Pearls and Pointers in Pediatrics

Educational Objectives

The goals of this program are to improve the management of overeating and the management of autism in children. After hearing and assimilating this program, the clinician will be better able to:

1.   Compare the normal instinctive eating cycle to the overeating cycle.

2.   Explain environmental and emotional triggers of overeating.

3.   Counsel parents about establishing healthy eating habits in children early on.

4.   List diagnostic criteria of autism and Asperger syndrome.

5.   Describe the efficacy of psychosocial and pharmacologic treatment of autism.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. May is the owner of Am I Hungry? Mindful Eating Program. Dr. Took and the planning committee reported nothing to disclose. In his lecture, Dr. Took presents information that is related to the off-label or investigational use of a therapy, product, or de­vice.

Acknowledgements

Dr. May spoke in Boston, MA, at the American Academy of Family Physicians’ (AAFP) Scientific Assembly, presented Oc­tober 14-17, 2009. Dr. Took was recorded in Albuquerque, NM, at 2009 Primary Care Update, Improving Patient Care, pre­sented October 31 to November 2, 2009, by the Interstate Postgraduate Medical Association. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Family-centered Approach to Preventing Obesity in Children

Michelle L. May, MD, Founder, Am I Hungry? Mindful Eating Program, and Author, Eat What You Love, Love What You Eat: How to Break Your Eat-Repent-Repeat Cycle, Phoenix, AZ

Normal instinctive eating cycle: based on built-in natural instinct; why  —  early on, children primarily eat to meet fuel needs; when  —  food-seeking behavior (eg, begging, irritability) occurs when signaled by body; what  —  children eat whatever they choose; parents can influence choices; parents responsible for deciding what and when children eat, while children decide if and how much they eat; how  —children eat with intention of feeling better af­ter eating; how much  —  children must be hungry before they start eating, and must stop eating before feeling miser­ably full; children expend energy (eg, play outside) and feel hungry again when energy low; cycle repeats each day; everyone born with instinctive ability to manage weight; determine influences on feeding behavior

Body weight: cannnot determine whether child sufficiently active by weight alone; outward manifestation of behav­iors or choices being made; discuss nutrition and physical activity with all patients

Environmental and emotional triggers of overeating: be cautious about demonizing food (eg, foods high in sugar); besides nutrition, food represents eg, reward, love, compensation, entertainment, distraction; eating serves other purposes besides providing nutrition; natural and evolutionary to seek high-carbohydrate foods for survival, but as­sociation of food with emotional and environmental cues learned; strong correlation between child’s body mass in­dex (BMI) and parental BMI

Overeating cycle: why  —  triggers; children learn to associate emotional states with overeating; what  —  older children and adults choose foods based on trigger (eg, sadness or stress can lead to overeating of chocolate or fast food); must understand what drives desire to eat; important to influence parents, grandparents, caregivers, family members, and food environment (eg, school) that child exists in; healthy food choices should be readily available in positive atmo­sphere; how  —  eating mindlessly; eating differently in private than in public due to shame and guilt associated with food; feeling need to hide behavior escalates that behavior; guilt compounds triggers; how much  —  external means for deciding when to stop eating include running out of food or time and engorgement followed by feeling miserable

Concept of cleaning plate: outdated and must be discarded; eg, “eat all your dinner, or you don’t get dessert”; sends message to children that 1) parent (server of food) knows more about their needs than they do; to please parents, children begin to ignore innate signals to stop eating; 2) meal must be less desirable than dessert; children naturally eat variety of foods and do not distinguish between “good” and “bad” food until concept taught to them; results in stronger desire to eat dessert than meal; 3) “if you’re good and you eat all the icky food, then you get to eat more food, even if you’re full”; teach parents to respect child’s innate cues of hunger and fullness

Other causes of increased BMI: portion sizes  —  eg, recipe that served 6 in 1960s now serves 4; lack of physical activity  —  many children no longer walk to school or play outside; children need activities to engage mind and spirit (boredom may lead to watching television and eating excessively); underlying issues  —  stress; eating to sat­isfy cravings that do not originate from hunger

Restrictive eating cycle: why  —  children restricted from eating certain foods (eg, due to allergy) often crave that food; rules about dieting drive restricted eating cycles, and often conflict or are problematic; when  —  according to rules; 1) do not eat after 7 pm; designed to help people stop eating while eg, watching television or when bored; applying rules that appear to be random and external results in reverting to previous eating behaviors when diet or restriction dis­continued; 2) eat every 3 hr or never let yourself get hungry; designed to address sporadic eating habits, disconnection between hunger and fullness, eating for reasons other than hunger, or restriction followed by gorging; instinctive eat­ers eat when hungry, stop when full, and become hungry again in few hours; external rule mimics instinctive eating pattern, and does not become internalized; 3) always eat breakfast; children who eat balanced breakfast perform better in school and have fewer behavioral problems; may be social issue; how  —weighing, measuring, counting, and keep­ing food journal usually not sustainable behaviors; exercise often used as punishment for eating, or as way to earn right to eat (negative association problematic)

Children and dieting: studies show children on diets eat more when not hungry, choose restricted food, and feel guilty after eating; dieting to control weight often ineffective and may promote weight gain, regardless of starting weight of child; girls whose parents encourage dieting nearly 3 times more likely to be overweight 5 yr later; avoid placing children on diets; recommend changes and interventions for long-term effects; important to work with fam­ilies to begin moving toward instinctive eating; flexibility important; help families learn to be in charge; family-centered approach involves emphasizing healthy eating and physical activity, not for weight loss, but for optimal growth, health, and sustainability

Key messages for families: 1) breastfeeding supports healthy weight; children stay connected to hunger and fullness be­cause mother cannot see milk to cajole child to drink more; breast milk exposes child to flavors eaten by mother; mothers who eat variety of vegetables may expose children to those flavors early; 2) eat when hungry; children in families with chaos (eg, single parent, financial challenges) develop sense of fear; fear of lack of food drives indi­viduals to eat when food presents itself; enable family to provide food consistently (eg, refer to social worker; help enroll in breakfast program or food stamps); 3) child decides when to eat; if child not hungry at dinner time, accept­able for child not to eat (present meal when child hungry [eg, in 1-2 hr]); adjust size and timing of snacks to ensure child hungry at dinner time

Decreasing eating triggers: education  —  teach parents to avoid using food to entertain, distract, reward, punish, bribe, comfort, or love children; ask about parents’ relationship with food; avoid teaching children about “good” and “bad” food to avoid creating more cravings and issues around food; emphasize what children can and should eat (eg, fresh fruit and vegetables, whole grains, lean protein, low- and nonfat dairy products); consistency impor­tant; involve children in meal planning, shopping, and food preparation; new flavors may require up to 10 expo­sures to new flavor before children adopt that flavor; soda  —  teenagers obtain 10% to 15% of calories from soda; rule of “never have soda” can create issues; large sodas problematic because drinks often do not satisfy hunger, re­sulting in consumption of high number of calories; family meals  —shown to decrease tobacco smoking and drug use, and increase family communication; limiting sedentary behavior  —American Academy of Pediatrics recom­mends limiting screen time to 2 hr/day; no television in bedroom; no Internet for young children in bedroom

Autism: Diagnosis and Treatment

Kevin J. Took, MD, Adjunct Associate Clinical Professor, University of Iowa Carver College of Medicine, and Medical Director of Child and Adolescent Psychiatry, Blank Children’s Hospital, Des Moines, IA

Epidemiology: recent study found rates of autism in adults same as in children and adolescents, suggesting diagnosis made with broader criteria; more prominent in boys; 50% of patients with autism have severe or profound mental retardation (MR), 30% have mild to moderate MR, and 20% in normal range; occurs at every socioeconomic level

Diagnostic criteria: autism  —  1) qualitative (ie, “not normal at any age”) impairment in social interaction; impair­ment in use of nonverbal cues (eg, eye-to-eye gaze, facial expressions, body postures, gestures); failure to develop peer relationships; lack of spontaneous seeking to share enjoyment, interests, or achievements with others; lack of social or emotional reciprocity; 2) qualitative impairment in communication; lack or delay of development of spo­ken language; marked impairment in ability to initiate or sustain conversation; stereotyped or repetitive use of lan­guage or idiosyncratic language (eg, echolalia, repeating movie lines); lack of make-believe play or social imitative play; 3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities; inflexible adherence to specific, nonfunctional routines or rituals; stereotyped and repetitive motor mannerisms (eg, hand flapping, self-in­jurious behaviors, rocking); preoccupation with parts of objects; onset before 3 yr of age; Asperger syndrome  —  1) qualitative impairment in social interaction; 2) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities; 3) no clinically significant delay in language development; age-appropriate self-help skills, adaptive behavior, and curiosity about environment; pervasive developmental disorder not otherwise specified (PDD-NOS)  —  atypical presentation; less severe than autism; children able to receive same state and school services as children diagnosed with autism; ask parents about difficulties with communication, eye contact, making friends, limited interests, and difficulty with changes in environment; refer for services

Course and prognosis: autism  —  course long and prognosis guarded; supportive home and early intervention im­proves prognosis; predictors of best outcome include IQ >70, and language ability by age 5 yr; condition may im­prove or deteriorate in adolescence; adolescents at risk for seizures; adult outcome studies show small percentage live and work independently, one-third live in partial independence, and most severely handicapped and dependent on others; Asperger syndrome  —  course and prognosis variable; PDD-NOS  —  outcome generally better than that of autism

Differential diagnosis: schizophrenia  —  rare in children; no hallucinations or delusions; MR  —  quantitative impair­ments without splintering of functioning; deafness or severe hearing impairment  —  children relate to parents, seek affection, and enjoy being held; selective mutism, social phobia, or obsessive compulsive disorder  —  children have social and communication skills

Diagnostic aids and rating scales: Childhood Autism Rating Scale (CARS); Checklist for Autism in Toddlers (CHAT); Modified-CHAT (M-CHAT); PDD Screening Test; Childhood Asperger Syndrome Test (CAST); Com­munication and Symbolic Behavior Scales Developmental Profile (CSBS DP); Autism Diagnostic Observation Schedule (ADOS); eye movement tracking in infants; Systemic Observation of Red Flags (SORF); average age of diagnosis in 2001, 5.83 yr (in 2004, 4.83 yr)

Target symptoms: communication, socialization, repetitive behaviors, or “stuck thinking”; aggression or self-injuri­ous behaviors; inattention, hyperactivity, or impulsivity (diagnosis of attention deficit/hyperactivity disorder often made in patients with PDD who require stimulants); insomnia; difficulty with changes in environment and transi­tions; activities of daily living (ADLs)

Psychosocial interventions: educational and vocational  —Individuals with Disabilities Education Improvement Act mandates free and appropriate public education in patients 3 to 21 yr of age; least restrictive environment (ie, main­stream; “as much as they can tolerate”, avoid overwhelming environment; usually implemented by 504 plans and individual education plans; Training and Education of Autistic and related Communication-handicapped CHildren (TEACCH); speech therapy, sign language, and picture exchange communication system; occupational therapy (eg, brushing or weighted vests); social skills development and group interaction; vocational training for older adoles­cents and young adults; behavioral  —  Applied Behavioral Analysis (ABA) for improved social skills and appropri­ate behavior; most intense treatment recommended for children 3 to 6 yr of age; some states mandate ABA for up to 40 hr/wk; amount of ABA controversial due to high cost (£$70,000 per child); discrete trial teaching; floor time (being with child on their level); relationship development intervention; sensory integration training to gradually desensitize (to eg, touch, textures); social stories to help prepare children for events that may cause anxiety; family  —support of parents and siblings; parents may be at risk for depression or stress-related illness; in-home ser­vices; respite services

Psychopharmacology: risperidone (Risperdal)  —  only medication approved by Food and Drug Administration for autism; approved for irritability in autism in children 5 to 16 yr of age; target symptoms include aggression, self-in­jury, severe tantrums, hyperactivity, impulsivity, and repetitive behaviors; consider medications when symptoms in­terfere with early school intervention and speech therapy; may cause weight gain or sedation; other atypical antipsychotic agents include aripiprazole (Abilify) and ziprasidone (Geodon; associated with least amount of weight gain); selective serotonin reuptake inhibitors  —  efficacy variable; recent studies suggest citalopram did not decrease repetitive behaviors, but can improve anxiety and difficulty with changes in environment; stimulants  —  effective for inattention, hyperactivity, and impulsivity; effect on oppositional defiant disorder “not great”; no worsening of stereotypic or repetitive behaviors; a2-adrenergic receptor agonists  —  eg, clonidine or guanfacine; consider use in young children before using stimulant or risperidone; helps hyperactivity, impulsivity, aggression, self-injurious behaviors, and tantrums; clonidine useful for improving sleep; side effects include drowsiness or irri­tability; benzodiazepines  —  eg, clonazepam, lorazepam; often used as needed for events (eg, physician visits, fam­ily outings); naltrexone  —  for severe self-injurious behavior; memantine or inhaled oxytocin  —  no good studies; melatonin  —  1 to 9 mg at bedtime effective for sleep; consider before clonidine or diphenhydramine (eg, Benadryl)

Other treatments: alternative  —  enzymes; gluten-free or casein-free diets; hyperbaric treatment; chiropractic manip­ulation; craniosacral therapy; no good studies showing effectiveness; not recommended  —  injection of sheep brain extract; holding therapy; facilitated communication; secretin; chelation; omega-3 fatty acids; high-dose leuprolide therapy

Suggested Reading

Coury D: Medical treatment of autism spectrum disorders. Curr Opin Neurol 2010 Jan 16 [Epub ahead of print]; Dawson G et al: Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics 125(1):e17, 2010; Kasari C et al: Current trends in psychological research on children with high-functioning autism and Asperger disorder. Curr Opin Psychiatr 18:497, 2005; May M: Eat What You Love, Love What You Eat: How to Break Your Eat-Repent-Repeat Cycle. Austin, TX: Greenleaf Book Group Press; 2010; Rossignol DA: Novel and emerging treatments for autism spectrum disorders: a systematic re­view. Ann Clin Psychiatry 21:213, 2009; Satter E: Children and restrained eating. J Am Diet Assoc 104:1546, 2004; Satter E: Chil­dren, the feeding relationship, and weight. Md Med 5:26, 2004; Schwarte L et al: Local Public Health Departments in California: Changing Nutrition and Physical Activity Environments for Obesity Prevention. J Public Health Manag Pract 16:e17, 2010; Stichter JP et al: Social Competence Intervention for Youth with Asperger Syndrome and High-functioning Autism: An Initial Investigation. J Autism Dev Disord 2010 Feb 17 [Epub ahead of print]; Wansink B et al: Consequences of belonging to the "clean plate club". Arch Pediatr Adolesc Med 162:994, 2008; Wildes JE et al: Self-reported binge eating in severe pediatric obesity: impact on weight change in a randomized controlled trial of family-based treatment. Int J Obes (Lond) 2010 Feb 16 [Epub ahead of print]; Zwaigenbaum L: Advances in the early detection of autism. Curr Opin Neurol 2010 Feb 11 [Epub ahead of print].