TOW #29: Infant sleep

Infant sleep is among the highest priority areas that we address in the early months, both from a safety and a quality of life standpoint. Those who have experienced a difficult sleeper can empathize with how incredibly challenging this is. The recommendation for Back to Sleep is unquestioned, but some other infant sleep guidance is less clearcut. It’s helpful to be familiar with various sleep recommendations to help families navigate these.

Materials this week:

Take-home points to review on infant sleep:

  1. Epidemiology of SIDS: Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant less than 1 year of age which remains unexplained after autopsy & review of death. Reducing SIDS through the Back to Sleep campaign has been a great success in pediatrics, as SIDS rates decreased by half since implementation in 1992. It is considered one of the top 7 research achievements in pediatrics. SIDS is uncommon before 1 month of age (~10% of SIDS deaths), peaks between 1 and 6 months of age, and is rare after 8 months.
  2. What are some risk factors for SIDS? SIDS involves convergence of 3 factors – environmental factors, a critical period of development, and intrinsic vulnerability (i.e., dysfunctional or immature cardiorespiratory systems). Environmental risks include prone sleep position, sleeping on a soft surface, bed sharing, young maternal age, overheating, multiple births, and multiple siblings. Intrinsic vulnerabillity includes preterm birth, low birth weight, male sex, maternal smoking during pregnancy, previous stillbirths, as well as URI infections.
  3. How should we discuss infant sleep? Our role is to support families with accurate information and explore their beliefs. In a 2012 study, less than half (43.5%) of internet resources contained accurate information about infant sleep. Ask open-ended questions about where baby is sleeping and in what position. Safest sleep for babies is on their backs in their own sleeping unit in the parents’ room without extra blankets or stuffed animals. Co-sleeping/ bed-sharing is the highest cause of death under 3 months- it is especially dangerous if parents smoke or drink alcohol. Review evidence and encourage room-sharing rather than bed sharing.
  4. What if a baby has difficulty sleeping? There are a number of resources out there and variable recs on strategies: 1) swaddle or not (mostly yes, but not once they are rolling over, so advised to stop before 4 months), 2) swaddle with arms or legs in or not (depends on baby-generally arms in, looser on legs), 3) pacifiers or not & for how long (yes, safe, may help sleep if baby takes one, better to wean early), 4) graduated extinction “cry it out”/”Ferberizing” or not, etc. It’s hard for parents to navigate all of this, so we need to discuss what we think works (based on research, experience, family preferences, etc). Personally I liked reading Dr. Richard Ferber’s actual book Solve Your Child’s Sleep Problems (which covers much more than graduated extinction – see great dialogue where he demystifies some of the interpretations of his work). To assuage parents, there are increasing studies of sleep training demonstrating no discernible adverse effects on babies’ development (and probably the opposite given the benefits!)- see above RCT.
  5. Refer to specialists when the family/infant are struggling. In Seattle, we are lucky to have some great sleep experts at Seattle Children’s. When all else fails, time is on the side of the parents. Some of the best pediatricians I know who’ve had infants with sleep challenges tried everything without much success until their infant grew and eventually became a good sleeper. There is hope!

TOW #28: Depression

As I sit here with a lightbox trying to get some relief from mood-dampening darkness this time of year(!), it seems quite an appropriate time to review how we identify and treat depression. In the movie Inside Out, I loved how the character Sadness demonstrated that we all need a little to appreciate the fullness in life. But, of course, too much is a bad thing, and recognizing and diagnosing when the usual ups and downs becomes depression is an important part of our pediatric practice. Addressing mental health, or “brain health,” as some suggest we refer to it, is a growing part of pediatrics. Dr. Laura Richardson, division chief in adolescent medicine, is a wonderful renowned expert on addressing adolescents with depression and included below are pearls that she shared. It can be a particularly S.A.D. time of year. Fortunately, there are ways we can support our patients and each other (plug for Resident Appreciation Days coming up Jan 29-Feb 2!).

Materials for this week:

Take-home points for depression:

  1. Epidemiology: Cumulatively, an estimated 14–25% of youths have at least one episode of major depressive disorder before adulthood, and 40% of these will have a recurrent episode within 2 years. Before puberty, girls and boys have equal rates of depression, but after puberty, it’s double for girls compared to boys.
  2. Screening: PHQ-9 is a useful and validated screening tool that is becoming the default tool for adolescent depression screening, and can help to follow persistence of symptoms. Irritability is often thought of as interchangeable with depressed mood as a key criteria of depression in teens.
  3. Diagnosis: You cannot rely on a single screening test to diagnose depression – more is needed. When unsure of the diagnosis in primary care, schedule a follow-up and perform a second screening. Dr. Richardson et al. found the strongest predictors of persistent symptoms are severity of depression symptoms at the time of presentation, and continued symptoms when re-screened 6 weeks later. This speaks to the importance of assessing symptom severity and following up with repeated screening.
  4. Treatment: Pediatricians need to play an “active monitoring” role to meet with, track, and support patients to make sure that they are getting better. We can make a difference by caring, tracking symptoms, helping people get to treatment, and actively coaching them to take steps to try to feel better (through better sleep, sharing what they are feeling with family members, spending time doing something enjoyable, decreasing their stresses at school, etc). Not everyone will engage in therapy, so we may be the only treatment source. Dr. Richardson and team also found we do even better when we do collaborative care management, such as using care coordination to support ongoing check-ins.
  5. Utilize resources available: Thanks to Dr. Sheryl Morelli who helped develop a local gen peds clinical guideline to review important resources, which includes PAL guidelines/resources and the AAP Guidelines for Adolescent Depression in primary care GLAD-PC materials.

TOW #27: Motivational interviewing

Motivational interviewing seems deceptively simple in concept, and is decidedly more complicated to implement effectively in practice. The UW first year medical students just got their first intro to MI this week (it’s great we are starting exposure earlier now, to build time for lifelong practice!). MI is especially helpful for behaviors related to all of those new year’s resolutions including healthy eating, physical activity, screen time, and substance use. This week happens to be National Obesity Awareness week, and the week after next is National Drug and Alcohol Facts Week (for teens to learn science-based facts about drug use), so timely for us to review tools that can help us promote related health behaviors.

Materials for this week

Take-home points:

  1. What are the key principles of MI? Why does it work? Behavior change is challenging for all of us, and we are usually ambivalent about change (and don’t like to be told what to do!). MI is founded on helping people do their own convincing for change by using techniques to highlight “change talk”- statements from the patient that argue in favor of making a change. Key elements in this approach include: 1) collaboration, with patient-centered communication approaches fundamental to implementing MI; 2) guiding style to elicit from our patients the changes they want to make; and 3) respect for patient autonomy: we all live our own lives and can’t make changes for each other so we encourage and support (some caveats here for adolescent behaviors that may be more immediately life-threatening/illegal).
  2. What are the key strategies of MI? There are several techniques shown to be effective. We demonstrate curiosity and collaboration through open-ended questions, and use these strategically to elicit change talk. Reflections allow us to demonstrate empathic listening and highlight discrepancies between desired values/ outcomes and current behaviors. We can use 1-10 scale “rulers” to ask about the level of importance and confidence of making changes, to bring out more about why a change is important, and how certain people feel they might be able to make it. These scales can be especially useful with adolescents and their concrete thinking-it can be helpful to get them to elaborate their one-word answers! Before giving advice, we want to first ask what people already know. Then, we can use “ask-tell-ask” to ask permission, then give short concrete advice/information that might be helpful, and then ask what they think of that, or how that might relate to them. Seeking permission before offering advice helps people to be more open to hearing it. You may simply say, “do you mind if I give you some advice?” or “would you be interested in hearing what has worked for some of my patients in the past?”
  3. How do we know what to apply when? It’s helpful to remember that we all go through different stages of being ready for change. This has been described in the Transtheoretical Model for Change (TTM), otherwise known as the Stages of Change. This model describes five distinct stages, and we can tailor our counseling and discussions to meet people where they are-using ask-tell-ask and respecting autonomy when people are pre-contemplative. We can use more eliciting with open-ended questions and Rulers to help people who are more ready to make changes. The 5 stages are:
    • Pre-contemplation: the person has not considered making any change
    • Contemplation: the person has considered change, but that is all
    • Preparation: the person is making a plan of how to change
    • Action: the person is in the early stages of carrying out a plan for change
    • Maintenance: the person has made a change and is making it stick
  4. How has motivational interviewing been used in pediatrics? MI has been shown to be helpful in decreasing weight, as in the BMI2 (Brief Motivational Interviewing to reduce Body Mass Index) by Resnicow et al. which showed decreased BMI percentiles at 2-year follow-up in overweight and obese 2- to 8-year-old patients whose families received an MI intervention versus usual care. MI has been applied successfully in adolescent care to address cigarette smoking, alcohol and marijuana use, chronic disease management, and safety behaviors.

TOW #26: Otitis media

Next week’s topic is otitis media, a quintessential topic year-round in pediatrics, but particularly during viral season. Indeed, we currently have an 8 yr old at home with recent URI and 24 hours of otalgia… at her request, pediatrician mom pulled out the trusty portable otoscope from med school last night (it’s gotten good use through the years!). Sure enough, a bulging, purulent TM with severe erythema… so how do we treat, and how does that vary by age group? Let’s review!

Materials for next week:

A few take-home points:

  1. How common is acute otitis media (AOM) and what are the pathogens? AOM is the most common condition for which medications are prescribed in children. Antibiotic stewardship has become an important goal in appropriately diagnosing and treating AOM. In the current vaccine era, S. pneumonia and non-typeable Haemophilus influenzae (H. flu) are now equally prevalent (~40-45%), followed by Moraxella catarrhalis (10-15%). Much less common are staph and group A strep. Viruses are also common and usually concurrent with the bacteria; in one study, 92% of AOM fluid had a bacteria, 70% had a virus, and 66% had both a virus and bacteria.
  2. What are the criteria to diagnose AOM? This has evolved somewhat through the years. The most recent guidelines have 3 main diagnostic components: 1) AOM is diagnosed in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa; 2) AOM may be diagnosed in children with “mild bulging of the TM” AND either “recent (less than 48 hours) onset of ear pain” (including rubbing, tugging, or holding in a nonverbal child) or “intense erythema of the TM;” 3) Diagnosis should NOT be made in children without middle ear effusion based on pneumatic otoscopy or tympanometry (we enhance the accuracy of diagnosis with pneumatic techniques especially for inconclusive visual findings). Studies have found a bulging TM has the highest predictive value for AOM, followed by a cloudy TM and impaired TM mobility. Note, slight redness of the TM does not indicate AOM, though moderate to severe erythema (including hemorrhagic) does correlate with AOM.
  3. How should we treat otalgia of AOM? Pain should be assessed with AOM, and we should provide clear guidance on how to manage it with oral analgesics. My daughter got a dose of ibuprofen last night (preferred at our house given the longer half life and dosing every 6 hours, and better taste of the generic brand compared to acetaminophen, per my kids’ taste buds!). It’s important to counsel that the ear pain may require scheduled pain medication for a day or two. We no longer have prescription topical otic analgesics on the market, as the prior medications were pulled by the FDA due to concerns about lack of safety and efficacy. To my knowledge, OTC otic analgesics (such as homeopathic or herbal remedies) have not been adequately studied to recommend them.
  4. When should we use antibiotics to treat? Antibiotics should be provided for children under 2 when AOM is diagnosed, unless it’s unilateral AOM and non-severe presentation (afebrile, mild otalgia), then we can use observation when jointly decided with parents. For children over 2 yo we can treat, or observe if they are non-severe, based on joint decision making. One recent RCT showed that middle ear effusion did indeed persist longer for children not treated (as above). For my daughter, given her age group and unilaterality, we are currently trying the watchful waiting approach and hoping for resolution (promising sign she slept well and had no complaints of pain this morning!). In her last bout a couple of years ago, after days of otalgia (pediatrician mom was stubbornly holding out), she had great improvement within 24 hours of starting antibiotics; it was a good reminder they really are warranted in some cases.
  5. What antibiotic treatment should we use? As pediatricians, we should probably be able to answer this in our sleep! High-dose amoxicillin (80-90mg/kg divided BID, up to 3g daily) remains the initial antibiotic of choice. Although beta-lactamase production is common among certain AOM pathogens (e.g., H. flu, M. catarrhalis), severe, invasive disease is often associated with Group A strep (susceptible to amox), or S. pneumoniae, whose resistance from penicillin-binding-proteins can be overcome by using high-dose regimens. Treatment duration is 10 days for children with severe disease or under 2 years of age. Shorter duration is appropriate for children >2yo with mild disease: 7 days in 2 to 5 years old, and 5-7 days in children over 5. We use amoxicillin-clavulanate (Augmentin, 90mg/kg/day divided BID) for children who either received amox in the past 30 days, have had recurrent infection unresponsive to amox, or have concurrent purulent conjunctivitis concerning for otitis-conjunctivitis syndrome (more likely non-typeable H. flu). If patients are allergic to penicillin, then we should choose a 2nd or 3rd generation cephalosporin (macrolides are not recommended), orally, or we can do 1-3 days of ceftriaxone IM (most respond to 1 dose, but there’s less treatment failure with 3).