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.

2018-19 TOW #47: Tuberculosis screening

We are fortunate to live in an increasingly diverse city with immigrants from around the world. At this time of year families are often planning summer travel to visit family members abroad, so this is a good time to think about how to screen for TB after travel. Materials for this week:

Key take-home points:

  1. What are the rates of TB in the US, and what are the risk factors among children? TB has been declining in the US and reached an historic low of 3.2 cases per 100,000 in 2012. The biggest risks are being born outside the US, or traveling to another country, especially for >1 week and staying with family. For children, additional risks include living among family members or visitors born in endemic countries, or living with high risk adults (including those affected by homelessness, incarceration, drug use or HIV). Those with chronic diseases, immunodeficiency, and/or those using high-dose steroids are also at higher risk of developing TB.
  2. Who do we need to screen for TB in clinic? It’s recommended to start screening for latent TB infection (LTBI) from the first time we meet patients and annually at well visits, or 10 weeks after return from travel (although considered acceptable to wait for annual check-ups). To assess LTBI risk factors, there are 4 validated questions: 1) Has a family member or contact had TB? 2) Has a family member had a positive TB test? 3) Was the child born in a high-risk country (i.e., outside US, Canada, Australia, New Zealand or Western Europe)? 4) Has the child traveled to a high-risk country for more than 1 week? (and SCH ID team adds: or has child had household visitors from a high-risk country?)
  3. Which screening tests do we use? Screening tests vary by age group: per the CDC, tuberculin skin test (TST or PPD) is still preferred for children less than 5. The preferred test for ages 5 and older is a blood test, the interferon gamma release assay (IGRA, e.g., QuantiFERON -TB Gold). IGRA tests measures interferon gamma response to mycobacterial antigens so are relatively specific to M. tuberculosis. They do not require a return visit, and are not cross-reactive with BCG vaccine. We can use a combination of tests to help establish diagnosis when there are indeterminate results, or concern for false positives or negatives.
  4. What happens if there is a positive TB screen? To establish a diagnosis of latent TB, rule out active disease through a chest x-ray, history and exam. The initial preferred treatment for positive latent TB is with isoniazid (INH) for 9 months (there are alternative schedules to this based on special patient needs).
  5. How common is BCG vaccine? How does BCG vaccine affect interpretation? Bacille Calmette-Guerin (BCG) immunization is widely used in TB endemic countries; the WHO estimates that 83% of the world’s population has received this vaccine. Most countries recommend giving the vaccine at birth, and the majority of children receive it before age 5. Because of the varying effects of BCG on interpreting TB tests, we use a conservative approach, and BCG status is not used in interpreting PPD reactions, and is not a contraindication for receiving PPD. Quantiferon gold testing is not affected by cross-reactivity with BCG, however the test has been less accurate for younger children, and may be more difficult to administer due to phlebotomy requirement.

2018-19 TOW #46: Adolescent immuniztions

There’s a lot going on in adolescence, including trying to complete additional recommended vaccines, the most challenging being HPV and flu. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of clinical settings do adolescents use? Most teenagers have a medical home in the US, and >90% of adolescent vaccinations are received in a pediatric, family medicine or community health clinic. A few receive vaccines in school clinics, internal medicine and OB-GYN settings.
  2. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series (1 dose at 11-12, 2nd at age 16), single dose of Tdap, 2-dose HPV vaccine series (separated by minimum of 5 months; it’s 3 doses if started at age 15 or older), and an annual influenza vaccine.
  3. What are adolescent immunization rates in the US? The 2016 National Immunization Survey showed that adolescents aged 13-15 years met the Healthy People 2020 goal of 80% coverage for Tdap (88% coverage) and first dose of meningococcal vaccine (82% coverage), but did not meet the HPV vaccine benchmark (50% of females, 38% of males). Flu vaccine rates are especially low for teens (49% of 13- to 17-year-olds).
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; family factors include not coming for annual wellness visits. There has been particular parental concern about the HPV vaccine safety and need for it at a younger age. The HPV vaccine is only effective against HPV strains before exposure to the strains. Even before teens start having sex, they may be at risk for HPV related disease. HPV DNA has been detected in cervicovaginal swabs from girls who report never having had vaginal intercourse, so the virus is also transmitted through other forms of sexual contact. Data suggest better immunogenicity to the vaccine when given at a younger age, and teens are motivated that it is only 2 doses if done before age 15.
  5. What are ways we can help increase vaccination rates? A strong provider recommendation is one of the most important factors that positively affects vaccination, as has been shown in several studies for the HPV vaccine. Other strategies are to review immunization records at visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccines due. System-level approaches include family-oriented ones like text reminders to families, web-based education and social marketing, as well as clinician-focused ones like automatic EMR reminders and incentives.

2018-19 TOW #45: Substance use

As pediatricians in primary care, our roles include universal screening, brief intervention, and referral to treatment (SBIRT) for adolescent substance use. After Washington state legalized adult use of marijuana in 2012, we entered a new era of adolescent substance use. One patient I saw under age 13 described in detail why marijuana was a “natural drug” that had medicinal properties to justify why she used it. The societal messages are confusing and often erroneous for teens, so it’s important for us to help provide accurate information and support.

Materials for this week:

Take-home points for substance use problems:

  1. What’s the epidemiology of youth substance use? Among US teens, average first use of alcohol is 13.1 years, ~50% have tried alcohol by 8th grade, and almost 80% have tried it by high school graduation. >50% have tried other drugs by the end of high school, most often marijuana, and ~20% have used prescription drugs non-medically (a BIG increase).
  2. What are the risk factors for substance abuse? Parents with substance abuse, history of abuse, depression or learning disabilities (especially ADHD), family conflict, friend use, and  living in a rural area. Data have shown that those who drink prior to age 15 years are 4 times more likely to develop alcohol use disorder than those who start at age 21. Protective factors include a stable, supportive home environment with clear parental expectation and rules, friends not involved with substances, and personal, academic and social success.
  3. What are the associated problems with substance use? There are many including school drop-out, violence, motor vehicle accidents, pregnancy, and permanent decrease in IQ with prolonged use. Youth getting Ds and Fs in school are 3x more likely to be using alcohol than those getting As.
  4. How should we screen? Use the HEADSSS assessment to screen all youth. It’s helpful to frame this as a “we care about you, teenage years can be hard, and we want to help.” It is also recommended to ask parents and teens together what they have talked about and their attitudes. If concerned, follow-up with the CRAFFT assessment: 2 or more positive responses are predictive of problem use.
  5. Where can we refer? Options to address problem use include mental health counseling and specific substance use treatment. Local resources: Adolescent medicine at SCH, and community programs such asRyther Center for Children and Youth and Therapeutic Health Services

2018-19 TOW #44: Circumcision

Newborn male circumcision is a topic that remains controversial in pediatrics, and overall the AAP has maintained a neutral stance on it. The most recent AAP report, issued in 2012, stated that overall, male circumcision has adequate benefits compared to risks to “justify access to the procedure for families who choose it.” In Washington State, families who choose circumcision must pay for the procedure out of pocket. At the UW Northgate Clinic, one of the available local sites, it costs about $300.

Materials for this week:

Key take-home points:

  1. What are the main benefits and risks of circumcision? Benefits include decreased risk of UTI before age 2, and decreased risk of heterosexual transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in female partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, and buried penis.
  2. What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
  3. What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw appearance from lysing foreskin adhesions, which can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
  4. When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, phimosis or paraphimosis, or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves).
  5. What advice do we give about care for the uncircumcised penis? The only care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractible foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 3 in about 90% of boys, and by teenage years in almost all boys.

2018-19 TOW #43: Hip dysplasia

Developmental dysplasia of the hip (DDH) is an important newborn-related topic. A 2016 report gave new updates that highlighted the “primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.”

Materials for this week:

Take-home points:

  1. What are the primary risk factors for DDH? Female gender (up to 75% of DDH), family history, and breech position in the 3rd trimester. As of the updated guideline, there is now also a risk factor noted for tight swaddling with legs adducted and extended. As many as one in six newborn babies have mild hip instability at birth, and approximately one per thousand has a dislocated hip.
  2. How do we screen for and prevent DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging. Hip-safe swaddling allows the legs to move into flexed and abducted hip position (i.e., legs not confined to a straight extended position). Safe baby carrying is the “Spread Squat position” – also known as the M-Position, or Jockey Position – with the thighs spread around the mother’s torso and the hips bent so the knees are level with or slightly higher than the buttocks. 
  3. What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy while supine with the hips and knees in straight leg position, and then with the hips and knees in flexed position (*be aware if hip dysplasia is bilateral, we obviously can’t compare sides). Galeazzi sign is unequal knee height when legs are flexed. Use Ortolani maneuver (abduction movement to detect a dislocated femoral head reducing into the acetabulum), which the newest guidelines say has the best predictive value. Barlow manuever may not be necessary and/or harmful if too much pressure is applied. If Barlow is used, it should be gentle pressure applied while adducting the hip after performing Ortolani. The Ortolani and Barlow maneuvers are really most reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds, hip movement, and leg length. Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred.
  4. What imaging do we use to screen? Ultrasound at age 6 weeks to 6 months, or plain x-rays at 4-6 months are considered fairly equivalent according to the data, and are implemented based on local availability of trained sonographers. Note, there are more false positives with early ultrasound, and many children with more subtle findings may be watched and rescreened.
  5. What constitutes a positive screen? Based on consensus, children who have unstable hips on exam (a “clunk” on Ortolani) or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Isolated hip clicks without the sensation of instability usually represent normal laxity and myofascial tissue movement over the bones and do not require referral.

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.