TOW #42: Vision problems

The eyes are the window to the soul, as the saying goes. If that's the case, we get to see all kids' souls if we are doing our jobs! We have a critical role in helping ensure that children's vision is developing appropriately, and intervening early when problems are detected. There is good evidence that we have a role in early identification of vision problems through vision screening, so it's recommended by the US Preventive Services Task Force.

Materials for this week:

Take-home points for vision assessment and problems:

  1. What are recommended vision screening guidelines? US Preventive Services Task Force recommends children <5 be screened to detect amblyopia, strabismus, and visual acuity defects. AAP guidelines include screening at all well visits, from newborn to age 3 using history, vision assessment, external exam, eye movements, pupil exam, and red reflexes. For ages 3 to 5, the AAP recommends adding age-appropriate visual acuity and direct ophthalmoscopy.
  2. Visual system development occurs throughout infancy and childhood and represents a "critical period" of vision development. Early on, we can test visual acuity by testing fix and follow for each eye by covering one at a time. By age 3-4 (up until 60 months), children should be able to see 20/40 on an age-appropriate eye chart, and by age 5 (60 months), should be 20/20. The visual system development is complete by age 8-10.
  3. Reasons for early referral: 1) persistent ocular deviation at 4 months of age; 2) asymmetry of appearance on the simultaneous red reflex test; 3) unexplained torticollis; 4) any witness of lack of ocular alignment or parental concern about ocular alignment (even if it's “just when tired”), and lack of visual acuity in each eye for age.
  4. Amblyopia or "lazy eye" is decreased vision in one or both eyes due to abnormal development of visual pathways in infancy or childhood. It is the leading cause of vision loss among children with a prevalence of 1-4%. Causes include deprivation (e.g., cataracts), strabismus (misalignment), and refractive error (nearsightedness, farsightedness or astigmatism (abnormal curvature of the lens)). Early treatment is important, but there is some evidence that treatment can help up to age 14. Treatment includes correcting refractive errors with glasses and patching to strengthen the weaker eye. Patching may start to improve vision within a few weeks, but usually lasts months. 
  5. Strabismus – eye misalignment is present in about 4% of kids. It can be identified via Corneal Light Reflex and Cover-Uncover test. For the corneal light reflex, when shining a light directly onto both eyes, if the light reflex is displaced nasally, this finding indicates an exotropia (the eye is turned out). When the light reflex is displaced temporally, this finding indicates an esotropia (the eye is turned in). The cover-uncover test should be performed while the child fixates on a small, interesting target, such as a small toy or sticker on a tongue depressor. (NOTE: a bright beam of a light may not provide as comfortable a target and does not adequately stimulate accommodation/focusing). As the child attends to the target, each eye is alternately covered. A shift in an eye’s alignment as it assumes fixation onto the target is a possible indication of strabismus.

TOW #41: Child abuse recognition and prevention

April is child abuse prevention month, so we are going to discuss this always challenging but critical topic in our field. We owe gratitude to the SCAN and CPS teams who work so hard to help evaluate and keep children safe. Our role in primary care encompasses strategies to build resilience, promote strong relationships/bonds, link families to resources, and screen and refer for concerns. The Protection, Advocacy and Outreach team at SCH has 3 prevention programs including Period of PURPLE crying, Medical-Legal Partnership and Positive Parenting (which provides funding for our Promoting First Relationships (PFR) training for residents).

Materials for this week:

Take-home points for child abuse recognition:

  1. We are mandated reporters for suspected child abuse and neglect and any allegations of sexual abuse. We are likely to encounter child maltreatment in our practices: 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child. It includes lack of adequate nutrition, hygiene, shelter, and safety.
  3. Corporal punishment is not recommended in any form by the AAP. Spanking (i.e., using “an open hand on the buttocks or extremities with the intention of modifying behavior without causing physical injury”) is the least objectionable, but is considered maltreatment if it is done so hard as to leave a bruise.
  4. Children of all SES levels are at risk for child abuse. In ~80% of cases, parents are perpetrators of child maltreatment. Some specific parent-level risk factors for child abuse include parent poverty, parent of multiple children under 5, history of substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for child development. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired pregnancy; or multiple gestation pregnancy.
  5. Bruising is the most overlooked form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising more associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and a referral to CPS. It's important for us to be aware of the bruising: before getting a diagnosis of child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury. 

TOW #40: LGBTQ Youth Health

This week's topic comes to us thanks to Dr. David Breland, one of our fabulous adolescent medicine docs, who provided the materials. If you are interested in more on adolescent health, check out the Teenology 101 blog by Dr. Yolanda Evans and specifically the LGBTQ articles. Also check out R3 Gwen Lieb's wonderful RCT on transgender youth that she presented this year.

Materials for this week:

Take home points for LGBTQ youth health:

  1. Most people who identify as LGBQT are healthy, however, there is a disproportionate number of LGBTQ youth who face barriers to health care and mental health problems, usually as a result of sexual prejudice and lack of family/community support.
  2. Recent studies estimate that somewhere between 3 and 10% of the adult population is LGBT. Estimates in teenage years are difficult because the sexual identity is evolving. Around 25% of 12 year olds feel uncertain about their sexual orientation.
  3. Begin to talk to patients separately from their parents by age 11 or 12 to allow them to speak with you confidentially. In visits with adolescents, we should explicitly remind them of confidentiality and use non-judgmental, gender-neutral language. Tailor the HEADSSS assessment to their age/development. In the study on LGBTQ youth health care preferences linked above, youth felt that provider qualities and interpersonal skills were just as important as provider knowledge and experience, and they placed little importance on a provider’s gender and sexual orientation.
  4. We should cover sexual attraction and sexual identity when we discuss sexual health. We can explain to patients we ask about their sexual health as part of routine visits because it's an important part of life, and we want all youth to feel comfortable and supported. We should ask adolescent patients about who they feel attracted to: “Do you feel attracted to girls, boys, both or neither?" Asking about gender identity can be done as: "do you identify with being male, female, both or neither?" 
  5. Recognize that LGBTQ patients have similar or elevated STI risks. We should provide counseling about safe sex and birth control to all adolescents. Female patients that identify as lesbian may still have male partners, so are at risk for STIs and pregnancy and should have PAP smears. Male patients have higher rates of STI exposure (in King Co in 2015 exposure rate was 44% among 15-19 yo men who have sex with men).