MISINFORMATION- THE CONVERSATION WE NEED TO BE HAVING

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“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…)

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The New Food Label Delay and the Importance of Added Sugars

It is important for pediatricians to show parents how to recognize added sugars in their children’s diet and stress the importance of limiting them. New and improved food labels could facilitate this kind of nutrition counseling. In May 2016, the FDA issued a rule changing what needed to be included in nutrition food labels. Originally, companies were expected to be in compliance by July 2018, just last month.1 However, many groups rallied against the new food labels, including the Sugar Association, the American Beverage Association, the Corn Refiners Association, and the American Bakers Association, to name a few.2 One part of the nutrition label that was criticized by these groups was a new section underneath “Total Carbohydrates.” This section will inform consumers about the quantity of added sugars in each product. However, the deadline has now been pushed back until January 2020 for food companies with revenue greater than 10 million dollars in food sales and until January 2021 for those with revenue less than 10 million dollars in food sales. Many of the public comments under the bill proposing the new food label came from industry groups who pointed to a lack of scientific research demonstrating intrinsically harmful effects of sugar.3 (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

Adverse Childhood Experiences

The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.

What is an Adverse Childhood Experience?

ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health [1]. These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) [2].

What is the impact of ACEs?

The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors [2]. Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia [3]. Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion [2].

What can we do to help as pediatricians and as citizens?

The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].

As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are [6]:

  • Food security: Are there times when you don’t have enough food?
  • Income: Do you ever have trouble making ends meet?
  • Housing: Is housing ever a problem for you?
  • Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
  • Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?

All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support [7]. Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.

Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.

https://www.aap.org/en-us/advocacy-and-policy/Pages/Advocacy-and-Policy.aspx

https://www.naeyc.org/resources/blog/support-and-advocate

https://www.cwla.org/our-work/advocacy/

http://childwelfaresparc.org/

 

Benjamin Masserano, MD

 

References

[1] https://developingchild.harvard.edu/science/key-concepts/toxic-stress/

[2] https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

[3] https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

[4] http://pediatrics.aappublications.org/content/pediatrics/early/2011/12/21/peds.2011-2663.full.pdf

[5] http://pediatrics.aappublications.org/content/128/6/e1680

[6] http://pediatrics.aappublications.org/content/120/3/e734

[7] http://www.211.org/

Reproductive Health in Adolescence

While pediatric care spans from birth to 18 years, issues of adolescence, particularly regarding reproductive healthcare, often seem to be overlooked. According to the CDC, among high school students in 2017, 40% had ever had sexual intercourse, 10% had four or more sexual partners, and 46% did not use a condom when they were most recently sexually active1. Appropriate reproductive healthcare is crucial considering these statistics and their implications on various issues such as teenage pregnancy and sexually transmitted infections (STIs), as well as the mental and emotional well being of adolescents. Therefore, care of an adolescent patient should always include taking a thorough sexual history, as well as providing guidance on sexual health and safe practices. (more…)

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

 

 

Food Insecurity and the Pediatrician’s Role in Fighting Hunger

Problem:

In the United States hunger remains a problem with far reaching consequences especially when it affects our youngest members of society. Though many would argue that food is one of our most basic human needs, it is something many United States families at times must go without. (more…)

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…)