Bastioned by the AAP’s statement1 in support of school reopenings amidst the ongoing COVID-19 pandemic, school governing bodies everywhere have established a spectrum of different masking requirements for students. Some may argue that masking could be disruptive to learning and development, particularly in young children. However, the caveat in the AAP’s statement must not be forgotten: that the school reopenings are to be driven by science and safety. Arrangements for social distancing at school are frequently changing, with some schools having greater capacity than others to space out students, and some school districts electing to continue the school year entirely online. Parents and guardians are often constrained by work or other life circumstances, including lack of financial or technological resources, giving them little choice but to send their children back to in-person education. Consistent masking practices for as many children as possible at school will greatly help to mitigate the associated risk of students and staff contracting and spreading COVID-19. Pediatricians are uniquely poised to advocate for this low-cost, minimally invasive intervention that may save countless lives of all ages.(more…)
Literacy in the Time of Coronavirus
Texas is returning to normalcy as restrictions are being eased from the COVID-19 pandemic. Children are still out of school and it remains to be seen when they will return to the classroom environment. The combination of idle time, travel restrictions, and social distancing practices present a significant challenge to parents with restless children at home – as well as an excellent opportunity to promote reading. Pediatricians should use each well-child visit right now to encourage parents to take time to read with their children.
The Council on Early Childhood found approximately two-thirds of children in the United States fail to develop reading proficiency by third grade.1 Reading proficiency by third grade is an important predictor of high school graduation rates, as those who cannot read by that mark are four times more likely to later drop out of high school.1-2 Early reading deficiencies can lead to a lifetime of economic consequences. The Program for International Assessment of Adult Competencies (PIAAC), in a 2016 survey, suggested roughly 1 in 5 U.S. adults do not have basic literary proficiency.3 Low levels of adult literacy and educational level are associated with less economic opportunity, poor health outcomes, and social dependency.1,4
The promotion of reading skills can start in infancy. Parents can read aloud to infants to encourage language development and model reading behavior.1 As infants age, they begin to mimic their parents by turning the pages of books. With picture books toddlers can make inferences from the images before they can read the words on the page. Gradually and with training they may begin to recognize letters and eventually words. Ideally, pediatricians would like our patients to be familiar with the alphabet and recognize their name prior to starting kindergarten. For older children and teenagers, quarantine can be an opportunity to expand their literary horizons. By reading popular novels, classic literature, or books from high school reading lists, students can improve their literacy.
Many resources are available to help parents promote reading. Reach Out and Read Texas has a partnership with many pediatric clinics to provide children with a book at each visit from 6 months to 5 years; their website (see link below) also includes expected reading milestones by age. The Dallas Public Library has Tumble books available for children grades K-12 (see link below) online and additional books are available with a library card (free with proof of residence). Google Play Books has free children’s books available online which are playable on iOS devices.
Donovan Berens, MD
- High PC, Klass P, Council on Early Childhood. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Pediatrics. 2014 August; vol 134 (2): 404-409
- Hernandez D. Double Jeopardy: How Third-Grade Reading Skills and Poverty Influence High School Graduation. Annie E. Casey Foundation. 2011 April. https://files.eric.ed.gov/fulltext/ED518818.pdf Date accessed 5/01/2020
- Mamedova S, Pawlowski E. Adult Literacy in the United States. National Center for Education Statistics Data Point, U.S. Department of Education. 2019 July. https://nces.ed.gov/pubs2019/2019179.pdf. Date accessed: 5/02/2020
- Torpey E. Education pays. Career Outlook, U.S. Bureau of Labor Statistics. 2019 February. https://www.bls.gov/careeroutlook/2019/data-on-display/education_pays.htm?view_full. Date accessed 5/02/2020.
Weight Stigmatization in Childhood Obesity
Childhood obesity represents a growing public health concern and a leading cause of morbidity among children. Multiple efforts have been implemented to curb obesity including educating parents to encourage dietary changes, physical activity, limiting screen time, and behavioral modification. However, relatively few strategies explore the social and psychological impact of the stigmatization of obesity in children, which represents a significant gap in our ability to provide care. It is important for pediatricians to model the approach to patients with unhealthy weight by realizing its stigma, using sensitive language, and engaging in motivational interview.
Weight stigmatization, which is defined as discrimination and stereotyping based on a person’s weight, has largely been cultivated and tolerated in our society. It is perceived as a way of motivating overweight children to lose weight. However, this approach generates negative psychological consequences on children as well as adults (Puhl et al. 2015). It is also ineffective at preventing further weight gain, social isolation, or eating disorders. Weight stigmatization creates a barrier for children to actively engage in healthy behaviors or to seek healthcare intervention. Multiple studies have shown that weight-based teasing correlates with an increased risk of worsening obesity (Haines et al. 2010).
Overweight children suffer from poor body image due to the weight teasing they encounter in their everyday lives. Weight stigmatization and victimization can arise not only from school friends but also from educators and parents. A study demonstrated that about 46% obese individuals experience greater weight victimization from members of their family than from others (Puhl et al. 2008). This shows how weight stigmatization has become normalized in our society: family members are concerned with their loved ones’ health and have a misconception that pushing their children harder will make them want to lose weight. This also creates a long-lasting emotional effect on a child when the weight stigmatization comes from a parent or a family member.
With childhood obesity remaining a public health crisis, pediatricians can display model behaviors with parents by educating families and society about the complexity of obesity (genetics, SES, environmental factors). This helps take away the assumption that the overweight individuals are to blame for their excess weight. Pediatricians can model sensitive communication, using more neutral terms for describing obesity such as “unhealthy weight” or saying “child with obesity” instead of “obese child”. Engaging in motivational interviewing is also more effective for pediatricians to encourage behavioral changes. They can counsel parents to consider the effect of weight stigmatization on their children and ensure that they are actively addressing weight victimization at their children’s schools.
Carine Halaby, M.D.
AAP- Stigma Experienced by Children and Adolescents With Obesity. https://pediatrics.aappublications.org/content/140/6/e20173034#xref-ref-28-1
Haines J, Kleinman KP, Rifas-Shiman SL, Field AE, Austin SB. Examination of shared risk and protective factors for overweight and disordered eating among adolescents. Arch Pediatr Adolesc Med. 2010;164(4):336–343pmid:20368486
Puhl R, Suh Y. Health consequences of weight stigma: Implications for obesity prevention and treatment. Curr Obes Rep. 2015;4(2):182–190pmid:26627213
Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Educ Res. 2008;23(2):347–358pmid:17884836
What We Can Do to Continue to Improve Babies’ Health Outcomes
Infant mortality is defined as the death of an infant prior to his or her first birthday. The infant mortality rate represents number of infant deaths for every 1,000 live births. In the United States, infant mortality rate was 5.9 deaths per 1,000 live births as of 2016. However, of the developed countries, the United States persistently has among one of the highest rates of infant mortality. Despite the overall decline in mortality rate, there remains significant disparities among populations that are likely attributed to multiple barriers to health care, from prenatal to postnatal care. Therefore, it is imperative as pediatricians to identify and address these barriers in order to improve maternal health care and subsequently reduce infant mortality.
The Center for Disease Control and Prevention (CDC) reported over 23,000 infant deaths in 2016. The leading causes of infant deaths include birth defects, preterm births and low birth weight, sudden infant death syndrome (SIDS), maternal pregnancy complications, and injuries (i.e. suffocation). The rates of deaths also vary based on multiple factors, such as socioeconomic status, education, neighborhood safety, race and ethnicity, and access to transportation. Non-Hispanic black infants remain disproportionately affected by infant mortality. Nationwide, the mortality rate of non-Hispanic black infants is 11.4 compared to 4.9 among non-Hispanic white infants in 2016. In the state of Texas, significant variability in mortality rates are even found within a particular group among different communities. Race and ethnicity alone are unlikely to create significant differences in rates.
The alarming rates of infant mortality have fortunately caught the public’s attention, and through the years actions have been taken to improve birth outcomes. Notably, overall infant mortality rate had a greater than 10% decline, from 6.86 deaths in 2005 to 5.9 deaths per 1,000 in 2015. With the development of safe sleep practices in the 1990s, there has been dramatic decline in the rates of SIDS across the country.
Armed with awareness that infant mortality rates in the United States are higher than many developed countries (i.e. Canada, France, Switzerland, and Australia), Congressman Steve Cohen (D-TN) recently introduced H.R.117 in Congress, the Nationally Enhancing the Wellbeing of Babies through Outreach and Research Now (NEWBORN) Act. This proposed legislation focuses on implementing pilot programs in high risk metropolitan areas to provide maternal care and address the leading causes of infant deaths. This could aid the targeted areas in the country that are subject to highest risk of infant mortality.
While there are no definitive measures to prevent many of the leading causes of infant mortality, there are ways to lower the risks. Providing maternal education prior to and during pregnancy, such as the importance of receiving adequate folic acid supplementation can prevent neural tube defects. To address preterm birth and low birth weight with their associated outcomes, our communities must provide adequate and accessible prenatal care for mothers.
Pediatricians should continue to advise safe sleep practices in households throughout the first year of life during clinic visits to reduce SIDS. We must continue to counsel parents on infant care, feeding and parenting in addition to postpartum care during well baby visits.
Consistent parental counseling and education at the local clinical setting along with advocacy at the legislative level will further contribute to nationwide efforts to seek solutions to improve birth outcomes and wellbeing of mothers and infants.
Melody Chiu, M.D.
Transforming the Lives of Children with Asthma
Asthma continues to be a major public health concern affecting 26.5 million Americans nationwide. Currently, it is the most common chronic condition among children with approximately 6.1 million children under the age of 18 diagnosed with asthma, and the third leading cause of hospitalizations in children. Asthma also has a significant financial impact, as it is currently responsible for an annual expenditure of $50.3 billion in healthcare costs and leads to numerous missed school and work days approximating $3 billion. Fortunately, asthma symptoms and costs can be controlled when affected individuals have access to appropriate care and education. Therefore, there is an increasing need to provide proper asthma education to patients and their families in order to prevent recurrent ER visits, hospitalizations, and even death. (more…)
Adverse Childhood Experiences
The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.
What is an Adverse Childhood Experience?
ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health . These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) .
What is the impact of ACEs?
The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors . Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia . Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion .
What can we do to help as pediatricians and as citizens?
The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].
As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are :
- Food security: Are there times when you don’t have enough food?
- Income: Do you ever have trouble making ends meet?
- Housing: Is housing ever a problem for you?
- Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
- Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?
All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support . Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.
Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.
Benjamin Masserano, MD
Telemedicine: establishing a secure connection for everyone
Despite the large role that technology plays in our society, delivery of health care continues to mostly occur in a face-to-face setting between doctor and patient. Telemedicine offers the opportunity for providers and patients to communicate remotely via video interfacing and mobile technology while still allowing for accurate diagnosis, quality doctor-patient interactions, and monitoring for complex medical needs. As healthcare providers, we must acknowledge that this form of interaction allows physicians to easily follow a patient’s progress, and save time and resources for our patients.
Addressing the violence in the news with children
Children are indirectly exposed to acts of violence and terrorism almost continuously via the media. News media continually cycles global events onto screens in every household. The stress of witnessing a shooting is no longer limited to the bystanders and civilians caught on the scene, but is spread diffusely across state and national borders to viewers in their homes including children. Pediatricians can help children and their caretakers process these tragedies better.
Exposure to such news stories can contribute to a stressful environment for the child. In recent years the AAP has focused on ‘toxic stress’ in a child’s life. Toxic stress has been defined as “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships” (National Council of Science: Excessive stress disrupts the development of brain architecture). A growing body of evidence suggests that ecology and biology interact to effect development, i.e., the ecobiodevelopmental framework. In the case of toxic stress, a stressful ecology inculcates lasting detrimental effects in biology and behavior. It can lead to development of poor coping skills, unhealthy lifestyle choices, chronic cardiovascular diseases and serves to perpetuate health disparities to mention a few.
Opinions vary on the extent and significance of the effect of exposure to news media coverage of acts of terror and violence. Increasingly, after such an incident, many articles emerge suggesting how parents should talk to their children about violence. Unfortunately, many children do not have the “buffering protection afforded by stable, responsive relationships” with their parents. Parents themselves may face a difficult time coming to terms with the same tragedies. This gap can be bridged by the pediatrician, school and public policy.
Pediatricians can routinely screen for toxic stress. The AAP has put forward many helpful resources which advise parents on how to talk to their children regarding media violence, tragedies they may have witnessed, school shootings and disasters. Whenever such news is circulating, pediatricians can ask parents if they have trouble communicating with their children about it, expand on their anticipatory guidance using the pre-existing AAP guidelines and recommend appropriate resources to them. Further, pediatricians in collaboration with mental health professionals can meet with parent-teacher associations to share how children are able to best process these events.
Schools can engage their own mental health services and counselors to have a discourse with children in an age-appropriate manner. In the absence of adequate resources, these sessions could be done in groups and limited to when the event is local.
Finally, state government officials can improve funding for mental health services for children and implement strategies to incentivize an increase in the mental health professionals catering to the pediatric population. Legislators can formulate guidelines for Social and Emotional Learning (SEL) curriculum for grades K-12 as exist for pre-kindergarten. As of December 2015, free-standing guidelines for Social and Emotional Learning exist only in the states of Illinois, West Virginia and Kansas. Bills proposing training of teachers and principals to address social and emotional development needs of students have been previously introduced in the U.S. House (H.R.850; H.R.497) and the U.S Senate (S.897) in 2015. In the same year, a bill (HB 3289) was also introduced in the Texas Legislature proposing formulation of a local school health advisory committee to address mental health concerns existing in school efforts and to make recommendations to the school district concerning the integration of social and emotional learning into the academic curriculum.
Adopting such a multi-pronged approach will better preserve the childhoods of the current generation and safeguard their adult lives as well.
1. National Scientific Council. Excessive stress disrupts the development of brain architecture. Journal of Children’s Services. 2014 Jun 10;9(2):143-53. Accessed July 11, 2016. URL: http://developingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Developing_Brain-1.pdf
2. Shonkoff, J.P.; Garner, A.S. Technical Report: The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012. doi:10.1542/peds.2011-2663
3. Committee on psychosocial aspects of child and family health, committee on early childhood, adoption, and dependent care, and section on developmental and behavioral pediatrics. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012. doi:10.1542/peds.2011-2662
4. Busso, D.S.; McLaughlin, K.A.; Sheridan, M.A. Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston marathon bombings. Depress Anxiety. 2014 July ; 31(7): 551–558. doi:10.1002/da.22282
5. Marie Leiner, M.; Peinado, J.; Villanos, M.T.M.; Lopez, I.; Uribe, R.; Pathak, I. Mental and emotional health of children exposed to news media of threats and acts of terrorism: the cumulative and pervasive effects. Frontiers in Pediatrics. 2016. doi: 10.3389/fped.2016.00026
6. Collaborative for Academic, Social and Emotional Learning. Identifying K-12 Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: https://pedsadvocacy.files.wordpress.com/2016/07/a46cb-state-scorecard-summary-table-for-k-12-12-16-15.pdf
7. Collaborative for Academic, Social and Emotional Learning. Identifying Preschool Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: http://static1.squarespace.com/static/513f79f9e4b05ce7b70e9673/t/55df7c05e4b031d82f728c5d/1440709637809/preschool-table-8-27-15.pdf
8. Texas Education Agency. Accessed July 9, 2016. URL: http://tea.texas.gov/index2.aspx?id=2147495508
Gohar Warraich, M.D.
It’s Time to Expand Family Medical Leave
The Family Medical Leave Act (FMLA) is a federal law that revolutionized the relationship between the American work force and medical care. The law grants employees the right to up to 12 weeks of unpaid leave from work due to the birth of a child or to take care of serious health needs for themselves or their immediate families. However, FMLA omits much of the American work force and only guarantees unpaid medical leave. This means that the protection offered by FMLA is unavailable and inadequate for many American families, leaving the health of millions of American children is at risk. As pediatricians we can advocate for our patients by supporting legislation that expands FMLA. (more…)
The Care of Refugee and Immigrant Children
The following is a general outline on approaching care of a refugee or immigrant child.
Comprehensive Health Screen –In addition to a general history and physical, providers should be aware of the unique health care needs of the immigrant or refugee child. The following are examples of what a pediatrician should consider when evaluating the health of an immigrant or refugee child:
- Nutrition (under-nutrition, malnutrition, vitamin/ nutrient deficiency or obesity)
- Exposures (lead, opium, heroin, betel nut, herbal treatments)
- Infectious Diseases (endemic to country of origin)
- Mental Health (depression, anxiety, post-traumatic stress disorder)
- Cultural Practices (female genital cutting or traditional cutting)
Access- connect children with public benefits and ensure that there is proper access to healthcare while in the States. (more…)
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