With all the changes and challenges we have faced as a society in the past year with the current pandemic, pediatricians should not lose sight of their important role in promoting oral health in children. While it was easy for me to note how the changes in eating habits that came with quarantine affected my clinic patients in terms of weight, I often missed an opportunity to address its potential effect on the development of the most common chronic disease of childhood, dental caries. As many as 24% of children ages 2-4, 53% of children ages 6-8, and 58% of 15-year-olds have had dental caries, and the incidence for the youngest children has only been increasing.1 As pediatricians, we can use recommended preventative strategies in our clinic and telehealth visits.
(more…)Education
The Importance of Masking in Schools
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.
Without clear scientific guidance indicating that children do not contribute significantly to the spread of the pandemic, we are left to answer the question of how to proceed this academic year.
#MaskUp Texas!
When Governor Abbott opened up Texas ahead of a downward trajectory in COVID-19 cases, the expectation was that social distancing and masking would still take place. While walking around the neighborhood, I was surprised to see unmasked diners at restaurants. There were couples and families, but also groups that did not seem to live together. As the weeks went on and restaurants were allowed to increase their activity, I saw indoor and outdoor tables with patrons back to back and yet masks were not donned. I wondered, when would we see the effects?
(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
Works Referenced:
- 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.
Additional Resources:
Mistreatment of Immigrant Children at the Southern Border
It was a little over a year ago when I first heard about the child separations happening at the U.S.-Mexico border. I had recently had my own son and it gave me a visceral feeling of horror imagining someone taking him away from me, not knowing where he was going, when I would see him again, or who would take care of him. I read a story of a 4-month-old taken from his mother as I held my own infant of a similar age. I imagined what kind of fear would drive me to make a dangerous journey with a newborn and beg for safety in a foreign country. Children continue to be separated from their parents and caregivers. They are kept in conditions unfit for anyone, and especially damaging for children. We need to speak out against the treatment of migrant children that is occurring and demand more humane solutions.
Whether unaccompanied or as part of a family unit, when children present for asylum, they are brought first through a Customs and Border Protection facility where by law, they are not to be detained for more than 72 hours (Linton et al., 2017). However, some children and families are being held for much longer (Linton et al., 2017). There are small, unwashed and underfed children taking care of younger, filthy toddlers without proper sanitation available, like clean diapers (Raff, 2019). Studies have shown negative physical and emotional symptoms among detained children under any circumstance (Linton et al., 2017), then their source of resilience might be stolen away- their caregivers. Even a short time in detention can have damaging psychological effects (Linton et al., 2017). Interviewed parents have described regressive behavior in their children after detention along with increased aggression and self-injurious behavior (Linton et. al 2019). They might come with parents or they may come with extended family members hoping to join their parents already in the U.S. (Linton et al., 2017). In 2016, “Family Case Management” was terminated, a short-lived program that was 99% effective in having these families in court, even by ICE’s own statements (Singer, 2019). The former program cost taxpayers about $38 a day, while the current system costs hundreds per day (Singer, 2019).
Children are dying. They are dying. They are kept in ‘prison-like conditions’ (Linton et al., 2017) and in the last year, at least 7 children have died in immigration custody after almost a decade of no deaths (Acevedo, 2019). Dr. Dolly Lucio Sevier, a pediatrician who visited a Customs and Border Protection facility in McAllen Texas, one of the facilities where immigrants are not to be held for longer than 72 hours. She met a baby whose uncle was forced to feed him for days from an unwashed bottle (Raff, 2019). She met a teenage mom whose baby was wrapped in diapers and plastic because they refused to give her clean clothes for her infant. This facility is known as the hielera, or ice box (Raff, 2019). This mom was trying desperately to keep her baby warm when she had nothing but concrete and mylar blankets (Raff, 2019). Dr. Sevier saw unmistakable signs of mental trauma and illness. The children had not been allowed access to soap, toothbrushes, clean clothes; and many had been in the facility weeks. They smelled, were malnourished, dehydrated, and most had at least a respiratory infection. The baby who had been drinking from a dirty bottle was fevered and ill (Raff, 2019).
Exposure to the ‘prison-like’ conditions present in the immigration facilities causes high levels of stress (Linton et al., 2017). It has been well documented that toxic stress will have lasting effects on the health of these children, even if they manage to somehow get past the mental effects of their trauma. They will be at higher risk for heart disease, cancer, diabetes, etc (Garner et al., 2015). Their present health and their future health are being destroyed in one fell swoop. The recognition and reduction of toxic stress in children should be a priority for all pediatricians (Garner et al., 2015), and should be part of a routine evaluation for the care of immigrant children (Linton et al., 2017).
The American Academy of Pediatrics issued a policy statement about the detention of immigrant children. The policy outlines many concerns and recommendations including that separating a parent or primary caregiver from their children should never occur unless there is a concern for the safety of the child (Linton et al., 2017). Practices in the CBP processing centers are inconsistent with AAP recommendations for the care of children, and therefore children should not be subjected to them. Community-based case management should be implemented for the children and their families (Linton et al., 2017). Children should receive timely and comprehensive medical care. “Treat all immigrant children and families seeking safe haven who are taken into US immigration custody with dignity and respect to protect their health and well-being” (Linton et al., 2017).
It is easy to feel helpless and overwhelmed. I urge you to not become complacent. Write your own opinion. Write your congressional representatives. Donate to the Annunciation House, which helps to house some immigrants. You can also give to RACIES (Refugee and Immigrant Center for Education and legal Services) or to the Human Rights Initiative of North Texas, both of which seek to help immigrants gain asylum and legal status, among other services. I encourage my fellow physicians to look for immigrants among our patients. Recognize the trauma they have been subjected to. Practice trauma-informed care and do your best to refer to services that can help.
Marie Varnet, MD
Acevedo, Nicole. “Why Are Migrant Children Dying in U.S. Custody?” NBCNews.com, NBCUniversal News Group, 30 May 2019, http://www.nbcnews.com/news/latino/why-are-migrant-children-dying-u-s-custody-n1010316.
Garner, Andrew S., et al. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.” Pediatrics, American Academy of Pediatrics, 1 Jan. 2012, pediatrics.aappublications.org/content/129/1/e224.short.
Linton, Julie M., et al. “Detention of Immigrant Children.” Pediatrics, American Academy of Pediatrics, 1 May 2017, pediatrics.aappublications.org/content/139/5/e20170483#xref-ref-10-1.
Raff, Jeremy. “What a Pediatrician Saw Inside a Border Patrol Warehouse.” The Atlantic, Atlantic Media Company, 4 July 2019, http://www.theatlantic.com/politics/archive/2019/07/border-patrols-oversight-sick-migrant-children/593224/.
Singer, Audrey. “Immigration: Alternatives to Detention (ATD) Programs.” Congressional Research Service, 2019, fas.org/sgp/crs/homesec/R45804.pdf.
Let’s talk about mass shootings
Mass shootings receive substantial media coverage and capture the public’s attention for days, even weeks. The United States has witnessed more than 290 mass shootings in 2019 so far [1]. Even more worrisome, the number of school shootings in the U.S. far exceeds that of several other high-income nations, even after accounting for population size [2]. Over the past decade, there were at least 180 shootings and 356 victims at K-12 schools across the U.S., 43 incidents this year alone [3]. They happened in big cities and in small towns, at homecoming games and during art class. Shootings have become a part of daily conversation around kids, in places that used to be considered “safe”, and the real cost of this crisis to the youth remains unknown. Pediatricians need to advocate and raise awareness that this generation may be facing increased levels of stress, decreased perception of safety, and higher prevalence of depression and anxiety than previous generations. We need to encourage routine screening for mental health problems in well-child visits, as well as empower parents with resources on how to approach conversations about this sensitive topic and how to manage their kids’ exposure to the media during catastrophic events.
Limited research has begun to elucidate the short-term direct and indirect effects of mass shootings on survivors and the broader community. Individual responses of survivors can include anxiety, depression, PTSS, grief, sleep problems, anger, demoralization, catastrophic thinking, and somatization symptoms [4]. Moreover, media coverage of mass shootings and their aftermath reaches far beyond the affected communities to the entire nation and beyond. As shown in the aftermath of the September 11 terrorist attacks (9/11), such indirect exposure can have mental health consequences. For example, in the National Epidemiologic Survey of Alcohol and Related Conditions, indirect exposure to 9/11 through the media was associated with increased risk for mood, anxiety, substance use disorders, and PTSD, relative to no reported 9/11 exposure [5]. Children may similarly associate schools with tragedy, violence and death, and they must go there daily.
In the span of two weeks in March 2019, two students who survived the mass shooting that occurred in February 2018 at Marjory Stoneman Douglas High School in Parkland, Florida, died by suicide. Drawing direct individual-level causal connections between mass shootings and suicide deaths cannot be done with certainty; however, these deaths painfully underscore the potential long-lasting consequences of gun violence, mass shootings specifically [4].
Pediatricians have a responsibility to acknowledge the magnitude of the problem and urge that appropriate research be done to better understand the influence of direct and indirect exposure to mass shootings on the mental and physical health, social functioning and development in the pediatric population. We can also bring this topic up in our health visits, especially right after a mass shooting with broad media coverage or one close to our area of practice. In Texas, two mass shootings with broad media coverage have occurred in the past month. We can start with a simple question about mood and anxiety in our well visits. This can offer a teaching opportunity for patients and their families and identify those who may benefit from other resources or therapies.
Fear, insecurity and anxiety can be transmitted to children from adults around them, even if they don’t fully understand the situation. This is why it is crucial that pediatricians educate parents and other members of the community that work directly with children (such as teachers) about the importance of having “the talk about mass shootings.” It can be done appropriately with 4 basic steps: (1) initiate the conversation, (2) answer their questions, (3) correct any misconceptions and (4) limit media exposure.
To find more information on how to have a conversation with children about shootings according to age group, visit the following resources:
- The National Child traumatic Stress Network: https://www.nctsn.org/resources/talking-children-about-shooting
- Healthy Children from the American Academy of Pediatrics: https://www.healthychildren.org/English/family-life/Media/Pages/Talking-To-Children-About-Tragedies-and-Other-News-Events.aspx
- National Education Association: http://www.nea.org/home/72279.htm
Elisa Geraldino, MD
References
- Gun Violence Archive. https://www.gunviolencearchive.org
- School Shootings in the U.S.: What Is the State of Evidence?AliRowhani-RahbarM.D., M.P.H., Ph.D.abCaitlinMoeM.S.ahttps://doi.org/10.1016/j.jadohealth.2019.03.016
- CNN. 10 years of School Shootings. https://www.cnn.com/interactive/2019/07/us/ten-years-of-school-shootings-trnd/
- Rowhani-Rahbar A, Zatzick DF, Rivara FP. Long-lasting Consequences of Gun Violence and Mass Shootings. JAMA. Published online April 12, 2019321(18):1765–1766. doi:10.1001/jama.2019.5063 https://jamanetwork-com.foyer.swmed.edu/journals/jama/fullarticle/2731087?resultClick=1
- Lowe, S. R., & Galea, S. (2017). The Mental Health Consequences of Mass Shootings. Trauma, Violence, & Abuse, 18(1), 62–82. https://doi.org/10.1177/1524838015591572
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.
References:
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
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…)
MISINFORMATION- THE CONVERSATION WE NEED TO BE HAVING
Photo by Pixabay on Pexels.com
“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…)
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 [1]. 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) [2].
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 [2]. 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 [3]. 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 [2].
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 [6]:
- 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 [7]. 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.
https://www.aap.org/en-us/advocacy-and-policy/Pages/Advocacy-and-Policy.aspx
https://www.naeyc.org/resources/blog/support-and-advocate
https://www.cwla.org/our-work/advocacy/
Benjamin Masserano, MD
References
[1] https://developingchild.harvard.edu/science/key-concepts/toxic-stress/
[2] https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html
[3] https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html
[4] http://pediatrics.aappublications.org/content/pediatrics/early/2011/12/21/peds.2011-2663.full.pdf
[5] http://pediatrics.aappublications.org/content/128/6/e1680
[6] http://pediatrics.aappublications.org/content/120/3/e734
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