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 #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.

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 #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 #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 #25: Media guidelines

As we hit the frenzy of holiday shopping for media devices, now is a great time to revisit media screening and counseling! Dr. Pooja Tandon MD MPH lent her great expertise in reviewing and updating this topic for us. Another national media expert among our faculty, Dimitri Christakis, served on the committee that updated the most recent national AAP media policy.

Materials to review:

Take-home points to review on media for youth:

  1. Media exposure for youth is significant with quantity and quality important for us to address. We now have a plethora of devices that contribute to media exposure for youth, and most babies are exposed to TV by 4 months old!
  2. The 2 most important questions to ask our families in clinic are: 1) How much screen media is your child exposed to every day? 2) Does your child have a TV or internet-connected device in the bedroom? I also like to ask “what guidelines have you set for media use at home?”
  3. Parents should be encouraged to set limits on screen time – this is less often done among low income families. Children whose parents make an effort to limit media use (through the home media environment and rules about screen time) spend less time with media than their peers. Parents should be “media mentors” and teach children and teens how to use media appropriately. I’ve heard experts talk about thinking of media use like having a driver’s license, where you demonstrate effective, safe use.
  4. Based on guidance from the AAP, we recommend no screen time for children under 2. As of 2016, apps are acceptable starting 18 months, and videochatting with family did not count toward screen time. We should limit recreational screen time to an hour per day. For older children screen time does not include school use or homework. If parents do allow more (a reality!), at least help them select more educational/prosocial media (like PBS, or shows recommended by Commonsense Media: www.commonsensemedia.org (which we rely on all of the time at our house for movie selection!)
  5. TVs in the bedroom are (and other media that are connected to the internet) are associated with many concerning negative effects on health. Counsel early about media to help prevent the placement of TV’s in the bedroom (which is over 50% by age 2-4 among low-income families). Parents should limit media time 1 hour before bed.