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 #21: Firearm injury prevention

This week’s topic seems particularly timely given the overwhelming physician response to the NRA’s “stay in your lane” tweet last week. We have many resources locally including the incredible Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention. The Seattle Children’s community benefit team and REACH pathway residents have worked to develop local resources and events.

Materials for this week:

Take-home points for firearm safety:

  1. Statistics: 1 in 3 homes in the US with children have firearms, many of which are not locked. 80% of unintentional firearm deaths of kids under 15 occur in a home. 64,000 adults in King County with a firearm in or around their homes reported storing their gun(s) loaded and unlocked. The safest thing is not to have a firearm in your home, as it is 43 times more likely to be used to kill a family member or friend rather than be used in self-defense. In a case-control study done by Grossman et al., storing firearms locked, unloaded, or separate from the ammunition was associated with significantly lower risk of unintentional and self-inflicted firearm injuries and deaths among adolescents and children.
  2. Many depressed teens die from suicide by firearms. If you are tight for time and cannot screen for firearms in every clinic wellness visit, be sure to include specific counseling in visits with depressed teenagers. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline.
  3. What to offer for gun safety? There are 5 main types of locking devices: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Generally, we should avoid devices that use keys. Visit www.lokitup.org for information about how to store firearms. We need to help advise that the safest way to store guns is unloaded, locked, and out of reach of young children and teenagers! Consider using a statement like: “Having a loaded or unlocked gun in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store your unloaded guns in a locked drawer or cabinet, out of reach of children.”
  4. How do we advise parents and firearm safety? We can counsel parents to ASK other parents about guns in their home before sending over their child to play: http://askingsaveskids.org/ Suggested wording includes:  “Knowing how curious my child can be, I hope you don’t mind me asking if you have a firearm in your home and if it is properly stored…” For family members, this might include: “[Mom, Dad] this is awkward for me and I mean no disrespect. I am concerned Susie will find one of the firearms in your home when we visit. Do you keep them locked up with the ammunition stored separately?”
  5. Does counseling work? Several studies have found counseling in office visits to be associated with improved safe storage of firearms. A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Likewise, Barkin et al. found that brief office-based counseling increased the use of safe storage.

2018-19 TOW #11: Bullying

With return to school and National Bullying Prevention Month coming up, this is an opportune time to discuss bullying. Bullying has received increasing attention and concern for children’s health in recent years. The effects of bullying can be devastating, and our role in identifying, discussing, and addressing bullying is really important. Our esteemed and internationally known child health and injury prevention expert at Harborview, Dr. Fred Rivara MD MPH, chaired a panel for the Institute of Medicine to report on bullying and how to prevent it.

Materials for this week:

Take-home points:

  1. How do we define bullying, and what are the forms? Bullying is an intentional, aggressive and repeated behavior that involves an imbalance of power or strength. The power difference can be in size, age, political, economic, or social advantage. Bullying includes physical, verbal, social (trying to hurt a person’s reputation within a group or organization), cyberbullying, and cyber harassment (bullying by an adult online).
  2. How frequent is bullying? Estimates are that ~20-30% of youth in the US report being bullied, and 1 in 3 youth is affected either as a victim or perpetrator or both. Cyberbullying is estimated for 7-15% of youth. While “bully” conjures up certain images, most kids who are bullying are typically developing boys and girls who are learning to navigate their social world.
  3. What are the effects of bullying? All forms of bullying can lead to physical illness, low self-esteem, anxiety and depression, including becoming suicidal. Some victims may also become bullies themselves.
  4. What are risk factors and how do we identify it? Risk factors for aggressive behavior include depression, school problems, living in violent communities, and having parents who are absent, abusive, or disengaged. Risk factors for being a victim include developmental or physical differences, such as intellectual disability or obesity and LGBT status. Red flags include somatic complaints, decreased motivation/school performance, avoiding school, frequently losing items or asking for money, unexplained injuries, and threatening to hurt self or others.
  5. What can we do to help prevent bullying? Ask questions to help screen. “Do you ever see kids picking on other kids?” “Do kids ever pick on you?” “Do you ever pick on kids? (And tell the truth; you’re not in trouble.)” The motto often shared is “Telling is not tattling. It is getting someone help” (not just to get someone in trouble). When we identify bullying, we should take concerns seriously. We should talk to children and their parents and provide counseling about the importance of getting help from an adult. We should contact school personnel directly if we are concerned they are not adequately addressing it. We should also refer the child to a therapist or counselor for help.

2018-19 TOW #10: Road traffic safety

This is always an important topic, even more so as kids return to school and will be on the road, and also because newly released guidelines for car seat safety were just published by the AAP. A big thank you to Dr. Beth Ebel MD MPH who provided key review points. Beth is a national expert on this topic and a former member of the national AAP committee who developed policy recommendations. Dr. Brian Johnston MD MPH, our Chief of Pediatrics at Harborview serves on the current committee that released the updated recommendations, below. (Fun fact: 3 former graduates of our program serve on the current committee (Brian, Sarah Denny, and Ben Hoffman!)

Materials for this week:

Take-home points for this week:

  1. As pediatricians, we must advocate for car seat and seatbelt use EVERY TRIP EVERY TIME. Most crashes occur on the day-to-day driving routes.
  2. We should know recommended car seat types for children of different ages and sizes. (See the AAP report). Basic summary:
    • Rear-facing 5-point harness carseat until reach weight limits (up to about age 4, previous recommendation was at least age 2).
    • Once forward facing, use a car safety seat to that seat’s weight and length limits (typically about 60 pounds).
    • When they exceed the seat’s limits, use a convertible belt-positioning booster seat (high back is preferred) until they have reached at least 4’9″, typically between ages 8-12.
    • Until age 13, always sit in rear seats in full lap and shoulder belt.
  3. Teen driving is the most dangerous time for teens in terms of risk of injury and death. Motor vehicle crashes are the number one cause of teen death. We can make it safer through driving contracts and graduated driver’s licenses (see the teen driving contract and state Graduated Driver’s Licences GDL laws).
  4. Distracted driving for teens and adults is a major issue and has increased with ubiquitous texting. It is now the law in our state to not use a phone or text while driving, and parents must be role models. Parents should use “chauffeur” time as catch up/phone down time for parent AND child.
  5. Review safe and active travel options. Encourage families to use the bus to navigate around the city for a weekend expedition. Use resources like One Bus Away, Metro transit route guide, and Google maps. Walking and biking to school are great and allow kids to be active, but kids must be visible and be safe. Check out Walking School Bus resources for local schools. When crossing the street, stay alert and put phones down!

2018-19 TOW #5: Water Safety and Drowning Prevention

Summer is a great time to review water safety, especially in Seattle where we have access to so much beautiful open water and sunshine to enjoy it. Safety around water is critical, as drowning is actually a leading cause of injury death for children. Seattle Children’s has partnered with community organizations through programs like Everyone Swims to develop materials and advocate for policy changes to prevent drowning, including contributions from our own residents.

Check out this week’s teaching resources here:

Take-home points for understanding drowning and promoting water safety:

  1. Epidemiology of drowning: Death from drowning is a top 3 cause of injury death in childhood. It is the leading cause of injury death for 1-4 year olds and the 2nd leading cause for 5-14 year olds. Unfortunately, it disproportionately affects minority children. Children can drown in only 1-2 inches of water. Adolescent males have a 10-fold increased risk of drowning compared to females. They have higher risk exposure, more risky behaviors (e.g., swimming alone and at night), and are more likely to drink alcohol in aquatic settings.
  2. Drowning definition: Drowning is no longer defined as death from submersion. The WHO defines it as “a process of experiencing respiratory impairment from submersion/immersion in liquid” and outcomes are classified as death, morbidity, or no morbidity.
  3. Risk reduction: Drowning can be prevented by many strategies including 1) adult supervision within arm’s reach, 2) life jackets, 3) pool fencing that encloses the pool and is at least 4 feet high, 4) swimming at lifeguarded areas, and 5) swimming lessons. The American Academy of Pediatrics (AAP) recommends children begin to learn to swim by age 4. In one study, taking formal swimming lessons was associated with an 88% reduction in drowning risk (Brenner et al. Arch Ped Adol Med 2009).
  4. Drowning prevention: Pediatricians have a role in helping prevent drowning. Screen for swimming ability at age 4-5 and refer to swim lessons (see pool info handouts on Everyone Swims tab on the SCH drowning prevention page). Discuss water safety with families and provide information, including handouts here: http://www.safekids.org/watersafety

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 #50: Marijuana Use

Among 12th graders, daily use of marijuana is now more common than cigarettes. As a legalized marijuana state in Washington, we should know about important implications for adolescents, and for pregnant and breastfeeding moms, as reviewed below.

Materials for this week:

Take-home points for marijuana use among adolescents:

  1. What are the active components of marijuana? Over 200 mixtures of cannabinoids come from the cannabis plant. One of the cannabinoid chemicals, tetrahydrocannabinol (THC), has psychoactive properties that has led to its recreational use. Cannabidiol (CBD) – a non-psychoactive cannabinoid, is another of the active chemicals for medicinal use. There are varying amounts of THC and CBD in any given plant.
  2. How prevalent is marijuana use?  The National Survey on Drug Use and Health showed the prevalence of past-month marijuana use in the US more than doubled between 2001-2002 and 2014-2015, with 8.3% of those aged 12 or older reporting past-month marijuana use. According to the NIH’s Monitoring the Future Survey, in 2015 34.9% of 12th graders in the US reported past-year use of marijuana. The 2015 survey also found that daily marijuana use exceeded daily tobacco cigarette use among 12th graders for the first time since the study’s inception (in the 1970s; 6% vs. 5.5%).
  3. What are the short-term effects of useWhat are long-term effects on developing brain? Side effects of marijuana use included impaired attention, concentration, and executive functioning. Tachycardia and systolic hypertension are two consistent physical effects. Other short-term effects include drowsiness, ataxia, increased appetite/thirst, conjunctival injection, dry mouth, anxiety, insomnia, hallucinations and short-term memory loss. In the long run, heavy marijuana use in the adolescent period interferes with synaptic pruning and myelination, causing changes in the hippocampal region, prefrontal cortex and white matter volume, which correlates with impaired cognitive functioning. These changes can affect attention span, concentration and problem solving, as shown in studies analyzing functional MRIs of marijuana users. Additionally, there is emerging data supporting increased risk of psychosis and predisposition to developing schizophrenia in adolescent marijuana users.
  4. What are differences between legalization and decriminalization? Legalization refers to allowing legal cultivation, sale, use, and/or possession of marijuana. Decriminalization means eliminating criminal penalties for possessing or using small amounts of marijuana. Both concepts have been debated, particularly for how it affects the adolescent population. The biggest support for decriminalization is shifting from law enforcement to a public health approach that emphasizes medical treatment for drug dependence or addiction. One of the problems with legalization (as we are seeing in WA) is the belief among adolescents that regular use does not cause harm. Nationally in 2015, 68.1% of 12th graders did NOT view regular  marijuana use as harmful.
  5. What are the effects of levels of THC for pregnant and nursing mothers? Breast milk can be up to 8 times as concentrated as the serum levels of chronic users, and THC is readily absorbed and metabolized by infants. The American College of Obstetricians and Gynecologists (ACOG) and Academy of Breastfeeding Medicine recommend stopping marijuana use (either recreational or medicinal) during pregnancy and breastfeeding given animal studies that suggest negative effects on brain development and lack of safety data in humans. It is important we discuss these risks with moms.

TOW #47: Travel Preparedness

School is out in a few weeks and that means many families are preparing for travel this summer. Next week’s topic reflects our increasing globalization that manifests in more children travelling internationally. This is a good time to review some of the key resources and recommendations for travel preparation visits.

Materials for this week:

Take-home points for travel preparedness with children:

  1. International travel among children is on the rise. In 2010, ~2.2 million US children aged ≤18 years traveled internationally. Children are less likely to get travel advice/visits compared to adults. In one review of children with post-travel illnesses evaluated at clinics, only 32% of the children visiting friends and relatives had received pre-travel medical advice, compared with 59% of adults.
  2. Most common illnesses encountered after travelling are diarrheal illnesses, skin conditions (including bites, cutaneous larva migrans, and sunburn), systemic febrile illnesses (especially malaria) and respiratory disorders. Injuries are also common, especially motor vehicle and water-related injuries. For food safety review: “Boil it, peel it, cook it, or forget it.”
  3. Vaccination review is key. Make sure children are up to date on common vaccines and then assess for travel-related vaccines. When indicated, we provide typhoid injection and yellow fever vaccines, and if given enough lead time, you can sometimes get it covered by insurance through a prior authorization. Some pharmacies provide these at reasonable costs-ask your clinic facility.
  4. Counsel on the special risks of children who are visiting friends and relatives in developing countries. They will have increased risk of exposure to malaria, intestinal parasites, and tuberculosis. Review malaria prevention and provide malaria prophylaxis medications, as appropriate. Zika virus is also a newer risk for families. Also remember assault and STI risk for teenagers who are travelling. Screen for tuberculosis after children return if they have visited an endemic country for a week or more. You can test as early as 10 weeks after they return (or you can wait until their annual well child exam).
  5. Resources for plane travel with infants/young children is also a common request. I was lucky (?crazy) enough to take flights with both of my daughters by 2 months of age. A few suggestions that I have used were compiled in this online article. A few other tips I would add: keep plenty of extra clothes, bottles, food, and hand sanitizer when travelling with young children. Travelling during non-viral/non-flu season is preferred when possible. Be sure parents have had all of their vaccines, and give babies theirs as early as possible (2 month vaccines can be given as early as 6 weeks).

TOW #41: Child abuse recognition and prevention

April is child abuse prevention month, so we are going to discuss this always challenging but critical topic in our field. We owe gratitude to the SCAN and CPS teams who work so hard to help evaluate and keep children safe. Our role in primary care encompasses strategies to build resilience, promote strong relationships/bonds, link families to resources, and screen and refer for concerns. The Protection, Advocacy and Outreach team at SCH has 3 prevention programs including Period of PURPLE crying, Medical-Legal Partnership and Positive Parenting (which provides funding for our Promoting First Relationships (PFR) training for residents).

Materials for this week:

Take-home points for child abuse recognition:

  1. We are mandated reporters for suspected child abuse and neglect and any allegations of sexual abuse. 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. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. 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.
  3. Corporal punishment is not recommended in any form by the AAP. Spanking (i.e., using “an open hand on the buttocks or extremities with the intention of modifying behavior without causing physical injury”) is the least objectionable, but is considered maltreatment if it is done so hard as to leave a bruise.
  4. Children of all SES levels are at risk for child abuse. In ~80% of cases, parents are perpetrators of child maltreatment. Some specific parent-level risk factors for child abuse include parent poverty, parent of multiple children under 5, history of 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 child development. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired pregnancy; or multiple gestation pregnancy.
  5. Bruising is the most overlooked form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising more 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 a referral to CPS. It's important for us to be aware of the bruising: before getting a diagnosis of child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury. 

TOW #8: Car safety

We continue another "summer of safety" topic this week with a deeper dive into automobile safety. A big thank you to Dr. Beth Ebel MD MPH who provided key review points – Beth is one of the national experts on this topic and a member of the national AAP committee who developed the policy statements below.

Materials for this week:

Take-home points for this week:

  1. As pediatricians, we should know recommended car seat types for children of different ages and sizes. (See the AAP report by Durbin et al). Basic summary: rear facing 5-point harness carseat until at least age 2, ages 2-8 years – forward facing car safety seat or convertible booster seat (high back is preferred) until they have reached at least 4'9", typically between ages 8-12; always sit in rear seats in full lap and shoulder belt after outgrown carseat/booster. We must advocate for carseat and seatbelt use EVERY TRIP EVERY TIME. Most crashes occur on the day-to-day driving routes.
  2. Teen driving is the most dangerous time for teens in terms of risk of injury and death-motor vehicle crashes are the number one cause of teen death. We can make it safer through driving contracts and graduated driver's licenses (see the teen driving contract and state Graduated Driver's Licences GDL laws).
  3. Distracted driving for teens and adults is a major issue and has increased with ubiquitous texting. Parents must be role models. Encourage parents to use “chauffeur” time as catch up/phone down time for parent AND child.
  4. Review safe and active travel options. Encourage families to use the bus apps to navigate around the city for a weekend expedition. Use the local resources like One Bus Away, and the transit route guide. Walking and biking to school are great and allow kids to be active-check out Walking School Bus resources for local schools. Discuss being alert when crossing the street – put phones down (and now pokemonGO down!)