2018-19 TOW #38: Child abuse recognition

April is child abuse prevention month, an important reminder to discuss this always challenging but critical topic. Our role in primary care encompasses strategies to build resilience, promote strong relationships, link families to resources, and screen and refer for concerns as mandated reporters. SCH’s Protection, Advocacy and Outreach team has 3 prevention programs: Period of PURPLE crying, Medical-Legal Partnership, and Positive Parenting (which funds our Promoting First Relationships (PFR) training).

Materials for this week:

Take-home points for child abuse recognition:

  1. How many children are affected by maltreatment? We are likely to encounter child maltreatment in our practices: 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. How are “neglect” and “verbal abuse” defined? Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child; it includes lack of adequate nutrition, hygiene, shelter, and safety. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. “Verbal abuse” refers to nonphysical forms of punishment intended to cause shame and humiliation.
  3. What is the AAP stance on corporal punishment and why? As of fall 2018, the AAP opposes any form of corporal punishment, including spanking, as it is not effective for changing long-term behavior and is associated with many adverse outcomes, including aggressive behavior and mental health problems. Here’s a very informative infographic on the psychology of spanking. Dr. Sege, who co-authored the AAP statement, discusses how you can talk to parents who were spanked themselves in this podcast (here’s the interview transcript).
  4. Which children are at highest risk for child abuse? Children in all SES levels are at risk, and in ~80% of cases, parents are perpetrators. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired or multiple gestation pregnancy. Parent-level risk factors include poverty, multiple children under 5, substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for development.
  5. What is the most overlooked form of abuse? Bruising is the most frequently missed form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and referral to CPS. Before being diagnosed with child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury.

2018-19 TOW #36: Learning disabilities

Our role in addressing child development extends into the school years as we help children when there are concerns about school performance. I had a long discussion with a school psychologist this week who helped identify important needs for one of my patients. This is a really important topic for us to be knowledgeable about to support families and partner effectively with schools.

Materials for this week:

Take-home points:

  1. How many children are affected by learning disabilities? The lifetime prevalence of learning disabilities in US children is 5-10%, so should be considered when children are having school difficulties. Learning disabilities are heritable, but specific genes are still being identified. fMRI studies show children’s brains with learning disabilities differ in structure and  function.
  2. How do we define a learning disability and what are the types? A learning disability is a disorder that affects a child’s ability to read, use and understand language, write, or do mathematical calculations. Learning disabilities have been described as a significant discrepancy between academic achievement and intellectual potential, despite receiving appropriate instruction. Two main types are verbal/language (affecting ~80% of those with learning disabilities including dyslexia, i.e., difficulty reading and dysgraphia, i.e., difficulty writing) and non-verbal (dyscalculia, including problems with visual-spatial relations, math, and problem solving). There is a lot of overlap, and children often have both types.
  3. What’s the pediatrician’s role in diagnosis? Usually, behavior problems are the first presenting symptoms. Children may act out or withdraw because they cannot meet the demands or may have difficulty paying attention to material they don’t understand. We should first identify or exclude other causes that impact academic performance such as psychosocial (e.g., abuse, neglect), medical (e.g., prematurity, drug exposure, hearing/vision problems) and developmental issues (e.g., ADHD). Formal testing required to confirm a specific diagnosis is typically the school’s role. We can refer the child to the school’s committee on special education for evaluation. The request should be in made in writing by the parent, and we can often be helpful by including a note outlining specific concerns. We can also refer for advanced evaluation by a psychologist or developmental-behavioral pediatrician.
  4. What’s our role in monitoring? Our role includes being an advocate for the child in interfacing with school personnel, assisting the family in understanding the diagnosis, and monitoring progress. We should routinely screen for associated problems that can arise such as new behavioral difficulties, anxiety, and depression.
  5. How should we interface with schools? First, we have to obtain permission with a signed Release of Information form from the parents. An important law to be aware of is the Individuals with Disabilities Education Improvement Act (IDEA) part B, a federal law ensuring that all students ages 3-21 receive a free and appropriate public education under the least restrictive environment, regardless of disability. If a child is found to qualify for special education services under IDEA laws, an individualized education program (IEP) is created, outlining the plan for special education service. We can access the Medical-Legal Partnership if we feel that children are not receiving services for which they qualify under the law.

2018-19 TOW #35: Menstrual disorders

As we help with the process of puberty, addressing the challenges that arise with menarche and menstrual disorders in adolescents is a common issue we see in primary care. This is a great topic for seniors who have done their adolescent rotation to facilitate.

Materials for this week:

Take-home points for this week:

  1. How is the menstrual cycle different for adolescents than fully mature females? In adolescents the hypothalamic-pituitary-ovarian (HPO) axis feedback loops are not yet mature. For the first 1-2 years after menarche, steroid hormones do not yet regularly have coordinated negative and positive feedback loops to cause ovulation, so menstrual cycles may be anovulatory or infrequent /irregular (oligoovulation). In the first year after menstruation, ~50% of cycles are anovulatory. One of the most difficult aspects of these cycles for teens is that they can cause prolonged and/or unpredictable bleeding.
  2. What’s considered a “normal” cycle for a teen? AAP and ACOG define normal menstrual cycles for adolescents as having an interval of 21–45 days with the duration of flow lasting <=7 days, and average product use of 3-6 pads/tampons per day. We should be concerned when there’s heavier bleeding (soaking through products after 1-2 hours), cycles >90 days apart for even one cycle, or a change from regular to very irregular.
  3. What defines “abnormal uterine bleeding (AUB)”? Bleeding that’s heavy or prolonged or occurs outside normal menstrual cycles. Ovulatory AUB, or heavy menstrual bleeding, occuring as part of the usual cycle, is most commonly caused by uterine problems (i.e., endometrial polyps, leiomyomas, malignancy) or bleeding disorders. Ovulatory dysfunction is AUB that presents as irregular, heavy, or frequent episodes of bleeding without a clear pattern. While this is usually from anovulatory cycles, it’s considered a diagnosis of exclusion; other causes to consider would be endocrine disorders, pregnancy and infection.
  4. When working up AUB, what are key parts of the history and physical? In addition to regular elements of H&P, we should obtain 1) Menstrual history: timing of menarche, usual frequency, duration, and volume of bleeding, presence of menstrual cramps, when/how did menstrual bleeding change, and any medical problems or lifestyle changes or other events that coincided with the change; 2) confidential HEADSSS review of substance use, sexuality, sexual activity, exposure to STIs, contraception, and any history of sexual abuse; 3) related ROS including symptoms of PCOS, thyroid disease, bleeding disorders, pelvic infection, anemia, psychosocial disorders like eating disorders/female athlete triad; and 4) physical exam including external genitalia; consider a full pelvic exam in sexually active females.
  5. What tests would you obtain? Depending on the presentation, appropriate lab testing could include a urine pregnancy test or quantitative hCG level, CBC, TSH, and iron studies. If there’s heavy bleeding, check coagulation studies including von Willebrand panel and possibly platelet function. An androgen panel would be useful if a patient is hirsute or has significant acne. An ultrasound would be done to help evaluate pelvic anatomy, uterine abnormalities and endometrial thickness – usually it could be done transabdominally, but transvaginal can provide better anatomy if patient is sexually active and more detail is needed.

2018-19 TOW #34: Lower extremity disorders

March seems to have come in like a lamb today with signs of spring showing-birds chirping, buds emerging, and longer days of sunshine! The UW cherry blossoms on the quad are scheduled to be in full bloom in 3 weeks. As children “bloom” and begin walking, we and parents are assessing lower extremity disorders. Here are materials to review about lower extremity / gait problems:

Take home points on lower extremity disorders to review:

  1. Lower extremity disorders of children are common: including clubfoot, flat foot, in-toeing, and toe-walking. They present commonly to pediatric offices and are a source of significant parental concern, but most are benign and resolve with time.
  2. The causes of in-toeing vary with age based on the different bones affected in the lower extremity. In babies, in-toeing is most often caused by metatarsus adductus, which is a flexible bending of the forefoot relative to the hindfoot, usually caused by intrauterine positioning. It is distinguished from clubfoot by passive flexibility to a neutral position and full mobility at the ankle. In toddlers, in-toeing is most often caused by internal tibial torsion. In children older than 3-4, in-toeing is most often femoral anteversion, and is sometimes exacerbated by sitting in a “W” position.
  3. Toe-walking carries a risk of Achilles contracture so flexibility of the Achilles should be evaluated and parents should be taught stretching exercises. Rule out muscular dystrophy (tire easily with running) and CP (usually can’t heel walk).
  4. A careful history and physical examination often yield the diagnosis. In most cases, imaging is not needed. Use a prone exam with knees bent at 90 degrees to evaluate hip internal and external rotation (which should be symmetric). Use thigh-foot angle to evaluate tibial position. Also evaluate for any leg-length discrepancy or hip misalignment. Be aware of Vitamin D deficiency as a possible cause of tibial bowing, especially after 18-24 months when physiologic bowing should be improving.
  5. Most of these disorders can be monitored and resolve with growth. Flat foot, in-toeing, and out-toeing, usually only require observation and reassurance for parents. In comparison, clubfoot has a non-rigid curvature of the lateral foot and prompts referral for serial casting and occasionally surgical correction. For out-toeing, referral to ortho should be done at age 3-4 years in case casting is necessary, which is ideally completed before the start of kindergarten.