TOW #2: Infant and Toddler Development

Next week is a chance to review cognitive and motor development for children, always a fun topic. Residents especially appreciate focusing in on development at clinic, as they tend to get this less overall in their clinical work.

Materials for this week:

Take-home points for assessment of infant and toddler development:

  1. Epidemiology: ~12-15% of children and adolescents in the US have a developmental disability and ~20% meet diagnostic criteria for a mental health disorder.
  2. Assessing development: includes surveillance which occurs at every WCC visit (asking about parents’ concerns, keeping a developmental hx, observing child, identifying risk factors, documenting findings) and formal screening with a validated tool like ASQ (AAP recommends at 9 mo, 18 mo, or 30 mo). Specific autism screening is recommended at 18 and 24 months.
  3. Types of development: developmental milestones are assessed in major areas of language and communication, fine and gross motor, cognitive and social-emotional domains. If delayed, we need to figure out which areas are involved. Global delay is more likely associated with medical conditions.
  4. Work-up: if concerned based on surveillance or screening, pay close attention to growth, especially head circumference, dysmorphology, neuro exam, and skin exam.
  5. Treatment: Any delays identified warrant follow-up and referral to Birth-to-Three for further evaluation (the benefit of the 24 month visit provides one additional time to assess development before the window closes for birth-to-three options).

TOW #1: Providing Well-Child Care

Welcome to our Topic of the Week (TOW) for 2016-17! TOW is our weekly teaching topic for residents and faculty to use in continuity clinics. Each week I will include materials to review together in clinic – a case discussion, important review or recent articles on the topic, online resources, and key take-home points. I seek to include a balance of topics related to well child and acute care (see category tags, which are searchable). I try to send these out on Thursday the week before. They are all kept on a blog, so hopefully handy for future reference as well. We encourage senior residents (and interns later in the year) to lead topics when they can. If you have any topic ideas or feedback, please let me know!

As we welcome new interns and senior residents to their roles this week, this is a great time to review our central tenets in providing effective well child care (WCC). WCC can be incredibly rewarding as a pediatrician, especially if you have the right tools and knowledge. We all recognize that providing comprehensive WCC is difficult in a 15-20 minute visit, so we have to prioritize. We are also being challenged to consider new models of care to truly impact chronic disease management over the lifetime, as Dr. Tumaini Coker discusses below and is actively researching – we hope she will soon be joining us on the faculty here.

Materials for this week:

Take-home points for this week:

  1. Why well child care? Through these visits, we have a unique opportunity to identify and address important social, developmental, behavioral, and health issues that can help change trajectories and have significant and long-lasting effects on children’s lives into adulthood. Pediatricians provide the vast majority of WCC to children in the US, which differs from other health systems where general practitioners or nurses provide it. As society changes, one of our current pediatric challenges is to adapt WCC to best address issues that most impact adult health including poverty, low education, environmental exposures, and ACEs (Adverse Childhood Experiences).
  2. What ages do we see kids for visits and why? We have >20 visits recommended with children between ages 0-18. Currently there are 6 visits recommended between birth to age 1 (newborn, 2-4 weeks, and 2, 4, 6 and 9 months). Visits are spaced out over the next 2 years (15, 18, 24, 30 months) and then annually after age 3. The timing for these has been largely influenced by providing vaccines, which is the most evidence-based prevention strategy we use in pediatrics, and by Bright Futures, developed by the maternal and child health bureau in the 1990s to standardize recommendations and care.
  3. How do we prioritize topics for WCC? For each recommended well child check  from newborn to age 21, Bright Futures includes guidelines for screening and a “menu” of 5 possible anticipatory guidance topics. Even with these pared down, there's a lot to cover, so we often still have to do more focusing. There's some data that parents can only retain up to 3-4 recommendations from a visit.
  4. What's the evidence for effective components of anticipatory guidance? Unfortunately, the studies are difficult to do and the data is limited. Because of this, the US Preventive Services Task Force often gives a Cateogry 1 (Insufficient Evidence to Evaluate) rating to pediatric screenings, such as for lead, and cannot say whether outcomes are improved because of the intervention. There are several preventive-health interventions from pediatricians that do have good supporting data including Reach Out and Read, promotion of breastfeeding, the “back to sleep” campaign, and avoidance of physical discipline.
  5. In the limited time we have, what's most important to cover? Most important is that we address parents' concerns and set an agenda with them (more on this topic to come). While I confess I don't love or routinely remember mnemonics, this one is a good list for basics to review, starting with parent concerns. "CHECUP"
  • C – Concerns (or questions)
  • H – History (past medical, birth, family, social)
  • E – Environment (home, typical day, nutrition, sleep) 
  • C – Child (development, growth, voiding)
  • U – Unanswered questions (inquire about further concerns)
  • P – Prioritized anticipatory guidance

TOW #50: Child nutrition and picky eating

Welcome to our last topic for this academic year! We have had a great year in clinics and have covered a lot of TOW ground. We are wrapping up with a topic that's close to my heart: child nutrition. As kids head into summer and junk food often abounds, it's a nice time to review a few key recommendations and resources.

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). As the daughter of a cardiologist, I have 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. Biggest dietary room for improvement from kids to parents: cutting down on added sugars, which are in everything from bread to yogurt to beverages.
  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 effects of an all fast food diet), but increasingly 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, raising our own food through gardening, and creating a positive environment for eating without distractions (no TV, no devices).
  3. Review with families the Division of Responsibility for feeding ("parent is responsible for what, where, when and child is responsible for how much"). Ellyn Satter, the well-known 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 consumption 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.

    • Not let children have food or beverages (except for water) between meal and snack times.
    • – See more at: http://ellynsatterinstitute.org/dor/divisionofresponsibilityinfeeding.php#sthash.Tws0BCY2.dpuf
  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 always preferred.
  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 recent study published in Pediatrics 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. We should help parents know that even infants show us feeding cues and to never force babies to finish a bottle or other food. 

TOW #49: Lead screening and poisoning

This week our topic on lead screening comes thanks to the Pediatric Environmental Health Specialty Unit (PEHSU) Director Dr. Catherine Karr and Ada Otter PEHSU nurse practitioner.

Materials for this week:

Take-home points for lead screening

  1. What is a safe blood lead level (BLL)? Based on strong research evidence, no measurable BLL is considered safe. Neurotoxicity associated with lower BLLs has been established by overwhelmingly consistent evidence from meta-analysis, so primary prevention of lead exposure is paramount. All detectable BLLs are reportable in WA State and the health department follows up with all BLLs > 5 mcg/dL.
  2. Why screen for lead? While lead is toxic to multiple body systems, the developing brain is particularly vulnerable. Most lead toxicity in the US is sub-clinical, only found on blood testing. Even low levels (<10mcg/dL) may be associated with behavioral problems (such as attention, aggression) and learning difficulties. Children aged 9-24 months are highest risk due to normal exploratory behavior – crawling, teething, putting non food objects in the mouth. Absorption across the gut is greater in children than adults.
  3. What are the sources of elevated lead levels? Ingestion of lead-containing dust or soil is the highest source, usually from old paint in homes older than 1950, but up through 1978, and homes from these eras being remodeled. As we have learned from Flint MI, lead is also in water sources, from contaminated water and old pipes. There are also newer sources of lead in imported products including candies, food, spices, make-up, and ceramics.
  4. Who should receive blood lead testing? In WA state, the 2016 guidelines identify children with these risk factors: 1) Lives in or regularly visits any house built before 1950 or built before 1978 with recent or ongoing renovations or remodeling, 2) From a low income family; income <130% of the poverty level. (Federal law mandates screening for all children covered by Medicaid), 3) Known to have a sibling or frequent playmate with an elevated blood lead level, 4) Is a recent immigrant, refugee, foreign adoptee, or child in foster care, 5) Has a parent or principal caregiver who works professionally or recreationally with lead, 6) Uses traditional, folk, or ethnic remedies or cosmetics. Unfortunately, screening questionnaires have not reliably identified kids, as Alex Windhorn just found for a topic review at Harborview, so when in doubt, screen.
  5. What do you do with an elevated level? The PEHSU provides a summary of key next steps based on BLL results (see link above). Next steps will include evaluation for anemia/nutrition since this may impact lead absorption, as well as determining the need for imaging or medical management.

TOW #48: Short stature

Another beautiful weekend of spring weather ahead! Hope you get to enjoy it. Next week is a time to review the evaluation and work-up of short stature.

Materials

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.
  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 (most children are within 10cm of 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. 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.