COVID-19 and meals for low income children

The coronavirus has become a hot topic. No breaking news there. Everyone is doing their best to protect the overall population health, I have no doubt. A lot of times when we make broad sweeping changes, however, we forget about the unintentional consequences. I heard today that a local school district is cancelling classes for at least a week. At first glance, this falls in line with every other major institutions’ decisions the past week. We most likely forget, however, that a large proportion of our school-aged children rely on school attendance to receive 2 meals per day.

Thankfully there have been proposals to aid during this difficult time to feed children who are reliant on the school system for meals. States can request waivers from the USDA to continue providing meals, with Texas recently drafting its own. I recommend to local pediatricians to advise families to contact their local school districts to inquire about meal assistance programs. I also recommend contacting your Congressional House of Representatives member asking to expand the SNAP food assistance program during this difficult time.

Zachary Stone, MD

Two Flu Myths

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

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

“The flu vaccine gave me the flu.”

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

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

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

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

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

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

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

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

For adults, flu vaccinations:

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

For kids, flu vaccinations:

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

For pregnant mothers, flu vaccinations:

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

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

Michael Hook, M.D.

References:

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

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

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

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

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

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

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

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

Building Resiliency

As pediatricians, we often care for children that may have had exposures to neglect, maltreatment, family violence, family separation or extreme poverty. Over time, we see the negative consequences of these experiences on our patients in the form of poor academic success, substance abuse, and medical and mental health problems. These experiences are termed adverse childhood experiences or ACEs and it is estimated that about 60% of the adult population in the United States has experienced at least one ACE. Pediatricians should identify and attempt to prevent ACEs: we can support and coordinate efforts to build resilience in children by understanding the effect of toxic stress and providing early interventions and continuity in care.

The hallmark ACE study conducted in 1998 by the CDC and Kaiser Permanente in California categorized ACEs into three major categories: physical and emotional abuse, neglect and household dysfunction (e.g., parent with mental illness, substance abuse or experiencing separation or divorce). The study showed dramatic associations between ACEs and risky behavior, psychological illnesses, serious illness and even a lower life expectancy in the children.

In a child’s life, experiencing ACEs can lead to toxic stress. Toxic stress occurs when a child stays in a constant state of elevated stress. Often children have a caregiver to give them comfort during normal times of stress. In these cases, the levels of stress hormones will return to baseline. However, when no supportive caregiver can comfort the child, such as in cases of neglect, emotional or physical abuse, the child’s stress hormone level remains high.  This can affect other aspects of a child’s health and development.

The link between adverse childhood experiences and adult health and well-being has been well studied. We know that as the brain develops, more frequently used circuits are strengthened, while those that are not used can eventually fade away in a process called pruning. Stronger circuits are associated with higher-level functioning, improved memory, emotional and behavioral regulation and language. In children exposed to toxic stress, the circuits are weaker and fewer, especially in the areas of the brain dedicated to learning and reasoning. For example, the excessive stress activation shifts mental and physiological resources from long-term development to immediate survival.  This increases the task of vigilance at the expense of focused attention. Ultimately, poor coping habits and mental health problems can develop. We also know that the exposure to stress hormone increases systemic inflammation which contributes to a higher risk of cardiovascular disease and diabetes among other medical problems. Finally, evidence shows that the longer we wait to intervene, the more difficult it is to achieve healthy outcomes.

The concept of resiliency explains why some children overcome stress better than others. As pediatricians, understanding this concept can help us to build stronger individuals. Resiliency is thought to be related to a greater number of positive experiences compared to negative experiences. We know that a very important part of developing resilience is at least one stable and committed relationship with a supportive caregiver. Promoting regular physical exercise, stress-reduction exercises and promoting strong core life skills for both the child and the adult are additional ways pediatricians can promote resiliency.

Trauma-informed care involves prevention, recognition and response to trauma-related experiences. Early identification is an important first step. As pediatricians, we should consider ACEs-based screening questionnaires for every patient to assess the potential need for other services. The next step would be to link these patients with services such as social work, developmental therapies, or mental health support with experience in trauma. This is often the most difficult part in delivering trauma-informed care, so it is important to identify the resources available in the local area.

Finally, to address prevention, we should work with our families to reduce the stress of daily life, such as connecting them to resources like  food pantries or substance abuse programs. We should teach skills to families regarding parenting and safe dating practices. To promote strong relationships with other adult caregivers, we should be know of available after-school and mentoring programs. The overall goal should focus on changing the environment and behaviors in ways that will prevent ACEs from happening in the first place.  

Amisha Patel M.D.

Sources:
Fox  SE, Levitt  P, Nelson  CA  III.  How the timing and quality of early experiences influence the development of brain architecture.  Child Dev. 2010;81(1):28-40.

Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998;14(4):245-258.

Shonkoff JP. Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr. 2016;170(10):1003–1007. doi:10.1001/jamapediatrics.2016.1559

Kuehn BM. AAP: Toxic Stress Threatens Kids’ Long-term Health. JAMA. 2014;312(6):585–586. doi:10.1001/jama.2014.8737


Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE). http://www.cdc.gov.foyer.swmed.edu/violenceprevention/acestudy/index.html. Accessed February 5, 2020.

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

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

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

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

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

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

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

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

Sources

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

Cristina Saez, M.D.

“What’s the Tea?” Current Recommendations on Media Use in the Pediatric Population

With the increasing use of technology in modern society, children have more access than ever to media and screens. Thus, the amount of time children spend playing video-games (who has heard of Fortnite?), on Snapchat, #Instagram, or TikTok, among others, has flourished, and this has become a hot topic amongst parents and pediatricians alike. For pediatricians, this shift towards a growing digital landscape is a moving target – society’s understanding of the impacts of social media and video games, particularly those of violent nature, is constantly shifting, and affecting how physicians address children’s medical needs. Pediatricians should be cognizant of this changing environment to best assess their patients’ electronic footprints and help guide recommendations.

Video games have been around since the 1950s, but they have become a growing force in the community particularly since the 1990s. With this rise came the concurrent increased exposure to “virtual violence”; while previously the exposure primarily occurred through platforms such as television, the exposure increased dramatically with the proliferation of computers and handheld consoles for video games. Discussions regarding the benefits and detriments of these violence-containing media have been polarizing, particularly regarding  short- and long-term behaviors, medical implications, and psychological effects.

Meta-analyses (2014, 2017) suggested that exposure to violent video games can pose a possible risk factor for aggressive behavior. Other studies found that addiction or depression may be sequelae from video-gaming, violence-containing or otherwise. Nevertheless, other studies have suggested some positive aspects of gaming. The 2014 meta-analysis also suggested that violent video games may also provide prosocial benefits and cooperative play that could foster cooperative behavior and empathy. Additional studies have been performed to evaluate the benefits of video games, with some suggesting improved spatial skills, improved efficiency with attention allocation, emotion-regulation tricks called “re-appraisal”, and “prosocial” and helpful behaviors.

Unfortunately, we lack enough data fully delineating causal effects from video games, and violence-exposing media at this time. Needless to say, this clears very little up. Are social media, video games, and violence-containing media good or bad? Should we let our children partake in these activities, or not? This is difficult to assess, and frankly, not useful to delineate the black and white of video games and social media, particularly in the rapidly changing technological environment.

What may be practical for families to do when raising their children in this technology-ubiquitous world is to follow 2016 American Academy of Pediatrics (AAP) official recommendations from three policy statements, published in Pediatrics® 2016, for media use in children: 

  • Avoid screen media for children younger than 18 months – if a parent chooses to continue with media, they should choose “high-quality programming” and interact with their child during the use.
  • Limit screen time to 1 hour in children ages 2-5 years old. Interactions and “co-viewing” media can help children interpret what they are seeing as well as form bonds with the adults they interact with
  • Find a balance of screen time with limits for children 6 years and older – emphasize the importance of healthy sleeping patterns, physical activity, and other healthful behaviors. Families should consider using the Family Media Use Plan tool with HealthyChildren.org, linked here: https://www.healthychildren.org/English/media/Pages/default.aspx
  • Have pre-determined media-free time together, as well as media-free locations
  • Continue to discuss the benefits and detriments regarding online media use and safe, appropriate media behaviors with children

Additional considerations that families should keep in mind include: 

  • Role-modeling media use for children in the whole family, not just the children
  • Avoiding technology use to regularly distract or soothe children
  • Understand that it is acceptable for older children and teens to be online; finding that balance between appropriate amounts, which foster typical teen development, and too much; this requires communication, trust, and frequent re-evaluation
  • Continue to encourage appropriate behaviors both on and off-line
  • Be mindful of red flags with a child’s online behavior; mistakes will be made, but be more cautious with behaviors such as bullying, sexting, or self-harming images
  • Provide education about privacy and online dangers (such as predators, sexting)

What can pediatricians and other providers do when faced with counseling regarding media use for their families in which media plays a large role in a child’s life? Suggestions from the AAP include:

  • Consistent discussion about the quantity, as well as quality, of children’s media consumption
  • Continue to encourage mindful screen-time, including co-viewing and co-playing
  • Recommend that parents screen what children are watching, particularly those younger than 6 years, and avoid virtual violence – children younger than 6 years are found to have difficulty delineating the fantasy of video-games from reality
  • Consider partaking in advocacy, and maintaining discussions with policy-makers or legislators. Minimal legislative action exists to decrease violence exposure in the media, and no single governing body monitors the content and ratings of games. Pediatricians can advocate for limiting access to violence-containing media for minors, as well as encourage increased creation of “child-positive” forms of media. 

Many questions still exist regarding both the short- and long-term impacts of exposure to violence in the media and video games. Parents and pediatricians alike require frequent reassessment to keep up with the changes in the interactive digital world. Constant discussions with children are recommended to continue to encourage safe and appropriate media use and video-gaming as they navigate through the vast realm of technology. Frequent re-consideration is critical as the landscape continues to evolve. 

Lori Xu, MD

References:

“American Academy of Pediatrics Announces New Recommendations for Children’s Media Use.” AAP.org, American Academy of Pediatrics, 21 Oct. 2016, http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Announces-New-Recommendations-for-Childrens-Media-Use.aspx.

“Children and Media Tips from the American Academy of Pediatrics.” AAP.org, American Academy of Pediatrics, 1 May 2018, http://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Children-and-Media-Tips.aspx.

Council On Communications And Media. “Media and Young Minds.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2591.

Council On Communications And Media. “Media Use in School-Aged Children and Adolescents.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2592.

Council On Communications And Media. “Virtual Violence.” Pediatrics, American Academy of Pediatrics, 1 Aug. 2016, pediatrics.aappublications.org/content/138/2/e20161298.

Coyne, Sarah M., et al. “Violent Video Games, Externalizing Behavior, and Prosocial Behavior: A Five-Year Longitudinal Study during Adolescence.” Developmental Psychology, vol. 54, no. 10, Oct. 2018, pp. 1868–1880., doi:10.1037/dev0000574.

Ferguson, Christopher J., and John C. K. Wang. “Aggressive Video Games Are Not a Risk Factor for Future Aggression in Youth: A Longitudinal Study.” Journal of Youth and Adolescence, vol. 48, no. 8, 4 Aug. 2019, pp. 1439–1451., doi:10.1007/s10964-019-01069-0.

Granic, Isabela, et al. “The Benefits of Playing Video Games.” American Psychologist, vol. 69, no. 1, Jan. 2014, pp. 66–78., doi:10.1037/a0034857.

History.com Editors. “Video Game History.” History.com, A&E Television Networks, 1 Sept. 2017, http://www.history.com/topics/inventions/history-of-video-games.

Hutchinson, Jeffrey W. “How to Advise Parents When Kids Can’t Put Video Game Controller Down.” AAP News, American Academy of Pediatrics, 21 Feb. 2019, https://www.aappublications.org/news/2019/02/21/masteringmedia022119

Prescott, Anna T., et al. “Metaanalysis of the Relationship between Violent Video Game Play and Physical Aggression over Time.” Proceedings of the National Academy of Sciences, vol. 115, no. 40, 1 Oct. 2018, pp. 9882–9888., doi:10.1073/pnas.1611617114.

Radesky, Jenny, et al. “Children and Adolescents and Digital Media.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593.

“Video Gaming Can Lead to Mental Health Problems.” AAP.org, American Academy of Pediatrics, 17 Jan. 2011, http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Video-Gaming-Can-Lead-to-Mental-Health-Problems.aspx.

“Virtual Violence Impacts Children on Multiple Levels.” AAP.org, American Academy of Pediatrics, 18 July 2016, http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Virtual-Violence-Impacts-Children-on-Multiple-Levels.aspx.

Watching our Words

We have all heard the Latin phrase primum non nocere, meaning first do no harm. While many of us may think of this phrase in terms of how we select the optimal treatments and make the best management decisions for our patients, this phrase should guide physicians in all interactions with patients. Most of the time, our first interactions with patients are verbal – taking the history. And if we are not as thoughtful about the way we speak to our patients from the beginning as we are when it comes to developing our plans, we may do them harm from our very first interactions. As physicians, we have devoted our lives to keeping ourselves up-to-date on the latest medical knowledge; we ought to embrace the same expectation when it comes to the way we speak to and about patients. I will provide three examples of language use that will demonstrate sensitivity toward patients, with the corresponding pitfalls which may actually cause harm.

First, the use of person-first language should be the default way that physicians address and discuss their patients. The American Psychological Association first began emphasizing person-first language in 1992 as a way to communicate information about individuals that limits that information’s ability to cause initial bias. For example, this means rather than referring to a patient as a “bronchiolitic” he/she should instead be referred to as “the patient with bronchiolitis.” It is also a way to prevent patients who have the same disease from being lumped together (i.e., “people with chronic pain” rather than “chronic pain patients.”) In general, medical trainees are taught to use this kind of language, but in practice, it is not always our habit. Similarly, while most of us would likely not refer to a patient as “the sickler in room 5” to their face, we may be tempted to use this disease-first language when discussing with colleagues. When we fail to use person first language when describing patients, we ignore their immediate personhood, choosing instead to focus on their disease condition as their identity.

However, the astute physician must be aware that there are exceptions to person-first language. One notable counter-example is the Deaf community. In general, the Deaf community prefers the use of the word Deaf (“deaf people” rather than “person with deafness”) because the overall opinion by the community is that deafness is a medical condition, not an impairment and that their identity as Deaf is not something of which to be ashamed. This serves as an example of the fact that physicians must become aware of the particular values of the communities they serve rather than attempting to learn oversimplified rules about language. Just as we pour ourselves over the details of scientific journal articles, looking for subtleties in disease manifestations and treatments, we must pay similar attention to detail when it comes to the preferred way to speak about and to our patients.

Finally, not only should we as physicians learn the ways patients would like to be addressed, we must also be those innovating change in language. One current medical frontier is the way we think about and treat mental illness. As we continue to remove the stigma of mental illness, we must deliberately change the words we use to speak of it. For example, it may not seem harmful to use the phrase “commit suicide.” On the contrary, while this phrase has been the customary way to speak, it actually does harm. The word “commit” places moral blame on the person who died, seeing as the word’s synonym include “perpetrate” and “violate.” Using the phrase “commit suicide,” rather than the more neutral phrase “die by suicide,” places unnecessary burden and judgment on surviving family members and friends who are already experiencing complex grief.  They often report feeling that they must obtain permission prior to grieving their loved one who died by suicide. Removing the stigma on mental illness includes removing judgmental phrases from our professional and personal lexicons.

Just as medical knowledge is constantly evolving, one need only look at the branching and twisted tree branches that map the progression of modern languages. We interact with our patients through language first and foremost and thus need to ensure that the words we use reflect our mission to serve.

Katie Dolak, MD

References

“Community and Culture – Frequently Asked Questions.” NAD. National Association of the Deaf, 2019, https://www.nad.org/resources/american-sign-language/community-and-culture-frequently-asked-questions/​ . Accessed 25 Nov. 2019.

Crocker, Amy F and Susan N Smith. “Person-First Language, Are We Practicing What We Preach?” Journal of Multidisciplinary Healthcare​, vol. 12, 2019, pp. 125-129.​

Shields, Chris, Michele Kavanaugh, and Kate Russo. “A Qualitative Systematic of the Bereavement Process Following Suicide.” Journal of Death and Dying, vol. 74, no. 4, 2017, pp. 426 – 454.

The Milky Way: A Pediatrician’s Role in Promoting Breastfeeding

It is well established that exclusive breastfeeding for the first six months of life and then breastfeeding combined with complementary solid foods for at least the first year of life is the ideal infant diet. As pediatricians, we need to promote breastfeeding and understand how to do this effectively.

Breastfed infants have a decreased risk of a multitude of diseases including asthma, obesity, type 1 and 2 diabetes, severe lower respiratory disease, acute otitis media, sudden infant death syndrome, gastrointestinal infections, bacteremia, urinary tract infection, lymphoma, leukemia, Hodgkins disease, and necrotizing enterocolitis (1,2). Interestingly, the breastfeeding mother also has many benefits including decreased postpartum bleeding, more rapid uterine involution, decreased menstrual blood loss, increased child spacing, earlier return to pregnancy weight, and decreased risk of breast and ovarian cancers (2). And on top of that, it is free! So why are only 1 in 3 infants getting breastfed at 12 months (3) and what can we do about it?

Over 80% of moms start off breastfeeding their infants. However, by three months of age, less than 50% are still exclusively breastfeeding. Barriers to breastfeeding include lack of knowledge, social norms, poor family and social support, embarrassment, lactation problems, employment and child care, and barriers related to health services (4). We need to understand these barriers and how we can help to alleviate at least some of them at our clinic visits.

Increasing rates of breastfeeding starts with proper education about the benefits of breastfeeding. Unfortunately, a national survey clearly demonstrated lack of understanding about the benefits of breastfeeding. It found that only a quarter of the US public believed that formula feeding could increase the risk of an infant getting sick (4). While it may be time consuming, we need to take the initiative to help moms understand the long list of benefits both them and their babies will receive from breastfeeding. Moms of lower socioeconomic status, and particularly less education, are less likely to breastfeed their children (5). Educating about this topic is our responsibility, especially for more vulnerable populations. We also need to educate our mothers about the laws that protect them including the ones that allow them to breastfeed in public or private locations and workplace laws that require employers to provide mothers with reasonable break time and a private, non-bathroom space to express breast milk (1). Breastfeeding while working is intimidating, and knowing the laws is vital.

Additionally, although breastfeeding is amazing, it is not always easy. We need to give realistic expectations about what the process looks likes. Unrealistic expectations lead to mothers believing that breastfeeding is not going well for them specifically and that they should stop. If there are issues occurring, lactation consultants are invaluable resources in helping a mother overcome these. We need to educate ourselves about the proper way to breastfeed so that we ourselves can also be a resource to our mothers. Finally, we need to promote breastfeeding by guiding our mothers to resources like free breast pumps from WIC instead of free formula.

As pediatricians, we want what is best for our patients. Too often, we ask what an infant is being fed, but we don’t help guide that decision. We are in a uniquely special position to help our patients’ mothers navigate this vital time in their child’s life. Together, we can increase rates of breastfeeding and improve infant health.

Kelly Lawson, MD

1) “Frequently Asked Questions (FAQs).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 4 Nov. 2019, https://www.cdc.gov/breastfeeding/faq/index.htm.

2) “Benefits of Breastfeeding.” AAP.org, https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Breastfeeding/Pages/Benefits-of-Breastfeeding.aspx.

3) “CDC Releases 2018 Breastfeeding Report Card.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Aug. 2018, https://www.cdc.gov/media/releases/2018/p0820-breastfeeding-report-card.html.

4) Office of the Surgeon General (US). “Barriers to Breastfeeding in the United States.” The Surgeon General’s Call to Action to Support Breastfeeding., U.S. National Library of Medicine, 1 Jan. 1970, https://www.ncbi.nlm.nih.gov/books/NBK52688/.

5) Heck, Katherine E, et al. “Socioeconomic Status and Breastfeeding Initiation among California Mothers.” Public Health Reports (Washington, D.C. : 1974), Association of Schools of Public Health, 2006, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497787/.

How Should We Approach Language Barriers in Healthcare?

Over 60 million people in the United States speak a language other than English at home, and greater than 25 million people have limited English proficiency (speak English “less than very well”) according to the American Community Survey [1]. It is inevitable that healthcare providers will work with patients whose primary language is not English at some point in their training or careers. Physicians should understand how language barriers can affect the health of their patients in order to provide better care for this population.

Studies have shown that language barriers can affect multiple components of healthcare including healthcare access, overall health status, satisfaction of care and patient safety [2, 3]. However, with over 100 different languages spoken in the United States, finding and working with appropriate interpreters can be challenging. As pediatricians, there can be an additional challenge of finding an appropriate balance while working between parents with limited English proficiency and their children who may be more fluent in English. Many pediatricians, including myself, can find language barriers to be an especially frustrating part of our work given the added time in visits and sometimes the uncertainty of whether your intended message was properly relayed to families. It may be helpful to look at why we should have some extra patience and attentiveness in these encounters.

A study looking at errors in medical interpretation and their consequences in pediatric care showed that medical interpretation errors are common. An average of 31 errors are made per clinical encounter. These errors can be categorized as errors of:

  • Omission (lack of interpretation of a word or phrase from parent or clinician)
  • Addition (addition of a word or phrase not mentioned in the interaction)
  • Substitution (different word or phrase was used)
  • Editorialization (addition of interpreter’s own views to interaction)
  • False fluency (incorrect word or phrase used)

Of all the errors, 63% (~19 errors per encounter) were found to have potential clinical consequences including: alterations of the history, omitting drug dosing/frequency/duration information and instructions, omission of previous workup/interventions, poor understanding of the child’s illness or treatment by parents and lack of clarity on plans for follow-up or referrals. Use of ad hoc interpreters (non-professional including staff, family, untrained individuals) were found to have an increased likelihood of committing errors that have potential clinical consequences compared to trained hospital interpreters (77% vs. 53%) [2]. Pediatricians should especially avoid having children interpret for parents given their limited understanding and unfamiliarity with medical terminology and added burden of responsibility.

The results of the study supported the use of trained interpreter services for all patients/families with limited English proficiency. Title VI of the Civil Rights Act requires recipients of federal financial assistance to provide interpreter services for patients with limited English proficiency. Many large institutions and universities have readily accessible professional interpreters, but smaller clinics and offices may not. Different services are available including various telephone interpreting lines and video interpreting services for American sign language communication. Studies have shown that use of telephone interpreting services is not inferior to having a bilingual health care professional. Interpreters may also be a resource to bridge the gap in cultural differences or misunderstandings [3].

Here are some tips to most effectively use medical interpreters [3]:

  • Meet with the interpreter before the interview to give some background information and set goals
  • Speak directly to the patient and not the interpreter
  • Use first-person statements and avoid saying things like “he said” or “tell her”
  • Speak in short sentences
  • Do not use idioms, acronyms, jargon or humor
  • Insist on sentence-by-sentence interpretation to avoid tangential conversations
  • Use the “teach back” method to ensure patient comprehension

Language barriers can have a significant impact on health. Although it may be difficult to work through language barriers, it is important for pediatricians to approach this challenge with patience and humility. Pediatricians should be equipped with the appropriate resources and understand that a little patience can go a long way in providing better care for this population.

Gina Lee, MD

References

  1. U.S. Census Bureau. American community survey. https://www.census.gov/content/census/en/data/tables/2013/demo/2009-2013-lang-tables.html. Accessed October 30, 2019.
  2. Flores G, Laws MB, Mayo SJ, et at. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6–14
  3. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476–80.

Impact of Social Media on Well-Being

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

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

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

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

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

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

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

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

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

Matthew Hibbs, M.D.

References

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

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

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

The “Social Visit”

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

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

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

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

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

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

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

Aaron Pope, MD

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

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

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

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