Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Miranda Hester

Many children and teenagers either have or can access a smartphone and tablet, which means lots of time spent using a number of apps. Although social media platforms require a user to be 13 years of age or older, younger children also want to be able to use them, just like their older siblings, cousins, and friends. The

 from the C .S. Mott Children’s Hospital in Ann Arbor, Michigan asked 1030 parents who had at least 1 child in the home that was 7 to 12 years of age about their child’s use of social media apps.

Parents reported different app use in the group. Among children who were 10 to 12 years of age, 49% had reported social media app use in the previous 6 months; 28% had only used educational apps; and 23% indicated no app usage. Fifty percent of children 7 to 9 years used only educational apps; 32% also used social media apps; and 18% reported no app usage. Roughly one third of the parents stated that their child had been educated on safe use at school. These parents were more likely to indicate their child used social media apps.

There are many factors that can come into play when a parent is deciding whether an app is safe and appropriate for their child. Top aspects included whether the app has parental controls (74%), deemed age appropriate (64%), and needed for school (63%). Parental control features that were used included parental blocks (66%), parental approval needed for new contacts (60%), privacy settings (57%), creating a daily time limit (56%), and requiring a passcode to access certain content in an app. However, 17% of children are using apps without any form of parental control. When asked about the nonuse of parental controls, 21% of the parents said that they couldn’t find information on setting up the controls; 39% find it too time-consuming to monitor use; and 32% stated that their child would just find a way around any form of parental controls.

Discussing their concerns for their child on social media apps, parents worried that their child would share private information and not realize it (69%); encounter a sexual predator (69%); be exposed to adult images or videos (64%); or be unable to differentiate true from false information (63%). When asked specifically about their child, 47% were not confident in their own child’s capability in telling whether another app user was an adult or child. Thirty-one percent of the parents were not confident that their child’s ability to differentiate what’s true from what’s false on social media apps. Parents of children who had been taught safe use in school were more confident about their child’s abilities in both areas.

The poll investigators had 2 recommendations to help better protect children who are just beginning to be exposed to social media. The first is that parental controls are only the start for keeping children safe. Parents should discuss the apps used with children, including asking them how an app works and what content they find funny. They should also look at what their child is posting and who they’re interacting with. To tackle the issue of learning to differentiate between what’s true and false, instruction at school could help give younger children the necessary tools and even offer programs for parents that help explain parental controls.

1. C.S. Mott Children’s Hospital. National Poll on Children's Health: Sharing too soon? children and social media apps. 2021;39(4). Published October 18, 2021. Accessed October 18, 2021

 https://mottpoll.org/reports/sharing-too-soon-children-and-social-media-apps

Articles

Social media apps have found a new audience in the many children who now carry a smartphone to keep in touch with parents and want to emulate older siblings and peers. A poll looks at whether they are using it safely.

Looking at social media app use in young children

 the FLUCELVAX® cell-based quadrivalent influenza vaccine for an expanded age indication for children as young as 6 months of age.

 The vaccine is now indicated for any patient who is eligible to receive an influenza vaccine in the United States.

The approval was based on phase 3 clinical trial data that showed the vaccine was as immunogenic and safe as the standard quadrivalent seasonal influenza vaccine in children 6 months of age to <4 years during the 2019 to 2020 annual influenza season. In the trial 2414 children were randomized to receive either FLUCELVAX® or the standard quadrivalent vaccine. Depending on vaccination history, a child received either 1 or 2 vaccine doses. Following immunization, participants received at least 180 days of follow-up and noninferiority of FLUCELVAX® was determined. The safety of the FLUCELVAX® vaccine was comparable to the standard vaccine and common adverse events included tenderness, irritability, and erythema at the site of injection. Complete data from the clinical trial was presented at the Pediatric Academic Society virtual Annual Meeting earlier in 2021.

Cell-based vaccines are meant to exactly replicate the influenza virus strains chosen by the World Health Organization. Because they avoid egg-adapted changes, they may potentially have greater effectiveness than other vaccine forms.

1. Seqirus. Seqirus receives FDA approval of its cell-based quadrivalent influenza vaccine, expanding the age indication to include children as young as six months. Published October 15, 2021. Accessed October 18, 2021. 

https://www.multivu.com/players/English/8933751-seqirus-fda-approval-of-cell-based-quadrivalent-influenza-vaccine-for-people-six-months-and-older/

Seqirus’s FLUCELVAX® cell-based quadrivalent influenza vaccine has been approved to expand the age indication to children as young as 6 months of age by the US Food and Drug Administration.

FDA approves cell-based flu vaccine for kids as young as 6 months

With medical advances leading to improved outcomes for the estimated 1600 children born with spina bifida and 75% to 90% of them surviving to adulthood, ensuring an effective transition from pediatric to adult care is important for lifelong health outcomes. Health literacy has been shown to be effective in care transitions for adults, but whether it would work similarly with the pediatric to adult transitions was not as well studied. A new report seeks to answer that question.

Investigators ran a cross-sectional study that collected patient-reported questionnaires between June 2019 and March 2020 at a multidisciplinary spina bifida center. Participants were included if they were aged 12 years or older; had a diagnosis of spina bifida, myelomeningocele and nonmyelomeningocele; and primarily spoke English or Spanish. The Brief Health Literacy Screening Tool was used to assess participants’ health literacy. The primary outcome of the study was total Transition Readiness Assessment Questionnaire (TRAQ) score.

There were data for 200 participants. Many of the patients were younger than 18 years (110 participants [55.0%]); White (136 participants [68.0%]); and had myelomeningocele (125 participants [62.5%]).Overall, the average TRAQ score 3.3. Adequate health literacy was reported by 74 participants, but 60 said that they had only marginal health literacy and 66 state that they had inadequate health literacy. A participants TRAQ score was linked to age, type of spina bifida, level of education, self-administration versus completion of the questionnaires with assistance, ambulatory status, urinary incontinence, and health literacy.Additionally, higher levels of health literacy were tied to higher TRAQ scores, with a fully adjusted model showing that when compared to inadequate health literacy, adequate health literacy was associated with an increase normalized of TRAQ score of 0.49 SD (95% CI, 0.19-0.79).

The investigators concluded that transition readiness is linked to health literacy, which is subsequently tied to higher TRAQ scores. They urge the development of health literacy programs that can help patients prepare for the transition from pediatric to adult care.

Rague J, Kim S, Hirsch J, et al. Assessment of health literacy and self-reported readiness for transition to adult care among adolescents and young adults with spina bifida. 

. 2021;4(9):e2127034. doi:10.1001/jamanetworkopen.2021.27034

Can health literacy help improve outcomes for pediatric to adult transitions for patients with spina bifida?

Improving the transition from childhood to adulthood for patients with spina bifida 

Life radically changed for children because of the pandemic, with school being one of the biggest changes. Although all children struggled with the shift, children with disabilities faced additional challenges. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Eric Q. Tridas, member of the National Joint Committee on Learning Disabilities based in St. Petersburg, Florida, looked at where education was before the pandemic, what happened because of the pandemic, and what should be done now

Tridas noted that education is built on 2 things, skill and content. In the early years of school, from pre-K to the 3rd grade, the focus of school is on skills like reading, writing, and basic math. Those skills are then used to help with the content side of education, giving students the tools necessary to read and write about topics such as science and literature. Before the pandemic, children with disabilities were as a group attaining lower academic achievement and faced gaps in opportunities for academic success and attaining goals. Many children in the group were involved in remediation that took them away from general education and the chance to learn new advanced skills, which further widened gaps. However, they were able to meet the same academic standards as their peers if they were given needed services and supports as well as instruction that was high quality.

As a result of the pandemic, nearly 50% of children around the world were still experiencing a partial or full school closure in 2021. Unsurprisingly, these closures exacerbated achievement gaps for children with disabilities and schools with a majority of students of color also faced significant gaps. A key reason was that many school districts didn’t have set plans with many not requiring tracking of academic progress or even whether children were attending. Mental health also faced challenges with children facing relapses or exacerbation of ongoing mental health challenges. Depression and suicidality also saw sharp increases. A study asking about changes in children’s behavior during the pandemic found that 77.5% weren’t sleeping as many hours as before; 58.9% were consuming more processed foods; 83.7% were doing less physical activity; and 92.9% had an increase in screentime. Even now with most schools back to in-person classes, the issues aren’t going way. With many teachers becoming ill with COVID-19 and a lack of substitutes, many children are finding themselves in school gymnasiums or auditoriums with no educational materials at all.

When focusing on bringing children up to academic requirements, schools should focus on both educational and social/emotional needs for students. They should also ensure that students do actually catch up. An accelerated learning program can get students caught up by focusing on essential concepts needed to attain grade level standards; personalizing instruction to play to a student’s strengths; using a child’s interests to get engagement; and providing small group instruction. Small group instruction, in particular, is important with a program involving just 50 hours per semester leading 2.5 years worth of math growth in just 1 year. To build social and emotional health, schools should:

Give opportunities to engage in physical activity

Create a school-wide plan to tackle depression and suicidality

To help these children, pediatricians should be ready to:

Provide information about accelerated instruction to families

Monitor/screen for depression and anxiety, particularly in older children

Refer for cognitive behavior therapy when appropriate

Work with schools to establish plans for addressing mental health concerns

Tridas E. Impact of school interruption on children with disabilities during the COVID-19 pandemic: compensatory and recovery educational services. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 11, 2021.

A look at what the pandemic and its many changes meant for the education of children with disabilities, presented at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition.

How the pandemic impacted education for children with disabilities

It’s a tale as old as time. You write a prescription for a patient with a chronic condition such as asthma and later on the patient reluctantly tells you that he or she has only being taking it a quarter of the time. Nonadherence for medication is an issue that many clinicians will have a number of frustrating anecdotes to share. In her presentation at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Heather De Keyser, MD, MS, assistant professor of pediatric pulmonology at the Breathing Institute, University of Colorado School of Medicine and Children’s Hospital in Aurora, discussed the impact and scope of non adherence, what may impact adherence, and ways to improve adherence.

Nonadherence to medication is a frustrating problem, with the worldwide average adherence for chronic diseases being around 50%. This nonadherence is costly with 1 study of 43,156 children who used Medicaid and asthma found that if high adherence to inhaled steroids rose from the 33.35% seen in the participants to just 40%, it would result in $8 million per year in cost savings and increasing adherence to 80% would result in $57 million per year in savings. Even with serious medical issues, adherence can be low with 58% nonadherence seen in the 6 months followed newly diagnosed epilepsy and rates of poor adherence for solid organ transplant ranging from 30% to 76%, with the poorest adherence in adolescent patients.

A variety of factors can influence adherence to medication including poor access to care, poor provider knowledge of formulary, patient/provider relationship, social determinants of health, stigma, medical beliefs that lead to intentional nonadherence, forgetfulness, poor technique, and medication administration responsibility. De Keyser noted that when you take into account primary nonadherence, meaning getting the prescription filled, which is 14% to 20% with the first fill and 24% to 40% for subsequent fills; secondary nonadherence, meaning the prescription have been filled but the medication hasn’t been use, accounting for 30% to 70%; and poor device technique, which accounts for 43% to 100%, true adherence with asthma medication is likely very little.

Ask any provider why a patient isn’t taking a medication and the answer is likely going to be “if only they knew how important it was.” However, De Keyser emphasized that the reasons behind nonadherence are complex. It can range from a prescription not being filled because it requires frequent refills to parents being unsure of the proper dose to the child or parent simply forgetting the dose. She also shared a study that looked at HIV medication adherence. Barriers related to habit were far more commonly reported by children and parents than barriers tied to education. Habit is indeed a strong driver of an action, thanks to the loop of cue, routine, and reward. The habit loop was used to improve oral care when a toothpaste company, wanting to sell more product, encouraged people via an ad to run their tongue along their teeth and if they felt a film to brush their teeth, which resulted the reward of no more film.

To improve adherence, she recommended asking all patients on chronic medications about adherence and verify with objective data, particularly when the condition is not well-controlled. When talking with patients and parents, it’s best to speak clearly, use data, and be non-judgmental. Using a personal anecdote about how you don’t always adhere to something related to good health, De Keyser mentioned lack of flossing for instance, can help put patients at ease and help them know that they aren’t alone. Then she recommended 4 techniques to improve adherence:

Place based cue - The patient puts the medication in a place where he or she will regularly see it throughout the day, such as the kitchen table or the sink in the bathroom.

Time based cue - The patient uses the medication at certain times of day like right before going to school or at morning and evening meal times.

Habit stacking - The patient connects using the medication to another established habit, such as right after waking up or right before brushing his or her teeth.

Technology - The patient uses timers on his or her smartphone, other smartphone apps, or electronic health monitors. De Keyser recommends using smartphone times and reminders for medications that require only a short course because notifications can become easy to ignore.

1. De Keyser H. It won’t work if you don’t take it: ways to improve medication adherence. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 10, 2021.

Nonadherence to medication is a frustrating element of treating patients, particularly those with chronic conditions. A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition offers insight into the common causes behind it and how to improve adherence.

Medication nonadherence: What may cause it and how to prevent it

Books offer a way to explore the world, different times, and even different worlds. They also offer a way for families to build resilience to tackle a stressful world. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Perri Klass, MD, FAAP, professor of pediatrics at New York University in New York City discussed how promoting parent-child reading time early in the child’s life not only encourages learning and literacy in the child, but also provides the tools to protect against adverse childhood experiences, which can lead to negative health outcomes.

The Reach Out and Read program was started 32 years ago as a project for both pediatricians and early educators. The intervention was initially targeted at children in families dealing with poverty, but was extended to all children. It was designed to promote literacy development, but over the years has come to also include school readiness, promoting brain development, and encouraging early relational health as its goals. Practices involved in the program have literacy-rich waiting rooms, which include volunteers to read books to children and gently used books. During the visits, the clinician offers guidance on creating routines, reading aloud, and incorporating developmentally appropriate interactivity. Additionally, a developmentally and culturally appropriate book is given to a child at every health supervision visit until age 5 years.

So what findings has the program found? Parents are more than twice as likely to read to their children and families are more than twice as likely to enjoy reading together. The likelihood of reading to a child more than 3 times a week also doubled after the invention. For the child, language development was improved by 3 to 6 months after initiation and the language ability also improves with more exposure. For the clinician, there is improved job satisfaction and overall the compliance for well child visits also improves.

Encouraging family reading time with small children also:

Promotes the development of routines, which can provide predictability when stressful situations arise

Develops loving and supportive relationships, which can buffer against toxic stress

Fosters lap time and face time, which encourage physical affection

Encourages parental feelings of self-efficacy due to routines

Decreases screentime and replaces it with a positive alternative

Develops early language skills that can give children the words they require to share their needs and feelings

Klass closed her session with a reminder that reading is a triumph of the early brain, requiring a whole variety of neural processes such as memory, cognition, and phonemic awareness to come together. Using that triumph by including family story time in a daily routine encourages the child to discover that books are source of fun and information that can open up a world of possibilities, all while being supported by family.

1. Klass P. Books build buffers: supporting family resilience through literacy. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 10, 2021.


A session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition shared how books can help families build the resilience that can aid in weathering stressful times.