Mental Health During the COVID-19 Pandemic

As we come up on a year after initial school closures and nationwide lockdowns due to the COVID-19 pandemic, we can reflect on the psychological and social effects these changes have had on children and adolescents. It has become evident to the pediatricians working in clinics, emergency rooms, and hospitals that our youth have experienced a mental health crisis. We must remain vigilant of the evolving health needs of our patients and adapt our practices to best serve those in our care.

The symptoms of this crisis can vary by age and developmental group. In one review, researchers found that children ages 3-6 are more likely to experience increased clinginess and fear of family members being infected with SARS-CoV-2, the coronavirus that causes COVID-19 disease (Singh 2020). However, children ages 6-10 are more likely to experience inattentiveness (Singh 2020). Certain themes have also been seen across all age groups: increase in disturbed sleep and nightmares, poor appetite, agitation, and separation-related anxiety (Singh 2020). Females of any age specifically saw a three-fold increase in rates of depression during the COVID-19 pandemic (Hawes 2021). Nearly half of female participants experienced elevated generalized anxiety during the pandemic (Hawes 2021). Various studies have found that certain factors predispose a child to have increased mental health challenges regardless of gender (Li 2020). These factors include having the infection, home confinement, concern of their basic needs being met, and prior mental health or behavioral challenges (Li 2020).

What can be done to help our children and adolescents come out of this pandemic as healthy, resilient individuals? A study looking at anxiety and depression prevalence in adolescents found that face-to-face communication and engaging in enjoyable hobbies such as exercise correlated with lower rates of anxiety and depression (Li 2020). Encouraging children to find an activity that brings them joy and partaking in that activity daily or a few times a week can be protective against developing worsening anxiety or depressive symptoms. Examples of activities that my patients have reported to me are learning to play guitar via YouTube videos, regular exercise such as outdoor running or lifting weights in a home gym, and baking.

Another study found that children having discussions with a parent or trusted adult about COVID-19 led to less mental health challenges in children and adolescents (Tang 2021). Parents and trusted adults can have a significant impact on how children and adolescents perceive and adapt to challenging situations. Adults should tailor these conversations to the age and developmental stage of the child to avoid overwhelming them with information that may be difficult to understand or rationalize. The conversations should be open, fact-driven, and conducted in a calm manner.

For teenagers specifically, social media and video games can be both protective and place them at an increased risk for anxiety and depression (Hawes 2021). These online activities allow them to maintain a sense of social connectedness where they otherwise may feel isolated from their peers. It allows for continued formation and exploration of friendships and relationships. However, in excess, social media can foster a negative environment of comparison and a “fear of missing out”. Teenagers may not know how to evaluate information and news that they encounter.

Creating a family media plan with time limits and age-appropriate supervision that all members of the family adhere to is a recommended solution (Hawes 2021). A family media plan should be tailored to each individual family’s situations and include specific time limits on TV, computer and video games, as well as social media sites. These types of plans allow teenagers the freedom to socialize while mitigating the negative effects of too much screen time and social media. To learn more about family media plans, you can follow this link to a separate post:  https://pedsadvocacy.com/2020/11/17/creating-a-family-media-plan/

Finally, keeping a structured routine can be beneficial in protecting against negative mental health consequences from the disruption of the pandemic (Hawes 2021). This is especially important for young children and children who have ADHD or other developmental and learning disabilities. When increased uncertainty exists, younger children can feel that stress even if they do not fully comprehend what is causing it. By maintaining a routine – wake up time, meal times, learning time, play time, bedtime – they are given a sense of stability and safety. Specifically, a structured bedtime routine can mitigate some of the negative effects stress can have on sleep, such as difficulty falling asleep.

As our world begins to move forward and eventually past this pandemic, it is important to continue to have these discussions about mental health with each other and our loved ones. Discussions about our emotions, what we are seeing on the news, and what steps we can take to keep ourselves and our families safe can help stabilize our lives. Furthermore, being available to listen to those are struggling with anxiety, depression, or another mental health concern can help keep our loved ones safe. If a child or teen does come forward with mental health concerns, share resources with their parent and caregivers, such as those listed below.

Hopefully, by implementing these various strategies, we can provide the support our children need to adapt and continue to grow into healthy, resilient adults.


  • HelpWhenYouNeedIt.Org over 350,000 listings for social services, mental health, substance use, legal and financial assistance.
  • Psychology Today offers a national directory of therapists, psychiatrists, therapy groups and treatment facility options
  • The Suicide Prevention Lifeline connects callers to trained crisis counselors (800-273-8255)
  • Mental Health Crisis Line for Dallas County: North Texas Behavioral Health Authority (866) 260-800
  • Crisis Text Line: Text 741741, free service available 24/7


  1. Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic [published online ahead of print, 2021 Jan 13]. Psychol Med. 2021;1-9. doi:10.1017/S0033291720005358
  2. Li W, Zhang Y, Wang J, et al. Association of Home Quarantine and Mental Health Among Teenagers in Wuhan, China, During the COVID-19 Pandemic. JAMA Pediatr. 2021;175(3):313–316. doi:10.1001/jamapediatrics.2020.5499
  3. Tang S, Xiang M, Cheung T, Xiang YT. Mental health and its correlates among children and adolescents during COVID-19 school closure: The importance of parent-child discussion. J Affect Disord. 2021;279:353-360. doi:10.1016/j.jad.2020.10.016
  4. Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Res. 2020;293:113429. doi:10.1016/j.psychres.2020.113429

Erin Finnerty, MD

Breaking Down Language Barriers in Healthcare

Working as a pediatric resident in Texas has given me the unique opportunity of serving a diverse patient population. For example, my continuity clinic has a substantial number of patients who only speak Spanish. Unfortunately, I do not speak Spanish, which is not ideal for my patients. As a doctor, I strive to provide the best medical care. So I’ve really reflected upon my experiences with my Spanish speaking population, and how to best navigate the language barrier. Since it’s not feasible to make all practicing physicians learn additional languages, I highly advocate for the next best thing, hiring in-person interpreter services.

Numerous studies have shown that language barriers negatively impact healthcare. A study in New York analyzed an urban, underserved Hispanic population.1 One group could speak English, while the other group could only speak Spanish. The study concluded that English speakers reported a higher satisfaction rate with their healthcare experiences; they were more likely to have medication side effects explained to them, which impacted their compliance. Another study analyzed racial and ethnic differences in access to healthcare.2 The study concluded that the marked disadvantage in Hispanic children’s access to care may be related to a language issue. Primary care is especially important for children because they require a plethora of immunizations and need to be monitored for developmental milestones.

At my clinic, I’ve been in experiences where the phone interpreter service unintentionally worsened the communication issues. The sub-optimal audio quality was exacerbated by the masks that we were wearing due to the COVID-19 pandemic. Sometimes when the interpreter said something, my patients would point at the phone and shake their heads, implying that the interpreter was not interpreting correctly. Other times, even with my limited Spanish knowledge, I realized that the interpreter was miscommunicating information to my patients. When my clinic hired someone to work onsite as our interpreter, the clinic ran so much smoother. The patients felt much more at ease with an in-person interpreter, and I could see them letting their guard down.

A study published by the American Journal of Public Health revealed that providing interpreter services is a financially viable way of enhancing healthcare delivery to people with limited English proficiency.3 The study showed that patients who utilized the interpreter services had significant increases in physician visits and prescription drugs, which suggests that the moderate cost of interpreter services led to the huge benefit of enhancing access to primary and preventive care. People are more inclined to seek healthcare when they understand their health condition, what treatment they need, medication side-effects, and the importance of medication compliance despite the side effects. As physicians, it’s important to break down barriers to healthcare access, and hiring in-person interpreters is one way to do so.

Brina Bui, MD


1. David RA, Rhee M. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. The Mount Sinai Journal of Medicine, New York. 1998 Oct-Nov;65(5-6):393-397.

2. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care. Am J Public Health. 2000;90(11):1771-1774.

3. Jacobs EA, Shepard DS, Suaya JA, et al. Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health. 2004;94, 866_869.

“SNAP Chat”: A brief commentary based on my personal experience with the Supplemental Nutrition Assistance Program


For about 5 years, from 2015-2020 while I was completing medical and graduate school in San Antonio, my family which consisted of myself, my wife, and our growing family (first one, then two, then three daughters) received SNAP benefits. While I do not claim to be an expert on the subject, I believe my experience gave me a unique perspective on aspects of SNAP that I had not previously considered thoroughly. After first briefly providing a generalized overview of the program, I hope to touch on a few perceived lingering limitations: 1) barriers to household participation, 2) barriers to ensuring proper nutrition, and 3) barriers to self-sufficiency. These limitations should be considered by pediatricians as they encounter patients and families who have food insecurity, so advice and resources can be helpful to and suitable for the families. 


Guiding patients who look up medical questions online

As pediatricians, we can guide patients and their families to learn how to look up medical questions online properly. Why is it important for people to learn how to do this? There are multiple reasons:

1. We are likely to instantly get a practically infinite number of answers to any question we pose to a search engine. It is not the quantity of answers that is lacking but often the quality. The ‘signal-to-noise’ ratio decreases as we get greater and faster access to more detailed information about the world (1).

2. Our minds are not adapted to handling such large amounts of data especially when we are emotionally invested. Our brains are apt to make quick, safe, somewhat-right judgements based on limited information (2), e.g., deciding if there is a lion in the nearby rustling bushes at night.

3. Few people get advice on how to find and interpret relevant information online. Although, most of it is common sense, patients and families may be emotional and vulnerable to misinformation. Facts obvious to clinicians may not be so to non-medical people and may go undiscussed.

4. The solution is not to ask people to refrain from ‘googling’. Virtually everyone will look up something online: a weird symptom, an unfamiliar disease given as the diagnosis to a close relative, or the side effects of a medication.

5. The internet will always be a source of both true and false information. Our knowledge is fallible, and science needs alternative points of view to move forward (3).

6. In medical ethics we accept that the principle of autonomy supersedes beneficence. This means that we believe that to truly help patients and families is to empower them to be able to make sound medical decisions, not to make the decisions for them.

Recommendations for discussing potential sources of confusion:

  • The problem of anecdotal “evidence”: e.g., “So-and-so tried this alternative treatment for her disease, and it worked for her so it might work for me”. An example can illustrate the difference between anecdotal and scientific evidence to patients. In a randomized controlled trial, a large group of patients is given the novel treatment A and a control group that is similar is given placebo or the standard treatment B. Then, data is collected from both groups and analysed using statistics to find a significant difference. Only then, we can say treatment A works or does not work. This should demonstrate why it is so difficult to draw any conclusions from anecdotes. Even if we assume the anecdote of someone’s success with an alternative treatment was not falsified, many factors could distinguish them from another patient, none of which can be controlled for. Even if all other factors were the same, any positive or negative effect seen from the alternative treatment will likely be due to random chance.
  • About social media posts: Remind patients and families that people do not have any obligation to tell the truth on social media, may have different motivations than expected, or may be unwittingly misleading by leaving out pertinent facts. Even if the social media post is citing seemingly scientific studies, try to verify that a) the studies are real, b) the studies are coming from a peer-reviewed scientific journal, and c) the post is not misrepresenting the study or misinterpreting its conclusions.
  • Why searching a disease could be better than a symptom:  usually a constellation of symptoms and physical exam findings make clinicians suspect one disease or another. A symptom by itself can be remarkably non-specific and lead to excessive worry or delay in seeking help. It’s probably a good idea to suggest sticking to reputable medical websites of institutions such as the American Cancer Society or the CDC for basic information.
  • The distinction between scientific articles published on medical journals and news articles or articles on science blogs: a) Scientific articles are peer-reviewed, b) data is gathered, analyzed, and interpreted by a professional who knows the context of previous studies and standards of practice, and c) any potential conflict of interest must be declared eliminating a potential source of bias. None of these can be guaranteed for non-scientific articles.
  • Documentaries, or videos online as a source: Even if they seem to have a high production cost, these usually conflate anecdotal evidence with real scientific evidence, embellish facts for dramatic effect, and do not have to meet any scientific standards.

Today’s families are surrounded by differing sources of knowledge. Thus, part of the doctor-patient relationship should more than ever be helping families sift through the information and make the right decisions for themselves and their children.

Can Ozlu, MD


  1. Taleb NN. Fooled by Randomness. New York: Random House; 2016.
  2. Kahneman D. Thinking, Fast and Slow. Penguin Books; 2012.
  3. Popper KR. The Open Society and Its Enemies. Princeton, NJ: Princeton University Press; 2011.

Creating a Family Media Plan

In these times of social distancing, I have found myself spending an increased amount of time on media. This includes social media, news websites, streaming platforms, online shopping; I am guilty of all of them. From my conversations with others and in further research, I have learned I am not alone in this. Many of my family, friends, and patients all endorse a similar increase. Between March and June of 2020, Lurie Children’s in Chicago polled 2,909 American parents of teenagers, and 63% reported their teenager was using social media more. Technology and media do have benefits and have especially helped in these times by allowing us to stay connected with loved ones, continue education, and even buy groceries from home. But they can also have negative consequences when not used in a responsible manner. I encourage all pediatricians to address media use with their patients and families. One way this can be done is by introducing the idea of a family media plan.  

In today’s era of COVID-19, virtual media is one of the easiest ways to stay connected with others. However, just because it is convenient does not mean it is benign. Facebook is still the most widely used social media website. A study from France used experience-sampling to see that rather than enhancing well-being, use of Facebook had the opposite result. The study indicated that Facebook use leads to decline in the two areas defined as cognitive and subjective well-being.  Cognitive wellbeing was how satisfied people are with their lives, and subjective well-being was how people feel moment to moment. In contrast to the use of Facebook, direct social interaction showed no change in cognitive well-being and an increase in subjective well-being.  

What about the effects of other types of media? For example, children watching television? Research shows higher media use in young children is associated with higher BMI, decreased sleep, and cognitive, language, and social/emotional delays. As far as delays, most of these are thought to be due to a decrease in a child’s interactions with their parent/caregiver. Watching television should not take the place of a child interacting with real people in their real environment, replace exercise, or decrease the amount of sleep a child gets.  

What does responsible media use look like in my own life, and how can I counsel my patients and their families? Not all use of media is bad, but it should be used judiciously. In looking for the answer to this question, I found the website www.healthychildren.org, which has information dedicated to creating a family media plan. It allows a family to create a comprehensive plan, which can be individualized for every member. It addresses screen free zones and times, device curfews, media manners and safety, healthy sleep and exercise, and more. You can find the information at https://www.healthychildren.org/English/media/Pages/default.aspx  

As a reference when creating your family media plan, the American Academy of Pediatrics recommends: 

  • For children younger than 18 months, avoid use of screen media other than video-chatting. Parents of children 18 to 24 months of age who want to introduce digital media should choose high-quality programming, and watch it with their children to help them understand what they’re seeing. 
  • For children ages 2 to 5 years, limit screen use to 1 hour per day of high-quality programs. 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 ages 6 and older, place consistent limits on 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. 
  • Designate media-free times together, such as dinner or driving, as well as media-free locations at home, such as bedrooms. 
  • Have ongoing communication about online citizenship and safety, including treating others with respect online and offline. 

While geared towards children and adolescents, I plan to make a media use plan for myself – and I encourage other adults to do so as well! 

Jenny Riepma, MD 


Cespedes EM, Gillman MW, Kleinman K, Rifas-Shiman SL, Redline S, Taveras EM. Television viewing, bedroom television, and sleep duration from infancy to mid-childhood. Pediatrics. 2014;133(5). Available at: www.pediatrics.org/cgi/content/full/133/5/e1163pmid:24733878 

Chiong C, Shuler C; The Joan Ganz Cooney Center at Sesame Workshop. Learning: Is there an app for that? Investigations of young children’s usage of learning with mobile devices and apps. Available at: http://dmlcentral.net/wp-content/uploads/files/learningapps_final_110410.pdf 

Cox R, Skouteris H, Rutherford L, Fuller-Tyszkiewicz M, Dell’ Aquila D, Hardy LL. Television viewing, television content, food intake, physical activity and body mass index: a cross-sectional study of preschool children aged 2-6 years. Health Promot J Austr. 2012;23(1):58–62pmid:22730942 



Kross E, Verduyn P, Demiralp E, et al. Facebook use predicts declines in subjective well-being in young adults. PLoS One. 2013;8(8):e69841pmid:23967061 

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.


Two to Tango: Shared Decision Making

Often patients or their parents can place an expectation on our shoulders to always have a plan and answers as their physician. The shaking truth of the medical field is that this is not always possible. While the expectation is seen as a privilege by most physicians, it can also lead to significant stress and pressure. When asked specific questions that are either unanswerable or unknown at that time, a physician may find it difficult. Shared decision making is fundamental for patient care as an effective tool for a physician to use when addressing such situations with patients and their parents.

The idea of shared decision making is more recent in the field, compared to the centuries of the practice of medicine (Veatch). It is a hallmark in patient-centered care because it relies heavily on patient and/or parental input into treatment decisions. Glyn Ewlyn, et al. described a practical way to implement shared decision making using:

  • Choices: making sure that patients/parents know different, reasonable options are available to them,
  • Options: providing detailed information about all options, and
  • Decision talk: supporting and allowing for time for the patients/parents to deliberate over the available options.

While shared decision making is an important part of patient care, its use can be limited in some situations, such as in emergencies that require immediate action or conditions that require extensive use of medical knowledge to make a decision. Other limitations to shared decision making include inadequate health literacy and cultural differences in autonomy (Glyn Ewlyn et al). Even in these situations, using shared decision making as much as possible at the patient/parent’s level of understanding can help. It can be employed as a tool to help move forward in difficult situations, or even to create an open dialogue and invite parents to share their input. 

Even in pediatrics, we can involve our patients in shared decision making to empower them to actively participate in their own health. One small example includes asking them the form of medication they like (e.g.pill, liquid, or chewable) (Furman). Although we are not asking them what treatment plan they want, offering even a small choice can help empower them in their own healthcare. 

While shared decision making can be used in a positive way to forge a bond between parents and pediatricians, a one-sided relationship, whether on the parent or physician side, can be detrimental to this balance. With the advent of the internet, parents have numerous different resources to use as they deliberate their options. This should be supported and encouraged within reasonable limits by pediatricians. The balance lies within the decision talk portion of shared decision making. Pediatricians should listen to parent’s wishes and informed decisions, and parents should work with the pediatricians and trust them to make decisions for their child’s well-being. With unbalanced power on either side, friction and erosion of patients’ care can occur.

Many questions still exist as to how to best integrate and implement shared decision making from both the parent’s and the pediatrician’s role in a child’s medical care. By implementing these three steps into each patient encounter, both with a patient and their parents, pediatricians can create an optimal balance in unknown or difficult situations. 

Chelsea Burroughs, M.D.


Elwyn, Glyn et al. “Shared decision making: a model for clinical practice.” Journal of general internal medicine vol. 27,10 (2012): 1361-7. doi:10.1007/s11606-012-2077-6

Furman, Lydia. “Shared Decision Making – Harnessing Trainee Enthusiasm.” American Academy of Pediatrics (2017). 

Veatch, Robert. “Models for Ethical Medicine in a Revolutionary Age.” The Hastings Center Report vol. 2, 3 (1972): pp 5-7. 

Barriers to successful HPV vaccination in US adolescents

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States with a peak prevalence in adolescents and young adults. It is a viral infection that can persist in the body and lead to a significant risk of developing various types of cancer later in life. HPV infection is preventable thanks to the advent of vaccination. The current 9-valent HPV vaccine is proven to be safe, effective and successfully prevents morbidity and mortality associated with HPV-related diseases. Pediatricians, in particular, play a key role as providers of vaccination but also need to become leaders in HPV-vaccination education for children, adolescents and their parents.
Current guidelines from the Centers for Disease Control and Prevention (CDC) US Advisory Committee on Immunization Practices (UCIP) and the American Academy of Pediatrics (AAP) recommend initiating the 9-valent vaccine with 2-dose schedule at ages 11-12 (although can be started as early as age 9) and 3-dose schedule for those starting at ages 13-26. [2]
However, the HPV vaccination rate in the U.S. is still very low, particularly among adolescents, with less than two-thirds of adolescents ages 13-17 receiving at least one dose of the HPV vaccine. In Texas, low vaccination rates are even more prevalent in rural areas and border towns with higher Hispanic/Latino populations. Thus, Hispanic women in areas such as the Rio Grande Valley are at significantly higher risks for cervical cancer incidence and mortality than Hispanic women generally in the U.S. [1-3]
Under current Texas health law, adolescents can obtain health information on safe sexual practices, self-request pregnancy tests, contraception and STI tests confidentially with medical providers. HPV vaccination, however, is under immunization/vaccine law and thus requires parental consent for a teen to be vaccinated. Studies have shown that there is misinformation in the community regarding HPV vaccination, and that leads to parents declining HPV vaccination for their children. That in in turn leads to lower vaccination rates. Some barriers to vaccination cited include concerns about vaccine’s effect on sexual behavior, low perceived risk of HPV infection, social influence, irregular preventive care and concern for out-of-pocket costs. Interestingly, parents also cited healthcare professionals’ recommendations as one of the most important factors in their decision to vaccinate. [1]
Misinformation appears to be the key driving force behind suboptimal vaccination rates. This is in line with studies that have shown that parent/adolescent education and vaccination availability are key to addressing the issue. As an example, a single onsite school-based active vaccination program coupled with physician-led education on HPV and HPV vaccines for parents/guardians, school nurses and pediatric/family providers in a rural community in south Texas led to almost double HPV initiation and completion rates. [1,3]
Parents can find it complicated to navigate around all the misinformation around vaccinations, especially in a climate of a generalized sense of distrust geared toward the medical/pharmacological enterprise. Pediatricians and family medicine providers should clearly inform patients and their parents about the distinct benefits and safety regarding HPV vaccination, and the drastic, positive impact the vaccine provides in preventing HPV-associated cancer.
Cost should be less of a barrier, because the Patient Protection and Affordable Care Act requires insurance companies to cover ACIP-recommended vaccines without copays, and federal programs provide vaccines to Medicaid eligible children without cost. Finally, pediatricians should also establish strategic partnerships with schools and local health providers to develop active education programs and on-site vaccination programs. These steps can improve successful HPV vaccination rates and reduce risks for HPV-associated cancers.
1. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to Human Papillomavirus Vaccination Among US Adolescents: A Systematic Review of the Literature. JAMA Pediatr. 2014 Jan; 168(1): 76–82.
2. Yang DY, Bracken K. Update on the new 9-valent vaccine for human papillomavirus prevention. Can Fam Physician. 2016 May; 62(5): 399–402.
3. Kaul S, Do TQN, Hsu E, Schmeler KM, Montealegre JR, Rodriguez AM. School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res. 2019 Dec;8:100189.

Two Flu Myths

“How I learned to stop worrying and love the shot”

Another year, another flu season! With each passing month, we get closer to the end (although we may have a late second peak according to Time Magazine! https://time.com/5784695/child-flu-2020/). Toward the end of flu season, I like to revisit some of the conversations I had about the flu vaccine: what were common concerns, what did I say in response, and what  up-to-date evidence is available. Two major points seemed to be a rationale some of the families took to decline the flu vaccine: (1) the flu vaccine gave me the flu and (2) the flu vaccine doesn’t stop the flu.  Here are some effective talking points for pediatricians to discuss flu vaccination with patients and their families who have those concerns.

“The flu vaccine gave me the flu.”

I’ve heard this sentiment echoed hundreds of times and it simply isn’t true. The injectable flu vaccine (“flu shot”) is an inactivated (“killed”) vaccine. It’s made by growing influenza virus in a lab, killing it using heat or chemicals then using those killed viruses/viral particles to produce the vaccine (https://www.cdc.gov/flu/prevent/how-fluvaccine-made.htm). When the body encounters the killed virus/viral particles, it responds and is primed to fight the real flu virus through primed recognition. The inactivation of the virus during production makes it impossible for it to reproduce, so it is unable to infect the body. 

The nasal spray (“flu mist”) vaccine is a ‘live-attenuated vaccine’, which is made of flu virus that is able to reproduce, but is in a weakened state (https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/prinvac.pdf). The idea behind these vaccines is the presence of replicating virus allows for a strong and lasting immune response, just like with a normal infection, but producing minimal/no infectious symptoms. While there is a theoretical risk of the vaccine mutating to re-gain its ability to cause infection (called ‘reversion’), this has never been observed clinically with influenza vaccination and is such a small risk that it is considered negligible (Murphey and Coelingh, 2002Zhou et al., 2016). However, if this miniscule risk still worries  parents, pediatricians can explain that there is NO risk for reversion with inactivated vaccine (the “flu shot”).

What people may have experienced in the past is either a reaction to the flu vaccine, or infection with flu prior to mounting a full immune response after vaccination. With vaccination, there is always a possibility of a minor immune reaction. This typically consists of headache, fever, or pain/soreness/redness at the injection site. These are thought to be caused by the “priming” of the immune system in response to encountering viral particles. It’s essentially the body using the vaccine as a punching bag in anticipation of the real thing! These minor reactions are considered common, last typically between 24-48 hours, and can be treated with antipyretics and NSAIDs (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html).

As I have often seen, families will wait until someone close to them gets the flu prior to seeking vaccination. While I will never stop my patients or their families from receiving the flu shot, waiting until someone is sick can be too late fora response from the vaccine. It’s estimated that it takes up to two weeks for the flu vaccine to take full effect, so getting vaccinated early is the best strategy. Immunity is estimated to last between 5-6 months after it takes effect; getting it early means you’re protected for the duration of flu season (https://www.cdc.gov/mmwr/volumes/68/rr/pdfs/rr6803-H.pdf). If a patient got the flu vaccine in response to seeing a nearby outbreak, then got the flu, the patient likely had  already been exposed, and the vaccine didn’t have enough time to take effect.

“The flu vaccine doesn’t stop the flu.”

For any patient or parent who says  this, I always respond, “Well you’re right! But not entirely.” While it is true getting a yearly flu vaccination doesn’t 100% prevent a personfrom getting influenza, it does significantly cut down on infections. During 2017-2018 flu vaccination prevented an estimated 6.2 million influenza illnesses, 3.2 million influenza-associated medical visits, 91,000 influenza-associated hospitalizations, and 5,700 influenza-associated deaths (https://www.cdc.gov/flu/about/burden-averted/2017-2018.htm).

The CDC estimates a 40-60% risk reduction of having a symptomatic influenza infection after vaccination (https://www.cdc.gov/flu/vaccines-work/effectiveness-studies.htm). This estimate also assumes a good match between circulating seasonal flu and the four influenza strains used in the yearly vaccine. One of the major challenges of yearly flu vaccination is that it’s a moving target. Influenza viruses are constantly recombining and changing, so it’s not feasible to have a vaccine that targets them all. So could a person be the unlucky one who gets a strain that’s not covered? It’s absolutely possible. This fact alone can make many people feel apathetic about flu vaccination.

More recently my responses have shifted from “the flu vaccine stops you from getting the flu” to “the flu vaccine reduced severity of flu symptoms, even if you end up getting it”. This shift has mainly been driven by my patients and their parents reading about flu vaccination and being concerned about the shortcomings that it has. But many people are surprised to hear me say that flu vaccines have been shown to reduce severity of flu illness. Strong and ever-growing amount of evidence back this claim:

For adults, flu vaccinations:

  • Reduced deaths, intensive care unit (ICU) admissions, ICU length of stay, and overall duration of hospitalization among hospitalized adults with flu (Arriola et al., 2017; Thompson et al., 2018)

For kids, flu vaccinations:

  • Reduced a child’s risk of dying from flu (Flannery et al. 2017)
  • Reduced children’s risk of flu-related pediatric intensive care unit (PICU) admission by 74% during flu season (Ferdinands et al, 2014)

For pregnant mothers, flu vaccinations:

  • Feduced a pregnant woman’s risk of being hospitalized with flu by an average of 40% (Thompson et al., 2019)
  • Reduced the risk of flu-associated acute respiratory infection in pregnant women by about 50% (Thompson et al., 2019)
  • Helps protect their babies from flu illness for the first several months after their birth, when they are too young to get vaccinated (Madhi et al., 2014)

While it can be a long and sometimes frustrating conversation to have with  patients and their parents about flu vaccination each year, I hope the above statistics and citations can help inform  future conversations. I’ve had more than a few parents change their minds on flu vaccinations this year after discussing what I’ve outlined. You never know what kind of conversations you may spark by being the expert in the room!

Michael Hook, M.D.


1. Ferdinands JM, Olsho LE, Agan AA, Bhat N, Sullivan RM, Hall M, et al. Effectiveness of influenza vaccine against life-threatening RT-PCR-confirmed influenza illness in US children, 2010–2012. The Journal of infectious diseases (2014) 210(5):674-83.

2. Arriola C, Garg S, Anderson EJ, Ryan PA, George A, Zansky SM, et al. Influenza vaccination modifies disease severity among community-dwelling adults hospitalized with influenza. Clinical Infectious Diseases (2017) 65(8):1289-97.

3. Madhi SA, Cutland CL, Kuwanda L, Weinberg A, Hugo A, Jones S, et al. Influenza vaccination of pregnant women and protection of their infants. New England Journal of Medicine (2014) 371(10):918-31.

4. Flannery B, Reynolds SB, Blanton L, Santibanez TA, O’Halloran A, Lu P-J, et al. Influenza vaccine effectiveness against pediatric deaths: 2010–2014. Pediatrics (2017) 139(5):e20164244.

5. Thompson MG, Kwong JC, Regan AK, Katz MA, Drews SJ, Azziz-Baumgartner E, et al. Influenza vaccine effectiveness in preventing influenza-associated hospitalizations during pregnancy: a multi-country retrospective test negative design study, 2010–2016. Clinical Infectious Diseases (2019) 68(9):1444-53.

6. Thompson MG, Pierse N, Huang QS, Prasad N, Duque J, Newbern EC, et al. Influenza vaccine effectiveness in preventing influenza-associated intensive care admissions and attenuating severe disease among adults in New Zealand 2012–2015. Vaccine (2018) 36(39):5916-25.

7. Murphy BR, Coelingh K. Principles underlying the development and use of live attenuated cold-adapted influenza A and B virus vaccines. Viral immunology (2002) 15(2):295-323.

8. Zhou B, Meliopoulos VA, Wang W, Lin X, Stucker KM, Halpin RA, et al. Reversion of cold-adapted live attenuated influenza vaccine into a pathogenic virus. Journal of virology (2016) 90(19):8454-63.

Two is better than one: dispelling myths about bilingualism in childhood

The United States is becoming more diverse every day. It’s nearly impossible to walk along the streets of any major city in America and not hear another language spoken. Texas is a prime example of this growing diversity. A 2015 survey using date from the US Census Bureau found that 35.4% of Texans speak a language other than English at home, and 83.3% of those people speak Spanish at home1. Some parents, however, are resistant to teaching their children Spanish at a young age because they believe teaching a child two languages at once will confuse them and possibly cause a language delay. These beliefs are myths, and it’s a pediatrician’s job to dispel them.

Here’s a common scenario: a mom who speaks both English and Spanish comes in with her 2-year-old son and when asked how many words he knows she nervously answers “He only knows 15 words in English, and I know he’s supposed to know at least 50, does this mean that he has a speech delay?” An informed answer needs additional information: how many words does he know in Spanish? If you combine the total amount of words the child knows in both languages, you will often find that he/she is in fact on track.

Along the same lines, bilingualism does not predispose children to having language delays and bilingual children with specific language impairments, ASD, or Down Syndrome do not have more challenges with speech than their monolingual counterparts2. In addition, what some parents perceive as language ‘confusion’ might actually be a phenomenon called code mixing, which occurs when a child mixes languages within the same sentence2. Think about it: a 2-year-old doesn’t have a large vocabulary yet to work with, so if he/she doesn’t know a word in one language it only makes sense to use the word that he/she does know in the other language. No studies have shown that code mixing affects the ability to distinguish between two languages or to learn an individual language more fully. 

Research has shown the advantages of bilingualism. Being fluent in at least two languages improves executive control, or the “ability to carry out goal-directed behavior using complex mental processes and cognitive abilities”2,3. Specifically, it improves inhibition, attention switching, and working memory, understood as improving self-control, multi-tasking, and short-term memory needed to complete daily tasks. Adult studies have shown that bilingualism may even be protective against the effects of cognitive aging2-4.

More recent studies have shown that bilingualism can lead to enhanced social understanding. The exact physiology behind these benefits is not completely understood, but it may be related to the fact that managing two languages requires using brain regions not usually used for language processing.  This exercises the brain and provides opportunities
for new connections and growth.

What is the best way for a child to learn two languages? First, the earlier a child learns another language, the easier it will be because of the immense plasticity of a child’s brain. This allows it to learn two languages just as well as it learns one. Better language acquisition occurs if it is simultaneous versus sequential, meaning it is preferential to teach a child two languages at once rather than one at a time. Some parents might choose to individually speak one language so that the child gets an equal amount of exposure, and while equal exposure is ideal, it is not essential for successful language acquisition2. Rather than focus on equality, parents should simply focus on maximizing the volume and variety of words their child hears.

What can pediatricians do to encourage bilingualism in children? Most importantly, pediatricians need to educate parents early on in the child’s life and dispel any myths that could deprive the child of precious exposure time. This is especially critical in the toddler years when
talking about language development at well-child checks. Pediatricians should also educate parents on the benefits of bilingualism. Clinics can provide Spanish children’s books in addition to English books to provide parents with another opportunity to expose their child to language. Our communities are becoming more diverse by the day, and as pediatricians we need to ensure that misinformation does not prevent parents from passing on what is often a crucial aspect of cultural identity: language.


  1. Bilingualism in Texas: The Perryman Group. Bilingualism in Texas | The Perryman Group. https://www.perrymangroup.com/publications/column/2016/10/24/bilingualism-in-texas/. Published October 24, 2016. Accessed January 21, 2020.
  2. Byers-Heinlein K, Lew-Williams C. Bilingualism in the Early Years: What the Science Says. Learn Landsc. 2013;7(1):95–112.
  3. Bialystok E, Craik FI, Luk G. Bilingualism: consequences for mind and brain. Trends Cogn Sci. 2012;16(4):240–250. doi:10.1016/j.tics.2012.03.001
  4. Bilingual Effects in the Brain. National Institutes of Health. https://www.nih.gov/news-events/nih-research-matters/bilingual-effects-brain. Published April 29, 2016. Accessed January 17, 2020.

Cristina Saez, M.D.