Uncategorized

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

Advertisements

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

 

 

MISINFORMATION- THE CONVERSATION WE NEED TO BE HAVING

love baby boys family

Photo by Pixabay on Pexels.com

“Misinformation is not like a plumbing problem you fix. It is a social condition, like crime, that you must constantly monitor and adjust to.” -Tom Rosenstiel

As a society, we are blessed to live in an age of abundant and easily accessible information. However, it can be difficult to distinguish between what is true and what is false. As pediatric providers, we have become aware of this- especially when it comes to parents who are concerned about vaccine safety. These concerns must be acknowledged and addressed. Along with providing medical advice and resources for reliable information, we should also be educating parents on how misinformation is presented. (more…)

The Need to Keep Families Together

According to the US Census Bureau, only 68% of children live in households with two parents, a figure that has been steadily decreasing over the past few decades1. The separation of parents and the lack of two-parent households occurs for a multitude of different reasons, and there are some cases in which it is better for the health and development of a child to live with a single parent. However, multiple independent studies have shown that generally, children have more health problems with only one parent in the household. One study2 that included 17,000+ preschool-age children showed that one parent homes had:

  • Increased risk regarding parent-reported poor health status [boys: odds ratio (OR) 1.39 (95% confidence interval (CI): 1.06-1.82), girls: 1.73 (1.28-2.33)]
  • Psychological problems [boys: 1.90 (1.38-2.61), girls: 1.58 (1.03-2.42)]
  • Overweight [boys: OR 1.23 (1.01-1.50)}
  • Asthma [only girls: OR 1.90 (1.15-3.15)]

 

Many of the above trends also hold true for refugee children displaced to countries without their parents. This is unsurprising, given the data above showing that removing one parent from the household already shows decreases in child health. The removal of both parents, in addition to the violence/trauma surrounding the move to a new home, would naturally be expected to prove problematic on the health and well-being of these children. A review3 of roughly 50 studies and 5,000+ children living in the USA and other high-income countries found that many of these children (especially those of adolescent age, those with mental health disorders or those experiencing trauma around the parent’s removal) experienced higher than average rates of PTSD, anxiety, depression and general health problems with inconsistent improvement over time.

 

While the factors surrounding the decline in two-parent households are very complex, the current refugee situation within the United States offers a clearer path of way to make an immediate difference. As many well know by now, 2,000+ children4 have been removed from their homes and many of their parents deported to Mexico or other countries including Honduras, Guatemala and El Salvador. Many of these children are toddlers or have mental/medical disorders (such as down syndrome, or those requiring complex medical care) that will add further difficulty and traumatization to the removal from their households.

 

Regardless of personal views on immigration legality and procedure, there is a substantial amount of data that supports the notion that children have better outcomes when they are with their families. This begs the question, what is the best way to help keep these children from being separated?

 

One of the easiest ways to get involved is to follow legislation that is currently in progress to help keep these families together. Following this legislation, keeping an eye out for events at a local level and contacting state representatives can all assist with this cause beyond what any one individual can do alone. There is a lot of legislature currently in progress surrounding this issue:

 

Across the board, children have better outcomes when their parents are around and able to provide both the financial and emotional support that children need to thrive and survive. While it is difficult to affect family divorce/separation rates, what we currently can do is advocate for the children being pulled away from their families in light of recent deportations. This can be done via legislation that is currently on the floor aiming to prevent dissolution and protect these children and these families. Immigration beliefs aside, these children deserve better than what they’re currently receiving, and it’s important to prioritize keeping these families together.

 

Taylor Valadie, MD

 

References:

1) US Census Bureau (November 2017) Families and Households https://www.census.gov/topics/families/families-and-households.html

2) Scharte M1, Bolte G; GME Study Group (2013) Increased health risks of children with single mothers: the impact of socio-economic and environmental factors. Eur J Public Health. 2013 Jun;23(3):469-75

https://www.ncbi.nlm.nih.gov/pubmed/22683774

3) Fazel, Mina. Reed, Ruth V. Panter-Brick, Catherine. Stein, Alan. (2011) Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet 2012; 379: 266–82 http://www.evidenceaid.org/wp-content/uploads/2016/03/1-s2.0-S0140673611600512-main.pdf

4) de Córdoba, Jose. Perez, Santiago (June 19 2018) Mexico Criticizes U.S. Over Policy Removing Immigrant Children From Parents. https://www.wsj.com/articles/mexico-rebukes-u-s-over-policy-removing-immigrant-children-from-parents-1529432369

Discussing Depression and Suicide in the Media

Avicii (Tim Bergling), Chester Bennington, Kate Spade, Mark Salling, Robin Williams, Anthony Bourdain: All names in media for the unfortunate fame of recent suicides. Similarly, TV shows such as “13 Reasons Why” (released to Netflix in 2017) and pop songs like “1-800-273-8255” by Logic (featuring Alessia Cara and Khalid), shed light on the persistent and ever growing issue of adolescent depression and suicide. There has been heated national debate regarding the effect media has on perpetuating suicidal thoughts versus raising awareness. Whether by parental choice or not, the discussion of mental health and self-harm has made its presence known to the public eye of children with these big names of Hollywood and pop culture. Just as it is important to address gun violence covered by media, pediatricians and parents must take strong roles in approaching the sensitive subject of depression. Suicide is itself a very private matter, however more recently it has become publicized, glorified, and often shamed. In light of these portrayals, it is crucial to remember it for what it is: a mental health illness.

According the CDC 2018 Vital signs, suicide rates across ages continue to rise with a significant jump by 30% from 1996 to present, in half the US states [1]. Suicide remains the 3rd leading cause of death in children 10-14 years of age, and (since 2016) the 2nd leading cause of death in adolescents 15-24 years of age. Looking state specifically, Texas falls in the range of 19-30% increase in suicide rates. Fortunately, amongst adolescents, attempt rates and health injury caused by suicide attempts, remains relatively stable between 2013-2015, according to Youth Risk Behavior Survey [2]. The disappointing reality exists that even under the watchful eye of healthcare providers, 77% of those who complete suicide have been seen by a primary care provider, and 40% have been seen by an emergency care provider in the year leading up to their suicide [3].

What can be done? And how do we intervene? Initial screenings are not only welcomed by adolescent patients [4] but also effective in providing a backbone for further follow up [5]. Systematic tracking of endorsed suicidality, with formulas/surveys such as the PHQ-9, help to quantify mental health and to make screening easier for the providers.

For parents and pediatricians alike, anticipatory guidance during adolescent well child exams or sports physicals can serve as a time to review key topics such as:

  • Warning signs of depression:
    • social withdrawal, loss of interest in prior hobbies, hopeless talk, extreme or labile emotions/mood swings, verbal outcries on social media
  • Open communication:
    • encouraging parent-teen relationships, providing attention and empathy before patient outcries (http://www.bethe1to.com/), avoiding shame, expressing concern about the patient
  • Access to guns/medications/drugs at home:
    • removing adult (or child) medications that can be abused, removing and locking away guns (4-10x higher likelihood of suicide in households with gun access) [6]
  • Cyberbullying:
    • Limiting social media use, monitoring internet searches on suicide (more than 5 hours of internet use daily associated with higher rates of suicide) [7]
  • When to escalate and who to reach out to with concerns:

By initiating a conversation early on with parents and adolescents alike, pediatric providers may alter the perspective on mental health. Pop culture media is not required to uphold the ethics of beneficence or non-maleficence. Ultimately, it is the responsibility of the pediatrician and the community at large to invest in the future of its young adults. We can do this by advocating for improved funding (in light of budget cuts to mental health services), and perpetuating positive and open dialogue early on regarding mental health and depression.

~Alisha Wang, MD

 

References:

[1] Suicide Rising Across the US: https://www.cdc.gov/vitalsigns/suicide/

[2] Trends in the Prevalence of Suicide-related Behavior: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/2015_us_suicide_trend_yrbs.pdf

[3] Parkland Leads Way Nationally with Innovative Suicide Screening Program: https://www.parklandhospital.com/phhs/news-and-updates/parkland-leads-way-nationally-with-innovative-suic-769.aspx

[4] To Ask or Not to Ask? Opinions of Pediatric Medical Inpatients about Suicide Risk Screening in the Hospital. Journal of Pediatrics. Mar 2016. https://www.jpeds.com/article/S0022-3476(15)01464-X/pdf

[5] Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents. Journal of Adolescent Health. Feb 2018. https://www.jahonline.org/article/S1054-139X(17)30466-4/fulltext

[6] With Suicide Now Teens’ Second-Leading Cause of Death, Pediatricians Urged to Ask About Its Risks. AAP. Jun 2016. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/With-suicide-Now-Teens%E2%80%99-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx

[7] Suicide and Suicide Attempts in Adolescents. AAP. Jun 2016. http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420

Parental Responsibility to Regulate Screen Time for Children

In 2016, the American Academy of Pediatrics (AAP) revised screen time guidelines for children. The previous guidelines advised no screen time for kids less than 2, and no more than 2 hours in front of the TV for kids over the age of 2. With the advent of smart phones and tablets making screen time and Internet access nearly ubiquitous, many pediatricians and other professionals felt the AAP was long overdue in revising screen time guidelines to be more appropriate for current and future generations of children. Newly revised 2016 guidelines were broken down into four basic age groups with added flexibility to customize screen time to fit the needs of the individual child, as follows:

  • For infants less than 18 months of age:
    • Parents should avoid use of screen media other than video chatting.
  • For infants 18 to 24 months of age:
    • If desired, parent should choose high-qualityprogramming, and watch with children to help them understand what they’re seeing.
  • For toddlers 2 to 5 years of age:
    • Parents should limit screen use to 1 hour per day of high-quality
    • 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 6 years of age and older:
    • Place consistent limitson 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.

These new guidelines recognize that visual media can be an important tool for development and educationwhen properly utilized. The problem is that many parents do not properly adhere to these guidelines. Contrary to what some may believe, these guidelines do not relax the parameters for screen time. Rather, these guidelines call for increasedparental investmentin actively regulating their child’s media consumption. Examples of inappropriate screen time, at times even commonly witnessed directly by pediatricians in clinic, include some the following:

  • Parents using video streaming on mobile devices as a means of distracting their infants or children.
  • Parents not adequately supervising screen time.
  • Parents failing to set consistent limits on media use.
  • Parents or children choosing to view poor quality programming with little educational benefit.

Adverse effects of unregulated screen time are well understood to include the following: obesity, sleep problems, problematic internet use (e.g. gaming disorders), negative effects on school performance, risky behaviors (e.g. substance abuse, inappropriate sexual behaviors), sexting, piracy, predators and cyber bullying.

Given the common adverse effects of unregulated media use, it is important to recognize that the above guidelines do not indicate AAP’s endorsement of screen time as a primary learning activity. The AAP recommends that parents prioritize creative, unplugged playtimefor infants and toddlers. The amount of daily screen time for older children depends on the child and family, but children should prioritize productive time over entertainment time.

The AAP provides an important but underutilized tool online that helps families build their own custom Family Media Plan (see link below). Pediatricians who wish to emphasize the importance of regulated screen time should consider providing this resource to families in their clinics. The plan provides a customizable template that includes setting important boundaries in the development of healthy screen time behavior.

Lastly, a quote from Bill Watterson, arguably one of the most creative minds of the late 1980s-early 1990s who is known for his authorship of Calvin & Hobbes, helps reinforce the importance of alternatives to screen time:

“We’re not really taught how to recreate constructively. We need to do more than find diversions; we need to restore and expand ourselves. Our idea of relaxing is all too often to plop down in front of the television set [or internet] and let its pandering idiocy liquefy our brains. Shutting off the thought process is not rejuvenating; the mind is like a car battery—it recharges by running.”

Alex J. Foy, MD

 

Sources and Resources:

Build Your Own Family Media Plan

https://www.healthychildren.org/English/media/Pages/default.aspx#home

10 Tips for Becoming a More Active Family

https://www.choosemyplate.gov/ten-tips-be-an-active-family

Children and Adolescents and Digital Media

http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593

Constantly Connected: Adverse Effects of Media on Children & Teens

https://www.healthychildren.org/English/family-life/Media/Pages/Adverse-Effects-of-Television-Commercials.aspx

Obesity and Food Insecurity: A Dichotomy in the Current State of Nutrition in America

Nutrition plays a vital role in growth, behavioral and cognitive development, reproductive health, and long-term health maintenance.  Pediatric is arguably the most vulnerable population to the affect of food availability. In the early stages of childhood, appropriate nourishment can facilitate growth, cognitive and motor development. In school age children, it can facilitate or hinder academic success, and set up a foundation for a lifetime of healthy lifestyle or predispose a child to multiple chronic morbidities such as fatty liver disease, diabetes, and hypertension. In their teenage years, poor nutrition can lead to infertility, either through anovulation from malnourishment or PCOS from obesity.

 

Children are entirely dependent on their caretakers for appropriate nutrition in the most crucial stages of their lives. In America, 16 million children currently live in food-insecure households, and more than one third of children and adolescents are overweight or obese. While obesity touches all colors, genders, and social-economic backgrounds in America, African Americans, Hispanics, and children from households with lower education level are especially affected.

 

Obesity is usually thought of as a disease of excess, however, there’s a positive correlation between poverty and obesity. According to a study of over 28,000 low-income children in the Massachusetts WIC program, children in food-insecure households have 22 percent greater odds of childhood obesity compared to their food-secure counterparts.  Though initially counterintuitive, several factors explain this relationship: lack of access to healthy food, greater exposure to obesity-promoting products, cycle of starvation and overeating, few opportunities for physical activities, high level of stress, depression, and anxiety, and limited access to healthcare.

 

Currently, several nutritional assistance programs such as WIC, Food Bank, and SNAP target low-income, food insecure populations. However, while these programs might address the issue of food insecurity and cycle of overeating and starvation, the types of food provided might contribute to obesity. For example, WIC provides 128 oz of fruit juice monthly to children ages 1-4, which is the maximum amount recommended by the AAP, food banks provide soda, juice, chips and other sugary snacks, and SNAP allows soft drinks, candy, cookies, ice cream, and cake to be purchased using monthly SNAP allowance. While the AAP’s policy statement in June 2017 does allow up to 3 oz of juice a day for 1-3 years old toddlers, it states that “fruit juice …has no essential role in healthy, balanced diets of children” and calls for pediatricians’ support to “reduce the consumption of fruit juice…by toddlers and young children already exposed to juice, including through…WIC.”

 

While we concentrate our efforts in providing assistance to food-insecure families, it is important to be mindful of the other phenomenon that tends to coexist with poverty and food insecurity: obesity.  When families are provided with juice, soda, and other non-nutritious food as part of their food package, it can be confusing and difficult to choose to consume only nutritious food. It is crucial for healthcare providers and nutritionists to counsel patients on healthy food choices, especially in families with limited access to resources and education.

 

Several resources can help families learn more about healthy food choices:

https://www.nutrition.gov/

https://www.choosemyplate.gov/

https://www.girlshealth.gov/nutrition/index.html

 

 

Phinga Do, MD

 

 

References:

https://ihcw.aap.org/Documents/COPC_Module1_RoleofHCProvider_FINAL.pdf

http://frac.org/wp-content/uploads/frac_brief_understanding_the_connections.pdf

http://pediatrics.aappublications.org/content/139/6/e20170967

https://fns-prod.azureedge.net/sites/default/files/wic/SNAPSHOT-of-WIC-Child-Women-Food-Pkgs.pdf

https://www.fns.usda.gov/snap/eligible-food-items

https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Pages/ChildNutrition.aspx

 

 

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.

(more…)