2019-20 TOW #5: Breastfeeding

Promoting breastfeeding in infants represents our earliest opportunities to influence nutrition and health for the lifetime. Among the many reasons to promote breastfeeding, the emerging data on how breastfeeding affects the microbiome for infants is pretty amazing. This data may help us better understand why breastfed babies get fewer infections and have other health benefits. Another benefit of breastfeeding: babies get exposed to flavors of healthy foods, and are more likely to eat them later.

Take-home points on breastfeeding challenges:

  1. What are the indicators of successful lactation to assess at initial well visits? Mother: milk is in, not too engorged, minimal nipple soreness with latching (should be improving, get better after first few sucks each feeding); starting to adjust to her newborn and has social support; Baby: feeding on both breasts 8-12 times in 24 hours, satisfied after 30-40 minutes of nursing; gaining 25-30 grams a day.
  2. What are the main problems with breastfeeding that often lead to early cessation? Primary breastfeeding challenges include poor latch, nipple pain, and problems with milk supply. While nearly all mothers try breastfeeding, almost half stop after a few weeks due to these challenges (and many others due to having to return to work without adequate support for breastfeeding). Most challenges are treatable with support from us, lactation specialists, and family/social support. Only about 5% of moms actually have physiologic problems that lead to inadequate supply.
  3. How can we help with these challenges? We need to know a few basics: observe feeds so we can help with latch in different positions, assess nipple pain (should improve with better latch and with time. but if not think of fungal and bacterial infections and vasospasm as causes), and help with milk supply. If milk supply is an issue, recommended strategies include rest, hydration, breast compression, and increased stimulation through feeding and pumping, and galactogogues including Reglan, fenugreek and oxytocin nasal spray.
  4. Why are late preterm infants at special risk for difficulty breastfeeding? Some appear large (6-7 pounds) but can be breastfeeding “imposters”; appear to be feeding well but are not transferring enough milk and not gaining weight well. They need extra attention, clear feeding plan, and benefit from early and ongoing lactation support to help them get there.
  5. How do we decide if a mom’s medication is compatible with breastfeeding? Look it up on LactMed, the NIH sponsored website to provide information about drugs and other chemicals while breastfeeding.

2019-20 TOW #4: Early adolescence well care

We move into the land of adolescents and the fun and challenge that can bring in well visits for ages 11-14 years. Perhaps invoking memories of our own experience at that age helps us be more empathetic to what early adolescents and their parents are experiencing as the tidal wave of hormonal changes hit the body! Let’s review some key approaches and resources for this age group.

Materials for this week:

Take-home points

  1. What are the priorities for well child visits in early adolescence (ages 11-14)? We will be addressing patient and parent concerns first, though may have a harder time eliciting them from patients at this age. That’s why it’s important to allow time 1:1 with the adolescent and to set the tone by explicitly reviewing confidentiality, discussing their strengths and then HEADSSS questions. Some adolescent docs have adopted “SSHADESS” as an alternative to HEADSSS as it reviews strengths and school first before other more challenging topics. As long as we ask more personal/intimate questions later in the interview, either approach can work.
  2. What are the Bright Futures priority areas for these ages? 1) Physical growth and development (puberty, body image, healthy eating, activity), 2) social and academic competence (connections with family and peers, relationships, school performance), 3) emotional well-being (coping, mood regulation, mental health, sexuality), 4) risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs), and 5) violence and injury prevention (seatbelts, helmets, firearms, personal violence).
  3. What are the most evidence-based aspects of our care? Vaccines for adolescents are again a bigger evidence-based aspect of our care at this age. In addition, using strengths-based interviewing and a motivational interviewing approach has been shown to be effective. MI has been applied successfully in adolescent care to address cigarette smoking, alcohol and marijuana use, chronic disease management, and adoption of safety behaviors.
  4. What are the recommended screenings? In addition to measuring weight, height, BMI, and BP, we should screen for vision once in early adolescence. The AAP recommends universal lipid screening for kids in this age group, which has been one of the more controversial recommendations; many opt for a risk-based screening. All other screenings would be considered selective: vision, anemia, TB, STIs, pregnancy, alcohol and drug use.
  5. How do we establish rapport with our patients at this age? What are some clinical pearls? As with children, we try to enter the kids’ world by asking about things they are enjoying, new activities, or their favorite subject. Particularly at this age we want to hear about patients’ strengths (see Dr. Ginsberg’s article above) – we can ask them to describe themselves, or ask how their family or friends describe them. Since parents and young teens are often not having great opportunities to converse, drawing this out during the visits by asking parents what they appreciate about their kids can lead to some amazingly reflective and positive dialogue.

2019-20 TOW #3: Middle Childhood Well Checks

We continue our journey through the land of well visits and review middle childhood (ages 5-10). Speaking from personal experience as a parent of kids this age, it’s a wonderful time to see children growing and developing as their personhood emerges. In primary care at this stage, we get to interact more directly with our patients and begin to develop more of a doctor-patient relationship. I’ve had the joy of attending a patients’ 5th grade graduation ceremony-just one example of the experiences that make primary care amazing!

Materials for next week:

Key take-home points:

  1. What are the priorities for well child visits in middle childhood (ages 5-10)? As always, we are addressing parent concerns first. During these years we discuss school readiness and school performance to help us assess how children are doing. Mental health becomes a bigger area to address including issues like bullying and body image; as well as limit setting and safety, as children become more independent including around strangers, using media, and walking and riding on streets.
  2. What are the Bright Futures priority areas for these ages? 1) School readiness/ school performance, 2) development and mental health, 3) nutrition and physical activity including limits/rules about screen time, 4) oral health, and 5) safety.
  3. What are the most evidence-based aspects of our care? There are not quite as many areas that are as well studied for this age group, but we do know that we should not try to cover too many topics – less is more and probably not more than 5. We know studies have shown parents value primary care and want us to discuss topics likes behavior, eating habits, and safety. Some studies have shown we can augment our verbal advice with approaches like safety-focused children’s books and parent videos and other tangible tools. One study looking at violence-prevention strategies in primary care using office-based counseling and free tools like timers and firearm locks demonstrated parent-reported changes in media use and firearm storage after the intervention.
  4. What are the recommended screenings? In addition to measuring weight, height, BMI, and BP, we should screen for vision and hearing. Anemia, TB, and dyslipidemia should be selectively screened based on risk factors.
  5. How do we establish rapport with our patients at this age? What are some clinical pearls? We can begin to interact first with the patients in these visits, then their parents. Entering the kids’ world by commenting on how much they have grown, something they are wearing, or reading or watching can be a fun starting point. For younger kids in this age range, I have found it really helpful to use the ROR books to assess school readiness/ reading/ counting, as well as their drawings of people and how they write their name. A strategy to learn about kids’ self-perception is to ask them what they like/are proud of about themselves and to ask parents what they appreciate about their kids to draw out more about their strengths and relationships.

2019-20 TOW #2: Early Childhood Well Child Care

We are moving on to the fun and challenge of early childhood WCC (ages 1-4). I’ve attached some cases to stimulate discussion, the link to the Bright Futures materials, and a review article that has some helpful tables about incorporating development-behavioral teaching in primary care. The cases are a way to introduce resources/concepts, and I’ve noted that we will also have more on several topics later in the year.

Materials for next week:

Key take-home points

  1. How do we prioritize what to cover in early childhood well child checks? Again, the most important element in providing patient-centered care is to ask about the parents’ concerns and priorities first. We hone in on the ongoing dramatic developmental and behavioral changes of these years, and the challenges those can bring for caregivers. There is a critical influence that environment plays in nurturing children’s development that affects their behavior, communication, nutrition and activity.
  2. What are the Bright Futures anticipatory guidance topics for early childhood? For toddlers/preschoolers, the major 5 areas vary somewhat by age, but general priorities are family support, routine (including sleep and nutrition), development (with discipline and response to tantrums important in year 2, and school readiness becoming a bigger emphasis for preschool years), oral health, and safety.
  3. What are the most important evidence-based components of early childhood visits? In addition to immunizations, there’s a bigger role for developmental screening and appropriate referral in this age group. There is great evidence for the benefit of literacy programs like Reach Out and Read and early childhood education programs like Head Start, so we have an important role in promoting these. Evidence also shows that our efforts to provide continuity and have ongoing relationships with parents helps with early child outcomes and lowers use of emergency care.
  4. What are the recommended screenings for early childhood visits? It varies some by age, but during this time we should screen for anemia and lead screening in year 2, vision starting at age 3, and hearing at age 4. In addition, we should do formal autism screening (at age 18 months-2 years). We continue to screen for social determinants of health (poverty, education, legal issues, housing and food security).
  5. How can we build rapport with parents and children for early childhood visits?  Again, we can acknowledge the really hard work parents are doing and how exhausting it can be to care for toddlers. Children at this age are also amazing in their rapid change and new skills, so we can help parents connect with that joy and wonder. In our family we joked that this required “advanced parenting,” as you’re trying to negotiate with little ones that can behave like demanding tyrants. It requires a ton of patience and awareness of the child’s experience to be empathic. As always, noticing parent strengths and the qualities they bring helps build those relationships.