TOW #10: Breastfeeding challenges

In this last week of August, National Breastfeeding Month, we are going to review breastfeeding challenges and our role addressing these as pediatricians in clinic. Among the many reasons to promote breastfeeding, the emerging data on how breastfeeding affects the microbiome for infants is pretty cool. These data may help us better understand why breastfed babies get fewer infections and have other health benefits.

Take-home points on breastfeeding challenges:

  1. Indicators of successful lactation to assess at first well visits: Mother: milk is in, she is not engorged, has minimal nipple soreness with latch that dissipates after the first few sucks; starting to adjust to her newborn and has social support; Baby: feeding on both breasts 8-12 x in 24 hours, satisfied after 30-40 minutes of nursing; gaining 25-30 grams a day.
  2. While nearly all mothers try breastfeeding, almost half quit after a few weeks usually due to a few main problems: poor latch, pain, and perceived low milk supply. The vast majority of these challenges are treatable with support from us, lactation specialists, and family/social support. Only about 5% of moms actually have physiologic problems that lead to inadequate supply.
  3. To help with these challenges, we need to know a few basics: observe feeds so we can help with latch in different positions, assess nipple pain (should improve over time, but think of fungal and bacterial infections and vasospasm as causes if not), and help with milk supply – reassurance if gaining wt. If milk supply is an issue, recommended strategies include rest, hydration, breast compression, and increased stimulation through feeding and pumping, and galactogues including Reglan, fenugreek and oxytocin nasal spray.
  4. Late preterm infants are at special risk for difficulty establishing breastfeeding. Some appear large (6-7 pounds) but can be breastfeeding "imposters"; appear to be feeding well but are not transferring enough milk and not gaining weight well. They need extra attention, clear feeding plan, and benefit from early and ongoing lactation support to help them get there.
  5. How do we decide if a mom's medication is compatible with breastfeeding? Look it up on LactMed, the NIH sponsored website to provide information about drugs and other chemicals while breastfeeding.

TOW #9: Colic (excessive crying)

Next week we are covering a bread and butter topic in outpatient pediatrics, the ever-so-challenging diagnosis of colic, or excessive crying. Dealing with an especially fussy infant as you're just learning to be a parent can be among the most challenging experiences a parent can face. Think about the stress you've felt listening to an infant crying on a plane, then imagine a parent having to deal with it every day! We want to harness evidence and empathy to help families through this.

Here are the materials:

Take-home points about colic:

  1. Epidemiology: how do we define colic and how many babies have it? Colic was defined by Wessel in 1954 as rule of 3's (crying for 3 hours or more per day on at least 3 days per week for >=3 weeks). It occurs in 15-25% of otherwise healthy babies and is most often benign and self-limited. Some have theorized babies who cried more had an evolutionary advantage for survival as it meant more holding and soothing. In clinic, I often say a baby has a "good survival instinct" when I am talking to families to normalize crying behaviors, or other contact seeking behaviors that get babies the help they need.
  2. What is the differential for excessive crying and what is the work-up? Less than 5% of cases have an identified cause. We need to think about cow's milk protein intolerance, GERD, abuse, infantile migraines, isolated fructose intolerance, maternal medications in breast milk (like fluoxetine), hair tourniquet, occult infection (especially UTI), and corneal abrasion. Mothers of infants with colic are more likely to have depression, so this should be assessed and referrals made, as needed. If there is no sign of other illness or injury on exam, then no routine work-up is needed.
  3. What is the natural history for colic? Colic begins at 2-4 weeks and worsens until 6-8 weeks then improves and usually resolves by 4 months of age. The increased crying behavior occurs in the afternoons and evenings, the same times of day as in non-colicky infants, often referred to as the "evening fussies." Colic can be considered a more extreme end of the spectrum of normal emotional development. Often there is a connection to difficult feeding behaviors and sleep, so these should be assessed.
  4. What are the long-term outcomes among infants with colic? At 4 months those who had colic may have more sleeping difficulties. There may be some differences in temperament and family functioning. But, there have been no long term differences found in cognitive development.
  5. What are the treatment options for colic? A crying infant can lead to parents feeling anger, frustration, and inadequacy. Asking about and addressing these emotions are important parts of caring for the parents. Helping parents know they can leave for 5-10 minutes to take a break is important. There is some evidence that babies with colic have different fecal microflora (including higher rates of Helicobacter pylori stool antigen positivity) and some signs of colonic irritation. Numerous studies of probiotics as a treatment for colic have been mixed overall, but there is data from small studies that suggest Lactobacillus reuteri may be effective in reducing crying time in exclusively breast fed infants.

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!)

TOW #7: Water safety

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: http://www.seattlechildrens.org/dp

Check out this week's teaching resources here:

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

  1. Epidemiology: 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. 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. Pediatricians have a role in drowning prevention. 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). Remind families about water safety and where to get information, including handouts here: http://www.safekids.org/watersafety