2018-19 TOW #10: Road traffic safety

This is always an important topic, even more so as kids return to school and will be on the road, and also because newly released guidelines for car seat safety were just published by the AAP. A big thank you to Dr. Beth Ebel MD MPH who provided key review points. Beth is a national expert on this topic and a former member of the national AAP committee who developed policy recommendations. Dr. Brian Johnston MD MPH, our Chief of Pediatrics at Harborview serves on the current committee that released the updated recommendations, below. (Fun fact: 3 former graduates of our program serve on the current committee (Brian, Sarah Denny, and Ben Hoffman!)

Materials for this week:

Take-home points for this week:

  1. As pediatricians, we must advocate for car seat and seatbelt use EVERY TRIP EVERY TIME. Most crashes occur on the day-to-day driving routes.
  2. We should know recommended car seat types for children of different ages and sizes. (See the AAP report). Basic summary:
    • Rear-facing 5-point harness carseat until reach weight limits (up to about age 4, previous recommendation was at least age 2).
    • Once forward facing, use a car safety seat to that seat’s weight and length limits (typically about 60 pounds).
    • When they exceed the seat’s limits, use a convertible belt-positioning booster seat (high back is preferred) until they have reached at least 4’9″, typically between ages 8-12.
    • Until age 13, always sit in rear seats in full lap and shoulder belt.
  3. Teen driving is the most dangerous time for teens in terms of risk of injury and death. Motor vehicle crashes are the number one cause of teen death. We can make it safer through driving contracts and graduated driver’s licenses (see the teen driving contract and state Graduated Driver’s Licences GDL laws).
  4. Distracted driving for teens and adults is a major issue and has increased with ubiquitous texting. It is now the law in our state to not use a phone or text while driving, and parents must be role models. Parents should use “chauffeur” time as catch up/phone down time for parent AND child.
  5. Review safe and active travel options. Encourage families to use the bus to navigate around the city for a weekend expedition. Use resources like One Bus Away, Metro transit route guide, and Google maps. Walking and biking to school are great and allow kids to be active, but kids must be visible and be safe. Check out Walking School Bus resources for local schools. When crossing the street, stay alert and put phones down!

2018-19 TOW #9: Colic

Next week we are covering a bread and butter topic in outpatient pediatrics, the ever-so-challenging diagnosis of colic, or excessive crying. Dealing with an especially fussy infant as you’re just learning to be a parent can be among the most challenging experiences a parent can face. Think about the stress you’ve felt listening to an infant crying on a plane, then imagine a parent having to deal with it every day for hours at a time! We want to harness evidence and empathy to help families through this.

Here are the materials:

Take-home points about colic:

  1. Epidemiology: how do we define colic and how many babies have it? Colic was defined by Wessel in 1954 as rule of 3’s (crying for 3 hours or more per day on at least 3 days per week for >=3 weeks). The Rome group updated this definition (as these time markers are somewhat arbitrary) in the Rome IV criteria for functional gastrointestinal disorders as “recurrent crying or ‘fussiness’ in a thriving, afebrile, well infant less than 5 months of age, without apparent cause, that cannot be resolved by the caregiver.” It occurs in 5-20% of otherwise healthy babies (and is seen globally), and is most often benign and self-limited. Some have theorized babies who cried more had an evolutionary advantage for survival as it meant more holding and soothing. In clinic, I often say a baby has a “good survival instinct” when I am talking to families to normalize crying behaviors or other contact-seeking behaviors that get babies the help they need.
  2. What is the differential for excessive crying and what is the work-up? Less than 5% of cases have an identified cause. We need to think about cow’s milk protein intolerance, GERD, abuse, infantile migraines, isolated fructose intolerance, maternal medications in breast milk (like fluoxetine), hair tourniquet, occult infection (especially UTI), and corneal abrasion. Mothers of infants with colic are more likely to have depression, so this should be assessed and referrals made, as needed. If there is no sign of other illness or injury on exam (including red flags of distended abdomen, fever, or lethargy), then no routine work-up is needed.
  3. What is the natural history for colic? Colic begins at 2-4 weeks and worsens until 6-8 weeks then improves and usually resolves by 4 months of age. The increased crying behavior occurs in the afternoons and evenings, the same times of day as in non-colicky infants, often referred to as the “evening fussies.” Colic can be considered a more extreme end of the spectrum of normal emotional development. Often there is a connection to difficult feeding behaviors and sleep, so these should be assessed.
  4. What are the long-term outcomes among infants with colic? At 4 months, those who had colic may have more sleeping difficulties. There may be some differences in temperament and family functioning. But, there have been no long term differences found in cognitive development.
  5. What are the treatment options for colic? There are very few evidence-based treatments, including a lack of evidence from Cochrane reviews for various pain-relieving agents or for manipulative therapies. There is some evidence that babies with colic have different fecal microflora (including higher rates of Helicobacter pylori stool antigen positivity) and some signs of colonic irritation. Studies of probiotics as a treatment for colic have been somewhat mixed, but there is data from a recent meta-analysis to suggest Lactobacillus reuteri may be effective in reducing crying time in exclusively breast fed infants. Infant crying can lead to parents feeling anger, frustration, and inadequacy. Asking about and addressing these emotions are important parts of caring for the parents. Give parents permission to put their baby in a safe place and leave for 5-10 minutes to take a break.

2018-19 TOW #8: Early learning

This topic is one that makes me hopeful for the world when we see the progress made in recognizing the importance of early learning for children and local and nationally advocacy to improve it. There’s a long way to go for universal access, but Harborview Pediatric Clinic has done a great job with Dr. Abby Grant’s leadership to strengthen an integrated referral approach to early learning. I am so excited to share the newer resources that social work students put together to help us identify where to refer our patients.

Take-home points about early learning:

  1. Our role: We as pediatricians have an opportunity to advocate for our patients through early learning settings: referrals to quality child care, preschool and Head Start programs, and also supporting work on policies and funding for these programs.
  2. Why preschool matters: Robust research shows that children who participate in high-quality preschool programs have better health, social-emotional, and cognitive outcomes than those who do not participate. Participating in quality early learning can boost educational attainment and income later in life – some studies have followed up participants into their 40s and 50s. A key factor in the most successful programs is very high-quality offered by well-trained staff.
  3. Preschool helps address disparities: Children from low-income families on average start kindergarten 12 to 14 months behind their peers in pre-literacy and language skills – they have the most to gain from preschool programs.
  4. We can do better: Only 41% of children from low-income families are enrolled in preschool compared to 61% of more affluent peers.
  5. Next steps: While most pediatricians inquire about early education, only a small proportion assist families in completing Head Start applications. Read the attached to learn more about options for publicly funded programs for your patients. Please remember to advocate for quality early learning settings for your patients and in our local and state policy decisions.

2018-19 TOW #7: Concussions

In addition to summer recreational activities, youth around our area are doing camps and early practices for the fall sports season. This is an opportune time to review concussions, a very timely topic in pediatrics (and society-at-large). We as pediatricians are called upon to address these injuries in clinic and clear youth for return to activities, as mandated by the Lystedt law in Washington.

Links for this week’s materials:

Key take-home points for concussions:

  1. What is a concussion? A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
  2. What’s the epidemiology of concussions? Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, followed by girls’ soccer. Girls have higher concussion rates than boys do in similar sports (possibly due to both physiologic reasons and higher reporting). Loss of consciousness occurs in about 10% of concussions, but may signal a more severe injury.
  3. What work-up should be done when concussion is suspected? Workup should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Review any assessments done at the time of injury (e.g. on-field SCAT5, etc). Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation. Consider using standardized tools to complete the evaluation, such as the SCAT5 and Child SCAT5 for ages 5-12.
  4. When should imaging be done? CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See the HMC algorithm for determining need for CT after head injury, based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
  5. How should we treat? Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend moderate cognitive rest and a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games); this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here’s a handout that reviews symptoms and return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking. Check out sports concussion resources from our sports medicine experts here.

2018-19 TOW #6: Infant and toddler development assessment

Next week is a chance to review cognitive and motor development for young children, always an important bread and butter topic in general pediatrics.

Materials for this week:

Take-home points for assessment of infant and toddler development:

  1. Epidemiology: What percent of children have a developmental disability or a mental health disorder? About 12-15% of children and adolescents in the US have a developmental disability, and ~20% meet diagnostic criteria for a mental health disorder.
  2. How do we assess development? First, we use surveillance which should occur at every WCC visit by asking about parents’ concerns, keeping a developmental hx, observing each child, identifying risk factors, and documenting findings. We also use formal screening with validated tools like the Ages and Stages Questionnaires (ASQ) or the Survey of Well-being of Young Children (SWYC). The AAP recommends formal screening at 9 mo, 18 mo and again at 30 mo. Specific autism screening is recommended at 18 and 24 months, typically done with the M-CHAT.
  3. What are the domains of development? Developmental milestones are assessed in major areas of language and communication, fine and gross motor, cognitive and social-emotional domains. If any sign of delay, we need to figure out which areas are involved. Global delay is more likely associated with other medical conditions.
  4. What physical evaluation should be done in clinic if concerned based on surveillance or screening? We should pay close attention to growth (especially head circumference), dysmorphology, neurologic exam, and skin exam (especially for signs of neurocutaneous disorders). Hearing should be evaluated formally for any language delays.
  5. How should abnormal developmental screening be handled? Any delays identified warrant follow-up and referral for formal developmental assessment through medical evaluation and Early Intervention programs (often referred to as Birth-to-Three). The benefit of the 24 and 30 month visits provide opportunities to assess development before the window closes for birth-to-three options. Ideally, all children should also have the benefit of early preschool to facilitate development. Clinics with EPIC have a built-in referral system for head start referrals (thanks to the Harborview team led by Abby Grant), which includes early head start for children under 3 with special developmental needs.