2018-19 TOW #18: Oral health

It’s Halloween next week, so that time of the year when children have access to ridiculous amounts of candy… thus a good opportunity to review oral health care! As far as Halloween goes, some dentists and parents have “buy-back” programs to replace candy with toys; others let kids binge eat one night, then throw away the rest (maybe best for the teeth, but I don’t love the message that sends about enjoying things in moderation…). I love that my daughter’s school collects it to send to the troops-she’s been very motivated to bring in as much as she can to win the class competition.

Materials for this week:

Take-home points for dental health:

  1. Who is most at risk for dental caries? Sadly, dental caries have become epidemic – they are now the most common diagnosis among otherwise healthy kids, with about one third of children with caries by age 3. Risk factors include children with special health care needs, parents with caries, especially during pregnancy, and low-income status. Parents’ oral health matters since they can transmit decay-causing bacteria like strep mutans to their children. Children can be colonized with the bacteria soon after birth, and earlier colonization increases risk for caries.
  2. When and how should we recommend fluoride? Use fluoride sources to protect teeth in 3 ways: brushing, fluoridated water, and fluoride varnish at the dentist and at well child checks (at least 2-3 times per year). Brush children’s teeth with fluoridated toothpaste 2 times a day as soon as teeth start erupting. Start with a grain of rice sized amount of toothpaste and move to a pea-sized amount about age 3 when kids can spit. Nighttime brushing is most important since we make less saliva at night to clean the teeth (my kids’ dentist has the motto “clean teeth before sleep”). Parents should help with nighttime brushing until children are about 7 or 8, and even a few times per week after that is recommended to monitor teeth. We should also recommend flossing once a day for teeth that are touching. I highly recommend the preloaded kids “flossers” – they were a game-changer for helping our kids to floss!
  3. What foods and drinks should we recommend to prevent cavities? The obvious ones are limiting sugary/high carbohydrate foods, especially sticky ones, and sugary drinks. When these are given, it’s best to offer at mealtime and let the pH come back into normal range between meals, which takes ~90 minutes. When children constantly have food/drinks in the mouth, such as with a bottle or sippy cup, the pH of the mouth never neutralizes, creating an ideal setup for cariogenic bacteria to collect and cause decay. That’s why it’s especially important to avoid grazing and offer tooth-friendly snacks between meals (whole fruits, veggies, protein snacks like cheese, water to drink). Once teeth are brushed, there should be no more bottles/breastfeeding at bedtime or overnight.
  4. What can we teach parents about how to check kids’ teeth? Baby teeth are important and decay can start as soon as the first tooth erupts. Decay is most likely to occur along the gum line of the upper incisors and also in the pits and in between the premolars and molars. Caries typically appear as white spots (decalcifications) and may progress to yellow/brown cavitations. Show parents how to “lift the lip” to check child for early signs of decay. Check out the AAP Flip Chart to learn more about oral health to review which teeth come in when and other topics. Did you know in a recent study of pediatric residents, only about 1/3 discussed sleeping at night with breast/bottle, only ~13% discussed the status of teeth, and <10% lifted the lip to examine front incisors. I know we can do better than that here!
  5. When should dental visits start? The ADA and AAP recommend children establish a dental home by 1 year of age, possibly earlier for children who are at very high risk of caries. Healthy teeth for parents is important, too. Encourage them to model good oral health and receive dental care as well.


2018-19 TOW #17: Community Pediatrics

Some of the R2 are on the REACH Pathway month 1 this block, and it’s a great time to be inspired by many pediatricians in our midst taking leadership roles in advocacy. I’m honored to know some of them as friends from my own residency class (go R’06’s!), including Rupin Thakkar MD who is our current WCAAP president. Rupin recently gave a shout out to our Harborview pediatricians, Drs. Vai Pidaparti R2 and Beth Dawson-Hahn for their immigrant health toolkit. Beth will be giving noon conference this week on her outstanding work advocating for immigrant children. I could highlight hundreds (likely thousands) of examples of pediatricians in our area who have made significant contributions through advocacy.

Materials for this week:

Take-home points for this week:

  1. What are some of the social and environmental needs our patients face that can affect their care? Many children being cared for in community-based pediatric settings, including our residency clinics, face numerous social needs that affect their health: food insecurity, poor housing, parent substance use or mental illness, family violence, and unsafe neighborhoods. Most of these have now been characterized as Adverse Childhood Experiences (ACEs) and are associated with developing toxic levels of stress that can impact long-term health. There is evidence that when we address these needs by helping parents and families, children fare far better over the lifetime.
  2. How do we prioritize addressing these needs? Henize et al. propose that one way to prioritize these is using the Maslow Hierarchy of Needs, i.e., addressing the most basic needs should be the focus before ones higher up on the pyramid. First are Physiologic needs for food and housing, then Safety from violence and mental health problems, then Love/Belonging, with children supported by loving parents who have community support, then Esteem and Respect, with education and employment, and finally, as these other needs met can come Self-Actualization or Achieving One’s Potential. Another helpful way to think about needs is the IHELLP mnemonic: Income, Housing, Education, Legal, Literacy and Personal Safety.
  3. Where do we find the community resources? Bright Futures divides potential community resources among 4 major categories that we should access for our patients: health, development, family support, and adult assistance. In our area two key ways to find needed assistance is through Within Reach and Washington State 2-1-1. Dr. Abby Grant, one of the former REACH residents and now REACH faculty and pediatrician at Harborview prepared this amazing list of community resources for our area.
  4. What are some of the recommended skills for engaging as pediatricians serving the community? The AAP policy statement defines some key skills: 1) working effectively in interdisciplinary settings, 2) partnering with public health, community organizations, and child welfare agencies, 3) recognizing root sources of health and pathology from children’s social, economic, physical, and educational environments, and 4) advocating on multiple levels including at the local, state, and national levels.
  5. If collaboration and partnerships are key to addressing social determinants of health, how do we do this? Henize and colleagues outlined a set of steps: 1) build a case through family-centered needs assessment, 2) organize and prioritize appropriate interventions, 3) work with key community partners to build and sustain interventions, and 4) operationalize interventions in the clinical setting. If you want to learn more about becoming an advocate, the AAP Committee on Community Pediatrics has advocacy training modules available.

Borrowing a line from Hamilton… Look around, look around, at how lucky we are to be alive right now… in our field of pediatrics and surrounded by these inspiring colleagues doing amazing work. I’m glad we have each other for the work that’s still ahead.

2018-19 TOW #16: Precocious Puberty

Time for more talk of puberty – this week we will discuss what happens if there are signs it’s happening too early.

Materials for this week:

Take-home points:

  1. How do we define precocious puberty? Development of pubertal changes occuring 2.5 standard deviations below mean age. Traditionally, that’s been <8 years for girls and <9 years for boys based on data from Europe in the 60’s. More recent cross-sectional data in the US has shown thelarche is occuring up to 2 years earlier in African American girls and 1 year earlier among white girls. However, the timing of menarche has only been about 4 months earlier than in prior studies. There’s less clear evidence of earlier puberty onset for boys. Many endocrinologists still use the <8 year cut-off, but it’s somewhat controversial.
  2. What are factors associated with precocious puberty? These include female sex, family history of early puberty, low birthweight or overweight/obesity in infancy or early childhood, exposure to endocrine disrupting hormones, and international adoption. The link with obesity is especially strong – probably due to effects of multiple hormones including leptin, insulin and estrogen.
  3. What are the types of precocious puberty? Most cases in girls are due to central early activation of the hypothalamic-pituitary axis (also known as gonadotropin dependent or complete precocious puberty). These can be from CNS tumors but are most often idiopathic. Much less common for girls is the peripheral form – sex steroids from ectopic or exogenous sources (also called gonadotropin independent or incomplete precocious puberty). Sources of excess estrogen production include follicular cysts, ovarian tumors and adrenal tumors, severe hypothyroidism. It can also be McCune-Albright syndrome, a rare genetic mutation leading to uncontrolled estrogen that includes café au lait spots, osseous lesions, and multiple endocrinopathies. Boys are more likely to have the peripheral form, especially from congenital adrenal hyperplasia (CAH).
  4. What should evaluation include? Physical exam to assess height, weight, and Sexual Maturation (Tanner) stage, findings of potential endocrinopathy (café au lait spots, acanthosis, signs of hypothyroidism). Females should be examined for estrogenization of the labia and vaginal tissue. A radiographic bone age should be obtained. Consider pelvic ultrasound to view ovaries if peripheral form is suspected. Labs should be obtained in consultation with an endocrinologist and may include early morning plasma estradiol, LH/FSH, and thyroid function. If there is adrenarche, add plasma DHEA, DHEAS, and 17-hydroxyprogesterone. GnRH stimulation test is the gold standard for central precocious puberty. When there is central precocity, especially before age 6, MRI would be used to assess for CNS lesions.
  5. What are adverse outcomes? Biggest are decreased adult height and psychosocial impact such as early sexual activity and drug and alcohol use. When appropriate, we may treat with a GnRH analog like leuprolide to slow central precocious puberty – this is considered generally safe and effective to delay puberty progression and improve adult height.

2018-19 TOW #15: Puberty – Normal and Delayed

It’s time to talk puberty! We will review normal/delayed this week followed by precocious puberty next week. The puberty topic is getting a little more airtime at my house with a 9.5 year old at home. We are gearing up for the highly acclaimed puberty classes, offered through SCH for 10-12 year olds.

Here are the materials for this week:

Normal and delayed puberty take-home points:

  1. What is puberty and what triggers it? Puberty is the process of normal sexual maturation culminating in full reproductive capability. Pubertal changes are due to increased secretion of sex steroids (gonadarche) triggered by the release GnRH from the hypothalamus and release of LH and FSH from the anterior pituitary. The genetic trigger for puberty is still not well understood. NOTE – Terminology is changing now: what used to be “Tanner Staging” is now more often being referred to in the literature as “Sexual Maturation Rating (SMR)” – see article for updates.
  2. When does puberty start for girls and what is the sequence? For females, average puberty onset is 11 years, but normal range is considered from 8-14 years. The average duration of pubertal development is 3 years (range of 2-6 years). Thelarche, the onset of breast development, is usually the first visible evidence of puberty in girls. The growth of pubic hair usually follows within the next 6 months, along with a growth spurt. Menarche usually occurs 2 years after the onset of pubertal breast growth and coincides with SMR (aka Tanner) Stage IV. After menarche, girls grow 4-6 cm on average (varies a lot), and finish growing within two years. Generally, early menarche is correlated with shorter adult height.
  3. When does puberty start for males and what is the sequence? For males, average puberty onset is 12 years (normal range 8-14). Increased LH, FSH, and testosterone cause testicular maturation and enlargement. Increased testicle size is the first visible evidence of gonadarche, though often not recognized until the growth of penile length and pubic hair, typically within 6 months. As the testicles mature, other physical features virilize including increased muscle mass and voice deepening. Facial hair growth usually happens 3 years after pubic hair onset. Pubertal growth spurt is later in males, and puberty lasts longer (typically 5 years).
  4. How do we identify delayed puberty? Delayed puberty is more common in boys than girls. Delay is considered as no pubertal changes by 13 in girls and 14 in boys. Work-up for both sexes includes reviewing weight gain and linear growth, obtaining a bone age, and looking for other evidence of endocrinopathy such as panhypopituitarism or hypothyroidism. Laboratory studies include serum LH and FSH levels, growth hormone secretion, thyroid function and, in males, a morning testosterone level. Typically, these patients should be referred to endocrinology.
  5. What are the causes of delayed puberty? Delayed puberty is divided into causes based on serum LH/FSH levels: 1) normal/low (constitutional delay and hypogonadotropic hypogonadism (e.g., CNS tumors, endocrinopathies) and 2) elevated (hypergonadotropic hypogonadism or gonadal failure)-most common cause among these is Klinefelter Syndrome in boys and Turner Syndrome in girls.