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…)
“Misinformation is not like a plumbing problem you fix. It is a social condition, like crime, that you must constantly monitor and adjust to.” -Tom Rosenstiel
As a society, we are blessed to live in an age of abundant and easily accessible information. However, it can be difficult to distinguish between what is true and what is false. As pediatric providers, we have become aware of this- especially when it comes to parents who are concerned about vaccine safety. These concerns must be acknowledged and addressed. Along with providing medical advice and resources for reliable information, we should also be educating parents on how misinformation is presented. (more…)
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
While pediatric care spans from birth to 18 years, issues of adolescence, particularly regarding reproductive healthcare, often seem to be overlooked. According to the CDC, among high school students in 2017, 40% had ever had sexual intercourse, 10% had four or more sexual partners, and 46% did not use a condom when they were most recently sexually active1. Appropriate reproductive healthcare is crucial considering these statistics and their implications on various issues such as teenage pregnancy and sexually transmitted infections (STIs), as well as the mental and emotional well being of adolescents. Therefore, care of an adolescent patient should always include taking a thorough sexual history, as well as providing guidance on sexual health and safe practices. (more…)
In 2016, the American Academy of Pediatrics (AAP) revised screen time guidelines for children. The previous guidelines advised no screen time for kids less than 2, and no more than 2 hours in front of the TV for kids over the age of 2. With the advent of smart phones and tablets making screen time and Internet access nearly ubiquitous, many pediatricians and other professionals felt the AAP was long overdue in revising screen time guidelines to be more appropriate for current and future generations of children. Newly revised 2016 guidelines were broken down into four basic age groups with added flexibility to customize screen time to fit the needs of the individual child, as follows:
- For infants less than 18 months of age:
- Parents should avoid use of screen media other than video chatting.
- For infants 18 to 24 months of age:
- If desired, parent should choose high-qualityprogramming, and watch with children to help them understand what they’re seeing.
- For toddlers 2 to 5 years of age:
- Parents should limit screen use to 1 hour per day of high-quality
- Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them.
- For children 6 years of age and older:
- Place consistent limitson the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health.
These new guidelines recognize that visual media can be an important tool for development and educationwhen properly utilized. The problem is that many parents do not properly adhere to these guidelines. Contrary to what some may believe, these guidelines do not relax the parameters for screen time. Rather, these guidelines call for increasedparental investmentin actively regulating their child’s media consumption. Examples of inappropriate screen time, at times even commonly witnessed directly by pediatricians in clinic, include some the following:
- Parents using video streaming on mobile devices as a means of distracting their infants or children.
- Parents not adequately supervising screen time.
- Parents failing to set consistent limits on media use.
- Parents or children choosing to view poor quality programming with little educational benefit.
Adverse effects of unregulated screen time are well understood to include the following: obesity, sleep problems, problematic internet use (e.g. gaming disorders), negative effects on school performance, risky behaviors (e.g. substance abuse, inappropriate sexual behaviors), sexting, piracy, predators and cyber bullying.
Given the common adverse effects of unregulated media use, it is important to recognize that the above guidelines do not indicate AAP’s endorsement of screen time as a primary learning activity. The AAP recommends that parents prioritize creative, unplugged playtimefor infants and toddlers. The amount of daily screen time for older children depends on the child and family, but children should prioritize productive time over entertainment time.
The AAP provides an important but underutilized tool online that helps families build their own custom Family Media Plan (see link below). Pediatricians who wish to emphasize the importance of regulated screen time should consider providing this resource to families in their clinics. The plan provides a customizable template that includes setting important boundaries in the development of healthy screen time behavior.
Lastly, a quote from Bill Watterson, arguably one of the most creative minds of the late 1980s-early 1990s who is known for his authorship of Calvin & Hobbes, helps reinforce the importance of alternatives to screen time:
“We’re not really taught how to recreate constructively. We need to do more than find diversions; we need to restore and expand ourselves. Our idea of relaxing is all too often to plop down in front of the television set [or internet] and let its pandering idiocy liquefy our brains. Shutting off the thought process is not rejuvenating; the mind is like a car battery—it recharges by running.”
Alex J. Foy, MD
Sources and Resources:
Build Your Own Family Media Plan
10 Tips for Becoming a More Active Family
Children and Adolescents and Digital Media
Constantly Connected: Adverse Effects of Media on Children & Teens
In the United States hunger remains a problem with far reaching consequences especially when it affects our youngest members of society. Though many would argue that food is one of our most basic human needs, it is something many United States families at times must go without. (more…)
At the start of every school year, thousands of high school athletes come in excited to hit the field. Unfortunately, heat related death in high school sports, especially high school football, remains a real risk due to lack of regulations and safeguards in place. However, these injuries and deaths are entirely preventable by proper practices. Pediatricians have a duty and an opportunity to protect these athletes from environments and circumstances that put them at increased risk for heat stroke and death.
Almost everyone, especially medical professionals, would agree that getting regular exercise is good for your health. Many studies have shown that regular exercise decreases the risk of cancer, heart disease, and premature death in general. In children, increased physical activity has been linked to better performance in school. Despite the clear benefits of physical activity on health and other outcomes, few patients report receiving physical activity counseling from their primary care physician. As physicians and leaders in the community, pediatricians should provide appropriate physical activity counseling to their patients, as well support efforts to better assess and address obstacles to regular physical activity in the pediatric population. (more…)
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.
Remember the days of playing hopscotch, kickball, or tag? Or maybe you can recall the joys of swinging from the monkey bars or the release from climbing on the jungle gym? Doctors, parents, and others are concerned that kids are losing out on physical activity during their school day to increase the amount of instruction. Working with schools and lawmakers should be our focus to protect recess and physical education time.
When schools replace physical education and recess with more instructional time and academic work, children lose valuable benefits from free time and play. The benefits include:
- Children need a release time from the classroom. They need to expend their energy.
- Studies have shown that children are able to focus in the classroom when they have recess time.
- Other studies have shown that children feel more positive and secure when recess is a part of their day.
- Children learn best by experience. The playground and gym provide this type environment for learning. They provide opportunities for problem solving, interpersonal communication, and other learning that cannot be taught as effectively in the classroom.
- Increases in diagnoses of childhood obesity ADHD have occurred in the pediatric population. Additional physical activity for those patients through recess and physical education could have beneficial effects.Recess and physical education also provides a much appreciated break for the classroom teachers.
As Mark Twain has echoed, let’s not let school get in the way of education. Let’s remember there is a time to read and a time to run. May we champion those policies and rules that protect recess and physical education.
Jacob Jones, MD