2018-19 TOW #25: Media guidelines

As we hit the frenzy of holiday shopping for media devices, now is a great time to revisit media screening and counseling! Dr. Pooja Tandon MD MPH lent her great expertise in reviewing and updating this topic for us. Another national media expert among our faculty, Dimitri Christakis, served on the committee that updated the most recent national AAP media policy.

Materials to review:

Take-home points to review on media for youth:

  1. Media exposure for youth is significant with quantity and quality important for us to address. We now have a plethora of devices that contribute to media exposure for youth, and most babies are exposed to TV by 4 months old!
  2. The 2 most important questions to ask our families in clinic are: 1) How much screen media is your child exposed to every day? 2) Does your child have a TV or internet-connected device in the bedroom? I also like to ask “what guidelines have you set for media use at home?”
  3. Parents should be encouraged to set limits on screen time – this is less often done among low income families. Children whose parents make an effort to limit media use (through the home media environment and rules about screen time) spend less time with media than their peers. Parents should be “media mentors” and teach children and teens how to use media appropriately. I’ve heard experts talk about thinking of media use like having a driver’s license, where you demonstrate effective, safe use.
  4. Based on guidance from the AAP, we recommend no screen time for children under 2. As of 2016, apps are acceptable starting 18 months, and videochatting with family did not count toward screen time. We should limit recreational screen time to an hour per day. For older children screen time does not include school use or homework. If parents do allow more (a reality!), at least help them select more educational/prosocial media (like PBS, or shows recommended by Commonsense Media: www.commonsensemedia.org (which we rely on all of the time at our house for movie selection!)
  5. TVs in the bedroom are (and other media that are connected to the internet) are associated with many concerning negative effects on health. Counsel early about media to help prevent the placement of TV’s in the bedroom (which is over 50% by age 2-4 among low-income families). Parents should limit media time 1 hour before bed.

2018-19 TOW #24: Atopic dermatitis

With all of this cold, dry sunny weather we’re having, it’s the season for dry skin and flares of atopic dermatitis. (Indeed, one of my daughters is constantly complaining of dry lips right now, and we are trying to forestall lip lickers’ dermatitis, to which she is prone!) This is a great time to review some tools of the trade and recent data.

Key points to review:

  1. Epidemiology: Atopic dermatitis (AD) is one of the most common skin disorders in young children, with a prevalence of 10% to 20% in the first decade of life. It is a chronic illness with multiple etiologies and requires multifaceted treatments. Almost half of children with AD develop it before 1 year of age, and the majority by age 5.
  2. Pathophysiology: Defects in the epidermal barrier function and cutaneous inflammation are 2 hallmarks of AD, which is why we target therapy with emollient barrier agents and anti-inflammatory treatments. Both skin with lesions and without have shown defects in transepidermal water loss, even measured at 2 days of age. Mutations in filaggrin, an important protein in skin barrier function, are predictive of multiple forms of atopy, including atopic dermatitis, food allergies, and asthma.
  3. Topical corticosteroids are the mainstay of therapy for inflammatory skin diseases like AD. They reduce inflammation in the skin by causing vasoconstriction and preventing inflammatory cells from entering the affected area, so they also have an anti-pruritic effect. Potency is actually determined by how much vasoconstriction they cause. For children with rapid flares, a recommendation is short-term bursts of mid- to high-potency topical steroids, typically applied twice daily for 7 to 10 days, then tapering to lower potency daily, then to intermittent application, 2-3 times per week.
  4. Regular use of emollients to prevent drying of the skin is also important in managing AD. Patients should use a dye-free, fragrance-free moisturizer and apply it at least twice per day and after bathing. In practice (and personal experience with my kids), my go-to has been petroleum jelly / white petrolatum (Vaseline). It’s effective, does not sting like other creams/lotions can, and is affordable.
  5. Prevention of AD – yes it’s possible! Data from 2 RCTs, one in the US/UK and one in Japan, has shown that applying moisturizers daily for infants from birth to 6 months can forestall development of eczema among infants who have at least one family member with AD. In a cost analysis, the most cost effective emollient was petrolatum (i.e., Vaseline/petroleum jelly). In the lay press, NYT highlighted these AD prevention studies.
  6. Side effects of topical steroids and calcineurin inhibitor options: Steroid side effects are most problematic when applied to skin without inflammation. Steroids should be applied to affected skin until 3 days after resolution. For those with more severe AD, treatment may continue weekly (or more often) to prevent flares symptoms. Use lower potency especially in the face and groin area where the skin is thinner / more susceptible to damage. Topical calcineurin inhibitors provide another treatment option. They are considered second line therapy for short term and noncontinuous chronic treatment, with improving evidence for safety since the 2006 FDA black box warning.

2018-19 TOW #23: Lipid screening

The topic of lipid screening and dyslipidemia treatment remains a controversial one in pediatrics! It depends on whether you are in the camp of not missing anyone who meets potential criteria for intervention vs emphasizing the potential harms of overtesting and overtreating: the age-old epidemiologic debate, not to mention a value-based care question. Nationally, variation in recommendations reflects this debate: the AAP has sided with universal screening, while others, including the US Preventive Services Task Force and the AAFP find insufficient evidence to recommend screening before age 20. Dr. Perri Klass summarized the debate in her NYT blog, quoting Dr. Fred Rivara, MD MPH about his statement against universal screening. The goal this week is to be familiar with some of the recs and the evidence to inform your understanding and decision-making.

Materials for this week:

Take-home points:

  1. Who should be recommended for lipid testing? It depends on if you follow targeted screening vs universal screening, or if you believe in no benefit of screening in childhood. The 2011 NHLBI guidelines recommend targeted screening for children 2-8 years old and adolescents 12-16 years old and universal screening for children 9-11 years old and adolescents 17-21 years old. The repeat is done at age 17-21 to assess after puberty which can alter levels. These same recommendations are endorsed by the AAP. In the targeted approach, screening is indicated in children or adolescents with a positive family history of dyslipidemia or premature cardiovascular disease (CVD) (including parent or 2nd degree relative <55 male, <65 female), an unknown family history, or children with other risk factors for CVD, like obesity, hypertension and diabetes.
  2. If you are screening, what tests would you do? In the NHLBI guidelines, the recommendation for universal screening was to use non-fasting lipids and calculate the non-HDL-C as follows: Non-HDL-C = total cholesterol (TC) – HDL-C. If the non-HDL-C was >=145, then do follow-up with fasting lipid panel. For targeted screening, the rec was getting an average of 2 sets of fasting lipid profiles (FLP) separated by 2 weeks to 3 months (as the individual levels can vary by up to 30mg/dl). Triglycerides (TG) are much more likely to be overestimated with non-fasting draw, but total and non-HDL levels are considered more reliable when non-fasting. All of this seems much more complicated, and in practice, most pediatricians may only obtain one measurement.
  3. What is the first-line treatment for elevated lipids? Initially, we recommend lifestyle intervention, including more fruits, vegetables, fish, wholegrains and low-fat dairy products, with reduced intake of fruit-juice, sugar-sweetened beverages and foods, and decreasing salt. We also recommend physical activity and losing weight, if appropriate. The fact that we essentially recommend this diet for all children is partly why many advocate not testing lipids because it does not change recs unless you have serious disease, which is rare. To treat overall elevated cholesterol or LDL, we focus more on dietary fat intake, but to treat elevated TG, we focus more on sugar and carbohydrate intake.
  4. If children have higher lipid levels that don’t respond to diet or have familiar hypercholesterolemia (FH), what is the treatment? There is more controversy here as well! The NHLBI guidelines do not recommend medication for children under 10 unless they have severe primary hyperlipidemia or a high-risk condition associated with serious morbidity. For children with FH, statin treatment in childhood is associated with improved carotid thickness. For children ≥10 years, starting a statin is recommended for those who have persistent elevated LDL (range from 130-190 based on family history and risk factors) after 6 months of lifestyle changes, with the goal of lowering LDL to below the 95th percentile (≤130 mg/dl). The safety of statins for long-term use has not been adequately studied for children, so we usually consult a specialist before starting statins. Routine monitoring for muscle and hepatic toxicity with CPK and transaminase levels would be done for patients on statins.
  5. When do we refer to a specialist and which one? Referral to a specialist has been recommended for those with LDL ≥250 mg/dl and TG ≥500 mg/dl even before a trial of lifestyle management, or when more than one lipid-lowering medication may be needed (such as a bile acid sequestrant or cholesterol absorption inhibitor). Around the country, different specialists manage lipids; in our region, the Endocrine Division runs the lipid clinic so patients would be referred to them when needed.