Teaching materials for this week:

Take-home points for this week:

  1. What’s the epidemiology of child obesity?: While some progress is being made, with promising data on declines among preschool youth, overweight/obesity rates remain high at 1 in 3 children with a BMI at or above the 85th percentile. Etiology of obesity is multifactorial including important environmental contributors that are affected by social determinants. As pediatricians, we should acknowledge the equity issues reflected in higher rates of obesity among those with more social disadvantage including low-income families, and Hispanic, African American and American Indian youth.
  2. What focused messages can we share in clinic? Focusing on behaviors/ environments that support healthy weight starts from infancy. Teach the Division of Responsibility for feeding in which “parents provide, and child decides.” The parent is responsible for what, where, and when food is served, and the child is responsible for how much to eat. We can use 5210 goals to help guide healthy weight behaviors: 5 fruits and veggies per day, watch no more than 2 hours of screen time, get 1 hour or more of physical activity, and have 0 sugary drinks. The Let’s Go! 5210 campaign was started by a pediatrician in Maine, and they have some great resources like Phrases that Help and Hinder. Families should choose their own goals through motivational interviewing, which has been shown in randomized trials in pediatrics to work in improving weight trajectories.
  3. How can we address this sensitive topic and avoid weight stigma in our practice? Recognize that obesity is highly stigmatizing and bias for weight is among the strongest biases culturally, even among children. We must be aware of our own biases as we treat patients and adopt inclusive, non-judgmental language, as recommended by Health at Every Size (HAES), which seeks to promote health-affirming behaviors and diversity of size, and to decrease weight stigma and emphasis. It’s helpful to acknowledge there are a lot of things outside the control of families (genes, community environment, etc), while also supporting specific behaviors that make a difference for health.
  4. What are the approaches for overweight and obese? For youth with BMI >85th percentile (overweight), and BMI> 95th percentile (obese), follow weight trajectory and family history to assess risk. Screening labs for metabolic risk factors (lipid panel, liver enzymes and A1c and/or glucose) are recommended starting at age 10 if obese (or overweight+risk factors). To promote healthy behaviors, refer to resources like the YMCA ACT! program – ACT! programs are enrolling this winter for 8-14 year olds around our area. We can also refer to SCH Wellness Clinics for multidisciplinary weight management from age 2 through adolescence. When metabolic problems are identified, see this article on treating comorbidities.
  5. What is the role of physical activity? For children at all weights, regular physical activity reduces the likelihood of comorbidities, even without decreasing BMI. It’s important for us to emphasize helping kids and parents find ways to be active and enjoy movement, no matter their body size.

TOW#36: Short stature

This week we review another very relevant growth topic, short stature, that may cause disproportionate parental concern. Let’s review definitions and most common causes/ concerning findings related to evaluation of short stature.

Materials for this week:

Take-home points for short stature in childhood:

  1. Epidemiology: Most short stature represents familial short stature or constitutional growth delay. Incidence of growth hormone deficiency is pretty rare at 1 in 4,000 to 10,000 short children.
  2. What’s the clinical definition of short stature?: Short stature refers to a child who is 2 standard deviations below the mean height for age and sex (<3rd percentile).
  3. What are patterns of growth with familial short stature and constitutional growth delay? Familial short stature typically follows a pattern of proportional wt/ht growth along a curve below normal that starts before age 3, but with a normal bone age and, ultimately, shorter adult height. Children with constitutional growth delay (“late bloomers”) also slow down before age 3, but follow a normal rate of growth around 5th percentile and catch up later. They often have delayed puberty and below-normal bone age, but ultimately adult height in the normal range. Use mid-parental height to determine what is expected height growth (most children are within 10cm of mid-parental height).
  4. When to do a work-up? Work-up is recommended when the child’s height deficit is severe (<1st percentile for age), the child falls off the curve, especially after age 3 (more concerning for acquired growth hormone deficiency), the growth rate is abnormally slow (<10th percentile for bone age), predicted height differs substantially from mid-parental height, or body proportions are abnormal. Work-up includes bone age x-rays, may include labs (if suspicious for another diagnosis: CBC, ESR, renal function, calcium, phosphorus, TFTs, TTG antibody, sweat test, karyotype, IGF-1, IGFBP-3), referral to endocrinologist.
  5. How do we treat? Most children with short stature can be observed and offered reassurance. Evidence is lacking that short stature causes psychological harm or that there is a long-term psychosocial benefit with growth-enhancing therapy. In a few children who are very short, hormone treatment may be helpful. Human growth hormone treatment increases the growth rate, modestly increases adult height, and is mostly considered safe, but it is expensive (~$50K per inch of height!) and the long-term risk:benefit ratio for essentially healthy children remains unclear. Low-dose oral oxandrolone is a relatively inexpensive option to accelerate growth, but has not been shown to increase adult height. It’s important to support children who may be smaller than classmates; some may need extra help coping with differences based on size.

TOW #15: Newborn concerns

Next week’s topic is about babies! For many of us, one joy of general pediatrics is the chance to care for babies. Babies are each a little miracle, and as we welcome them into the world, they bring us hopefulness and faith in humanity. As Henry David Thoreau said “Every child begins the world again.” We could use an extra dose of that right now.

Note: this is a great topic for you senior residents to lead the discussion!

Materials for this week:

Take-home points:

  1. Attachment: babies thrive when their caregivers are thriving. Given what we now know about neural wiring in the first 1000 days of life, it is critical to assess the parents’ ability to care for and connect with their infant. Mothers should be screened for post-partum depression and referred for treatment, if needed. Demonstrate for parents how to comfort babies such as 5 S’s (suck, swaddle, swing, shush, side-lying), and lots of talking and holding. There is no such thing as “spoiling them” by holding them too much! Interns who have had Promoting First Relationships (PFR) training this year, this would be a perfect topic to review with your clinic team and patient families.
  2. Helping parents be experts: provide parents encouragement, point out what they are doing well to connect and care for babies, and how they are the most important people in their infant’s life. Give them tools, such as www.text4baby.com where they can sign up for texts based on baby’s birth date that give tailored resources, reminders, and tips.
  3. Normal newborn behavior: parents need to know about common things they will see that can seem worrisome (sneezing, hiccupping, spitting up, primitive reflexes, rashes, crying, etc). Review some common skin findings here.
  4. Nutrition: helping babies grow/gain weight is a central concern in the first few months of life, and we need to provide guidance and reassurance on appropriate weight gain and support for breastfeeding. We can teach to read babies cues of hunger and fullness from the beginning. Breastfed babies (fully or partially breastfed) should be on a vitamin D supplement of 400 IU per day to prevent rickets.
  5. Sleep: providing a safe sleep environment is key to babies thriving-babies should be on their backs and in their own sleeping unit without extra blankets or stuffed animals to avoid suffocation and SIDS. Co-sleeping/ Bed-sharing is the highest cause of death under 3 months, and is especially dangerous if parents smoke or drink alcohol. Ask open-ended questions about where baby is sleeping and in what position to facilitate honest conversatoins. Review evidence and encourage room-sharing rather than bed sharing. The AAP has sleep guidelines out now that recommend co-rooming. Also review positional plagiocephaly and how to avoid it (tummy time, rotate positions in crib and get babies out of containers (e.g. swings, carseats, babyseats) when not sleeping)!

 

TOW #47: Abnormal 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 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.
  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.
  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.
  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.

TOW #38: Nutrition and picky eating

We continue National Nutrition Month with another nutrition-related topic: nutrition guidance 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 >2 year olds to eat? For those age 2 years and older, the AHA recommends a diet that relies on fruits and vegetables, whole grains, low-fat dairy, beans, fish, and lean meat (frankly, that mostly applies to under 2, just in different forms). Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars, which are in everything from bread to yogurt to beverages, and eating less processed foods. As the daughter of a cardiologist, I've been watching 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 showing the effects of a purely fast food diet), 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 has been teaching residents 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. 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 television during meals is associated with kids' poorer food choices in multiple studies. Sitting down at a table for meals with others is preferred. It doesn't have to be at dinner, if that doesn't work for families, but find meals they can eat and enjoy together regularly. We have found one way to do this is to start our family dinners with a gratitude practice.
  5. Portion size matters as a cue to eating/hunger, with more evidence for effects in toddlers/preschoolers and up, but some emerging evidence this may even be true for infants. A study published in Pediatrics in 2016 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.