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…)
As pediatricians, we often care for children that may have had exposures to neglect, maltreatment, family violence, family separation or extreme poverty. Over time, we see the negative consequences of these experiences on our patients in the form of poor academic success, substance abuse, and medical and mental health problems. These experiences are termed adverse childhood experiences or ACEs and it is estimated that about 60% of the adult population in the United States has experienced at least one ACE. Pediatricians should identify and attempt to prevent ACEs: we can support and coordinate efforts to build resilience in children by understanding the effect of toxic stress and providing early interventions and continuity in care.
The hallmark ACE study conducted in 1998 by the CDC and Kaiser Permanente in California categorized ACEs into three major categories: physical and emotional abuse, neglect and household dysfunction (e.g., parent with mental illness, substance abuse or experiencing separation or divorce). The study showed dramatic associations between ACEs and risky behavior, psychological illnesses, serious illness and even a lower life expectancy in the children.
In a child’s life, experiencing ACEs can lead to toxic stress. Toxic stress occurs when a child stays in a constant state of elevated stress. Often children have a caregiver to give them comfort during normal times of stress. In these cases, the levels of stress hormones will return to baseline. However, when no supportive caregiver can comfort the child, such as in cases of neglect, emotional or physical abuse, the child’s stress hormone level remains high. This can affect other aspects of a child’s health and development.
The link between adverse childhood experiences and adult health and well-being has been well studied. We know that as the brain develops, more frequently used circuits are strengthened, while those that are not used can eventually fade away in a process called pruning. Stronger circuits are associated with higher-level functioning, improved memory, emotional and behavioral regulation and language. In children exposed to toxic stress, the circuits are weaker and fewer, especially in the areas of the brain dedicated to learning and reasoning. For example, the excessive stress activation shifts mental and physiological resources from long-term development to immediate survival. This increases the task of vigilance at the expense of focused attention. Ultimately, poor coping habits and mental health problems can develop. We also know that the exposure to stress hormone increases systemic inflammation which contributes to a higher risk of cardiovascular disease and diabetes among other medical problems. Finally, evidence shows that the longer we wait to intervene, the more difficult it is to achieve healthy outcomes.
The concept of resiliency explains why some children overcome stress better than others. As pediatricians, understanding this concept can help us to build stronger individuals. Resiliency is thought to be related to a greater number of positive experiences compared to negative experiences. We know that a very important part of developing resilience is at least one stable and committed relationship with a supportive caregiver. Promoting regular physical exercise, stress-reduction exercises and promoting strong core life skills for both the child and the adult are additional ways pediatricians can promote resiliency.
Trauma-informed care involves prevention, recognition and response to trauma-related experiences. Early identification is an important first step. As pediatricians, we should consider ACEs-based screening questionnaires for every patient to assess the potential need for other services. The next step would be to link these patients with services such as social work, developmental therapies, or mental health support with experience in trauma. This is often the most difficult part in delivering trauma-informed care, so it is important to identify the resources available in the local area.
Finally, to address prevention, we should work with our families to reduce the stress of daily life, such as connecting them to resources like food pantries or substance abuse programs. We should teach skills to families regarding parenting and safe dating practices. To promote strong relationships with other adult caregivers, we should be know of available after-school and mentoring programs. The overall goal should focus on changing the environment and behaviors in ways that will prevent ACEs from happening in the first place.
Amisha Patel M.D.
Fox SE, Levitt P, Nelson CA III. How the timing and quality of early experiences influence the development of brain architecture. Child Dev. 2010;81(1):28-40.
Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258.
Shonkoff JP. Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr. 2016;170(10):1003–1007. doi:10.1001/jamapediatrics.2016.1559
Kuehn BM. AAP: Toxic Stress Threatens Kids’ Long-term Health. JAMA. 2014;312(6):585–586. doi:10.1001/jama.2014.8737
Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE). http://www.cdc.gov.foyer.swmed.edu/violenceprevention/acestudy/index.html. Accessed February 5, 2020.
Cases of tuberculosis (TB), an airborne bacterial disease, in the US have been steadily decreasing, thanks to improved socioeconomic conditions, focused screening efforts, and thorough follow-up. 9,272 TB cases were found in the US in 2016, down from about 21,210 cases in 1996 . Pediatric TB cases have also been on the decline. In 2016, about 4% of the TB cases were pediatric. However, data from the past several years shows the incident caseload has remained steady . (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…)
When I was in the third grade, my classmate, Jennifer, passed away. It was 1996, and for the past three years, she had fought an uncommon form of leukemia. In the end, she did not live to see her 10th birthday. Each year, over ten thousand children below the age of 19 in the United States will be diagnosed with some form of cancer. Jennifer was by no means alone in her struggle.
The good news is that more and more of these children are becoming success stories. While in 1960, only five percent of children with cancer survived longer than five years, that number has since skyrocketed to over eighty percent. This is excellent news! But as 1,200 children will suffer the same fate as Jennifer in 2017, we must continue to strive to improve our ability to treat and cure cancer.
As pediatricians, we have a responsibility to encourage Congress to increase federal support for pediatric cancer research. Bill HR 820 was introduced in the House by Representative Michael McCaul on 2/2/17, and seeks to “maximize discovery and accelerate development and availability, of promising childhood cancer treatments.” Known as the Childhood Cancer STAR (Survivorship, Treatment, Access, and Research) Act of 2017, this bill seeks to help research efforts through a variety of different ways. First, through the continued and expanded establishment of cancer biorepositories, that researchers would be able to access and study in a laboratory setting. This is an obvious first step, and one that we welcome as an extension of the NIH funding already afforded to research in pediatric oncology.
Second, and critically, the bill amends the Public Health Service Act to state that there must be a pediatric oncologist on the National Cancer Advisory Board, to better advocate for our pediatric patients at the national level.
Additionally, the act sets forth several sections focused on the research of late effects of childhood cancer—an important inclusion, as there will be over 500,000 pediatric cancer survivors by the year 2020. We cannot afford to ignore this population, as well as their impact on the health care system in the future. Similarly, the bill seeks to establish cancer survivorship programs, and offer grants to improve follow-up medical and psychiatric care.
These are all worthy goals, and we will be closely monitoring the progress of this bill. Currently it is in the Subcommittee on Health, but we hope that it will move forward, for the good of all pediatric cancer patients in our country. It is encouraging to see legislation that so directly advocates for children in America.
See the bill here:
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.
Medicaid and CHIP are essential to children’s healthcare in the United States. It is critical that we continue to fund both of these programs to ensure that our nation’s children continue to receive well child care from their primary care provider. Well child care includes routine visits for vaccinations, ongoing surveillance visits for chronic health conditions, or yearly “check-ups.” (more…)