2018-19 TOW #22: Newborn concerns

For many of us, one joy of general pediatrics is the chance to care for babies. As we welcome them into the world, they seem to bring us hopefulness and renewed faith in the human potential. As Henry David Thoreau said, “Every child begins the world again.”

Note: this is a great topic for you senior residents to lead the discussion!

Materials for this week:

Take-home points:

  1. Attachment: babies thrive when their caregivers are thriving. Given what we now know about neural wiring in the first 1000 days of life, it is critical to support parents’ ability to care for and connect with their infants. Mothers should be screened for post-partum depression and referred for treatment, as needed. Observe and comment on how parents are comforting babies in visits, such as talking and holding (and possibly the 5 S’s-suck, swaddle, swing, shush, side-lying). Help parents beware of how phone use and screen time may interfere with interaction with babies. We have to debunk the misguided idea of “spoiling them” by holding them too much-in fact, we know that infant brains shows positive effects with high nurturing. Promoting First Relationships (PFR) offers a great framework for supporting parents with these concepts in clinic visits. All of the great PFR handouts are available on the TOW mainpage sidebar with your UW NetID here.
  2. Helping parents be experts: provide parents encouragement, point out what they are doing well to connect and care for babies, and how they are the most important people in their infant’s life. Give them tools (such as PFR handouts) and resources like www.text4baby.com where they can sign up for texts based on baby’s birth date that give tailored resources, reminders, and tips.
  3. Normal newborn behaviors and findings: parents need to know about common things that can seem worrisome (sneezing, hiccupping, spitting up, primitive reflexes, rashes, crying, etc). Review some common skin findings here.
  4. Nutrition: helping babies grow/gain weight is a central concern in the first few months of life, and we need to provide guidance and reassurance on appropriate weight gain and support for breastfeeding. Whether breastfed or not, all babies should be cuddled and held with nurturing interactions during feeding. We can teach about reading babies cues of hunger and fullness from the beginning. Breastfed babies (fully or partially breastfed) should be on a vitamin D supplement of 400 IU per day to prevent rickets.
  5. Sleep: providing a safe sleep environment is key to babies thriving-babies should be on their backs and in their own sleeping unit without extra blankets or stuffed animals to avoid suffocation and SIDS. Co-sleeping/ Bed-sharing is the highest cause of death under 3 months, and is especially dangerous if parents smoke or drink alcohol. Ask open-ended questions about where baby is sleeping and in what position to facilitate honest conversations. Review evidence and encourage room-sharing rather than bed sharing. The AAP has sleep guidelines that recommend co-rooming. Also review positional plagiocephaly and how to avoid it (tummy time, rotate positions in crib and get babies out of containers (e.g. swings, carseats, babyseats) when not sleeping)!

2018-19 TOW #21: Firearm injury prevention

This week’s topic seems particularly timely given the overwhelming physician response to the NRA’s “stay in your lane” tweet last week. We have many resources locally including the incredible Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention. The Seattle Children’s community benefit team and REACH pathway residents have worked to develop local resources and events.

Materials for this week:

Take-home points for firearm safety:

  1. Statistics: 1 in 3 homes in the US with children have firearms, many of which are not locked. 80% of unintentional firearm deaths of kids under 15 occur in a home. 64,000 adults in King County with a firearm in or around their homes reported storing their gun(s) loaded and unlocked. The safest thing is not to have a firearm in your home, as it is 43 times more likely to be used to kill a family member or friend rather than be used in self-defense. In a case-control study done by Grossman et al., storing firearms locked, unloaded, or separate from the ammunition was associated with significantly lower risk of unintentional and self-inflicted firearm injuries and deaths among adolescents and children.
  2. Many depressed teens die from suicide by firearms. If you are tight for time and cannot screen for firearms in every clinic wellness visit, be sure to include specific counseling in visits with depressed teenagers. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline.
  3. What to offer for gun safety? There are 5 main types of locking devices: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Generally, we should avoid devices that use keys. Visit www.lokitup.org for information about how to store firearms. We need to help advise that the safest way to store guns is unloaded, locked, and out of reach of young children and teenagers! Consider using a statement like: “Having a loaded or unlocked gun in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store your unloaded guns in a locked drawer or cabinet, out of reach of children.”
  4. How do we advise parents and firearm safety? We can counsel parents to ASK other parents about guns in their home before sending over their child to play: http://askingsaveskids.org/ Suggested wording includes:  “Knowing how curious my child can be, I hope you don’t mind me asking if you have a firearm in your home and if it is properly stored…” For family members, this might include: “[Mom, Dad] this is awkward for me and I mean no disrespect. I am concerned Susie will find one of the firearms in your home when we visit. Do you keep them locked up with the ammunition stored separately?”
  5. Does counseling work? Several studies have found counseling in office visits to be associated with improved safe storage of firearms. A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Likewise, Barkin et al. found that brief office-based counseling increased the use of safe storage.

2018-19 TOW #20: Tobacco Exposure and Cessation

This week’s topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up next week on Thursday November 15th. The American Cancer Society designates the 3rd Thursday of November (the Thursday before Thanksgiving) each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking cessation.

Materials for next week:


Take-home points:

  1. How many children are exposed to secondhand smoke? How does teen smoking relate to adult smoking? More than half of US children have secondhand smoke exposure (based on biological samples of population data). Approximately 90% of adults who smoke began smoking prior to age 19 (which is why tobacco companies target ads to youth…) Each day, an estimated 4400 American teenagers try their first cigarette. 80% of youth who smoke will continue to smoke into adulthood.
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with non-respiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What’s the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective.  Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. All states have quitlines with counselors who are trained specifically to help smokers quit. The quitline number is meant to be remembered: 800-QUIT-NOW (800-784-8669). There’s also an online chat via the National Cancer Institute.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. “Is your child around anyone who smokes?” is a neutral way to open up the conversation. If the parent is smoking I often follow-up with “How are you feeling about smoking?” as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don’t forget about using 1-10 scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) This is a great stat to highlight: Getting help through medications and counseling doubles or even triples the chance of successfully quitting. 
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes, especially among teenagers.

2018-19 TOW #19: Acute Asthma

It’s the time of year when our clinics and the ED are starting to see more kids with viral-induced asthma exacerbations, so it’s an opportune time to review the guidelines and resources to address these. The REACH pathway residents have provided some helpful materials, which I have included below. Locally we also have the wisdom of the great Dr. Jim Stout, faculty at Odessa Brown, who has been a national leader in asthma quality of care research.

This week’s teaching materials:

Take-home points for acute asthma management:

  1. Epidemiology: the CDC estimates that 8.3% of children have asthma, making it one of the most prevalent diseases of childhood. Rates are higher among blacks, certain Hispanic groups, and those in poverty. Among those with asthma below age 18, 57.9% report having one or more asthma attacks, so the majority of kids with asthma will be treated for exacerbations.
  2. Severity guides treatment: Determining severity is based on many components including level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating respiratory scores used at Seattle Children’s Hospital (SCH), such as in the SCH asthma pathway.
  3. Initial treatment: For moderately severe symptoms, give albuterol MDI 8 puffs (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), start dexamethasone (0.6mg/kg, max of 16mg), and repeat in 24 hours. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity and history.
  4. Education is critical: as we know, education about asthma is so important to families’ understanding and implementation of treatment. It’s important to review and update asthma action plans during exacerbations. Families should receive coaching and should be able to demonstrate use of MDIs with a valved holding chamber (VHCs or “aerochamber”). There are great written resources and videos out there on avoiding triggers through the NW Clear Air Agency. Families in Seattle/King Co are eligible to receive a free home health assessments through the American Lung Association. Most families do not know about this great program, so referral is key.
  5. Provide follow-up: it’s important to have follow-up within a few days (in person for more moderate cases, or maybe by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also important. The Washington Medical-Legal Partnership (MLP) has great sample letter templates we can use to help families notify landlords of needed repairs, such as improving ventilation, removing mold or insects. If you need additional assistance, remember to refer patients via the Washington MLP at Seattle Children’s Hospital (patients are eligible if they are patients at SCH).