TOW #30: Developmental Dysplasia of the Hip (DDH)

Developmental dysplasia of the hip (DDH) is an important newborn-related topic with some recent updates. The AAP published an updated clinical report on DDH in Dec for the first time in 16 years. The report highlighted the "primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial."

Materials for this week:

Take-home points:

  1. What are the primary risk factors for DDH? Female gender (up to 75% of DDH), family history, and breech presentation. As of the updated guideline, there is now also a risk factor noted for tight swaddling with legs adducted and extended. (Preferred safe swaddling is flexed and abducted hip position).
  2. Who should we screen for DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging.
  3. What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy (*if hip dysplasia is bilateral, we can't compare sides) while supine with the hips and knees in straight-leg position, and then with the hips and knees in flexed position. Galeazzi sign is unequal knee height when legs are flexed. Then we use Ortolani maneuver- newest guidelines say Ortolani has best predictive value and Barlow may not be necessary and/or harmful if too much pressure is applied. If Barlow is used, it should be gentle pressure applied while adducting the hip after performing Ortolani. The Ortolani and Barlow maneuvers are really most reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds and hip movement. Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred.
  4. What imaging do we use to screen? Ultrasound at age 6 weeks-6 months, or plain xrays at 4-6 months. There are more false positives with early ultrasound and many children with more subtle findings may be watched. 
  5. What constitutes a positive screen? Based on consensus, children who have unstable hips on exam, or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Infants who have only hip clicks do not require further imaging or referral.

TOW #29: Food allergy

Next week’s topic is on food allergies, a hot topic with regard to the evolving literature and recommendations.

Materials for next week:

A few take-home points:

  1. Epidemiology: As many as 1 in 13 children is thought to have a food allergy. Along with other allergies, the rate of rise of food allergies has been rapid. While well-meaning, the recommendation to delay introduction of foods probably led to an increase in allergy development as children were sensitized through exposure, such as through the skin. Generally, the most common allergens in childhood include egg, milk, peanut, tree nuts, wheat, soy, fish, shellfish,and sesame.
  2. How do we prevent food allergies? This is perhaps the most exciting and dramatic change in practice in terms of solid food introduction. We are now recommending introduction of solids foods between 4-6 months with a variety of foods fairly quickly, including foods containing peanuts, eggs, and tree nuts. Mixing a bit of water into peanut butter to make it soupy is one way to expose infants to peanut butter (more recipes/options in the appendices here). Especially for eggs, baking them into foods denatures the proteins so may be the best initial exposure for babies with a higher food allergy risk based on family history of atopy/allergy. Also egg yolks are less allergenic than egg whites, so could be offered first. Breastfeeding for at least 4 months and breastfeeding at the time when new foods and cow’s milk protein are introduced is associated with decreased risk of allergy.
  3. How do we diagnose food allergies? Symptom reaction to the food: usually these are Type-1 IgE-mediated hypersensitivity reactions that happen within minutes of ingestion: including skin (most common), oral or nasal mucosal, GI, or respiratory reactions, or a combination of these in full anaphylaxis. Typically symptoms resolve within 4-12 hours. There are also Type-4 cell-mediated hypersensitivity reactions to food, such as milk protein allergy, that cause mostly GI symptoms. Some children may avoid a food due to symptoms they experience, and we should also pay attention to these behaviors. Once a reaction has occurred, testing options may help to better evaluate the allergy but are not fully diagnostic. A skin-prick test for food allergy is recommended but it's not 100% specific, as there is a high false positive rate. Serum specific IgE testing is useful for patients who cannot discontinue antihistamine therapy or for those with extensive skin disease or dermatographism. An oral food challenge is considered the gold standard and may be part of making the diagnosis when it's in question.
  4. How do we manage food allergies? Strict avoidance of the allergenic food is the primary approach. The exception is for some foods, especially egg and milk, which may be tolerated in cooked forms, with exposure helping build tolerance to other forms of the foods.
  5. How do we treat reactions and prevent death from anaphylaxis? Food-induced anaphylaxis is a "rapidly progressive, multiorgan allergic reaction that can result in death." Recognition and quick response is essential for appropriate management to save lives. The symptoms may be uniphasic, biphasic, or protracted. In all cases, most important is rapid treatment with IM epinephrine. Repeated epinephrine dosing should be used when symptoms progress or response is not optimal. All patients with any moderate to severe IgE-mediated reactions to foods should have self-administered IM epinephrine available. Mild skin-only reactions may be treated with diphenhydramine.

TOW #28: Atopic dermatitis

With all of the cold, dry sunny weather we have had, it's the season for dry skin and flares of atopic dermatitis. (Currently we are treating lip lickers’ dermatitis for my 5 yr old, so I can relate!) This is a great time to review some tools of the trade and recent data.

Key points to review:

  1. Epidemiology: Atopic dermatitis (AD) is one of the most common skin disorders in young children, with a prevalence of 10% to 20% in the first decade of life. It is a chronic illness with multiple etiologies and requires multifaceted treatments.
  2. Pathophysiology: Defects in the epidermal barrier function and cutaneous inflammation are 2 hallmarks of AD, which is why we target therapy with barrier agents and antiinflammatory treatments.
  3. Topical corticosteroids are the mainstay of therapy for inflammatory skin diseases like AD. They reduce inflammation in the skin by causing vasoconstriction and preventing inflammatory cells from entering the affected area, so they also have an anti-pruritic effect. Potency is actually determined by how much vasoconstriction they cause. For children with rapid flares, a recommendation is short-term bursts of mid- to high-potency topical steroids, typically applied twice daily for 7 to 10 days, then tapering to lower potency daily, then to intermittent application, 2-3 times per week.
  4. Regular use of emollients to prevent drying of the skin is also important in managing AD. Patients should use a dye-free, fragrance-free moisturizer and apply it at least twice per day and after bathing. In practice (and personal experience with my kids), my go-to has been petroleum jelly / white petrolatum (Vaseline). It's effective, does not sting like other creams/lotions can, and is affordable. I was intrigued with recent data showing that applying moisturizers regularly for infants could forestall development of eczema. Most cost effective was petroleum jelly.
  5. Side effects of topical steroids: Steroid side effects are most problematic when applied to skin without inflammation-apply steroids to affected skin that it is red or inflamed, typically not more than 2 weeks at a time (however, in clinical practice, this may be adjusted for those with more severe AD, or another option may be switching to topical calcineurin inhibitors). Use lower potency especially in the face and groin area where the skin is thinner / more susceptible to damage.

TOW #27: Childhood obesity

In this time of new year's resolutions, we can harness the focus on wellness to offer encouragement for families facing challenges with weight. Obesity prevention and intervention is a topic close to my heart, so I am excited to highlight the great local resources we have including the ACT! program, in partnership with the YMCA, and the Child Wellness and Adolescent Wellness Clinics at SCH. We have many wonderful local obesity research experts in our clinics, including Drs. Lenna Liu, Jay Mendoza, and Pooja Tandon. A big thanks to Dr. Allison LaRoche for her help updating materials for this topic. Feel free to email any of us with questions.

Teaching materials for this week:

Take-home points for this week:

  1. What's the epidemiology of child obesity?: Childhood obesity is recognized as one of the most important issues of our time. While some progress is being made, with promising data on declines among preschool youth, we still have a long way to go with overweight/obesity rates persistently high at 1 in 3 children, and even higher among some demographic groups. Etiology of obesity is multifactorial, with higher rates among low-income families, and certain racial-ethnic groups including Hispanic, African American and American Indian youth. Prevention is much easier than weight loss, so focusing on behaviors/ environments that support healthy weight starts from infancy.
  2. What focused messages can we share in clinic? Learn the Division of Responsibility for feeding ("parents provide, child decides" – parent is responsible for what, where, when food is served and child is responsible for how much to eat). Use 5210 goals to help guide healthy weight behaviors among our children: 5 fruits and veggies per day, watch no more than 2 hours of screen time, get 1 hour or more of physical activity, and have 0 sugary drinks. The 5210 Let's Go! campaign was started by a pediatrician in Maine and was adopted to help families learn healthier habits. It can be helpful to let families choose their goals through motivational interviewing, which has been shown to work in decreasing weight in an RCT in pediatric practices.
  3. How can we address this sensitive topic and avoid weight stigma in our practice? Recognize that obesity is highly stigmatizing-bias for weight is among the strongest biases culturally, even among children. We must be aware of our own biases as we treat patients. We want to use sensitive language to be supportive of families and keep them engaged: discuss “healthier weight/ unhealthy weight” and specific behaviors rather than a focus on being overweight/obese. It's helpful to acknowledge there are a lot of things outside the control of families (genes, community environment, etc), AND there are behaviors families can adopt that make a difference for health. 
  4. What are the approaches for overweight and obese? For youth with BMI >85th percentile (overweight), follow weight trajectory and family history to assess risk. Screening labs (lipids, liver enzymes and A1c and/or glucose) are recommended to assess metabolic complications among overweight children with higher risk. Refer to resources like the YMCA ACT! program – ACT! programs are enrolling this winter for 8-14 year olds around our area. For youth with BMI> 95th percentile (obese), do screening labs starting at age 10 (or earlier if BMI>99th percentile), offer the ACT! program, as well as early referral to SCH Wellness Clinics for multidisciplinary weight management from age 2 through adolescence. When metabolic problems are identified, see the above article on management of comorbidities.
  5. What is the role of physical activity? For children at all weights, regular physical activity reduces the likelihood of comorbidities, even without necessarily decreasing BMI. It's important for us to emphasize helping kids and parents find ways to be active and fit, no matter what their body size.