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Lee Tetreault:

Hello and welcome to Frequently Asked Questions from the session, Myths and Data, Review of Most Relevant Research for Pediatric General Practice. We are joined today by Dr. Jeff Brosco. Doctor, before we begin, can you provide a few key pointers for our audience from today's session? 

Jeff Brosco: 

Sure, a couple of things to begin with. Pediatricians, primary care docs, we spend a lot of time providing advice and helping families and caregivers understand what's happening with their child. So there are two key things of this, I think one is that we want that to be evidence-based as much as possible. We want advice to be based on what the research shows and not just what is culturally appropriate all the time. The second thing is that how we communicate that is also based on research. And so, if we want families to be reassured by what we tell them, we need to understand what the research tells us about communication skills.

The third sort of general point is what I call the big three, little three. And this is just a mnemonic that we use often, and very often when I'm seeing families and talking to them, sometimes the story goes all over the place and I sometimes get lost what the main point was. The big three, little three for me, are how's the child learning? How's the child getting along with peers? And how's the child getting along with grown-ups which usually means following the rules. And the little three are eating, sleeping, and toileting. And the little three, eating, sleeping, toileting are more important when a child is little, like a baby. And the big three are more important when they're a teenager, but they're all important at all ages. And I structure my notes this way, I structured my interviews this way. It's a way of keeping track in my head of what all the major categories that I wanna speak to a family about.

Lee Tetreault:

Great, Doctor. So let's get into some of these frequently asked questions. So we have a situation, we have a six-month-old healthy infant, parents ask what solid foods they should offer to their child, they're concerned about allergies. What would you advise? 

Jeff Brosco: 

So I think this is the kind of question that comes up fairly often for us in primary care. And there's been some really dramatic news in the last five years on this. And one of the things we used to worry about a lot and still do, of course, is peanut allergy 'cause it can be among the most severe kinds of allergies a child can have. And for decades, we recommended staying away from peanuts in the first year of life and other foods that are highly allergenic and it turns out we were completely wrong. And when we did a randomized perspective study, and it was done about five years ago, it showed that in fact, providing peanuts in a variety of forms, peanut butter, peanut crackers, those kinds of things, obviously not real peanuts or not the peanut shaped size and those children actually had much less allergies to peanut, later on in life.

So exposure was good. So what this tells me is a couple of things. First is, a lot of what we say about nutrition, we have to be careful, we have to be humble about it 'cause until we do a randomized perspective study, we don't really know. And the second thing is, it turns out, if you wanna prevent allergies than early exposure is probably a good thing. The American Academy of Pediatrics has a clinical practice guideline, on this that is worth reviewing.

Lee Tetreault:

Another case, two-month-old healthy infant, breastfeeding only, growing well, spits up with every feed, and the parents are very concerned. What would you advise there? 

Jeff Brosco: 

So some common things that you hear is you maybe burp the baby, you add something to the formula and those kinds of things. Some people even start meds. And it turns out that the best thing you can do is nothing. Again burping, there was one randomized control study in India that looked at 76 moms and their babies and what they found was that if you burped your baby, they spit up more. That made it worse. So burping is probably not a good thing to do. You don't have to stop families from doing it, but you certainly don't wanna advise them to do it.

A second question is about should you start meds? And the answer is no. There are very few circumstances in which medications for simple reflux like this, where the baby has painless, effortless spitting up and is growing well. The use of medications is showing more and more side effects early in life. So you wanna stay away from those meds unless it's really necessary. 

Lee Tetreault:

And what would be your recommendation in ensuring breastfeeding? 

Jeff Brosco: 

So, in ensuring breastfeeding, it turns out that the three most important things are that number one, that there is an intention to breastfeed. That the mom and the family were interested in doing it in the first place. Secondly, that the mom felt self-efficacy that she felt like, "Oh yeah, I can do this, I'm able to do it." And thirdly there was social support. And I think this is an interesting study that looked at breastfeeding because it's probably true of many things that we do as pediatricians, as family medicine physicians and that is our job is, as much as possible, to help the family recognize what a good goal is, what their intention is, feel like they're able to do it, that the self-efficacy is one of the best predictors of someone being able to do it and that the family, the entire family's on board. Because if grandmother doesn't think it's a good idea, it's gonna be really hard for a mother to do. And breastfeeding is a good example. That's what the research shows, but I think this is true for a lot of different things in the routine advice we provide.

Lee Tetreault:

And lastly doctor, what would be your recommendations in addressing mental health concerns in a pediatric practice? 

Jeff Brosco: 

So this is perhaps one of the most important things facing us in child health today. In Florida, for example, there are about 400,000 children with a behavioral health condition, and fewer than half get any treatment whatsoever. The things that we can do in primary care, are really important. First, there's a lot of room for prevention. When we talked to families about discipline in the first few years of life, and child development and help get kids on the right track, there's oodles of evidence that shows that that's one of the most important things we can do. For those of you who are thinking about having group sessions where children go through a very specific curriculum and parents go through parent training curricula, those are wonderful for helping prevent mental health issues in the first place. And secondly, we in primary care really just have to get better at dealing with ADHD, anxiety, and depression, when it shows up in our practice. There are not enough mental health experts out there and so we need to build up our own expertise and the American Academy of Pediatrics and other professional organizations, have lots of materials for us to get better at this.

Lee Tetreault:

This is really helpful information, doctor, thank you so much for your time today.

Jeff Brosco: 

Thank you.