2018-19 TOW #1: Agenda setting

Welcome to TOW 2018-19!

About TOW: I’m excited to kick off another year of continuity clinic teaching and our TOW series. A big welcome to our fabulous new crew of interns! TOW is intended to provide standard teaching topics that allow us to review key aspects of outpatient care for children. Each month I try to include a range of topics so that if you’re on a clinic month you’ll have variety, from well visits to acute care issues that affect all ages, including social determinants of health. The format is structured around case-based resources and review materials that can stimulate discussion. For each topic, I write a brief bulleted highlight of the topic that everyone can review by email, whether they are in clinic that week or not. I’ve created a blog format with hyperlinked resources and key-word linked, so hopefully it’s easy to access anytime. There are 50 topics per year over a 2 year cycle, and you can also review archived topics (including age-based well visit review from last year’s set). The scheduled topics for the year will be posted on the blog sidebar. Here’s the blog link you can bookmark: http://depts.washington.edu/uwpeds/tow/

This week’s topic is agenda setting, which we are doing early in the year to review the importance of setting an agenda in outpatient visits, which by nature have fixed times and require prioritizing. Agenda setting allows us to make sure we have addressed the most important concerns for the family, and balance these with our own agenda for the visit. This is really important in building relationships with families and helping them feel that we are responsive to their needs.

Materials for this week:

Take-home points for setting the agenda:

  1. What is agenda setting? A brief dialogue at the beginning of the visit between patient/family and clinician to ensure we can agree on the most important priorities for the visit. It can be as simple as opening with “What concerns do you want to be sure we discuss today?” or “What are your priorities for today’s visit?” Asking “what else?” until no more concerns come up can help us elicit all concerns and set priorities. We can then follow with adding ours: “Thank you. That’s really helpful – I agree those are important. I also want to be sure we talk about X today. Is that okay?”
  2. Why agenda setting is important? Multiple reasons: Agenda setting helps us 1) address the most important family concerns (we can easily fill the time with our own agenda/priorities in well child checks), 2) avoid trying to do too much with one visit and running behind, and 3) not hearing about a major issue until the end of a visit – “the doorknob complaint.” Some studies have found that up to half of patient complaints and symptoms were not elicited in an interview. The likelihood of psychosocial complaints being brought up without asking about them is especially low.
  3. What are barriers to agenda setting? Our biggest concern is that it will take too much time. Actually, doing agenda setting well has been found to add just seconds to the visit and helps avoid the doorknob complaints that can take a lot of time. Another concern is that too many issues will be elicited. Adult studies have found that patients typically have 2-3 concerns (up to 5), and this seems to be similar for pediatric visits. When a long list does occur, this may have some diagnostic meaning – like parental anxiety/depression.
  4. What if there are too many issues to address in one visit? This is important for us to acknowledge if we can’t get to everything and work with parents to prioritize. Parents will accept addressing some items later if their importance is validated, an attempt is made to deal with the most pressing ones, and it is discussed at the outset. We can also use respectful redirection/ interruption to get back on track when parents digress.
  5. How do we use this in a way that still keeps us on time? The 5-step patient-centered beginning of interview is one suggested approach: 1) Set stage with welcome, introductions, privacy/ confidentiality, ensuring comfort, 2) elicit chief concerns and set agenda (may be helpful to inform them how much time you have available), 3) use open-ended questions and attentive listening (this is where it’s really important to not interrupt right away), 4) elicit more specifics, 5) check accuracy, ask more questions, summarize, then move into clinician-centered phase (exam, etc.).

TOW #50: Marijuana Use

Among 12th graders, daily use of marijuana is now more common than cigarettes. As a legalized marijuana state in Washington, we should know about important implications for adolescents, and for pregnant and breastfeeding moms, as reviewed below.

Materials for this week:

Take-home points for marijuana use among adolescents:

  1. What are the active components of marijuana? Over 200 mixtures of cannabinoids come from the cannabis plant. One of the cannabinoid chemicals, tetrahydrocannabinol (THC), has psychoactive properties that has led to its recreational use. Cannabidiol (CBD) – a non-psychoactive cannabinoid, is another of the active chemicals for medicinal use. There are varying amounts of THC and CBD in any given plant.
  2. How prevalent is marijuana use?  The National Survey on Drug Use and Health showed the prevalence of past-month marijuana use in the US more than doubled between 2001-2002 and 2014-2015, with 8.3% of those aged 12 or older reporting past-month marijuana use. According to the NIH’s Monitoring the Future Survey, in 2015 34.9% of 12th graders in the US reported past-year use of marijuana. The 2015 survey also found that daily marijuana use exceeded daily tobacco cigarette use among 12th graders for the first time since the study’s inception (in the 1970s; 6% vs. 5.5%).
  3. What are the short-term effects of useWhat are long-term effects on developing brain? Side effects of marijuana use included impaired attention, concentration, and executive functioning. Tachycardia and systolic hypertension are two consistent physical effects. Other short-term effects include drowsiness, ataxia, increased appetite/thirst, conjunctival injection, dry mouth, anxiety, insomnia, hallucinations and short-term memory loss. In the long run, heavy marijuana use in the adolescent period interferes with synaptic pruning and myelination, causing changes in the hippocampal region, prefrontal cortex and white matter volume, which correlates with impaired cognitive functioning. These changes can affect attention span, concentration and problem solving, as shown in studies analyzing functional MRIs of marijuana users. Additionally, there is emerging data supporting increased risk of psychosis and predisposition to developing schizophrenia in adolescent marijuana users.
  4. What are differences between legalization and decriminalization? Legalization refers to allowing legal cultivation, sale, use, and/or possession of marijuana. Decriminalization means eliminating criminal penalties for possessing or using small amounts of marijuana. Both concepts have been debated, particularly for how it affects the adolescent population. The biggest support for decriminalization is shifting from law enforcement to a public health approach that emphasizes medical treatment for drug dependence or addiction. One of the problems with legalization (as we are seeing in WA) is the belief among adolescents that regular use does not cause harm. Nationally in 2015, 68.1% of 12th graders did NOT view regular  marijuana use as harmful.
  5. What are the effects of levels of THC for pregnant and nursing mothers? Breast milk can be up to 8 times as concentrated as the serum levels of chronic users, and THC is readily absorbed and metabolized by infants. The American College of Obstetricians and Gynecologists (ACOG) and Academy of Breastfeeding Medicine recommend stopping marijuana use (either recreational or medicinal) during pregnancy and breastfeeding given animal studies that suggest negative effects on brain development and lack of safety data in humans. It is important we discuss these risks with moms.

TOW #49: Adverse Childhood Experiences (ACEs)

We are fortunate to be in a time in pediatrics when the neuroscience is catching up with what we have long known about social determinants of health affecting children’s development. The original study on Adverse Child Experiences (ACEs) was published 20 years ago in a collaboration between the CDC and Kaiser. Growing understanding of the science behind toxic stress outcomes is generating renewed interest and investment in early childhood programming, such as here in King Co with the Best Starts for Kids program, and nationally in programs like the AAP Resilience Project, among others.

A big thanks to the fantastic advocacy of Drs. Colleen Gutman (Chief ’17) and Abby Grant who helped prepare these resources to inform your clinic practices. These materials also build on and relate to the approaches we have discussed in Promoting First Relationships (PFR).

Resources for this week:

Take-home points on ACEs/Trauma-informed care:

  1. Ecobiodevelopmental framework (EBD) – As reviewed in the AAP Technical Report, “an emerging, multidisciplinary science of development supports an EBD framework for understanding the evolution of human health and disease across the life span.” Science has shown significant associations between the “ecology of childhood” and many developmental outcomes and life course trajectories.
  2. ACEs definition: Adverse childhood experiences (ACEs) are experiences in early life that have detrimental effects on child development and adult health outcomes including abuse, neglect, being exposed to intimate partner violence, mental illness, and drug addiction. In addition, poverty and racism can exacerbate the effects of other ACEs.
  3. Toxic stress definition: Adversity and maltreatment in childhood are thought to affect development and health through chronic exposure to stress. This repeated and ongoing activation of stress response pathways is termed “toxic stress”, in contrast with normal, healthy, physiologic stress response mechanisms. Children experiencing adversity and maltreatment have been shown to have elevations in inflammatory cytokines and dysregulation of their HPA axis, and their brains may develop differently.
  4. Protective factors: Thankfully, the presence of a positive, nurturing adult is powerful in protecting against the negative effects of toxic stress. While there is great variability in genetic susceptibility to stress reactivity, nurturance mediates and protects against the negative effects of toxic stress and adversity (not just in humans, but across animal species, too).
  5. Pediatricians’ role in addressing ACEs/toxic stress: we are being called upon to take more active roles in developing and implementing science-based strategies to reduce toxic stress in early childhood, and hopefully thereby tackle some of the pressing disparities in learning, behavior, and health. We can become knowledgeable about the concepts and resources on trauma-informed care (as above). We can take a “universal precautions” approach and treat everyone with respect and humility. We can be aware of somatic symptoms that may be signals of untreated stress/trauma. We can also give special attention to care provided to those who are affected by trauma to help build nurturing and resilience, and avoid retraumatizing children and/or caregivers.

TOW #48: Fatherhood

In honor of Father’s Day next weekend, we are going to review the role of dads and how to expand beyond our traditionally mother-centric perspective of child-raising to be intentional about engaging fathers (and other support parents) in the care of children. Many more children are being raised in families where parents are not married, where mothers are working, and/or where the father is the primary parent, so supporting fathers to be actively involved as parents is increasingly important. Indeed, we have some great father role models in our program!

Materials for this week:

Take-home points on fathers’ role in parenting:

  1. Definition of father has expanded: a father can be any male adult who is most committed to, caring for, and supportive of the child including a stepfather, grandfather, adolescent father, father figure, or a co-parent in a gay relationship, regardless of living situation, marital status, or biological relation.
  2. Barriers to fathers’ involvement in child’s health care: 4 major barriers include employment (lack of flexibility, etc), interpersonal (cultural barriers, mother not wanting father to be involved, or not living in home), personal (lack of knowledge, comfort), and health care system (lack of access to records, appt times, etc).
  3. Fathers’ involvement matters: The presence of fathers positively impacts health, mental health, and educational achievement of children. We can encourage single mothers to increase the involvement of dedicated male role models in a child’s life. Additionally, we can discuss the importance of an involved father figure and parenting tips directly with fathers whenever possible. We can help dads know what a difference they make.
  4. Dads may need coaching and encouragement: Men are less likely to have babysat or helped care for siblings when growing up compared to women. We need to address dad, learn his name, make eye contact with him, and include him when providing information about parenting. We also need to ask him direct questions and remind mom of the importance of involving dad. We can help foster the mentality of teamwork as the best way to support the child. Doing this at the nursery and newborn visits is especially helpful to set the tone from the start, like handing the baby to the dad or asking dad to help change the diaper. Specific ways for us to encourage dads to be part of care include doing the bedtime routine (the sleep expert Dr. Craig Canapari emphasizes a simple sleep routine that one parent can do solo), and doing night-time feedings.
  5. Advocate for parent-leave policies: Data from countries like Denmark that have generous paternity leave policies show impressive outcomes: dads become involved from the beginning, and it’s better for the country’s overall productivity, as it supports more moms to return to work when both parents engage and share in child-rearing. We can all advocate through the AAP and other pediatric organizations to have more family-friendly leave policies in the US; encouragingly, our local tech employers seem to be setting the stage for adopting them, and we can hope the trend finally spreads!

TOW #47: Travel Preparedness

School is out in a few weeks and that means many families are preparing for travel this summer. Next week’s topic reflects our increasing globalization that manifests in more children travelling internationally. This is a good time to review some of the key resources and recommendations for travel preparation visits.

Materials for this week:

Take-home points for travel preparedness with children:

  1. International travel among children is on the rise. In 2010, ~2.2 million US children aged ≤18 years traveled internationally. Children are less likely to get travel advice/visits compared to adults. In one review of children with post-travel illnesses evaluated at clinics, only 32% of the children visiting friends and relatives had received pre-travel medical advice, compared with 59% of adults.
  2. Most common illnesses encountered after travelling are diarrheal illnesses, skin conditions (including bites, cutaneous larva migrans, and sunburn), systemic febrile illnesses (especially malaria) and respiratory disorders. Injuries are also common, especially motor vehicle and water-related injuries. For food safety review: “Boil it, peel it, cook it, or forget it.”
  3. Vaccination review is key. Make sure children are up to date on common vaccines and then assess for travel-related vaccines. When indicated, we provide typhoid injection and yellow fever vaccines, and if given enough lead time, you can sometimes get it covered by insurance through a prior authorization. Some pharmacies provide these at reasonable costs-ask your clinic facility.
  4. Counsel on the special risks of children who are visiting friends and relatives in developing countries. They will have increased risk of exposure to malaria, intestinal parasites, and tuberculosis. Review malaria prevention and provide malaria prophylaxis medications, as appropriate. Zika virus is also a newer risk for families. Also remember assault and STI risk for teenagers who are travelling. Screen for tuberculosis after children return if they have visited an endemic country for a week or more. You can test as early as 10 weeks after they return (or you can wait until their annual well child exam).
  5. Resources for plane travel with infants/young children is also a common request. I was lucky (?crazy) enough to take flights with both of my daughters by 2 months of age. A few suggestions that I have used were compiled in this online article. A few other tips I would add: keep plenty of extra clothes, bottles, food, and hand sanitizer when travelling with young children. Travelling during non-viral/non-flu season is preferred when possible. Be sure parents have had all of their vaccines, and give babies theirs as early as possible (2 month vaccines can be given as early as 6 weeks).