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…)
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…)
Children’s Hospitals Need More COVID-19 Emergency Relief Funding
Since the start of the COVID-19 pandemic, the financial losses of businesses and employees in the service, retail, and entertainment industries have been the subject of a large amount of media attention. What many Americans would not expect is that health systems are also under major financial strain during this difficult time. Pediatricians can act now by writing their U.S. Representative or Senator to express the need for additional emergency funding for children’s health systems.(more…)
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 . 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 . 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 . 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 . 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 . 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 .
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
- 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
E-cigarettes: the pediatrician’s role in an epidemic
The Surgeon General issued an advisory to warn about the rising use of vaping in minors (middle and high school children). E-cigarettes were introduced to the US market in the mid-2000s, and the market has expanded rapidly. In 2011, only 5% of high schoolers had used or experimented with them at some point, but only 4 years later in 2015, that percentage had grown to 13% of middle school and 39% of high schoolers. Because the use of electronic delivery systems for nicotine is a rising danger, pediatricians should include a routine discussion with teenagers as part of patient visits.
The dangers of vaping have been suspected by the medical community since its introduction, and evidence is accumulating to validate those fears. Evidence does support the suspicion that nicotine predisposes the adolescent brain to more severe tobacco addictions. Biological studies (animal models and human population data) indicate that the teenage brain is more susceptible to addictions–earlier exposure leads to stronger addictions and increased likelihood of experimenting with other substances. Thus, the fear that nicotine delivery systems are a bridge (rather than just an alternative) to more serious tobacco addictions is validated by the data so far.
Conversely, it is also true that electronic nicotine systems can help current smokers wean the nicotine addiction. However, from a public standpoint, this could be far outweighed by the number of younger non-smokers who are led to develop a habit they might have otherwise avoided. The solvents and flavors in e-cigarettes are not benign either. While they are safer (by current estimates) than traditional tobacco smoke, they do cause inflammation of the airways. For example, two common additives (diacetyl and acetyl propionyl) have been shown to cause popcorn lung/bronchiolitis obliterans. Like other consumable additives, the FDA has long considered them safe for ingestion, but the aerosolized form can still cause damage to lung tissue.
The toxicity of nicotine itself forms the most obvious risk to young people. First of all, nicotine has been shown to irreversibly decrease attention and processing speed and to increase the fear response mechanism. In other words, teenage nicotine exposure will impair memory and attention span for life and increase the likelihood of anxiety and depression. This risk decreases when exposure is delayed until adulthood, so the teenage years represent a critical window.
Second, nicotine is very toxic in utero. It increases the risk of SIDS, hearing impairment, language delays, ADHD, and possibly obesity. It may begins disrupting the normal development of brain circuitry as early as 5 weeks gestation, and even secondhand exposure to vaping can result in significant serum nicotine levels. These facts should be strongly emphasized to adolescent girls who may wish to be mothers someday, as well as to anyone who lives in proximity to women of childbearing age.
Finally, nicotine has long been known to acutely increase heart rate and blood pressure. Its long-term cardiovascular consequences are still unknown. Other nicotine-replacement systems (nicotine patches, etc) have not been shown to cause cardiovascular toxicity, but the prolonged, irregular doses from vaping have not yet been sufficiently studied.
This is a prominent issue among young people in our country independent of racial or economic demographics, and pediatricians should give it a proportionate level of attention. Parents should be informed of its dangers during well child visits and given data about the specific risks. Given its prevalence, this should be a routine topic of anticipatory guidance for middle-school children and older. Also, local governments and schools should be encouraged to aggressively regulate teenage access to these devices and limit marketing to that audience. Evidence shows that regulation does prevent a large fraction of teenage vaping, and pediatricians should play an active role in voicing the importance of this legislation. As health care providers, we have the opportunity now to intervene in our communities and forestall some of the long-term consequences of this new epidemic among young people in our country.
Natasha Varughese, MD
E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. US Health and Human Services 2016.
Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Levy DT, et al. Tob Control 2018;0:1–7
The impact of local regulation on reasons for electronic cigarette use among Southern California young adults. Hong H, et al. Addictive Behaviors, 2018 (ahead of print).
Sports: Healthy Competition vs Performance Anxiety
With school back in full swing, kids are joining their friends and classmates in school sports. Sports can be a great way for growing children to develop fine and gross motor skills. However, it can also be an area of stress and pressure to perform. (more…)
Let’s Talk About Bullying
It is the first month of school for many of our children out there which can be a very exciting time. For many parents, it means their house is a little quieter in the day and the return to a normal routine. For children it means a new pencils, a fun backpack, seeing their friends every day, and a fresh start. However, this time of year can also lead to anxiety and the fear of not “fitting in”. For some children, it can also mean bullying. It is vital that pediatricians and parents understand what bullying is as well as what to look for and what to do if a child is affected by bullying.
Bullying is an unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. This behavior is typically repeated over time. Bullying encompasses verbal abuse, social abuse, and physical abuse. Verbal abuse is writing or saying cruel things. It includes teasing, name-calling, threats, taunting, and inappropriate sexual comments. Social bullying is when someone hurts someone else’s reputation or relationships. It includes leaving someone out on purpose, spreading rumors about someone, telling other children not to be friends with someone, and embarrassing someone in public. This can include cyberbullying, which can take place through text messaging, social media websites, apps, e-mail, web forums, or multi-player online games. Cyberbullying has the potential to “go viral” and spread very quickly. Physical bullying involves hurting a person’s body or possessions. Both boys and girls can be a bully or be bullied.
The effects of bullying, both of the bullying and the bullied, can have long-term consequences. Kids who are bullied can experience depression and anxiety. These issues may persist into adulthood. They also can have an increased amount of health complaints and decreased academic achievement. In fact, children who are bullied are more likely to miss, skip, or drop out of school. Kids who bully others are more likely to abuse alcohol and other drugs in adolescence and as adults, get into fights, vandalize property, and drop out of school. They are also more likely to partake in early sexual activity, have criminal convictions as adults, and be abusive toward their romantic partners, spouses, or children as adults.
Due to all of these potential negative consequences, it is important for both pediatricians and parents to be able to recognize signs of both being bullied and bullying others. Only 40% of children notify an adult in times of bullying. Therefore, it is important for pediatricians and parents to ask kids about bullying with questions such as, “how are things going at school?” or “is anyone being picked on?”. Since not all children being bullied will exhibit physical signs, it is important for parents to look for many different signs and symptoms. These include unexplainable injuries, lost or destroyed clothing, books, electronics, or jewelry, frequent headaches or stomach aches, and changes in eating habits, like suddenly skipping meals or binge eating.
Other signs of bullying include difficulty sleeping or frequent nightmares, declining grades, loss of interest in schoolwork, or not wanting to go to school, sudden loss of friends or avoidance of social situations, feelings of helplessness or decreased self-esteem, and self-destructive behaviors such as running away from home, harming themselves, or talking about suicide. Signs that children are bullying others includes getting into physical or verbal fights, becoming increasingly aggressive, getting sent to the principal’s office or to detention frequently, having unexplained extra money or new belongings, blaming others for their problems, not accepting responsibility for their actions, and being competitive and worrying about their reputation or popularity.
Even after identifying that a child is being bullied or is a bully themselves, it is hard to know what to do. In the case of a child being bullied, one of the first steps is teaching children how to respond. It is important to teach children to look the bully in the eye, stand tall and stay calm, and to know when to walk away. Also teach your child to have them say firmly things such as “I don’t like what you are doing” or “Please do not talk to me that way”. This will not be instinctive to most children so it is important to practice these skills so they feel more prepared when the time comes. Parents should also encourage their children to make friends with other children inside and outside of school. This can be done by encouraging children in activities that they are interested such as team sports, music groups, or other social clubs.
Another important thing to teach children is to know how to ask for help. Children should know that being bullied is not their fault and they should reach out to their teacher, school counselor, or school principal. Parents should talk with the school principal if the child is too scared to ask for help or if the child continues to be fearful or affected. If the results from these conversations are not resulting in action on the school’s part, make a written request to the principal asking for a copy of the school district’s policies on reporting and investigating bullying. Most school districts have procedures for parents and others to make written reports. Some states require schools to make investigations of reports of bullying. If the local campus is not responsive, make a written request to the school superintendent.
If a child is experiencing cyberbullying only a few actions need to be taken differently. First, don’t threaten to take away the child’s devices as this may seem as a punishment. Instead, if there is online evidence of the bullying, take and save a screenshot in order to report the bullying to the social media platforms in which the abuse happened as well the school or police if appropriate. Otherwise, support the child in the same ways as mentioned above.
It can also be a stressful situation as well if your child is bullying others. It is important to be consistent and set firm limits on a child’s aggressive behavior by using effective, nonphysical discipline such as loss of privileges. Another way to influence your child’s behavior is by being a positive role model and showing children they can communicate what they want without teasing, threatening, or hurting others. In addition to these measures, help children understand how bullying can hurt other children. Communication is also important in these situations and parents should be speaking with the school and other parents in order to try to find practical solutions to the bullying that is occurring.
Chelsea Day, MD
American Academy of Pediatrics. Bullying and Cyberbullying. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Bullying-and-Cyberbullying.aspx. August 28th, 2018.
Healthy Children. Bullying: It’s Not Okay. https://www.healthychildr en.org/English/safety-prevention/at-play/Pages/Bullying-Its-Not-Ok.aspx. August 28th, 2018.
Healthy Children. Cyberbullying.https://www.healthychildren.org/English/family-life/Media/Pages/Cyberbullying.aspx. August 28th, 2018.
Stop Bullying. Warning Signs for Bullying. https://www.stopbullying.gov/at-risk/warning-signs/index.html. August 28th, 2018.
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
Heat Stroke in High School Football Players: A Lack of Regulation Placing Children at Risk
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.
Keep Schools Safe: No place for firearms
In 1990, the country took action to decrease the amount of gun violence present in schools across the nation by passing the federal Gun-Free School Zones Act originally part of the Crime Control Act. Now, a pending bill called the Safe Students Act, H.R. 34, proposes repealing prohibition of guns on school campuses and would threaten that protection. As pediatricians committed to improving children’s health and safety, we must help prevent this dangerous bill from becoming a law. (more…)
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