TOW #25: Health literacy

In pediatrics, we care for children of very diverse backgrounds, which is part of the joy of our work. One challenge for parents is interpreting our guidance and instructions. This is especially difficult if parents have lower health literacy, which encompasses reading and numeric interpretation. One of our wonderful hospitalists, Dr. Sarah Zaman, has done research to assess parents’ knowledge of their child’s diagnosis at Seattle Children’s and showed that many parents do not even understand the basics of the diagnosis. The quote from George Bernard Shaw sums up the challenge: “The problem with communication is the illusion that it has occurred.”

We can assess health literacy and practice skills to provide information to families to ensure they understand us. (See the related topic on helping families with Limited English proficiency)

Here are the materials for this week:

Take-home points on assessing and augmenting health literacy:

  1. How do we define “health literacy”? Health literacy is defined by the AMA as “the ability to perform basic reading and numerical tasks required to function in the health care environment.”
  2. How common is low health literacy? More than 1/3 of adults are considered to have basic or below basic health literacy, meaning they may struggle with understanding growth charts, immunization schedules or dosing medication. Many people read below the highest grade they completed, and most adults read at an 8th-9th grade level, while health care material is often written at a 10th grade level. While our knowledge base has exploded and there is more access than ever to information, as Dr. Koh writes in his commentary in JAMA (above), “The paradox is that people are awash in knowledge they may be unable to use.”
  3. What are ways to assess health literacy? We can assess health literacy using validated tools or, more practically, understanding risk factors: for pediatric caregivers these include not completing 12th grade, not living with the child’s other parent, and not reading for pleasure. These are all associated with 6th grade or below reading level.
  4. How should we approach low health literacy? A “universal precautions” approach is recommended, regardless of a person’s health literacy. This means we should explain things as clearly as we can to everyone using “living room language”. We can ask directly if they have a medical background, which can sometimes help us tailor our information; however, we still need to be careful about making assumptions of what people know/understand. A few examples illustrate this: my spouse, who has a non-medical doctorate and a better vocabulary than me, has to remind me when he does not know medical terminology during our conversations. Even parents who have medical careers but work with adults often will admit they do not feel comfortable or familiar with pediatric issues.
  5. What strategies have been shown to improve understanding? One of the best is the Teach-Back Method, asking parents/adolescents to repeat back the plan. Trainees sometimes worry this may sound condescending, but we can use it in a self-deprecating way: “I know this can be confusing, and I want to make sure I have explained things clearly. Would you mind repeating back what you heard so we can be sure it made sense to you?” Teach-back is associated with increased patient-centered communication in pediatric primary care. Another very effective approach is to use pictures. A review of articles that used pictures in medical teaching showed that patients recalled 1.5-2 times more information with pictures. A great way to do this in clinic is to draw on the exam table paper. I love using this as an opportunity to teach kids / parents more about how the human body works. Finally, use easy-to-read measuring tools for dosing medications, including clearly marked syringes that are close in size to the prescribed dosage.

TOW #24: Discipline

This week’s topic comes courtesy of the expertise of our own wonderful Dr. McPhillips. We have certainly been the beneficiary of her sage advice in our household.

Materials for this week:

Take-home points for discipline:

  1. Definition: Discipline means “to teach” and should not be confused with “punishment.” Fundamentally, we want children to know that we love them and care about them, and that’s why we set age-appropriate limits. We promote “positive discipline” in pediatrics: having a loving relationship, teaching and modeling what we want them to do (and setting up their environment for them to be successful), and reinforcing limits by decreasing unwanted behaviors without shaming or corporal punishment.
  2. Extremes in discipline are a problem: Authoritarian parenting tends to be overly restrictive, demanding, and “doing it because I say so.” Permissive parenting is too loose and sets few limits, allowing a child too much leeway in deciding the rules. The best outcomes are with an authoritative approach: being firm AND loving, setting limits and knowing it’s okay, providing boundaries and opportunities to make decisions within those boundaries.
  3. Spanking is not recommended. While spanking may still be used by a lot of parents, it has many negative associations including increased aggression, emotional distress, and escalating to abuse, and is less effective at older ages. We can direct families to more effective strategies and help explain that spanking overall is a less effective strategy. Check out this interesting infographic about spanking.
  4. Time-outs are one strategy; if used, know some pitfalls. Time-outs are one strategy used to remove children from a situation where they may be harming themselves or others and to reinforce calming themselves down before re-joining activity. These have become more controversial among discipline experts and alternatives are offered, especially parent time-outs! Those who advocate child time-outs remind us they should not be viewed as punishment, and are especially preferred to physical punishment. To be effective, time-outs need to be consistent, kept short, and clear. Parents need to be calm and use few words and to convey that they are not leaving/abandoning their child.
  5. Help parents recognize triggers and build positive connections. We want to help parents recognize their child’s needs, especially for love and connection, and know their child’s triggers for negative behavior. One great trigger acronym I’ve learned from my husband (a clinical psychologist) is HALT: Hungry, Angry, Lonely, Tired. These triggers are true for all of us but especially for young children. Recognizing meltdowns/ misbehavior as a sign of unmet need in a little one can help us be more empathic and calm in our responses as adults. The PFR approach offers some strategies to help us prompt this dialogue like hitting the “pause” button and asking “wondering questions” that allow parents to tune in to what children may be feeling and experiencing.

TOW #23: Hypertension

This year, updated guidelines for hypertension were released by the AAP with the lead author our own nephrologist, Dr. Joseph Flynn. Next week we will focus on reviewing this topic and familiarizing ourselves with the updates. This is a dense one, so try to at least review some of the key tables and summarized recommendations in the practice guidelines.

Materials for this week:

Take-home points:

  1. How do we define “hypertension” in the pediatric patient? What’s the difference between elevated BP (previously “prehypertension”), stage 1 hypertension, and stage 2 hypertension? There is no known cut-off for elevated BP in childhood that affects cardiovascular (CV) outcomes, so the definition of HTN in children and adolescents is based on the normative distribution of BP in healthy children (excluding those with overweight/obesity) based age, sex and height. Height has been incorporated since 1996 since it affects BP measurement. Persistently elevated BP (formerly termed “prehypertension,”) is defined as BP values from the 90th to 94th percentiles or between 120/80 and 130/80 mmHg in adolescents. Stage 1 HTN is defined as auscultatory-confirmed BP readings at 3 different visits ≥95th percentile (or <95th percentile +12 mmHg) or 130/80 to 139/89 mmHg (whichever is lower). Stage 2 HTN is ≥95th percentile + 12 mmHg, or ≥140/90 mmHg (whichever is lower). Thankfully, for adolescents it’s easier to remember as Stage 1 and 2 are aligned with adults, so it’s 130/80 to 139/89 mmHg or ≥140/90 mmHg, respectively.
  2. What’s the prevalence of clinical HTN in children and adolescents? Prevalence of HTN is ∼3.5%.‍ Persistently elevated BP (formerly termed “prehypertension”) is also ∼2.2% to 3.5%. The rates are higher among children and adolescents who have overweight and obesity, so these children’s data were removed from the new tables in the updated guidelines (cut-points are therefore lower than they used to be).‍
  3. Which children and adolescents need regular blood pressure monitoring and how should BP be obtained? We should be checking BP annually at all well visits for ages 3+. We should do it at all visits for children <3 who have an underlying risk factor (e.g., prematurity <32 weeks, congenital heart disease, renal disease, UTIs, transplant, etc). The guidelines state that we can use automated oscillometric devices for BP measurement, as long as they are validated for pediatrics. If elevated BP is suspected, we should confirm with auscultation. If the initial BP at an office visit is elevated, we should obtain 2 additional BP measurements at the same visit and average them, then use the averaged auscultatory BP measurement to determine the patient’s BP category (throwing out the automated one). If HTN is suspected/diagnosed, we should do ambulatory blood pressure monitoring to rule out white coat hypertension and determine persistence/severity of HTN.
  4. What work-up do we need to do to evaluate for secondary causes, comorbidities, and end-organ damage in the pediatric hypertensive patient? Use the history and PE to identify possible underlying causes of HTN, such as heart disease, kidney disease, renovascular disease, endocrine-related, drug-induced, and sleep apnea-associated HTN. Recommended work-up for all patients includes: BP of both upper extremities and at least 1 leg BP, Urinalysis, Chemistry panel (including electrolytes, BUN/Cr), Lipid profile (fasting or nonfasting), Renal ultrasonography in those <6 y of age or those with abnormal urinalysis or renal function. Children and adolescents ≥6 y of age do not require an extensive work-up for secondary causes of HTN if they have a positive family history of HTN, are overweight or obese, and/or do not have history or physical examination findings suggestive of a secondary cause of HTN. If starting pharmacologic treatment for HTN, it is recommended that echocardiography be done to assess for cardiac organ damage.
  5. How do we treat hypertension in children? The treatment goal is reduction in SBP and DBP to <90th percentile and <130/80 mmHg in adolescents ≥ 13yo. At the time of diagnosis of elevated BP or HTN, we should provide advice on the DASH diet (which has evidence of benefit for youth) and recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) (evidence level C). We should also consider subspecialty referral. If lifestyle modifications are not successful, and especially if there is LV hypertrophy on echo, symptomatic HTN, or stage 2 HTN, clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic.