2018-19 TOW #42: Vision screening

The eyes are the window to the soul, as the saying goes. If that’s the case, we get to see all kids’ souls in clinic! There is good evidence that we have a role in early identification of vision problems through vision screening, so it’s recommended by the US Preventive Services Task Force.

Materials for this week:

Take-home points for vision assessment and problems:

  1. What are recommended vision screening guidelines? US Preventive Services Task Force recommends children <5 be screened to detect amblyopia, strabismus, and visual acuity defects. AAP guidelines include screening at all well visits, from newborn to age 3 using history, vision assessment, external exam, eye movements, pupil exam, and red reflexes. For ages 3 to 5, the AAP recommends adding age-appropriate visual acuity and direct ophthalmoscopy.
  2. Visual system development occurs throughout infancy and childhood and represents a “critical period” of vision development. Early on, we can test visual acuity by testing fix and follow for each eye by covering one at a time. By age 3-4 (up until 60 months), children should be able to see 20/40 on an age-appropriate eye chart, and by age 5 (60 months), should be 20/20. The visual system development is complete by age 8-10.
  3. Reasons for early referral: 1) persistent ocular deviation at 4 months of age; 2) asymmetry on the simultaneous red reflex test; 3) unexplained torticollis; 4) any witness of lack of ocular alignment or parental concern about ocular alignment (even if it’s “just when tired”), and lack of visual acuity in each eye for age (refer if 20/30 or worse in either eye after age 5).
  4. Amblyopia or “lazy eye” is decreased vision in one or both eyes due to abnormal development of visual pathways in childhood. It is the leading cause of vision loss among children with a prevalence of 1-4%. Causes include deprivation (e.g., cataracts), strabismus (misalignment), and refractive error (nearsightedness, farsightedness or astigmatism (abnormal curvature of the lens)). Early treatment is important, but there is some evidence that treatment can help up to age 14. Treatment includes correcting refractive errors with glasses and patching to strengthen the weaker eye. Patching may start to improve vision within a few weeks, but usually lasts months.
  5. Strabismus – eye misalignment is present in about 4% of kids. It can be identified via Corneal Light Reflex and Cover-Uncover test. For the corneal light reflex, when shining a light directly onto both eyes, if the light reflex is displaced nasally, this finding indicates an exotropia (the eye is turned out). When the light reflex is displaced temporally, this finding indicates an esotropia (the eye is turned in). The cover-uncover test should be performed while the child fixates on a small, interesting target, such as a small toy or sticker on a tongue depressor. (NOTE: a bright beam of a light may not provide as comfortable a target and does not adequately stimulate accommodation/focusing). As the child attends to the target, each eye is alternately covered. A shift in an eye’s alignment as it assumes fixation onto the target is a possible indication of strabismus.

2018-19 TOW #41: Temperament in the pediatric visit

Temperament is a great topic to integrate discussion about parenting approaches, and recognizing child needs/preferences. This is a good time to review with colleagues how the Promoting First Relationships (PFR) approaches might help teach parents to recognize child needs, including temperament. Remember that PFR handouts are available for each of the well visits on the TOW blog page. I’ve found them really helpful in anticipatory guidance and addressing parents’ behavior/development concerns.


Take-home Points

  1. What is the definition of temperament and its underlying theory? Temperament is a little challenging conceptually, but can be generally thought of as the ways we self-regulate and react in different situations. Temperament is associated with both emotions and behavior. It emerges early in life, is largely influenced by genetics, and mostly stable over our lifetime. We know temperament can affect developmental pathways and be associated with future psychopathology, but it has been difficult to agree on a consistent definition and exactly how this influences children’s behavior and future.
  2. How many different temperament types are there? There are 10 main temperament traits generally assessed in childhood (adaptabillity, approach, sensory sensitivity, reactivity, distractibility, persistence, mood, regularity and emotional sensitivity). There are 3 main temperament clusters in childhood: “easy” children, “slow to warm up” and “difficult,” based on combinations of traits. Easy children are, well, easy. “Slow to warm up” kids tend to be more careful, to have low adaptability to new situations, and to have difficulty separating from parents. “Difficult” children may be more irritable or fearful, have low adaptability and short attention span, have disordered sleep-wake-eat cycles, and may respond more intensely. I really love framing this more positively as “spirited” to characterize the “difficult” temperament clusters. The book “Raising Your Spirited Child” by Mary Sheedy is a classic and so helpful when parenting a child that is more temperamentally challenging.
  3. How does parenting interact with temperament? We want to use labels carefully to help parents recognize that some children are more prone to having certain behavior/difficult reactions. This is not because they want to make life hard, but may just be how they are wired. Having parented a “slow to warm up” child through toddler years, I can say that it really did help me to learn about temperaments to be more empathic. We can help parents understand it’s not necessarily their fault when their child is easily upset, and also that sometimes a temperament mismatch between parents and children affects their interactions.
  4. How can we use concepts of temperament to discuss parental concerns? It’s helpful to use open-ended questions to explore concerns and give parents a “pause” moment to understand their child’s perspective, such as “What do you think may be going on with her/him when you see this behavior? How do you think s/he is feeling?” Also exploring how parents may be reacting/ feeling to help you understand their perspective / temperament. Simply pausing before offering advice may allow parents insight into their child’s and their own reactions, and help us provide better guidance and reflections.

2018-19 TOW #40: Head shape

An important aspect of evaluating infant growth is head size and shape. Positional plagiocephaly has increased with back to sleep recommendations, and treatment continues to evolve, in part thanks to research by some of our wonderful local craniofacial experts.

Materials for this week:

Take-home points for assessing abnormal head size and shape, especially plagiocephaly:

  1. Clinical definitions: Newborns have 7 skull bones separated by 6 major sutures important to skull growth: 1 metopic, 2 coronal, 1 sagittal, and 2 lambdoid. Craniosynostosis is defined as premature fusion at one or more of the cranial sutures, resulting in restriction of skull growth at that site. Unilateral flattening over the occiput is due to either positional plagiocephaly or lambdoid suture craniosynostosis (much more rare).
  2. Epidemiology: During the first two years of life, 75% of head growth occurs; only 25% occurs after age two. About 20% of infants have positional plagiocephaly in the first 4 months, which increased with 1992 “back to sleep” guidelines. Craniosynostosis affects 1 in 1800. Lambdoid synostosis affects 3 in 100,000.
  3. Physical exam: Look at the head from multiple angles, especially from the top. Positional plagiocephaly has a “parallelogram” shape with the ipsilateral ear pushed forward and ipsilateral bossing with no palpable ridge. Lambdoid synostosis is distinguished by a trapezoid shape with ipsilateral ear pulled back and contralateral bossing with a palpable ridge over the suture. Another tip to remember is metopic suture closes in the first year of life and can cause some normal ridging on forehead (abnormal closure leads to a triangular shape of the head).
  4. Work-up: Generally clinical exam is most important so follow head size and shape closely. If concerned, refer locally to craniofacial clinic to decide on imaging. In more remote areas, where referral access is more limited, imaging may need to be done first, which would typically start with skull x-ray and/or cranial ultrasound (depending on availability of technicians skilled in ultrasound).
  5. Management: Provide patient education about position, including changing direction baby is facing in the crib, keeping babies out of “containers” (carseats, swings, etc.) and promoting tummy time. Refer to PT for any concerns of decreased mobility or torticollis. Refer to craniofacial around 5-6 months if not improving. Helmet therapy costs about $2000 and may not be covered by insurance. It is usually implemented between 6-9 months. Follow developmental status closely as plagiocephaly is associated with higher rates of developmental delay at 36 months.

2018-19 TOW #39: Nutrition and picky eating

This is a topic close to my heart, and it’s really a rich, packed one. Please try to digest (pun intended!) whatever element is most helpful for you to learn/review.

Materials for this week:

Take-home points:

  1. What should we recommend for children to eat? The American Heart Association and AAP say diets should focus on fruits and vegetables, whole grains, low-fat dairy, beans, fish, and lean meat. (I like Michael Pollen’s 7-word summary: “Eat food, not too much, mostly plants.”) Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars (in everything from bread to yogurt to drinks), and eating less processed foods. As the daughter of a cardiologist, I’ve watched with interest the debates over fat and animal fats in our diets. As in many health-related issues, the answer seems to be “it depends”: some people are more susceptible to lipid changes with animal fats, even when maintaining a healthy weight, but for others, animal fats in moderation may be okay, and is certainly preferable to added sugars.
  2. How we eat not just what we eat matters. There’s certainly some truth to the adage “we are what we eat,” (best dramatized by the movie Super Size Me), but it’s also “we are HOW we eat.” Our society has emphasized food on the go, and there’s been a growing interest in teaching children a more balanced message: mindful eating (which our own amazing Dr. Lenna Liu teaches about), raising our own food through gardening, and creating a positive environment for eating without distractions.
  3. Review with families the Division of Responsibility for feeding, especially for picky eaters (“parent is responsible for what, where, when and child is responsible for how much”). Ellyn Satter, a child dietitian who developed this model, reminds us of key elements: make eating times pleasant (no pressuring, battles, cajoling, etc.), only offer water between snacks and meals, be aware of lack of food experience while not catering to likes and dislikes. When giving new foods, offer along with ones kids already know. Children can self-regulate and recognize when they are full or hungry. It’s typical to taper off food intake between 15 months and 3 years as growth rate slows, termed “physiologic anorexia.” I like to show parents how the BMI chart goes DOWN during these times, and that it is expected they will look skinnier (and will seem much pickier!)
  4. Portion size matters as a cue to eating/hunger, with more evidence for effects in toddlers/preschoolers and up, but some evidence this may even be true for infants. One study found that 2 month old babies who were formula fed using large bottles (holding >=6 oz.) gained more weight by 6 months than babies fed with bottles <6 oz.
  5. Promote interaction not distraction during meals. Media has a pervasive influence on children’s food choices and even young children are heavily marketed to by the food industry. Watching TV during meals is associated with kids’ poorer food choices in multiple studies. Sitting together for meals has many positive effects, and doesn’t just have to be at dinner, but can be any meal. To spur interaction, we have found it helpful to start our family dinners with a gratitude practice.