TOW #18: Lead screening

We are continuing our advocacy-related theme topics over the next few weeks during the REACH Pathway month. There has been tremendous advocacy done by pediatricians to help prevent and address lead toxicity. Most recently this has included the inspiring work by pediatrician Dr. Mona Hanna-Attisha in Flint MI who was one of the first people to raise awareness about dangerous lead levels in the water supply 2 years ago. We are fortunate to have two prominent environmental health pediatricians, Drs. Catherine Karr and Sheela Sathyanarayana, in the general pediatrics team here at UW who do research and advocacy to keep children safe from toxins. They both contributed to this teaching topic.

Materials for this week:

Take-home points for lead screening

  1. What is a safe blood lead level (BLL)? Based on strong research evidence, no measurable BLL is considered safe. Neurotoxicity associated with lower BLLs has been established by overwhelmingly consistent evidence from meta-analysis, so primary prevention of lead exposure is paramount. All detectable BLLs are reportable in WA State and the health department follows up with all BLLs > 5 mcg/dL.
  2. Why screen for lead? While lead is toxic to multiple body systems, the developing brain is particularly vulnerable. Most lead toxicity in the US is sub-clinical, only found on blood testing. Even low levels (<10mcg/dL) may be associated with behavioral problems (such as attention, aggression) and learning difficulties. Children aged 9-24 months are highest risk due to normal exploratory behavior – crawling, teething, putting non food objects in the mouth. Absorption across the gut is greater in children than adults.
  3. What are the sources of elevated lead levels? Ingestion of lead-containing dust or soil is the highest source, usually from old paint in homes built before 1950, but up through 1978, and homes from these eras being remodeled. As we have learned from Flint MI, lead is also in water sources, from contaminated water and old pipes. There are also newer sources of lead in imported products including candies, food, spices, make-up, and ceramics.
  4. Who should receive blood lead testing? In WA state, the 2016 guidelines identify children with these risk factors: 1) Lives in or regularly visits any house built before 1950 or built before 1978 with recent or ongoing renovations or remodeling, 2) From a low income family (<130% of the poverty level). (Federal law mandates screening for all children covered by Medicaid), 3) Known to have a sibling or frequent playmate with an elevated blood lead level, 4) Is a recent immigrant, refugee, foreign adoptee, or child in foster care, 5) Has a parent or principal caregiver who works professionally or recreationally with lead, 6) Uses traditional, folk, or ethnic remedies or cosmetics. Unfortunately, screening questionnaires have not reliably identified kids, as one of our residents found for a topic review at Harborview, so when in doubt, screen.
  5. What do you do with an elevated level? The PEHSU provides a summary of key next steps based on BLL results on their website. Next steps will include evaluation for anemia/nutrition since this may impact lead absorption, as well as determining the need for imaging or medical management.

TOW #17: Medical-legal partnership

Next week’s topic is the Medical –Legal Partnership model, to remind us to collaborate and refer our patients/families to legal support. We are fortunate to have our own MLP in Washington originally formed as a partnership which included Harborview, Odessa Brown and local attorneys. The current Washington MLP directors are our own amazing Drs. Ben Danielson and Brian Johnston and SCH director Annette Quayle. Scott Crain JD at the Northwest Justice Project has been instrumental in addressing legal problems for pediatric patients in our system and teaching residents and others about the program. He now works with a team of lawyers as the MLP has grown. A huge thank you to Scott and his colleagues for their important work!

Materials for this week:

Take-home points regarding Medical-Legal Partnerships (MLP):

  1. History of the MLP model: The MLP model was first started at Boston Medical Center over 20 years ago and has been gaining in reach and availability. Hundreds of formal MLPs now exist in health care settings. Research has demonstrated their effectiveness in improving outcomes in primary care.
  2. Why we need MLPs: Given that more than 20% of children live in poverty in the US and close to 40% live in near poverty, pediatricians can best address the needs of the whole child by engaging with multi-disciplinary teams including legal professionals and social work to advocate for our patients. While we cannot know the intricacies of benefit eligibility, we can screen for needs and refer. Approximately 50% of all low to moderate- income households are estimated to have at least one unmet legal need (e.g., public benefit denial or unsafe housing, access to education services, etc).
  3. Use a screening tool to assess need: Use the I-HELP mnemonic (Income, Housing, Education/ Employment, Legal Status, and Personal and Family Stability and Safety) to help screen for needs.
  4. MLPs can address social determinants of health: In one study, families referred to an MLP showed increased access to health care, food, and income resources; two- thirds reported improved child health and well- being. An important note about legal services provided by the Washington MLP: it does not handle malpractice, criminal issues, personal injury or other fee-generating cases, or other civil legal cases where a referral for services is readily available elsewhere. They do not handle immigration-related legal issues, but do work closely with and refer to the Northwest Immigrant Rights Project.
  5. Residents can be instrumental in MLPs: One study documented that residents made over 40% of the referrals in a pediatric continuity clinic. Patients of residents at Seattle Children’s are eligible to have referral to the MLP, in addition to the partner clinics involved.

Here’s to advocating and teaching others to advocate!

TOW #16: Acne

One of the great things about general pediatrics is seeing patients of all ages, from newborns to adolescents, often back-to-back in clinic. We covered newborn concerns last week, so this week we’ll review a topic near and dear to adolescents: acne!

Acne is a near ubiquitous experience of adolescence, and one of the more distressing aspects to teens. We are poised to be frontline helping them deal with it. Materials for this week:

Take-home points for this week on acne:

  1. Epidemiology: Acne is the most common skin disorder in the United States, affecting approximately 85% of young people between 12 and 24 years of age. Adolescent acne usually begins with puberty onset, occurring earlier in girls than boys. Most people outgrow it, but 12% of women and 3% of men continue to have clinical acne at 44 years of age.
  2. Pathogenesis: Acne is chronic inflammation of the pilosebaceous unit, which consists of a hair, its associated sebaceous gland, and the opening to the skin surface known as the follicular ostium (“pore”). These are concentrated on the face, back and chest, where acne mostly occurs. Four interrelated processes contribute to acne development: 1) abnormal keratinization obstructing the follicle, 2) androgen stimulation and increased sebum production, 3) secondary inflammation, and 4) proliferation of bacteria. Genetics and environment influence these processes.
  3. Misconceptions of acne causes: For many years, avoiding foods such as chocolate, soft drinks, milk, fatty foods, and ice cream was recommended; however, the literature does not support these restrictions to decrease acne (though warranted for obesity). Dirt or poor hygiene do not cause acne, so frequent face washing does not improve acne and may worsen it through irritation.
  4. Knowing the acne severity grading can help with determining appropriate treatment strategies.
Acne severity grading
Grading
Lesion Type
Distribution
Scarring
Mild
Few to several comedones, few scattered papules
Less than 1/4 of the face, mostly T zone
None
Moderate
Many papules and pustules, variable comedones, 1-2 nodules
Roughly 1/2 face
Few, shallow
Severe
Numerous papules and pustules and nodules; variable comedones; sinus tracts and/or cysts
Face, back, and/or
chest
Moderate to extensive, hypertrophic and/or deep

 

  1. Treatment: Topical agents treat the different causes: retinoids treat keratinization, benzoyl peroxide treats secondary inflammation and bacteria, and topical antibiotics treat bacteria. Topical agents are first line for mild and moderate, while oral agents (antibiotics, oral tretinoin – Accutane, oral contraceptives) are used for severe cases. For mild acne, we often start with a single agent – either a retinoid or benzoyl peroxide (note benzoyl peroxide 5% has been found as good as 10% with less side effects). For mild to moderate, combine agents that address different pathways (retinoid + BP or topical antibiotic). Anticipatory guidance is critical to adherence: topical medications are preventive and require 8 to 12 weeks to assess efficacy. The entire area affected must be treated, not just current lesions, and long-term therapy usually is required. Clinical tip: recently most insurance plans are covering the combination product OTC Differin gel 0.1% instead of tretinoin (Retin-A). Our pharmacists report this product to be similarly effective and better tolerated than tretinoin. Notes on how to order this in Epic.

TOW #15: Newborn concerns

Next week’s topic is about babies! For many of us, one joy of general pediatrics is the chance to care for babies. Babies are each a little miracle, and as we welcome them into the world, they bring us hopefulness and faith in humanity. As Henry David Thoreau said “Every child begins the world again.” We could use an extra dose of that right now.

Note: this is a great topic for you senior residents to lead the discussion!

Materials for this week:

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 (PFR) training this year, this would be a perfect topic to review with your clinic team and patient families.
  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.
  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. 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 to facilitate honest conversatoins. Review evidence and encourage room-sharing rather than bed sharing. The AAP has sleep guidelines out now that recommend 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)!