TOW #26: Sibling rivalry

"I don’t believe an accident of birth makes people sisters or brothers. It makes them siblings, gives them mutuality of parentage. Sisterhood and brotherhood is a condition people have to work at."  ~Maya Angelou

Sibling rivalry materials are provided thanks to our beloved Dr. McPhillips who developed teaching for this topic. This issue is near and dear to my heart as we often meet many of the criteria for intense sibling rivalry at our house!

Materials for this week:

Take-home points for sibling rivalry:

  1. Frequency: Sibling rivalry is a predictable, normal and healthy response to the birth of a new brother or sister. Check out this pretty hilarious ad about what it feels like to have a new sibling! 
  2. Why it’s normal: Sibling rivalry demonstrates that an older child is appropriately attached to his/her parents and that he/she is able to respond to a perceived threat to this relationship. Absence of sibling rivalry is worrisome!
  3. Risk factors: More common in same sex siblings. More common in girls than boys. The smaller the age difference—the greater the rivalry (and the closer the friendship). There is no “ideal” spacing of children, although experts suggest that 3 or more years between kids may decrease some rivalry.
  4. Natural history: Less common as children become older, especially after about 8 years old (friends, school and outside interests more important to sense of place in world).
  5. How to address: Involve older children in age-appropriate care for their younger child/infant so they feel included, provide special time for the older child, acknowledge feelings, point out all the wonderful things the older child can do that the younger one will want to emulate.

TOW #25: Lipid screening and dyslipidemia

The topic of lipid screening and dyslipidemia treatment remains a controversial one in pediatrics! It depends on whether you are in the camp of not missing anyone who meets potential criteria for intervention vs emphasizing the potential harms of overtesting and overtreating: the age-old epidemiologic debate, not to mention a value-based care question. Nationally, the variation in recommendations reflect this debate: the AAP and experts with the NHLBI report have sided with universal screening, while others, including the US Preventive Services Task Force and the AAFP highlight insufficient evidence to recommend screening before age 20. Several articles highlight the viewpoints on each side, as summarized by Dr. Perri Klass' summary in her NYT blog, who quoted Dr. Fred Rivara, MD MPH about his statement against universal screening. The goal this week is for you to be familiar with some of the recs and the evidence, to inform your understanding and decision-making.

Materials for this week:

Take-home points:

  1. Who should be recommended for lipid testing? It depends on if you follow targeted screening vs universal screening, or if you believe in no benefit of screening in childhood. The 2011 NHLBI guidelines recommend targeted screening for children 2-8 years old and adolescents 12-16 years old and universal screening for children 9-11 years old and adolescents 17-21 years old. The repeat is done at age 17-21 to assess after puberty which can alter levels. These same recommendations are endorsed by the AAP. In the targeted approach, screening is indicated in children or adolescents with a positive family history of dyslipidemia or premature cardiovascular disease (CVD) (including parent or 2nd degree relative <55 male, <65 female), an unknown family history, or children with other risk factors for CVD, like obesity, hypertension and diabetes.
  2. If you are screening, what tests would you do? In the NHLBI guidelines, the recommendation for universal screening was to use non-fasting lipids and calculate the non-HDL-C as follows: Non-HDL-C = total cholesterol (TC) – HDL-C. If the non-HDL-C was >=145, then do follow-up with fasting lipid panel. For targeted screening, the rec was getting an average of 2 sets of fasting lipid profiles (FLP) separated by 2 weeks – 3 months (as the individual levels can vary by up to 30mg/dl). Triglycerides (TG) are much more likely to be overestimated with non-fasting draw, but total and non-HDL levels are considered more reliable when non-fasting. All of this seems much more complicated, and in practice, most pediatricians may only obtain one measurement.
  3. What is the first-line treatment for elevated lipids? Initially, we recommend lifestyle intervention, including more fruits, vegetables, fish, wholegrains and low-fat dairy products with reduced intake of fruit-juice, sugar-sweetened beverages and foods, and decreasing salt. We also recommend physical activity and losing weight, if appropriate. The fact that we essentially recommend this diet for all children is partly why many advocate not testing lipids because it does not change recs unless you have serious disease, which is rare. To treat overall elevated cholesterol or LDL, we focus more on dietary fat intake, but to treat elevated TG, we focus more on sugar and carbohydrate intake.
  4. If children have higher lipid levels that don't respond to diet or have familiar hypercholesterolemia (FH), what is the treatment? There is more controversy here as well! The NHLBI guidelines do not recommend medication for children under 10 unless they have severe primary hyperlipidemia or a high-risk condition associated with serious morbidity. For children with FH, statin treatment initiated in childhood is associated with improvement in carotid thickness. For children ≥10 years, starting a statin is recommended for those who have persistent elevated LDL (range from 130-190 based on family history and risk factors) after 6 months of lifestyle changes, with the goal of lowering LDL to below the 95th percentile (≤130 mg/dl). We have ongoing questions about safety of statins for long-term use, as they have not been adequately studied for children, so starting a statin would often be done in consultation with a specialist. Routine monitoring for muscle and hepatic toxicity with CPK and transaminase levels would be done for patients on statins.
  5. When do we refer to a specialist and which one? Referral to a specialist has been recommended for those with LDL ≥250 mg/dl and TG ≥500 mg/dl even before a trial of lifestyle management, or when more than one lipid-lowering medication may be needed (such as a bile acid sequestrant or cholesterol absorption inhibitor). Around the country, different specialists manage lipids; in our region, the Endocrine Division runs the lipid clinic so patients would be referred to them when needed.

TOW #24: Primary care of the 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 have ongoing special care to offer, which we review for this topic.

Materials for this week:

Take-home points

  1. How do we support families after graduation from the NICU? It's important for us to help families through this transition to a new care setting and assess their social support and emotional health. We can help them understand what to expect and offer more frequent visits between the usual well visits. We want to review that we use corrected age (subtract their 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 24 months, 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 long would be typical to fortify milk for premies? Babies under 2 kg or <28 weeks at birth typically receive a transitional formula of 22kcal/oz at discharge from the NICU. As infants demonstrate consistently good growth, they can be switched to term formula, which is often between 4-9 months but may take longer. Premature formula provides extra calcium and phosphorus, which is important for preventing osteopenia of prematurity. Some recommend additional vitamin D (up to 1000 IU) for premies compared to term infants (who should receive 400 IU if they are breastfed or partially breastfed). To prevent anemia, Iron should be provided at 2mg/kg/day until 1 year of age.
  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 that can be shed in the hospital. We also want to ensure that all family members have had Tdap and flu vaccines to "cocoon" the infants and protect them from illnesses. 
  5. What should neurodevelopmental follow-up entail? When discharged, all high-risk neonates should be referred to early intervention or the state birth to three developmental program. Premature infants should be monitored for development in the pediatrician office 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 this is recommended around 8-10 months.