TOW #39: Early learning

A huge thank you to our passionate advocate, Dr. Abby Grant, who took the lead to develop this topic with one of our recent grads, Dr. Kiersten Derby. I am so excited about some of the newer resources that were shared with us by Nancy Ashley, a local advocate, including her searchable database.

Take-home points about early learning:

  1. Our role: We as pediatricians have an opportunity to advocate for our patients through early learning settings: referrals to quality child care, preschool and Head Start programs, and also supporting work on policies and funding for these programs.
  2. Why preschool matters: Robust research shows that children who participate in high-quality preschool programs have better health, social-emotional, and cognitive outcomes than those who do not participate. Participating in quality early learning can boost educational attainment and income later in life – some studies have followed up participants into their 40s and 50s. A key factor in the most successful programs is very high-quality offered by well-trained staff.
  3. Preschool helps address disparities: Children from low-income families on average start kindergarten 12 to 14 months behind their peers in pre-literacy and language skills – they have the most to gain from preschool programs.
  4. We can do better: Only 41% of children from low-income families are enrolled in preschool compared to 61% of more affluent peers.
  5. Next steps: While most pediatricians inquire about early education, only a small proportion assist families in completing Head Start applications. Read the attached to learn more about options for publicly funded programs for your patients. Please remember to advocate for quality early learning settings for your patients and in our local and state policy decisions.

TOW #38: Nutrition and picky eating

We continue National Nutrition Month with another nutrition-related topic: nutrition guidance and picky eating. This is a topic close to my heart, and it's really a rich, packed one. Please try to digest (pun intended!) whatever element is most helpful for you to learn/review. 

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). Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars, which are in everything from bread to yogurt to beverages, and eating less processed foods. As the daughter of a cardiologist, I've 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.
  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 the effects of a purely fast food diet), but 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 (which our own amazing Dr. Lenna Liu has been teaching residents about), raising our own food through gardening, and creating a positive environment for eating without distractions.
  3. Review with families the Division of Responsibility for feeding, especially for picky eaters ("parent is responsible for what, where, when and child is responsible for how much"). Ellyn Satter, a 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 intake 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 (and will seem much pickier!)
  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 preferred. It doesn't have to be at dinner, if that doesn't work for families, but find meals they can eat and enjoy together regularly. We have found one way to do this is to start our family dinners with a gratitude practice.
  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 study published in Pediatrics in 2016 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.

TOW #37: Failure to thrive

It's national nutrition month, so we are going to focus on a couple of nutrition-related topics this month. Next up in TOW-land: failure to thrive. Some of the approach to this topic has evolved, including starting with less medicalization/work-up and reserving hospitalization to limited situations. Great clinical pearl from the astute R3 Dr. Caleb Stokes MD PhD: "someone in Canada (where everyone is nicer) gave me the suggestion of calling it "slow to thrive" so new parents don't feel like they or their child is failing." 

Materials for next week:

Failure to Thrive (FTT) take-home points to review:

  1. Diagnosis of FTT starts with appropriate growth measurement and correct data input on the growth chart/EMR. Re-measure when a child plots below the 5th percentile (or any measurement not tracking) to ensure accuracy. FTT can be missed or misdiagnosed due to incorrect measurement/ data input. In children less than 2 years of age, we use recumbent length (not height). Measure head circumference until age 3.
  2. Plot the growth trajectory on the appropriate chart. Use the World Health Organization (WHO) charts for children aged 0 to 2, Centers for Disease Control and Prevention (CDC) charts for children over 2, or a need-specific growth curve (e.g., premature infants, Down syndrome) available from the CDC.
  3. FTT is not considered a syndrome but is a physical sign of inadequate nutrition to maintain growth. It has several definitions: most common being less than 3rd percentile weight-for-age on more than one occasion OR crossing two major percentiles (90th, 75th, 50th, 25th, 10th, and 5th) downward. Shifts in percentiles can be normal in healthy developing children. In one study, between birth and 6 months of age, 39% of healthy children crossed two major percentile lines (up or down), as did 6% to 15% of children between 6 and 24 months of age.
  4. Use the history and physical to help differentiate FTT etiology: 1) inadequate caloric intake, 2) inadequate absorption, 3) excess demand or 4) inadequate utilization (or some combination). There are no routine lab tests for FTT and only 1-2% of diagnostic tests ordered in the hospital for FTT evaluation help to establish an etiology. If no obvious concerns on history or physical suggest medical disease, we can start nutritional and social therapy before obtaining more work-up (which might inlude CBC, urinalysis and lead levels). FTT due to low caloric intake will result in decreased weight followed by decreased height (stunting), and finally, if severe, decreased head circumference. Head circumference tends to be spared from , so think about congenital abnormalities if there is a pattern of more symmetric decrease across all three growth parameters.
  5. Hospitalization for FTT should be limited to more severe cases not responding to intervention or for short stay where coordinating multidisciplinary care is considered most helpful. Note that in-hospital weight gain has been studied, and has not been shown to be sensitive or specific indicator for non-organic FTT.


TOW #36: Learning disabilities

Our role in addressing child development extends into the school years as we help children when there are concerns about school performance. We have recently had a number of discussions at our Harborview clinic about how to help patients navigate the system when there are school issues. This is a really important topic for us to be knowledgeable about to support families and partner effectively with schools.

Materials for this week:

Take-home points:

  1. Epidemiology: the lifetime prevalence of learning disabilities in US children is 5-10%, so should be considered when children are having school difficulties. Learning disabilities are heritable, but specific genes are still being identified. fMRI studies show children's brains with learning disabilities differ in structure and  function.
  2. Definition: A learning disability is usually defined "as an unexpected, specific, and persistent failure to acquire efficient academic skills despite conventional instruction, adequate intelligence, and sociocultural opportunity." Typically, they are divided into verbal/language (which affects more children (~80% with learning disabilities) including dyslexia, i.e., difficulty reading, dysgraphia, i.e., difficulty writing) and non-verbal (dyscalculia, including problems with visual-spatial relations, math, and problem solving), but there is a lot of overlap and children often have both.
  3. Pediatrician’s role in diagnosis: Usually, behavior problems are the first presenting symptoms. Children may act out because they cannot meet the demands or may have difficulty paying attention to material they don’t understand. We should first identify or exclude other causes that impact academic performance such as psychosocial issues (e.g., abuse, neglect), medical (e.g., prematurity, drug exposure, hearing/vision problems) and developmental (e.g., ADHD) problems. Formal testing required to confirm a specific diagnosis is typically left to the school. We can refer the child to the school’s committee on special education for evaluation. The request should be in made in writing by the parent, and we can often be helpful by including a note outlining specific concerns. In certain cases, we can refer for advanced evaluation by a psychologist or developmental-behavioral pediatrician.
  4. Our role in monitoring: Our role includes being an advocate for the child in interfacing with school personnel, assisting the family in understanding the diagnosis and monitoring progress. We should routinely screen for associated problems that can arise such as new behavioral difficulties, anxiety, and depression.
  5. Interfacing with schools: First, we have to obtain permission with a signed Release of Information form from the parents. An important law to be aware of is the Individuals with Disabilities Education Improvement Act (IDEA) part B, a federal law ensuring that all students ages 3-21 receive a free and appropriate public education under the least restrictive environment regardless of disability. If a child is found to qualify for special education services under IDEA laws, an individualized education program (IEP) is created, outlining the plan for special education service. We can access the Medical-Legal Partnership if we feel that children are not receiving services they are eligible for under the law.

TOW #35: Promoting wellness/self-care with patients

While the residents are getting a wellness boost in the midst of finishing up the winter season, it's a great time to consider ways we can discuss these strategies with patients and review materials that are out there. We can "walk the talk" – on both our own care and sharing these strategies with families.

Materials/Resources for this week:

Take-home points for promoting wellness and self-care among our patients:

  1. Rising concerns about teen stress and mental health: As rates of depression and anxiety have risen for kids and teens, we are called upon as pediatricians to become more comfortable discussing these conditions – and what we can do about them – with our patients. Many teens may take some time to warm up to the idea of seeing a therapist or another provider, so you will be their first stop, and sometimes the only one.
  2. Priorities for wellness promotion: just as for us, sleep, nutrition, and physical activity are all biggies for youth, but increasingly tools like relaxation skills (e.g. breathing techniques, stretching), biofeedback, mindful eating, and positive psychology practices like offering gratitude have shown success among youth.
  3. Wellness is a suite of activities, most are learned skills: long before the frontal lobe is fully developed, we can practice self-care and wellness. These skills are not necessarily innate, so we get better with practice: think of them like exercises for the mind. I also have found traction reminding patients that professional athletes get help to build these skills to perform at the top levels!
  4. Offer resources for parents to support their children/teens: Parents are crucial in offering guidance, resources, and role modeling, so involve them. Many resources are available for parents to learn about self-care strategies for their teens, like this one on managing stress before it gets to be too much.
  5. Walk the talk: "doctor, heal thyself" is a well known expression in medicine. Be familiar with self-care techniques, find ones that work for you, and share options with your patients- we can all be more deliberate about self-care/wellness amidst the daily stressors of life.

Have a great week full of wellness!