TOW #23: Media guidelines

As we begin the frenzy of shopping for media devices for the holidays, now is a great time to revisit media screening and counseling! A big thank you to one of our local experts Dr. Pooja Tandon for lending her expertise in reviewing and updating this topic for us. Additional national media experts among our faculty, Drs. Megan Moreno and Dimitri Christakis, served on the committees that updated the most recent national AAP media policy released last month.

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?
  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. Youth should demonstrate knowledge/skills to use, like having a driver’s license.
  4. Based on guidance from the AAP, we recommend no screen time for children under 2 (even apps!) Note in the recent guidelines, apps were acceptable starting at age 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 shows such as Sesame Street).
  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.

TOW #22: Newborn concerns

For many of us, a highlight of general pediatrics is the chance to care for babies. Welcoming the newest members of the human race and providing guidance to their caretakers is a joy and privilege. Part of the fun in doing that comes from having knowledge and a sense of comfort with infants that we can impart to parents. This is a great topic for you senior residents to lead the discussion!

Materials for next week:

A few 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 training this year, this would be a perfect topic to review with your teams.
  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: http://newborns.stanford.edu/PhotoGallery/
  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. Remember, 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 so you get honest answers. Review evidence and encourage room-sharing rather than bed sharing. The AAP has new sleep guidelines out now that recommends 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 #21: Tobacco exposure

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This week's topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up on Thursday November 17th. The American Cancer Society designates the 3rd Thursday of November each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking.

Materials for next week:

Take-homes points:

  1. How many children are exposed to secondhand smoke? More than half of US children have secondhand smoke exposure (based on biological samples of population data).
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with nonrespiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What's the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. "Is your child around anyone who smokes?" is a neutral way to open up the conversation. If the parent is smoking I often follow-up with "How are you feeling about smoking?" as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don't forget about using scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) Using pharmacologic treatment doubles the chance that a smoker will quit.
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes.

TOW #20: Precocious puberty

It's time for more talk of puberty – this week we will discuss what happens if there are signs it's happening too early.

Materials for this week:

Take-home points:

  1. How do we define precocious puberty? Development of pubertal changes occuring 2.5 standard deviations below mean age. Traditionally, that's been <8 years for girls and <9 years for boys based on data from Europe in the 60's. More recent cross-sectional data in the US has shown thelarche is occuring up to 2 years earlier in African American girls and 1 year earlier among whites. However, the timing of menarche has only been about 4 months earlier than in prior studies. There's less clear evidence of earlier puberty onset for boys. Many endocrinologists still use the <8 year cut-off, but it's somewhat controversial.
  2. What are factors associated with precocious puberty? These include female sex, family history of early puberty, low birthweight or overweight/obesity in infancy or early childhood, exposure to endocrine disrupting hormones, and international adoption. The link with obesity is especially strong – probably due to effects of multiple hormones including leptin, insulin and estrogen. 
  3. What are the types of precocious puberty? Most cases in girls are due to central early activation of the hypothalamic-pituitary axis (also known as gonadotropin dependent or complete precocious puberty). These can be from CNS tumors but are most often idiopathic. Much less common for girls is the peripheral form – sex steroids from ectopic or exogenous sources (also called gonadotropin independent or incomplete precocious puberty). Sources of excess estrogen production include follicular cysts, ovarian tumors and adrenal tumors, severe hypothyroidism, and rarely McCune-Albright syndrome (a genetic mutation leading to uncontrolled estrogen and includes café au lait spots, osseous lesions, and multiple endocrinopathies). Boys are more likely to have the peripheral form, especially from congenital adrenal hyperplasia.
  4. What should evaluation include? Physical exam to assess height, weight, and Tanner stage, findings of potential endocrinopathy (café au lait spots, acanthosis, signs of hypothyroidism). Females should be examined for estrogenization of the labia and vaginal tissue. A radiographic bone age should be obtained. Consider pelvic ultrasound to view ovaries if peripheral form is suspected. Labs should be obtained in consultation with an endocrinologist and may include early morning plasma estradiol, LH/FSH, and thyroid function. If there is adrenarche, add plasma DHEA, DHEAS, and 17-hydroxyprogesterone. GnRH stimulation test is the gold standard for central precocious puberty. When there is central precocity, especially before age 6, MRI would be used to assess for CNS lesions.
  5. What are adverse outcomes? Biggest are decreased adult height and psychosocial impact such as early sexual activity and drug and alcohol use. When appropriate, we may treat with a GnRH analog like leuprolide to slow central precocious puberty – this is considered generally safe and effective to delay puberty progression and improve adult height.