2019-20 TOW #1: Infant Well Child Care

It’s exciting to kick off another year of continuity clinic teaching and our TOW series.

We are starting with a review of well child care at different ages in the first 4 weeks. This is a great opportunity to highlight recommended screening and priorities for these visits, and your clinical pearls. For interns not in clinic this month, please refer back to them later!!

Materials for this week:

Key take-home points:

  1. How do we prioritize what to cover in infant well child checks? There is widespread acknowledgement that providing comprehensive WCC is difficult in a typical ~20 minute visit, and it’s impossible to cover everything. National organizations like the AAP and pediatric research have helped define key priorities. And, others, including one of our own faculty, Tumaini Coker MD MPH, have highlighted the need to do more to address social determinants of health in WCC. One critical element in providing patient-centered care is to first ask about the parents’ concerns and priorities, e.g., “What do you want to make sure we talk about today? What are your questions and concerns?”
  2. How can Bright Futures resources be used? Bright Futures is the AAP-endorsed and supported guidance for primary care practices to prioritize components to include in comprehensive well-child and adolescent care. For each recommended well child check from newborn to age 21, there are guidelines for screening and 5 key recommended areas to discuss. For infants, the major 5 areas to prioritize are family functioning, development, growth and nutrition, oral health, and safety. Many sites use Bright Futures patient education handouts, which are great to review briefly when preparing for visits.
  3. What are the most important evidence-based components of infant visits? Providing immunizations and helping families stay up to date (more on this in a future topic!) is the most evidence-based. There is also evidence for programs that help parents thrive in parenting roles. We want to identify untreated mental illness or substance abuse, and if parents understand normal infant behavior, such as crying, and how to connect with and comfort their infants. Strategies like those taught in Promoting First Relationships (PFR) are effective (more on that to come as well). Questions to help explore include: “How are you doing? How are things going for your family?” To explore the relationship, perception of infant, we can ask “Tell me about your baby. What do you like best about him/her?” or “What has been difficult? What has surprised you?” These help us identify red flags for high-risk social interactions that may warrant more support.
  4. What are the recommended screenings for infant visits? It varies by age, but after the newborn hearing and metabolic screenings, most screenings (including blood pressure, vision, hearing, and anemia screenings) are selective for at-risk infants, such as for preterm infants or those who have abnormal findings on exam or by parent report. It is recommended to do a formal development screening at 9 months. In addition, we can make the case for the benefit of routine screening for social determinants of health (poverty, education, legal issues, housing and food security-more on these to come).
  5. What ways can we build rapport with parents for infant visits? Acknowledge how hard parents are working, and normalize how difficult it can be caring for infants. Also notice their strengths as a parent. It’s helpful to note out loud the positives about their interactions with their babies, e.g., “Wow, look at how your baby gazes at you – it’s so clear how much they want to see and hear you. It’s amazing how she already knows you. When you respond with comforting like that, this helps her feel safe and secure and know she’s loved.”

2018-19 TOW #50: Social media

Social media is now at essentially ubiquitous levels of use among adults and adolescents. The new interns just discussed how to use it safely now that they are practicing doctors. Let’s review for youth as well.

Materials for this week:

Take-home points:

  1. How do we define social media? Social media can be defined as any online applications that allow for the creation and exchange of user-generated content. The collaborative approach is what separates “Web 1.0” functionality (i.e., static Internet pages) from “Web 2.0” where there is continuous modification and participation by users.
  2. How often are internet and social media used in children and adolescents? Even back in 2015, the Pew Internet and American Life Project found that 92% of teens went online daily. Nearly one quarter used the internet “almost constantly” via smartphones, with 73% of teens owning a mobile device and 91% using it to go online. We know the numbers have only increased! What I was surprised to learn is that even 50″% of 5 year olds and 70% of 8 year olds went online daily. By 4 years of age, nearly 75% of children had their own mobile device in a study of low-income urban minority children. A separate study found that by age 10, more than half of children had accessed an online social network site. We have truly entered a new digital age.
  3. What are some of the positives of social media use? (this is like an MI-style pro-con discussion!) There are 2 main categories: social connectedness and learning. Social media facilitates staying connected with friends and family, making new friends, and also creating social inclusion through community engagement. On the learning front, there are data that it helps with motivation to learn, and can be associated with higher test scores, especially for older youth. It also allows teens to access health information easily and anonymously. Additionally, it allows for self-expression, developing an individual identity, creativity, and exposure to ideas.
  4. What are some of the negatives? We now know there are quite a few: all of those positives seem to have their negative corollary. Risks of social media include cyberbullying, sexting, dissociating one’s online and offline life, and permanence of the digital footprint. Additional negative aspects include exposure to age-inappropriate and/or sexually explicit content, addiction to the Internet, and what’s been termed “Facebook depression”. By extension, these can negatively impact grades, relationships with family and friends, and physical and mental health (including sleep deprivation). Online exposure to alcohol and tobacco use, and sex is associated with earlier initiation of these high-risk behaviors.
  5. How can parents help youth navigate the Internet and social media? Parents should have open and honest discussions about Internet and social media use. Parents should evaluate sites their child wishes to participate in, discuss safe and appropriate usage, and routinely supervise and monitor usage. Though 94% of parents report ever talking with their teen about appropriate content to view and share online, only 40% do it frequently. At our house, our daughters need to use their devices in family areas (not in the bedroom). Even so, my daughter was trying to get on a Harry Potter website that required her to be 18 this weekend! It does take constant vigilance to be aware and support youth. The data are rapidly emerging on risks of depression with a lot of use. Adults need to model and encourage moderation. Avoid phone use during meals and before bed as a start. I like saying “the phone / device has it’s own bedtime and sleeping place.”

2018-19 TOW #49: LGBTQ+ Health

This week’s topic comes to us thanks to Dr. David Inwards-Breland, one of our fabulous adolescent medicine docs, who provided the materials. If you are interested in more on adolescent health, check out the Teenology 101 blog by Dr. Yolanda Evans and specifically the LGBTQ articles.

Materials for this week:

Take home points for LGBTQ youth health:

  1. What are some particular health care needs for LGBQT+ youth? Most people who identify as LGBQT+ are healthy, however, there is a disproportionate number of LGBTQ+ youth who face barriers to health care and mental health problems, usually as a result of sexual prejudice and lack of family/community support.
  2. How many teenagers identify as LGBTQ+? Recent studies estimate that somewhere between 3 and 10% of the adult population is LGBTQ+. Estimates in teenage years are difficult because the sexual identity is evolving. Around 25% of 12 year olds feel uncertain about their sexual orientation.
  3. How should we approach sexual health discussions? Begin to talk to patients separately from their parents by age 11 or 12 to allow them to speak with you confidentially. In visits with adolescents, we should explicitly remind them of confidentiality and use non-judgmental, gender-neutral language. Tailor the HEADSSS assessment to their age and development. In the study on LGBTQ+ youth health care preferences linked above, youth felt that provider qualities and interpersonal skills were just as important as provider knowledge and experience, and they placed little importance on a provider’s gender and sexual orientation.
  4. What are ways to ask about sexual attraction and sexual identity? We can explain to patients we ask about their sexual health as part of routine visits because it’s an important part of life, and we want all youth to feel comfortable and supported. We should ask adolescent patients about who they feel attracted to: “Do you feel attracted to girls, boys, both or neither?” Asking about gender identity can be done as: “do you identify with being male, female, both or neither?”
  5. What are risks for STIs among LGBTQ+ patients? We should provide counseling about safe sex and birth control to all adolescents. Female patients that identify as lesbian may still have male partners, so may be at risk for STIs and pregnancy and should have PAP smears. Male patients have higher rates of STI exposure (in King Co in 2015 exposure rate was 44% among 15-19 yo men who have sex with men). Patients with high risk for HIV infection should be considered for pre-exposure prophylaxis (PrEP).

2018-19 TOW #48: Injury prevention

Next up in TOW-land is reviewing injury prevention, a timely topic for summer months, which are known as “trauma season” to all those at Harborview. Please offer appreciation to your colleagues taking care of injured children this summer at HMC. We also offer gratitude to our injury prevention experts including Drs. Beth Ebel, Brian Johnston, and Fred Rivara, who dedicate their time to making kids safer across our nation/globe.

Materials for review:

Take-homes points:

  1. How big a problem are childhood injuries? About 1 in 4 children has an unintentional injury that requires medical care each year. Injury is the leading cause of death among children and adolescents > 1yr in the US. Injuries cause 42% of deaths in children ages 1-4 and 65% of deaths ages 4-18.  Injury peaks during the toddler years (ages 1 to 4) and again during adolescence and young adulthood (ages 15 to 24). The problem is even more profound in developing countries.
  2. Have childhood injury rates changed over time? Thankfully, injury rates have decreased due to multiple public health and health care efforts. Between 2000 to 2009, the unintentional injury death rate for US children <19 declined by 29%. This is attributed to seat belts and carseats, reduced drunk driving, increased use of child-resistant packaging, as well as better awareness and improved medical care. The highest deaths remain due to motor vehicle accidents, drownings, and firearms, so we cover those more in-depth in other topics.
  3. How do we best prevent Injuries? Mace and colleagues describe the “four E’s of injury prevention”-education, engineering (modifying environmental or product design), enforcement (mandating appropriate laws), and economics (creating financial incentives and disincentives). In general passive interventions that don’t require someone to act (like air bags, road design) work better than active ones that require users to choose them (like seatbelts, helmets), and certainly better than education alone (as Kat Bonsmith recently reviewed for us in her informative RCP on baby-proofing).
  4. What’s the pediatrician’s role in education (and advocacy)? In the primary care setting, education is the main way we provide anticipatory guidance, and the AAP recommends every well-child visit include age-appropriate injury prevention counseling. However, only approximately 50% of pediatric residents and practitioners provide injury prevention counseling at well-child visits. We have to be strategic because we can’t cover every topic every time. Bright Futures helps guide which injury prevention topics to cover at each age. Extending our role to advocacy addresses the even more important “E’s” that produce system improvements to protect thousands of children.
  5. Are there “teachable moments” after an injury? Due to the lack of data, there is some controversy that the “teachable moment” has an added effect after an injury, but its reasonable to ensure people have the information and tools they need to prevent future injuries. At Harborview, the peds team distributes injury-specific information and resources as often as possible, such as bicycle safety and helmets after an unhelmeted bicycle injury, a new carseat after an MVA, or window guards after a fall.