#MaskUp Texas!

When Governor Abbott opened up Texas ahead of a downward trajectory in COVID-19 cases, the expectation was that social distancing and masking would still take place. While walking around the neighborhood, I was surprised to see unmasked diners at restaurants. There were couples and families, but also groups that did not seem to live together. As the weeks went on and restaurants were allowed to increase their activity, I saw indoor and outdoor tables with patrons back to back and yet masks were not donned. I wondered, when would we see the effects? 


Literacy in the Time of Coronavirus

Texas is returning to normalcy as restrictions are being eased from the COVID-19 pandemic. Children are still out of school and it remains to be seen when they will return to the classroom environment. The combination of idle time, travel restrictions, and social distancing practices present a significant challenge to parents with restless children at home – as well as an excellent opportunity to promote reading. Pediatricians should use each well-child visit right now to encourage parents to take time to read with their children.

The Council on Early Childhood found approximately two-thirds of children in the United States fail to develop reading proficiency by third grade.1 Reading proficiency by third grade is an important predictor of high school graduation rates, as those who cannot read by that mark are four times more likely to later drop out of high school.1-2 Early reading deficiencies can lead to a lifetime of economic consequences. The Program for International Assessment of Adult Competencies (PIAAC), in a 2016 survey, suggested roughly 1 in 5 U.S. adults do not have basic literary proficiency.3 Low levels of adult literacy and educational level are associated with less economic opportunity, poor health outcomes, and social dependency.1,4

The promotion of reading skills can start in infancy. Parents can read aloud to infants to encourage language development and model reading behavior.1 As infants age, they begin to mimic their parents by turning the pages of books. With picture books toddlers can make inferences from the images before they can read the words on the page. Gradually and with training they may begin to recognize letters and eventually words. Ideally, pediatricians would like our patients to be familiar with the alphabet and recognize their name prior to starting kindergarten. For older children and teenagers, quarantine can be an opportunity to expand their literary horizons. By reading popular novels, classic literature, or books from high school reading lists, students can improve their literacy.

Many resources are available to help parents promote reading. Reach Out and Read Texas has a partnership with many pediatric clinics to provide children with a book at each visit from 6 months to 5 years; their website (see link below) also includes expected reading milestones by age. The Dallas Public Library has Tumble books available for children grades K-12 (see link below) online and additional books are available with a library card (free with proof of residence). Google Play Books has free children’s books available online which are playable on iOS devices.

Donovan Berens, MD

Works Referenced:

  1. High PC, Klass P, Council on Early Childhood. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Pediatrics. 2014 August; vol 134 (2): 404-409
  2. Hernandez D. Double Jeopardy: How Third-Grade Reading Skills and Poverty Influence High School Graduation. Annie E. Casey Foundation. 2011 April. https://files.eric.ed.gov/fulltext/ED518818.pdf Date accessed 5/01/2020
  3. Mamedova S, Pawlowski E. Adult Literacy in the United States. National Center for Education Statistics Data Point, U.S. Department of Education. 2019 July. https://nces.ed.gov/pubs2019/2019179.pdf. Date accessed: 5/02/2020
  4. Torpey E. Education pays. Career Outlook, U.S. Bureau of Labor Statistics. 2019 February. https://www.bls.gov/careeroutlook/2019/data-on-display/education_pays.htm?view_full. Date accessed 5/02/2020.

Additional Resources:



Children’s Hospitals Need More COVID-19 Emergency Relief Funding

Since the start of the COVID-19 pandemic, the financial losses of businesses and employees in the service, retail, and entertainment industries have been the subject of a large amount of media attention. What many Americans would not expect is that health systems are also under major financial strain during this difficult time.  Pediatricians can act now by writing their U.S. Representative or Senator to express the need for additional emergency funding for children’s health systems.


Two to Tango: Shared Decision Making

Often patients or their parents can place an expectation on our shoulders to always have a plan and answers as their physician. The shaking truth of the medical field is that this is not always possible. While the expectation is seen as a privilege by most physicians, it can also lead to significant stress and pressure. When asked specific questions that are either unanswerable or unknown at that time, a physician may find it difficult. Shared decision making is fundamental for patient care as an effective tool for a physician to use when addressing such situations with patients and their parents.

The idea of shared decision making is more recent in the field, compared to the centuries of the practice of medicine (Veatch). It is a hallmark in patient-centered care because it relies heavily on patient and/or parental input into treatment decisions. Glyn Ewlyn, et al. described a practical way to implement shared decision making using:

  • Choices: making sure that patients/parents know different, reasonable options are available to them,
  • Options: providing detailed information about all options, and
  • Decision talk: supporting and allowing for time for the patients/parents to deliberate over the available options.

While shared decision making is an important part of patient care, its use can be limited in some situations, such as in emergencies that require immediate action or conditions that require extensive use of medical knowledge to make a decision. Other limitations to shared decision making include inadequate health literacy and cultural differences in autonomy (Glyn Ewlyn et al). Even in these situations, using shared decision making as much as possible at the patient/parent’s level of understanding can help. It can be employed as a tool to help move forward in difficult situations, or even to create an open dialogue and invite parents to share their input. 

Even in pediatrics, we can involve our patients in shared decision making to empower them to actively participate in their own health. One small example includes asking them the form of medication they like (e.g.pill, liquid, or chewable) (Furman). Although we are not asking them what treatment plan they want, offering even a small choice can help empower them in their own healthcare. 

While shared decision making can be used in a positive way to forge a bond between parents and pediatricians, a one-sided relationship, whether on the parent or physician side, can be detrimental to this balance. With the advent of the internet, parents have numerous different resources to use as they deliberate their options. This should be supported and encouraged within reasonable limits by pediatricians. The balance lies within the decision talk portion of shared decision making. Pediatricians should listen to parent’s wishes and informed decisions, and parents should work with the pediatricians and trust them to make decisions for their child’s well-being. With unbalanced power on either side, friction and erosion of patients’ care can occur.

Many questions still exist as to how to best integrate and implement shared decision making from both the parent’s and the pediatrician’s role in a child’s medical care. By implementing these three steps into each patient encounter, both with a patient and their parents, pediatricians can create an optimal balance in unknown or difficult situations. 

Chelsea Burroughs, M.D.


Elwyn, Glyn et al. “Shared decision making: a model for clinical practice.” Journal of general internal medicine vol. 27,10 (2012): 1361-7. doi:10.1007/s11606-012-2077-6

Furman, Lydia. “Shared Decision Making – Harnessing Trainee Enthusiasm.” American Academy of Pediatrics (2017). 

Veatch, Robert. “Models for Ethical Medicine in a Revolutionary Age.” The Hastings Center Report vol. 2, 3 (1972): pp 5-7. 

Barriers to successful HPV vaccination in US adolescents

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States with a peak prevalence in adolescents and young adults. It is a viral infection that can persist in the body and lead to a significant risk of developing various types of cancer later in life. HPV infection is preventable thanks to the advent of vaccination. The current 9-valent HPV vaccine is proven to be safe, effective and successfully prevents morbidity and mortality associated with HPV-related diseases. Pediatricians, in particular, play a key role as providers of vaccination but also need to become leaders in HPV-vaccination education for children, adolescents and their parents.
Current guidelines from the Centers for Disease Control and Prevention (CDC) US Advisory Committee on Immunization Practices (UCIP) and the American Academy of Pediatrics (AAP) recommend initiating the 9-valent vaccine with 2-dose schedule at ages 11-12 (although can be started as early as age 9) and 3-dose schedule for those starting at ages 13-26. [2]
However, the HPV vaccination rate in the U.S. is still very low, particularly among adolescents, with less than two-thirds of adolescents ages 13-17 receiving at least one dose of the HPV vaccine. In Texas, low vaccination rates are even more prevalent in rural areas and border towns with higher Hispanic/Latino populations. Thus, Hispanic women in areas such as the Rio Grande Valley are at significantly higher risks for cervical cancer incidence and mortality than Hispanic women generally in the U.S. [1-3]
Under current Texas health law, adolescents can obtain health information on safe sexual practices, self-request pregnancy tests, contraception and STI tests confidentially with medical providers. HPV vaccination, however, is under immunization/vaccine law and thus requires parental consent for a teen to be vaccinated. Studies have shown that there is misinformation in the community regarding HPV vaccination, and that leads to parents declining HPV vaccination for their children. That in in turn leads to lower vaccination rates. Some barriers to vaccination cited include concerns about vaccine’s effect on sexual behavior, low perceived risk of HPV infection, social influence, irregular preventive care and concern for out-of-pocket costs. Interestingly, parents also cited healthcare professionals’ recommendations as one of the most important factors in their decision to vaccinate. [1]
Misinformation appears to be the key driving force behind suboptimal vaccination rates. This is in line with studies that have shown that parent/adolescent education and vaccination availability are key to addressing the issue. As an example, a single onsite school-based active vaccination program coupled with physician-led education on HPV and HPV vaccines for parents/guardians, school nurses and pediatric/family providers in a rural community in south Texas led to almost double HPV initiation and completion rates. [1,3]
Parents can find it complicated to navigate around all the misinformation around vaccinations, especially in a climate of a generalized sense of distrust geared toward the medical/pharmacological enterprise. Pediatricians and family medicine providers should clearly inform patients and their parents about the distinct benefits and safety regarding HPV vaccination, and the drastic, positive impact the vaccine provides in preventing HPV-associated cancer.
Cost should be less of a barrier, because the Patient Protection and Affordable Care Act requires insurance companies to cover ACIP-recommended vaccines without copays, and federal programs provide vaccines to Medicaid eligible children without cost. Finally, pediatricians should also establish strategic partnerships with schools and local health providers to develop active education programs and on-site vaccination programs. These steps can improve successful HPV vaccination rates and reduce risks for HPV-associated cancers.
1. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to Human Papillomavirus Vaccination Among US Adolescents: A Systematic Review of the Literature. JAMA Pediatr. 2014 Jan; 168(1): 76–82.
2. Yang DY, Bracken K. Update on the new 9-valent vaccine for human papillomavirus prevention. Can Fam Physician. 2016 May; 62(5): 399–402.
3. Kaul S, Do TQN, Hsu E, Schmeler KM, Montealegre JR, Rodriguez AM. School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res. 2019 Dec;8:100189.

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.


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.

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.


  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


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