Disclosure of Potential Conflict of Interest

ONTARIO COLLEGE OF FAMILY PHYSICIANSHEALTHY CHILD DEVELOPMENT: IMPROVING THE ODDSThe 18 Month Visit: Strategies for Implementation in Community Practice May 4, 2012 Family Practice Nurses Association Annual Conference M

Disclosure of Potential Conflict of Interest The Ontario College of Family Physicians received funding for the Healthy Child Development Program from the Ministry of Health and Long Term Care for the Province of Ontario. Dr. Patricia Mousmanis has received funding from the Ontario College of Family Physicians, Best Start: Ontario’s Maternal Newborn and Early Child Resource Center, University of Toronto, Northern Ontario School of Medicine, McMaster University as a clinical tutor in the Early Years Program, Public Health Units of Ontario, Local Hospital and Community CME Events, the MDCME Program and from Memorial University of Newfoundland. The McMaster E Learning Module was developed by Dr Anthony Levinson and his team ( which included Dr Mousmanis) and was funded by the Ministry of Community, Youth and Social Services. There has been no commercial sponsorship of this program.

Learning Objectives By the end of this program, the participant will be able to recognize how family practice teams can optimize proactive health and developmental surveillance and learn how to use the new billing code in family practice offices to understand the research evidence regarding clinical examination that is included in the 18 month well child visit and be able to use the clinical practice tools recommended by the expert panel ( Nippissing and the Rourke) during well baby visits to use the 18 month well child visit as an example of how to do a full review of parent-child interactions and learn how to screen for behavioral, nutritional and developmental concerns, to be aware of how to access community resources to provide assistance to families with young children in order to optimize developmental and health outcomes and to be able to access specific resource for those children with risk factors and delays

“Why Invest In Kids?”Ontario Children

Neuromaturation Early Years • The Early Years Intervention Biological Environment Birth Genetic Social / Ecological Environment Conception

Sensitive periods Age in years

Family Discord School readiness, socio-emotional, physical, cognitive and language function Lack of Support Services Poverty Lower trajectory, lower function Preschool Appropriate Discipline Reading to Child Parent’s Education Emotional Awareness Strategies to Improve Healthy Development and School Readiness Trajectories Readiness to Learn Birth Late infancy Late Toddler 6 mo 12 mo 18 mo 24 mo 3 yr 4 yr 5 yr Early infancy Early Toddler Preschool Adapted from Halton N, McLearn K. Families with children under 3. What we know and implications for Results and Policy. In Halton, McLearn and Shuster eds. Child Rearing in America. Challenges Facing Parents and Young Children. New York. Cambridge University Press 2002

Typically Developing Child Child with CNS insult Risk Factors Dysfunctional Dysfunctional Nurturant Caring Environment Nurturant Caring Environment dysfunctional For Child: Interactions & Relationships with Caregivers are the most crucial factors Atrisk Opportunity To thrive High risk

Risk Factors The Early Years Intervention • Nature and nurture are continuously interacting - the concept of EPIGENETICS. • Children and families are “at risk” as circumstances change. • Early identification and intervention to reduce risks are important. • Universal vs high risk approach (Early Years Report): Best approach is to offer assistance to all families universally with added support for those who require additional professional services.

Susan • Susan and her mother Sharon arrive for an 18 month well child visit . This is Susan’s first visit to your center. She has been well except for several ear infections. Susan is a picky eater so mother asks for advice and suggestions about feeding her toddler. They are recent immigrants to Canada. Mother and Father both work full time and Susan is cared for by her elderly grandparents who do not speak English. • Susan was born at 36 weeks gestation after an uneventful pregnancy. She had a difficult post partum period and required neonatal ICU for 1 week. She had regular follow-up with a pediatrician in their home country for the first six months, but after that, the family moved and used walk in clinics for immunizations.

Sharon • Sharon, the mother, is 8 weeks pregnant, expecting a second child. Sharon has a history of iron deficiency anemia but has not been on vitamins due to lack of funds. She is working in a factory which produces various chemicals including pesticides. • Sharon has a glass of wine daily with her evening meal. Sharon has a history of depression and wonders whether antidepressants are safe to use in pregnancy. She is often tired and has no energy at the end of her busy day to play with her child. She is grateful that her husband’s parents live with them and provide full time babysitting care for her daughter. • Susan and Sharon are exposed to second hand cigarette smoke at home because the grandfather is a very heavy smoker.

Further Info Re Susan and Sharon • Susan, the child, infrequently finishes the main course of meals • Susan does not eat vegetables or meat • Susan drinks 5 bottles of milk per day • Susan is given a bottle of apple juice to take to bed with her at night to help her sleep • Sharon, the mother, eats fish daily (especially tuna and swordfish) and wants to start Susan on a similar diet • Susan is quite pale and does not seem as energetic as her cousins the same age

Risk Factors: Clinical Implications • Introduction • “Research supports evidence that neuromaturation is directed by genetic mechanisms whose timing is regulated by and whose unfolding is sensitive to environmental influences” Epigenetics • Factors that may be risks to a vulnerable fetus or child occur • Preconception • Prenatal • Perinatal • Postnatal • Early Years Preconception Issues-Use Preconception Checklist Periods

www.ocfp.ca Healthy Child Development: Improving the Odds

Perinatal Developmental Vulnerability • Neonatal Risk Factors i.e.) birth trauma, prematurity, infection, metabolic/endocrine, Rh ABO incompatibility • Maternal Risk Factors i.e.) Postpartum Depression, limited social support, problematic substance use,health issues • Paternal Issues i.e.) Family support issues, mental health concerns, cultural considerations • Parkyn Postpartum Screening Tool - children with congenital or acquired health challenges, developmental factors, family interaction factors-universal screen for all families - home visiting for those at risk – New Changes for Healthy Babies Healthy Children are coming in 2012

Transactional Model Anxiety Avoidance Mother Birth Complication Difficult Temperament Language Delay Child From Sameroff, A. et at, 2000

Antenatal and Postpartum Major Depressive Disorder • child’s first adverse life event. • Newport DJ, Wilcox MM, Stowe ZN. Clin Neuropsychiatry. 2002 • exposure to MDD influences both fetal and early childhood development independently • Henry AL, Beach AJ, Stowe ZN, Newport DJ.. Clin Obstet Gynecol. 2004 • cause appears to be multi-factorial

Edinburgh Postnatal Depression Scale • Screening for postnatal depression. • above threshold: 92.3% likely depressive illness • Clinical assessment and judgment: confirm diagnosis & severity. • 10 statements: feeling in the past week • less than 5 minutes • not all anxiety disorders, phobias or personality disorders • validated in pregnancy and in fathers • translated into many languages • Cox JL, Holden JM, Sagovsky R. Br J Psychiatry. 1987 [http://www.rcpsych.ac.uk/publications/gaskell/81_1.htm

Edinburgh Postnatal Depression Scale (EPDS) …how you have felt IN THE PAST 7 DAYS… • I have been able to laugh and see the funny side of things. • I have looked forward with enjoyment to things. • I have blamed myself unnecessarily when things went wrong. • I have been anxious or worried for no good reason. • * I have felt scared or panicky for not very good reason. J.L. Cox, J.M. Holden, R. Sagovsky. British Journal of Psychiatry June, 1987

Edinburgh Postnatal Depression Scale (EPDS)continued 6. * Things have been getting on top of me. 7. * I have been so unhappy that I have had difficulty sleeping. 8. * I have felt sad or miserable. 9. * I have been so unhappy that I have been crying. 10. * The thought of harming myself has occurred to me. J.L. Cox, J.M. Holden, R. Sagovsky. British Journal of Psychiatry June, 1987

Neonatal Assessment • Observation of parent child interaction • General physical examination • Neurological examination • Screening – PKU, Thyroid, Metabolic Tests, Hearing - high risk protocol for neonatal ICU • Feeding -encourage breast feeding • Anticipatory guidance – safety, care,”Back to Sleep”, avoid bedsharing, pillows and blankets

Family Health Team Community Health Center Role • More proactive approach to intervention vs. “wait and see” • Increased awareness of risks and clinical problems • Increased use of community resources

Infant Developmental Risks • 1)Development Delays: relates to observed behavior • i.e.) motor, language, cognitive, psycho social • 2) Failure to Thrive: relates to physical health and growth • i.e.) malnutrition, chronic illness, environmental (e.g.) nature of parent/infant & relationship • i.e.) parental factors, infant factors 3) Abuse, Neglect and Deprivation: relates to the quality of the environment and care • i.e.) role of resilience • i.e.) diet, exercise, social experiences, car seats, helmets, pets 4) Attachment Problems: relates to the nature of the parent-infant relationship

Developmental Risk Interactions Failure to thrive Abuse Neglect Deprivation Attachment problems Developmental Delays

Current Recommendations for Feeding in the Second Year • Joint working group of the Canadian Pediatric Society, Dietitians of Canada and Health Canada • “Small, frequent, nutritious and energy-dense feedings of a variety of foods from the different food groups are important to meet the nutrient and energy needs during the second year” • Emphasis on small, frequent feedings and variety

Assessing Growth • The CDC growth charts are considered references and were created in 2000 based on a North American population that was both breast and bottle fed • In April 2007 WHO released their new Child Growth Standards • In 2010, the WHO standards were approved for general use by the Dieticians of Canada

WHO Child Growth Standards • Multicentre Growth Reference Study • Used culturally and ethnically diverse sample population-breast fed to 6 mths • An optimal start in life-achieve potential • Some longitudinal and cross sectional data-motor milestones included • The prescribed nature of the sample allows for the creation of a standard

WHO Growth Chart

Advice for children • Young children need to eat small amounts of food throughout the day. • Nutritious foods that contain fat do • not need to be restricted. • These foods are a concentrated source • of calories that are needed for growth. • Parents and caregivers are role models.

Normal Toddler Eating • Skeptical – do not automatically like new foods and need time to learn to like them • Erratic – intake varies from day to day, week to week and favorite foods change • Opinionated – will not eat something just because you want them too • It is normal for a toddler to show marked likes/dislikes and to reject a food after 1 bite

Dealing with the Picky Eater • “Division of Responsibility” • Parents “are responsible for the what, when and where of feeding” • Children are “responsible for the how much and whether of eating”

Parents Decide: • What – small frequent feedings, a variety of foods based on Canada’s Food Guide • Where – meals should be eaten at the dinner table, with the child seated in a comfortable chair • When – at consistent times each day, with the rest of the family

Factors that interfere with toddlers’ self-regulation • Parental pressure to eat • Parents/caregivers failing to recognize or respect verbal and non-verbal cues with respect to hunger and satiety • Parental control • Lack of limits or structure

Toddler Portion Sizes • Balance of food group servings should be the same as for adults, but the size of the servings is smaller • Should have 4-6 small feedings per day • Sample lunch: ½ bagel with butter, 4oz whole milk, ½ apple, 1”cubed piece of cheese

Why is 18 Months Pivotal? • Developmental Issues • Speech and Language – Literacy • Parenting/Behaviour Issues • Family/Social Issues • Last scheduled immunization until age 5

Overview of Web Portalwww.18monthvisit.ca

Clinical Strategies For Health Care Providers • Screening and Identification • risk • developmental problems • Risk Reduction • Education / support • Treatment / referral • Monitoring and Ongoing Care • Advocacy and Developmental Enhancement • education • community awareness and interaction • community involvement and advocacy

Infant Health SurveillanceWell Baby/Child Care • Review parent concerns • Monitor physical growth and development • Assess parent-child interactions • Counsel about development, safety, nutrition and community resources • Encourage parents • Provide immunization and other preventive care • Identify risks/problems for action

Evidence based examination • Height, weight and head circumference • Inquiry re: feeding etc, elimination, sleep and soothing patterns, parent child interaction, child discipline techniques • Physical examination – reviewing specific screening for vision ,hearing and clinical manoeuvres as suggested by evidence based research(lift lip to look for dental caries, red reflex, cover/uncover test, inquiry about hearing and vision) • DeveDevelopmental Surveillance– observation and inquiry as indicated by age with use of a parent screening tool

Normal • All “yes” checks on NDDS • No concerns on Rourke Abnormal - One or more “no’s” on NDDS or other developmental concerns Parenting Community programs 24 Months Repeat surveillance Use Rourke Record to determine areas of difficulty Review Vision and Hearing Screening -contact central number for children’s services Speech and language delay/difficulty only Symptoms of social difficulty/autism Delay with motor development or GDD Social/Emotional or Parent and family issues • Preschool Speech and language • Early intervention Services • Monitor closely • Pediatric assessment • Early intervention Services • Preschool Speech and language • Autism Intervention • M-CHAT • Pediatric assessment • Early intervention Services • Community Care Access Centre (CCAC) • Children’s mental health services • Healthy Babies Healthy Children Community Team Works Collaboratively Physicians, Early Intervention Services, Healthy Babies Healthy Children, Preschool Speech & Language Services, Preschool Autism Services, Ontario Early Years, CCAC, Child Care Centers, Children’s Treatment Network Office Visit Nipissing Screen (NDDS) : Parent Rourke Record Developmental Flowchart for 18 month visit

Tools specific for well child visits • Infant/ Well Child Health Surveillance • Rourke Record – Birth to age 6 years • Addresses parental concerns • Evidence based guidelines and record • Developmental screening “red flag” • Reminder of age appropriate issues • Includes safety & family issues • New version June 2011 evidence based for Canada/ Ontario version available since November 2011 • Nipissing District Developmental Screen • Facilitates parental concerns at age appropriate stages • Effective anticipatory guidance/Updated fall 2011 • Validated for delay detection i.e.) 1 “NO” deserves follow-up - 18 MONTH VISIT FLOW CHART - M-CHAT: Modified Checklist for Autism in Toddlers

Oliver – age 18 months • Oliver’s general health has been good. He was born after an unremarkable pregnancy and delivery at 40 weeks gestation. The mother reports that Oliver is developing well and the mother has answered yes for all the questions on the 18 month Nipissing chart! He has been walking independently from 15 months, and he is starting to feed himself with his right hand. She does note that he has always preferred to use his right hand to play with toys, but she is not concerned as most people in her family are right handed. He is able to identify 3 body parts and has 10 words that he is able to use consistently. He enjoys looking at books and pointing to pictures. Growth charts indicates that Oliver is growing well. As you measure his height, weight and head circumference, you wonder if he has mild hypertonia in the left elbow flexors but you are not convinced. You do note when grabbing a toy Oliver always uses his right hand. When he is standing –he is occasionally up on his left toe.

Problem List • Did Oliver start walking too late? • Is it too early to develop a strong handedness? • Is there cognitive delay? • Is hypertonia in the extremities at this age normal? • Is Oliver’s toe walking pathologic in nature?

Language Milestones: 18 months Understands many words Identifies several body parts when named Follows spoken directions such as ‘get the ball’ Plays by simple acts of pretending (e.g. feed dolls or stuffed animals) Uses gesture and facial expression to get the message across Imitates sounds and words Makes more than 5 different consonant sounds, like /m/, /n/, /b/, /d/, and /g/ Spoken vocabulary of at least 20 words * (range of 20-50 words) *new milestone

Motor Milestones – 18 months Gross motor skills: • Walk alone / moves about house without adult • Walks up stairs while holding on with one hand • Push a toy while walking forward Fine Motor skills: • Feed self with spoon with little spilling • Drink from a cup • Develop a pincer grasp • Point with pointer finger • Build a tower of two to four blocks • Does not preferentially use one hand to complete tasks

Nipissing District Developmental Screen (NDDS) • Developmental screening tool for parents • Any “No” response deserves further clarification and possible action • Two ‘No” responses is clinically correlated with significant developmental delay • Linkage of milestones to the Rourke Record • Basis for developmental discussion • Provides specific age appropriate ideas for parents to optimize development

Using the NDDS • It is a screen, not a diagnostic tool • It needs to be used for ALL children, not selectively • It can facilitate discussion regarding development • New version Fall 2011 and pictoral version pending in 2012 • It engages parents in the process of evaluation

Filling in the questionnaire, the parent: • Has time to reflect about the child • Is made aware of different aspects of development • May be prepared to discuss concerns with the physician or nurse

Disclosure of Potential Conflict of Interest