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Impact of Social Media on Well-Being

What do you do when there is a pause in conversation or have a small break? Do you nap, stretch, pick up a book, or scroll through social media. I can safely say a majority of the world chooses the last option. Previous surveys suggest that 22% of teenagers log on to their favorite social media site more than 10 times per day (Schurgin 801). Thanks to smart phones access to social media is omnipresent. There is probably a good chance you are even reading this from your phone because it was shared on your timeline. Both parents and pediatricians need to understand social media can have a negative impact on their children and patients especially teenagers, and be able to provide guidance to them.

Since I have your attention, I want you to try a thought experiment. Think about the last time you were on Instagram, Snapchat, or Facebook. Your friends are sending pictures of their amazing vacation to Greece, Japan, or Mexico. They are modeling their delicious food and cultural experiences. Now, how do you feel at this moment? How do you feel while sitting in your cubicle or lying on your couch after your hard day at work? How do you think your children feel when they see the same photos?

When we see these photos and experiences its natural to compare our experiences. However, it is very easy to look at our lives “unfiltered” and feel a sense of loss. As a media user, I have felt this feeling. I have felt the fear of missing out and I am not alone.

            Let’s talk about usage. How do you or does your child use social media? Are you actively posting or casually browsing others’ posts? Research performed at UT Dallas shows passive browsing to be more harmful to mental health. Adolescents were at increased risk of depression and anxiety. In 2016, a Scottish study evaluated social media’s impact on sleep and self-esteem in adolescence. They found adolescence with increased social media use, at night and overall, had lower self-esteem and higher rates of depression and anxiety.

Social media skews our perception of experiences by representing only positive experiences. We are catching a glimpse of the best moments in people’s days. That glimpse is enough to prompt you to compare your life to theirs. Picture centric media platforms like Instagram are more likely to promote appearance and life comparisons with others. As a result, adolescents and adults may feel more negatively about their self-image.

Researchers have proposed a phenomenon called “Facebook depression” (Schurgin 802). Social media exposure can be a trigger for depression in some adolescents. Although Facebook has seen a decrease in usage, the premise is still relevant. Teenagers are at a critical point in their lives when acceptance by peers is crucial.

Social media has benefits as well as drawbacks. Social media provides children and teenagers the opportunity to collaborate within their community. They can stay in touch with friends and share ideas. They learn from podcasts, videos, and even blogs like this one. Social media can be used to develop social skills. A great example is the ability for students to work collaboratively on class projects together with ease. There is a myriad of benefits for our children.

Unfortunately, those benefits come with risks. Social media can contribute to anxiety and depression, but it’s only one of the many contributing factors in most cases. We can start to understand the impact of social media on well-being by understanding what makes social media so fun. Parents need to understand what their teenagers are talking about. When social media is used right it can be enjoyable and safe. Parents need to understand the technology that adolescents are using and also be able to openly discuss how their kids are using it. Social media is prevalent throughout our entire lives so we must treat it as part of our daily routine.

Pediatricians should encourage parents to create an online plan for themselves and their children. The plan can include discussing online issues and checking privacy settings. The goal is to encourage well-being and safe practices on the internet. Social media is omnipresent; however, it does not have to be omnipotent. We are in control of how we use it and how it makes us feel.

Matthew Hibbs, M.D.

References

Okeeffe, G. S., & Clarke-Pearson, K. (2011). The Impact of Social Media on Children, Adolescents, and Families. Pediatrics127(4), 800–804. doi: 10.1542/peds.2011-0054

Psychologists Examine Mental Toll of Passive Social Media Use. (2019, September 26). Retrieved October 2, 2019, from https://utdallas.edu/news/research/social-media-fear-missing-out-2019/.

Woods, H. C., & Scott, H. (2016). #Sleepyteens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem. Journal of Adolescence51, 41–49. doi: 10.1016/j.adolescence.2016.05.008

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The “Social Visit”

We have all been there… your last patient of the day is 20 minutes late to their appointment. All you can think about is how much more time do you give them, before telling the front desk to reschedule the appointment. With all those notes backed up, it would be nice to focus on finishing up, so you can get home before you miss another dinner. However, even after giving them an additional 15 minutes, they do not show up. During those times is not uncommon to hear or think things like, “they better have a good excuse”, “why can they not get here early like everyone else”, or “they have had no-shown 3 appointments, let’s fire them from the clinic.”

But in those moments, it is vital that we start to move away from the thought process of how this missed appointment affects us, to the thought of how does this missed appointment affect the patient and why could they not make it in today? Not only do missed appointments have negative effects on the patient, they can also impact the healthcare system as a whole [1,2]. While evidence suggests the majority of appointments are missed because of forgetfulness, other factors have been reported by families to affect their ability to attending clinic visits, such as: [2]

  • Issues with transportation
  • Schedule conflict (work, school, other appointments)
  • Feeling appointments were unnecessary
  • Child’s health improved
  • Not feeling well
  • Time commitment 
  • Insurance issues

Typical responses to a high volume of missed appointments in a clinic usually involve efforts to improve communication with families via reminder calls/text, open access scheduling to improve appointment wait times, and extended clinic hours to provide more flexible assess to care [2-4]. But none of these fully address issues with transportation, financial short falls, lack of insurance, or any of the countless other hardships families face while navigating a complex medical system. Each no-showed appointment is a unique problem that requires a unique solution, because the underlying factors can vary from day to day and patient to patient.

This is a perfect place to have the “social visit”: think of it as the well-child visit par excellence. These visits would be tailored to identify factors that act as barriers to receiving timely medical and preventive care. During these visits, referrals can be made to community resources, education can be provided on how preventative care is essential for maintaining health, and time can be dedicated for family-provider interactions to establish a robust therapeutic alliance. 

In a perfect world, this would be done in the clinic so providers and families can personally come together and tackle their unique situation as a united team. However, if you cannot get patients into the clinic for regular visits, how effective is the “social visit” going to be if they do not show up for that either? Thankfully, it could also be completed by phone, which would allow for greater flexibility for families and hopefully lead to improved relationships and clinic attendance.

As pediatricians, we have the responsibility to make the effort to start changing the thought process and culture around missed appointments. These are perfect opportunities to reach out to families and provide assistance that they might not otherwise be willing to ask for. Additionally, we must advocate for our patients to make sure they have access to the “social visit”, regardless of billing/productivity constraints. We should push for protected time to make this happens, with the ultimate goal of changing the perspective, so we start to look at the causes of health disparities as medical diagnoses.

Aaron Pope, MD

1.         Cameron E., et al. “Health care professional’s views of paediatric outpatient non-attendance; implications for general practice.” Fam Pract. 2014 Feb; 31(1): 111–117. Published online 2013 Nov 15. doi: 10.1093/fampra/cmt063

2.         Samuels RC., et al. “Missed appointments: Factors Contributing to High No-Show Rates in an Urban Pediatrics Primary Care Clinic.” Clin Pediatr (Phila). 2015 Sep;54(10):976-82. doi: 10.1177/0009922815570613. Epub 2015 Feb 12.

3.         O’Connor M., et al. “Effects of Open Access Scheduling on Missed Appointments, Immunizations, and Continuity of Care for infant Well-Child Care Visits.” Arch Pediatr Adolesc Med. 2006;160(9):889-893. doi:10.1001/archpedi.160.9.889

4.         Aral L., et al. “‘Did not attends’ in children 0-10: a scoping review” Child Care Health Dev. 2014 Nov;40(6):797-805. doi: 10.1111/cch.12111. Epub 2013 Oct 18.

Autism is diagnosed starting at age 2. But what can we do before then?

In recent years, autism has been at the forefront of many discussions in pediatrics. Its prevalence has increased from 1 in 150 children to 1 in 59 over the last 20 years according to the CDC[i]and this is likely due in large part to our ever-growing knowledge of the condition and efforts promoting early diagnosis. Research thus far has shown that early diagnosis and intervention have been instrumental in generating positive outcomes. But how early can we start “therapy” for autism when it can’t even be diagnosed until 24 months of age? We now have research to show that pediatricians should be encouraging parents to consistently talk to their young children even if they aren’t getting any responses back.[ii]

A recent study published in the journal Autism Research delved a bit deeper into the concept of early intervention.[iii]Dr. Meghan Swanson conducted a study looking at 96 infants, 60 of whom had an older sibling with autism. Such a design was necessary given the age restriction on diagnosis and that younger siblings of children with autism have a 20% chance of having autism as well. This statistic was proven true as 14 of those 60 subjects were later diagnosed with autism at 24 months (23%). Dr. Swanson’s method was to monitor 2 full days of audio in the child’s home via LENA audio software- one day when the child was 9 months old and again at 15 months. The LENA software counts number of words as well as “conversation turns,” meaning when one person speaks and another responds. The content of what is said is not evaluated. The subjects’ language skills were then later assessed at 24 months. 

As mentioned, 14 of the subjects were ultimately diagnosed with autism and were placed in the “high-familial-risk who have ASD” group. The remaining subjects were divided into 2 groups: 1) those with older siblings affected by autism but who did not have autism themselves (high-familial-risk who did not have ASD, n=46) and 2) low-familial-risk who exhibited typical development (n=36). The conclusions of the study were two-fold. First and most important, a richer home language environment with higher numbers of adult words and conversational turns correlated to better language development for ALL study groups. Second, higher parent education levels corresponded to richer home language environment. 

As these results show, the benefit from caregiver interaction particularly in the realm of reciprocal spoken language is not restricted to typically developing children. Pediatricians should advise parents to enhance their child’s development from birth by speaking to them regardless of whether they are able to respond appropriately or at all. To be clear, autism is not a diagnosis that is caused by parenting style. The diagnosis will be present or not regardless of parental intervention. However, this study shows that frequent and early communication from birth can improve language development even in children with autism. Additionally, there are centers available that can provide more directed therapies for children struggling with language, social skills, and other developmental milestones. Life Skills Autism Academy is opening its flagship location in Plano, Texas where children 18 months to 5 years can receive personalized one-on-one therapy and assistance in developing an appropriate Individualized Education Plan (IEP) and advocating for the child in the school system.[iv]

Pediatricians can share this knowledge to help all their infant patients improve language development and kickstart their learning with the goal of success in school and beyond. 

Rachel Tonnis, MD


[i]https://www.cdc.gov/ncbddd/autism/data.html 

[ii]https://utdallas.edu/news/research/autism-language-skills-study-2019/

[iii]Swanson, Meghan R. “Early language exposure supports later language skills in infants with and without autism.” Wiley Online Library. Dallas, TX. 1 Sep. 2019. https://onlinelibrary.wiley.com/doi/abs/10.1002/aur.2163.

[iv]https://www.dallasnews.com/business/health-care/2019/08/29/life-skills-autism-academy-opening-in-plano-plans-to-provide-one-on-one-therapy/

New “Public Charge” Rule: How does it affect our patients’ families?

Texas is home to approximately 4.7 million immigrants (an estimated 17% of the state population), including approximately 317,000 immigrant children1. Of these immigrants, approximately 1.7 million are naturalized US citizens, nearly 1 million are eligible to become naturalized US citizens, and nearly 2 million are undocumented immigrants1,2. The number of US-born children in Texas who live with an undocumented family member is reported to be approximately 1 million, with approximately 500,000 children with an undocumented parent1,3. Obtaining permanent residency status is a lengthy process and a source of anxiety for many immigrants. Recent changes to the US Department of Homeland Security (DHS) rules regarding which public benefits count negatively towards obtaining permanent residency may impact these families and children. Pediatric healthcare providers should be prepared to help immigrant families understand how the use of public benefits could impact changing their immigration status.

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Why is Healthcare Expensive?

The United States has the most expensive health care system in the world [1]. This has led to extensive discussions and debates on how best to finance it and what kind of insurance system will be preferred to ensure access to everyone. While healthcare financing is an important aspect of this discussion, the root cause of why healthcare is expensive and whether we should address this root cause are usually not at the forefront of national or public discussion. While insurance billing and administration costs are a large contributing factor, pediatricians should educate themselves on other root causes of why healthcare is expensive and advocate for broader discussions about the  salaries of healthcare professionals and the cost of pharmaceuticals and medical devices. 

The reason why healthcare is expensive is complicated, but it mainly comes down to the fixed cost that is charged for each service provided. When it comes to basic human needs such as food and clothing, people usually have a wide range of options in terms of what they can pay for a given item. Expensive food types and  famous brands of clothing are not a necessity for everyone, and there are options for cheaper alternatives. With healthcare, there are no options. Hospitals, clinics, pharmaceutical and medical device companies set the prices for the service and the therapeutics provided, which are mostly standard across the board. The only thing that comes close to a cheaper alternative in medicine is the availability of generic drugs. While the prices for generic drugs decline, the average price for  brand-name prescription drugs increased 164% between 2008 and 2016 [2]. 

Salaries are another component of the expense of U.S. healthcare. On average, European physicians get paid much less than physicians in the United States: in Germany they make about one-third less [3]. The salary of healthcare professionals is one of the least discussed contributors to the healthcare cost in the United States. While most physicians, including pediatricians, are strong advocates for increased access to healthcare, most of their focus has been on changing healthcare financing [4]. Salaries of physicians, particularly for some specialties and for those in private practice, play a significant role in increasing the healthcare cost. The high student loan debt for medical education  fuels the need for medical graduates to factor in the salary when choosing their future career. While salary is not the only factor, generally the lesser paying specialties attract less interest from medical graduates while the higher paying specialties are the most competitive. Because asking physicians not to worry about their salaries in the face of the large amount of student loans they carry would be unreasonable, addressing the cost of medical education could be one step to begin tackling one of the root causes of the increasing healthcare costs. 

Rising prices for pharmaceuticals and medical devices is another complicated aspect of healthcare cost. While research and advances in new technologies continue to lead to novel diagnostic and treatment methods, they have  come with significantly higher cost [3]. The prices of these new therapeutics and devices are solely set by the industry. Patients usually have no alternative options, particularly when it comes to the most advanced treatments that are protected with patents with no generic alternatives. While many of the governments in Europe have mechanisms in place to negotiate drug prices with pharmaceutical companies, there is no such current practice in the U.S.[3]. Moreover, diagnostic tools such as CT scans or MRIs do not have generic forms that patients can choose from. Unless we find a way to reduce the continued escalation in price that comes with advances in technology,  healthcare costs will not stop increasing. 

Pediatricians should  lead discussions about ways to address the root causes of increasing healthcare cost. We are  caring for children who deserve options to access the best diagnostics and treatments available. Advocating for public health insurance such as Medicaid and CHIP  is necessary, but the sustainability and further expansion of such or new programs will require reducing the direct cost of healthcare. Pediatricians should engage in broader discussions on these topics to generate sustainable solutions at the local and national level. 

Tewodros (Teddy) Mamo, M.D.,Ph.D.

References:

[1]: Landrigan CP, “Cutting Children’s Health Care Costs.” Pediatrics. 2018 Aug;142(2). https://pediatrics.aappublications.org/content/142/2/e20181549#ref-1 

[2]: Galea S., “The Cost of Pharmaceuticals, the Role of Public Health”, Dean’s note, ethics & human rights, health law, pharmaceuticals, Jun, 2016.  http://www.bu.edu/sph/2016/06/05/the-cost-of-pharmaceuticals-the-role-of-public-health/ 

[3]: DPE Fact Sheet, “The U.S. Health Care System: An International Perspective” 2016. https://dpeaflcio.org/programs-publications/issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/ 

[4]: “Understanding the Economics of the Healthcare Environment – Financing and Utilization”, AAP article on Practice Transformation, accessed on 8/18/2019.https://www.aap.org/en-us/professional-resources/practice-transformation/economics/Pages/Financing-and-Utilization.aspx

Children’s Social Media Consumption and Eating Behavior

With the advancements in technology and the introduction of high-speed internet, our societies have been facing a whole new set of issues and concerns especially when it comes to the role and impact of social media on the development and health of our children.  Pediatricians should educate parents about the influence of social media on their children’s eating habits and share resources to counteract the effects of unhealthy foods digital marketing.

A decade ago I never thought I would have to include restricted social media use and modified Facebook or YouTube home content as part of my diet plan. Nowadays, our exposure to social media influencers significantly impacts our subconscious decisions even when it comes to snack choices. This is also true for our young children and adolescents.

Is it true that our children are following social media influencers when it comes to food consumption.? And is social media contributing to the obesity epidemic?

A randomized trial study published in Pediatrics by Anna E. Coates et al. included 176 children between 9 and 11 years old.  The children were assigned to view mock Instagram profiles of two popular YouTube vloggers and influencers promoting healthy or unhealthy snacks or nonfood products.  The results of this study indicated that children who viewed unhealthy snacks content had a statistically significant increase in food intake compared to those who viewed the influencers promoting healthy snacks. Thus, the study concluded that marketing of unhealthy foods through social media influencers increased children’s food intake of 26% more kilocalories compared to children who viewed healthy food behavior.

With childhood obesity remaining a major health epidemic, it is crucial for pediatricians to recognize the impact of digital marketing on the health and eating behavior of children exposed to thousands and thousands of social media influencers on a daily basis. Methods for restricting social media food marketing content should be implemented to protect the health of the new generation of children and adolescents.

Parents can be advised to have a family media use framework to control the content of social media that their children view. Parents should start the conversation early about social media influence with their children, explaining the risks of the promoted unhealthy foods on their children’s health.

Sonia Allouch, MD

References:

  • AAP COUNCIL ON COMMUNICATIONS AND MEDIA.  Media and Young Minds. Pediatrics. 2016;138(5):e20162591

https://pediatrics.aappublications.org/content/138/5/e20162591

  • Coates AE, Hardman CA, Halford JCG, et al. Social Media Influencer Marketing and Children’s Food Intake: A Randomized Trial. Pediatrics. 2019;143(4):e20182554

https://pediatrics.aappublications.org/content/pediatrics/143/4/e20182554.full.pdf

  • Coyne S, Radesky J, Collier KM, Gentile DA, Ruh Linder J, Nathanson AI, Rasmussen EE, Reich SM, Rogers J.  Parenting and Digital Media. Pediatrics 2017;140;S112

https://pediatrics.aappublications.org/content/140/Supplement_2/S112

  • Robinson TN, Banda JA, Hale L, Shirong Lu A, Fleming-Milici F, Calvert SL, Wartella E.

Screen Media Exposure and Obesity in Children and Adolescents. Pediatrics 2017;140;S97

https://pediatrics.aappublications.org/content/140/Supplement_2/S97

Be Kind to the Brain

“I could not leave the team behind. I needed to get back in. They told me I had to keep going and move.” These harrowing words send chills down my spine. Why all the upset? These statements represent the sentiment often carried by those who subsequently suffer from a concussion. During one of my hospital shifts, I met a young man who arrived in agony from a severe headache. He was hit in the head several times throughout the week during football practice. He was hit not 2, not 3, but 4 times before he sought help. Each impact led to worsening headache, blurry vision, and dizziness, but it was ignored.

Concussion is a group of symptoms representing a type of traumatic brain injury that results in chemical damage to the brain. Brain damage can result from a direct blow to the head or an indirect hit to the body that results in the head and brain shaking. This type of damage is frequent in children who participate in sports, especially football and soccer [1]. It, however, can occur several other ways. The CDC estimates that as many as 3.8 million suffer from a concussion annually, with females suffering more frequently.

It is imperative that parents, coaches, teachers and medical professionals recognize the signs. These can include: headache, vomiting, light sensitivity, sound sensitivity, slurred speech, emotional changes, memory issues, and problems with sleep. Loss of consciousness may or may not occur. There are several scoring systems that can help aid in a child or adolescent that you suspect experienced a concussion [2]. When in doubt, set them out! The CDC offers wonderful information and training online to become familiar with the condition [2].

As the pediatrician or concussion specialist, you can work to structure a schedule that will allow the patient to get better. This will involve a graduated program that increases their activity level as the individual improves [3]. The school should provide the student with the necessary accommodations to ensure full recovery. Rest is a crucial component of this process. Without it, the child or young adult may risk developing long term memory problems, behavior issues, and significant depression [4]. Most patients recover after two weeks but some take months to regain their baseline health. You are encouraged to follow the child or adolescent and perform the necessary exams to assess progress.

My patient spent several days in pain, unable to move from his hospital bed. He explained with great detail that he was not his normal self. He felt angrier, sadder, and unable to cope with daily activities. I have seen worse outcomes; thus, I end with a message to pass to all those who seek your care. It is okay to step out of a game when you are hurt. It takes courage to tell someone you need help. We are proud that you recognize it. You are a rock star and the game is not worth gambling your life. Also, missing one game, does not mean missing an entire season. Allow the brain the time to heal; it will love you for it!

References

1. Meehan III, W. P., & O’ Brien, M. J. (2018, November 14). Concussion in children and adolescents: Clinical manifestations and diagnosis. Retrieved from UptoDate: https://www.uptodate.com/contents/concussion-in-children-and-adolescents-clinical-manifestations-and-diagnosis?source=history_widget

2. US Department of Health and Human Services. (2017, June 22). Heads Up. Retrieved from The Centers for Disease Control and Prevention: https://www.cdc.gov/headsup/index.html

3. Centers for Disease Control and Prevention. (n.d.). Cole’s Story: Coach Saves a Wrestler’s Life by Knowing Concussion Signs and Symptoms. Retrieved from https://www.cdc.gov/headsup/pdfs/stories/coles_story_one_pager-a.pdf

4. Forgrave, R. (2017, January 10). The Concussion Diaries: One High School Football Player’s Secret Struggle with CTE. Retrieved from GQ Magazine: https://www.gq.com/story/the-concussion-diaries-high-school-football-cte

Abdelrahim Abdel, MD

Building Your Vaccine Conversation Toolkit

We, as pediatricians, have the incredible opportunity and privilege of providing life-savingmedicine to children in the form of immunizations. Overall vaccination coverage remains high nationally, but the percentage of young children who have received no vaccines has increased over the past several years. This fact has recently gained significant attention both in the medical community and in the political arena. Of course, many factors may be contributing to lack of immunization in some communities, including lack of access to healthcare or health insurance, but the discussion about causality is most often focused on vaccine hesitancy among parents. As physicians who are interacting daily with parents who may be hesitant about vaccines (or simply parents who have questions about immunizations in general), pediatricians must be prepared to participate in discussions about vaccines in a productive and meaningful way.  

Certainly, there is need for advocacy regarding immunizations at a population level. However, there is also an immense opportunity for advocacy at the individual patient level. A 2013 survey conducted by the AAP showed that 87% of pediatricians have encountered parents who refuse a vaccine. Studies have shown that howproviders initiate and pursue vaccine recommendations with parents is associated with parental vaccine acceptance. In other words, it is not simply our responsibility as pediatricians to provide the recommendation to immunize – it is our responsibility to engage parents in discussion about vaccines, answer their questions, address their concerns, and help them feel confident in choosing to immunize their children. 

In order to participate successfully in these discussions with families, we must stock our proverbial toolkits with a plethora of skills and strategies. We all have our own unique communication style, but incorporating some key (and proven) tools into our everyday practice is essential to our effort to increase vaccination uptake while maintaining partnerships with families.

  • Using a presumptive approach– We are taught in medical school and residency to use open-ended questions when obtaining a history. When discussing vaccines with parents, using the opposite approach has actually been shown to be more effective. It is important to remember that most parents areplanning to vaccinate, and we can introduce the topic with that assumption. Using a presumptive approach means using language such as, “Johnny is due for 3 shots today,” as opposed to “What do you think about Johnny’s shots today?” One study showed that, among all parents, more parents chose to vaccinate their children when providers used a presumptive approach.
  • Debunking myths – Families may have questions about some of the commonly publicized concerns about vaccines, and we must take time to appropriately address them. The goal is to increase families’ familiarity with the facts while avoiding making the misinformation more familiar. Minimizing the influence of misinformation is a difficult and complex challenge, but one which pediatricians can be well-equipped to handle with practice. In a resource called “The Debunking Handbook” by J. Cook and S. Lewandowsky, the authors state that there are 3 key elements to debunking: 
  • Focus on the facts rather than the myth.
  • If the myth is mentioned, it should be preceded by the warning that the information is false.
  • The debunking should include an alternative explanation that addresses the important qualities of the misinformation in question. 

Using this debunking strategy has been demonstrated to be effective. This video from the CDC is a concrete example of a pediatrician answering difficult questions from parents using some of these debunking techniques: https://www.cdc.gov/cdctv/diseaseandconditions/vaccination/get-picture-childhood-immunization.html

  • Motivational interviewing– Studies have shown that only providing facts and information to vaccine hesitant parents is an ineffective method to increase parents’ intention to vaccinate. Motivational interviewing (MI) is a patient-centered approach focusing on enhancing a person’s ownmotivation for change. It employs the techniques of using open-ended questions to explore concerns (if any are encountered after using a presumptive approach), providing affirmations and reflective listening, and summarizing what the person has expressed to you. One study showed that MI training for providers was effective at increasing uptake of the HPV vaccine. Here is an example of an MI-style interview (borrowed from an MI training module through Denver Metro Alliance for HPV Prevention):

Parent: “I think Mary is way too young for an HPV vaccine. I mean, she’s only 11 years old. I think you doctors are pushing this too soon. Someday, she may consider getting vaccinated, but not now.” 

Provider: “It’s really hard for you to believe that the HPV vaccine is right for Mary when she’s so young. That just doesn’t make any sense at all.” 

Parent: “Exactly!”

Provider: “Well I can certainly understand why you would feel that way (affirmation). May I share the reasoning behind vaccinating early (autonomy, supportive education) – then you can tell me what you think?” (collaboration)

Becoming comfortable with MI can take time. There is an abundance of training videos and modules for providers online, but the best way to practice is in daily conversations with our patients and families. Using MI when we encounter vaccine hesitancy allows parents to feel heard and respected, encourages them to share their honest concerns and thoughts without pressure or judgement, and may lead them to form new conclusions about vaccines. 

We cannot depend on any one of these tools in isolation and must be prepared to call on them in tandem as questions and concerns from parents arise. Remember that our responsibility is to build trust with families and to be able to have honest and thoughtful conversations about decisions that affect their child’s health. Encountering vaccine hesitancy can seem overwhelming, frustrating, and discouraging at times. However, we must realize that success comes in many forms and that the conversations will be ongoing. Stocking our toolkits with strategies like these is a simple way to take advantage of the precious time we spend with families and the immense opportunity to advocate for every one of our patients. 

Gaylan Dascanio, MD

Resources:

Opel, D. J., MD, MPH. (2015). The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience. The American Journal of Public Health, 105(10), 1998-2004.

Cook, J., Lewandowsky, S. (2011), The Debunking Handbook. St. Lucia, Australia: University of Queensland. November 5. ISBN 978-0-646-56812-6. [http://sks.to/debunk] 

Reno JE et al. Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing. J Health Commun. 2018;23(4):313-320. 

https://www.cdc.gov/vaccines/hcp/conversations/index.html

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).

Helping Your Child Succeed at School

A new school year is once again upon us! And for those with children who may need a little extra help in their classes, this may be a stressful time. Children with disabilities or impairments may be eligible for modifications or accommodations at school to help them learn and succeed.

Knowing if your child has a disability impacting their learning can be challenging. Usually a student will begin to have poor, down trending grades.  He/she may have difficulty remembering to do homework or may struggle to complete it.  If this is not brought up by your child’s teacher, you may need to speak up. An evaluation may need to be performed by the school in order to test for certain learning disabilities or other issues. Additionally, you should speak with your child’s pediatrician for developmental, vision, and hearing screens.

Some students qualify for special education services under the federal law, Individuals with Disabilities Education Act. If eligible, an individualized education plan (IEP) is developed to lay out goals for the school year and describe any services or supports the student may need.  Any child age 3 or older with a suspected disability can request a free full individual evaluation from the local public school district.  Several categories of eligibility exist, including specific learning disability, hearing/visual impairment, and “other health impairment.”

Other students may qualify for accommodations under Section 504 of the Rehabilitation Act of 1973. These can include supports such as reminders to stay on task, preferential seating in the classroom, shortened assignments, and other items.  You can ask your child’s teacher or school counselor for a “504 meeting.”

It is vital to know that your child will only receive services if it has been shown that your child’s learning has been affected by these issues and problems with functioning at school exist. If this is the case, a meeting for either special education or 504 accommodations will involve a plethora of staff (classroom teachers, diagnostician or school psychologist, special education teacher, campus administrator, and others).  The group, along with you the parent, decides what the child needs. You, as a parent, will have the option to review the proposals and agree or disagree. Do this to make sure your child is getting all the services he/she may need. Make sure to discuss any changes you would like to be made.

The 504 plan or IEP should be reviewed annually. If you are not seeing appropriate changes to your child’s performance or learning goals – speak up.  Ask your child’s pediatrician for any suggestions or recommendations for your child.   You are the best advocate for your child!

To learn more, visit:

https://sites.ed.gov/idea/

https://www2.ed.gov/about/offices/list/ocr/504faq.html

Kristina Ciaglia, MD