Asthma continues to be a major public health concern affecting 26.5 million Americans nationwide. Currently, it is the most common chronic condition among children with approximately 6.1 million children under the age of 18 diagnosed with asthma, and the third leading cause of hospitalizations in children. Asthma also has a significant financial impact, as it is currently responsible for an annual expenditure of $50.3 billion in healthcare costs and leads to numerous missed school and work days approximating $3 billion. Fortunately, asthma symptoms and costs can be controlled when affected individuals have access to appropriate care and education. Therefore, there is an increasing need to provide proper asthma education to patients and their families in order to prevent recurrent ER visits, hospitalizations, and even death. (more…)
Cases of tuberculosis (TB), an airborne bacterial disease, in the US have been steadily decreasing, thanks to improved socioeconomic conditions, focused screening efforts, and thorough follow-up. 9,272 TB cases were found in the US in 2016, down from about 21,210 cases in 1996 . Pediatric TB cases have also been on the decline. In 2016, about 4% of the TB cases were pediatric. However, data from the past several years shows the incident caseload has remained steady . (more…)
With school back in full swing, kids are joining their friends and classmates in school sports. Sports can be a great way for growing children to develop fine and gross motor skills. However, it can also be an area of stress and pressure to perform. (more…)
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!
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Kristina Ciaglia, MD
It is the first month of school for many of our children out there which can be a very exciting time. For many parents, it means their house is a little quieter in the day and the return to a normal routine. For children it means a new pencils, a fun backpack, seeing their friends every day, and a fresh start. However, this time of year can also lead to anxiety and the fear of not “fitting in”. For some children, it can also mean bullying. It is vital that pediatricians and parents understand what bullying is as well as what to look for and what to do if a child is affected by bullying.
Bullying is an unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. This behavior is typically repeated over time. Bullying encompasses verbal abuse, social abuse, and physical abuse. Verbal abuse is writing or saying cruel things. It includes teasing, name-calling, threats, taunting, and inappropriate sexual comments. Social bullying is when someone hurts someone else’s reputation or relationships. It includes leaving someone out on purpose, spreading rumors about someone, telling other children not to be friends with someone, and embarrassing someone in public. This can include cyberbullying, which can take place through text messaging, social media websites, apps, e-mail, web forums, or multi-player online games. Cyberbullying has the potential to “go viral” and spread very quickly. Physical bullying involves hurting a person’s body or possessions. Both boys and girls can be a bully or be bullied.
The effects of bullying, both of the bullying and the bullied, can have long-term consequences. Kids who are bullied can experience depression and anxiety. These issues may persist into adulthood. They also can have an increased amount of health complaints and decreased academic achievement. In fact, children who are bullied are more likely to miss, skip, or drop out of school. Kids who bully others are more likely to abuse alcohol and other drugs in adolescence and as adults, get into fights, vandalize property, and drop out of school. They are also more likely to partake in early sexual activity, have criminal convictions as adults, and be abusive toward their romantic partners, spouses, or children as adults.
Due to all of these potential negative consequences, it is important for both pediatricians and parents to be able to recognize signs of both being bullied and bullying others. Only 40% of children notify an adult in times of bullying. Therefore, it is important for pediatricians and parents to ask kids about bullying with questions such as, “how are things going at school?” or “is anyone being picked on?”. Since not all children being bullied will exhibit physical signs, it is important for parents to look for many different signs and symptoms. These include unexplainable injuries, lost or destroyed clothing, books, electronics, or jewelry, frequent headaches or stomach aches, and changes in eating habits, like suddenly skipping meals or binge eating.
Other signs of bullying include difficulty sleeping or frequent nightmares, declining grades, loss of interest in schoolwork, or not wanting to go to school, sudden loss of friends or avoidance of social situations, feelings of helplessness or decreased self-esteem, and self-destructive behaviors such as running away from home, harming themselves, or talking about suicide. Signs that children are bullying others includes getting into physical or verbal fights, becoming increasingly aggressive, getting sent to the principal’s office or to detention frequently, having unexplained extra money or new belongings, blaming others for their problems, not accepting responsibility for their actions, and being competitive and worrying about their reputation or popularity.
Even after identifying that a child is being bullied or is a bully themselves, it is hard to know what to do. In the case of a child being bullied, one of the first steps is teaching children how to respond. It is important to teach children to look the bully in the eye, stand tall and stay calm, and to know when to walk away. Also teach your child to have them say firmly things such as “I don’t like what you are doing” or “Please do not talk to me that way”. This will not be instinctive to most children so it is important to practice these skills so they feel more prepared when the time comes. Parents should also encourage their children to make friends with other children inside and outside of school. This can be done by encouraging children in activities that they are interested such as team sports, music groups, or other social clubs.
Another important thing to teach children is to know how to ask for help. Children should know that being bullied is not their fault and they should reach out to their teacher, school counselor, or school principal. Parents should talk with the school principal if the child is too scared to ask for help or if the child continues to be fearful or affected. If the results from these conversations are not resulting in action on the school’s part, make a written request to the principal asking for a copy of the school district’s policies on reporting and investigating bullying. Most school districts have procedures for parents and others to make written reports. Some states require schools to make investigations of reports of bullying. If the local campus is not responsive, make a written request to the school superintendent.
If a child is experiencing cyberbullying only a few actions need to be taken differently. First, don’t threaten to take away the child’s devices as this may seem as a punishment. Instead, if there is online evidence of the bullying, take and save a screenshot in order to report the bullying to the social media platforms in which the abuse happened as well the school or police if appropriate. Otherwise, support the child in the same ways as mentioned above.
It can also be a stressful situation as well if your child is bullying others. It is important to be consistent and set firm limits on a child’s aggressive behavior by using effective, nonphysical discipline such as loss of privileges. Another way to influence your child’s behavior is by being a positive role model and showing children they can communicate what they want without teasing, threatening, or hurting others. In addition to these measures, help children understand how bullying can hurt other children. Communication is also important in these situations and parents should be speaking with the school and other parents in order to try to find practical solutions to the bullying that is occurring.
Chelsea Day, MD
American Academy of Pediatrics. Bullying and Cyberbullying. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Bullying-and-Cyberbullying.aspx. August 28th, 2018.
Healthy Children. Bullying: It’s Not Okay. https://www.healthychildr en.org/English/safety-prevention/at-play/Pages/Bullying-Its-Not-Ok.aspx. August 28th, 2018.
Healthy Children. Cyberbullying.https://www.healthychildren.org/English/family-life/Media/Pages/Cyberbullying.aspx. August 28th, 2018.
Stop Bullying. Warning Signs for Bullying. https://www.stopbullying.gov/at-risk/warning-signs/index.html. August 28th, 2018.
“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…)
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…)
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:
- 3263: Humane Treatment of Migrant Children Act (July 25 2018) https://www.govtrack.us/congress/bills/115/s3263/text
- Res. 982: Of inquiry requesting the President, and directing the Secretary of Health and Human Services, to transmit, respectively, certain information to the House of Representatives referring to the separation of children from their parents or guardians as a result of the President’s “zero tolerance” policy (July 18 2018) https://www.govtrack.us/congress/bills/115/hres982/text
- R. 6232: Preventing Family Separation for Immigrants with Disabilities Act (June 26 2018) – https://www.govtrack.us/congress/bills/115/hr6232
- R. 6180: Mental Health Care for Children Inhumanely Separated from Parents by the Federal Government Act of 2018 (June 21 2018) https://www.govtrack.us/congress/bills/115/hr6180
- R. 6135: Keep Families Together (June 19 2018) https://www.govtrack.us/congress/bills/115/hr6135/summary
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
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
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
The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.
What is an Adverse Childhood Experience?
ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health . These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) .
What is the impact of ACEs?
The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors . Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia . Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion .
What can we do to help as pediatricians and as citizens?
The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].
As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are :
- Food security: Are there times when you don’t have enough food?
- Income: Do you ever have trouble making ends meet?
- Housing: Is housing ever a problem for you?
- Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
- Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?
All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support . Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.
Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.
Benjamin Masserano, MD
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…)