As we celebrate the rollout of the new Covid vaccines, don’t forget the standard immunizations and other steps to keep children safe.
My latest column, about the American Academy of Pediatrics’ new guidance on youth sports in the time of Covid, drew two very different sets of parental responses. The guidance emphasizes the importance of wearing face coverings, and also the importance of making sure that any young athletes who have had Covid infections — even asymptomatic infections — are checked out medically before they return, gradually, to full activity.
Some readers were shocked and horrified that youth sports and college sports are going on at all, even with face coverings; to some parents, that is the very definition of unnecessary risk, with players, coaching staff, perhaps parents and even spectators congregating, with the possibility of close physical contact and heavy breathing. Others were shocked and horrified at the idea of asking athletes to wear face coverings during exercise.
Those are not equivalent reactions, or at least not from my point of view. To weigh and measure the risks of participating in athletics, or to think about how to modify the normal athletic schedule to reduce infections are aspects of thinking sensibly around public health risks and benefits. That’s very different from refusing to acknowledge the increasing body of evidence that face coverings protect everyone — the wearer and the wearer’s contacts, and are safe during exercise.
It’s been a semester like no other, and I asked some people who have been taking care of the health of college athletes what they’ve learned and what they’ll be taking forward into the unknown territory of the winter and the spring.
A New York Times analysis released Friday found that more than 6,600 college athletes, coaches and staff members had tested positive for the coronavirus, and there have been reports of spectators behaving in risky ways.
To many people, intercollegiate competition, with attendant travel risks, by definition brings up highly problematic issues of university priorities, and the risks that students are asked to take.
“It’s not reasonable to ask adolescents and young adults to take on additional risks for the enjoyment of spectators and the financial gain of their universities,” said Dr. Adam Ratner, the director of pediatric infectious diseases at New York University School of Medicine and Hassenfeld Children’s Hospital at N.Y.U. Langone Health.
There are places where athletes have been exempt from campus shutdowns, he said: “Everyone is used to there being a different set of rules for athletic programs at universities,” and it’s particularly troubling to see that playing out in a pandemic.
What happens with a college’s sports program has to be seen as part of the larger question of what happens with campus life — whether the dorms are open, whether classes are happening, and whether there is an effective plan in place for limiting exposures and testing for infections.
While some conferences — the Ivy League, for example — have canceled their seasons, there are places that have kept their sports programs going even though they decided it was too dangerous to teach in the classroom, said Marc Edelman, a professor of law at Baruch College who consults on sports-related legal issues, and was the lead author on an article on college sports in the time of Covid in the Michigan State Law Review.
Basketball season, which will be indoors, will be even more dangerous than football season from the point of view of infections, he said.
“These schools have reached the conclusion, right or wrong, that because of the risks of the virus, students should be at home with their families, studying on Zoom,” Mr. Edelman said. “But they’re willing to take a small number of students, who are disproportionately minorities, and fly them back and forth across the country to compete in sporting events indoors because it’s revenue-generating. Ethically, that’s appalling, and logically it doesn’t make sense.”
Other colleges and universities, which do have students on campus and in the classroom, have modified their athletic seasons and the rules they expect their athletes to follow, amid changing information about the virus and its effects, different sports with different degrees of potential exposure, and a changing social landscape.
Dr. Peter Dean, a pediatric cardiologist who is the team cardiologist for University of Virginia athletes, noted, for example, that at the beginning of the epidemic, as it became clear that Covid infection could cause inflammation of the heart in adults, no one in pediatric cardiology knew what the implications were for children and adolescents. Now, cardiologists are much more focused on checking out those athletes who have had moderate or severe Covid infection, or who have persistent symptoms such as chest pain, fatigue or palpitations. “What we’re doing now seems to be working to protect athletes’ hearts,” said Dr. Dean, who sits on the American College of Cardiology sports and exercise leadership committee; so far, there have not been reports of unexpected cardiac events on the athletic field.
Dr. Dean said that in his experience, the students involved in fall sports had been particularly careful to follow the rules about reducing possible Covid exposure. “The fall sport athletes have something to lose, they’re being safe, not going to parties,” he said. “They want to play,” and they know that if they test positive, they can’t.
His colleague Dr. James Nataro, the chairman of pediatrics at the University of Virginia, who is a pediatric infectious diseases expert who studies emerging infections, said that the university, which had students on campus and held in-person classes in the fall, generally did well. “Against almost every prediction, the students complied, the students were just wonderful,” he said.
The school is part of the Atlantic Coast Conference, which modified its schedule to include more in-conference games, Dr. Nataro said, and spectators were kept to a minimum. Still, he said, it was clear, watching football games, that “there were lots of opportunities for transmission,” and some of the good results may have been a matter of luck. And though he himself loves football, he said, he worries about “the lesson it sends if people turn on the TV and watch all these guys without masks standing next to each other — that image isn’t lost.”
Some of the schools that canceled or curtailed their sports seasons were those that do not generate significant revenue from televised games.
Dr. Thomas McLarney, the medical director of Davison Health Center at Wesleyan University, which is a Division III school, said that for fall sports that involve close contact — football, lacrosse, soccer — the teams practiced and worked on their skills, but they did not play against other teams and “did not scrimmage even with themselves.”
In sports like tennis, where strict distancing is possible, he said, there was some opportunity for Wesleyan’s athletes to play — sometimes wearing masks while playing outside. For swimmers, the locker room was taken out of the equation; students changed in their dorm rooms, and then dried off as best they could when they got out of the pool, before going back to their rooms to change back (it helped that it was a relatively warm fall).
“I thought our plan was very good,” Dr. McLarney said, but of course, the plan was only good if the students followed it. “Our students were extremely compliant, I give these folks so much credit,” he said, adding that he was annoyed to come home and turn on the evening news, only to see stories about students taking risks.
Student athletes, Dr. McLarney said, “were hungry for being with other athletes, and we felt we could provide that to some extent — they would rather be out mixing with other teams, but they understood, it’s a pandemic.” Wesleyan is a member of the New England Small College Athletic Coalition, which made the decision in October to cancel winter sports as well, because of pandemic concerns.
“It’s hard,” Dr. Dean said. “We didn’t learn about this in medical school.”
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What does it mean to consider gun violence a public health problem, especially when it comes to children?
The American Academy of Pediatrics announced the development of a new initiative last week reacting to the violence in St. Paul, Baton Rouge and Dallas, an attempt as pediatricians to find ways to protect children, adolescents and young adults.
This isn’t a new issue for the academy; the existing policy on firearm injuries in children emphasizes the importance of sensible gun control, along with the importance of counseling parents about how to reduce risks. Pediatricians as a group have long been concerned about the psychological effects of exposure to violence and the culture of gun violence.
But how can pediatricians make a difference? “I would like us to think deeply about this being trauma for kids,” said Dr. Benard Dreyer, the president of the academy. He emphasized that the discussion must include the overlapping issues of race and the impact of racism on children and adolescents.
This past week, children, along with the rest of us, have seen a truck used as an assault weapon in Nice, France, reminding us that violence takes many forms. Many families worry about how to discuss with our children the disturbing images and stories that play out in the news media. There is an overarching sadness to this discussion. We would like to tell our children that they live in a better, safer country, that the world is getting safer, and that we are making some progress on racism and racial disparities.
Parents need to protect young children from repeated exposures to graphic images, and to be mindful with all children about just how much they’re seeing and hearing. Be there to watch with an older child, both so that you can monitor the exposure, and so that you can talk about disturbing stories and convey the message that it’s O.K. to have these conversations, even when there are no easy answers. The A.A.P. offers age-related guidelines for talking to children about tragedies and other news events on the Heathy Children website.
When children are very upset or worried, they may have nightmares or other sleep disturbances, or complain of physical problems which perhaps will keep their parents nearer, or otherwise, according to their ages, may signal depression or anxiety. Again, it can help to make it clear that you’re willing to talk about these events and the emotions they engender, and willing to get pediatric or mental health help for a child who is particularly distressed.
Beyond what we say in difficult conversations with our frightened or troubled children, adults face the challenge of really making the world safer.
Dr. William Begg, the emergency medical services medical director for the area of Connecticut that includes Newtown, was in the emergency room when the shooting happened at Sandy Hook Elementary School in 2012. He co-founded United Physicians of Newtown, a medical group working to keep children safe from guns.
“I’ve said at every opportunity we have to look at gun violence as a public health issue,” he said. “I think we have to do more as physicians.”
Parents who choose to own guns need to understand how dangerous an accessible gun can be, especially a gun kept in the home, often loaded and unlocked.
“Those are the guns that get used in suicides and unintentional killings and some of the intentional killings,” said Eric Fleegler, a pediatric emergency physician and health services researcher at Boston Children’s Hospital.
As sample safety measures, Dr. Fleegler brought up good safety locks, or even biometric safes, which can be opened only by the right person’s fingerprints, as well as the possibility of safe repositories where people could store guns outside their homes, either temporarily or permanently.
Dr. Begg said it’s important that pediatricians have the opportunity to talk to parents who are gun owners.
“I would never tell a parent, you can’t own a gun; what I would tell a parent is, you should make an informed choice knowing the facts, knowing your family situation,” he said. “I think if people understood the data, many people would make a different choice.”
When you consider guns as a public health issue, the first thing you look for is data and research, but under pressure from the gun lobby, Congress has restricted the Centers for Disease Control and Prevention and the National Institutes of Health from doing or funding research on gun violence and how to prevent it.
Researchers look for associations between injury rates and possible interventions, safety measures and regulations. A study published in 2013 in the Journal of the American Medical Association by Dr. Fleegler and his colleagues showed that states with more firearm laws had fewer firearm-related fatalities; the association was true for both homicides and suicides.
As with so many public health issues, risks are greater for children in poverty and greater for minority children. “The numbers are staggering no matter who you are, but worse the poorer you are, the darker your skin, especially for violence and homicide,” Dr. Fleegler said.
According to the C.D.C., in 2014, homicide by firearm was the second leading cause of death among 15- to 24-year-olds in the United States, with suicide by firearm in fourth place. For those 10 to 14, where the numbers are much lower, the order was reversed, with suicide by firearm the third leading cause of death, and homicide by firearm fourth.
We lost more than 10,300 males from age 10 to age 19 to violence-related firearm deaths from 2010 to 2014; 63 percent of them by homicide, 36 percent by suicide, and 1 percent by legal intervention. The death rate for the black males was 26.3 per 100,000, compared with 6.6 per 100,000 for the white males.
The public health approach means talking to parents about how to keep their children safe, and looking for strategies—technological, behavioral, and legal—to make everyone safer.
Think about what it has meant to bring down the numbers of children dying in car crashes. We don’t look at collisions as unavoidable twists of fate. We look for strategies — technological, behavioral, and legal — to reduce the incidence of collisions and minimize the damage that they do to small bodies.
“We need to take away the notion that we shouldn’t regulate the safety of firearms,” Dr. Fleegler said. “We take pride in our cars, but the idea of removing safety regulations makes no sense.”
Dr. Begg said that for the first 25 years of his career, while practicing in different emergency rooms around the country, he saw patients harmed by gun violence and took care of them, but did nothing to address the larger problem.
“After the Sandy Hook tragedy where I saw the children of my friends and the children of my community, I didn’t know if my children were going to be affected — they were in lockdown also in school,” he said. “I decided I was going to devote the next 25 years of my career to promoting gun violence safety. There’s a lot more change to come.”
Credit Emily Berl for The New York Times
The digital world is changing around us at a dizzying pace; parents want guidance, and pediatricians want to answer their questions with helpful and scientifically valid advice. The American Academy of Pediatrics’ policy on children and media is probably best known for two recommendations: to discourage any screen time for children under 2, and to limit screen time to two hours a day for older children.
As new technologies have transformed many aspects of daily life, new questions have arisen. Did discouraging screen time for children under 2 mean no Skyping with Grandma? Did a limit of two hours for older children mean that if a sixth-grader did her homework on her computer, as assigned, she had used up her allotment? When those guidelines were originally composed in the 1990s, screen time was essentially taken to mean time in front of the television, or time spent playing old-style computer games; by 2013, the policy had changed to limiting “total entertainment screen time” for older children, while still “discouraging” all screens for those under 2.
The children and media policy and guidelines are undergoing review and revision, but in the interim, the academy convened Growing Up Digital, a symposium of experts and researchers last May, and came up with a list of tips — “Beyond ‘turn it off’: How to advise families on media use” — published in September in AAP News, which goes to pediatricians. These suggestions were meant to expand and enhance the existing guidelines by taking notice of new technology and new science.
“We have a variety of policy statements, but technology is always faster than how we can deal with it,” said Dr. Ari Brown, an Austin, Tex.-based pediatrician who was the chairwoman of the American Academy of Pediatrics’ Children, Adolescents and Media Leadership Work Group, and the lead author of the article. “We need to be able to provide practical guidance for parents that they can use now based on science.”
Although these tips on children and media were not meant to replace the existing guidelines, they attracted a good deal of media attention themselves, some of which suggested that a major change had taken place: The collective pediatric wisdom, which had been essentially anti-screen, was now opening the door and letting in the LED light.
”When you look at the press response, this was a foreseeable response but an unfortunate response: The AAP says media is great for kids!” said Dr. David Hill, the chairman of the A.A.P. Council on Communications and Media’s executive committee, and one of the authors of the article. In fact, he continued, the message was much more nuanced: “The A.A.P. says media are diversifying, that quality of the media is critical, that there is much we still have to learn.”
The pediatric wisdom has always been that you should err on the side of protection and prevention; we advise no screens for children under 2 because there’s no evidence of benefit, and a lot of concern about harm; because we worry about what screen time may be replacing in the lives of young children, who need direct human interaction to learn and develop.
Take that Skyping-with-Grandma question (or Skyping with a deployed military parent), which keeps being raised as an example of good screen time for children under 2. Every single pediatrician I spoke with brought that up — not, I suspect, because it’s such a burning question for parents, but because it’s pretty much the best reason anyone has come up with for encouraging a very young child to look at a screen.
“There are some preliminary studies — and I emphasize preliminary — that babies as young as six months can learn from prosocial media,” said Dr. Victor Strasburger, a distinguished professor emeritus of pediatrics at the University of New Mexico School of Medicine and a co-author of the original policy statement, “but they learn 20 times better from parents. I think very judicious use of technology for under-2s may be okay, but personally I don’t see the hurry.”
I hope very much that the go-ahead-and-Skype-with-Grandma message doesn’t somehow blur into a more general sense that screens are a good idea for the very young. Grandma is a good idea for the very young, and the technology here is supporting the interacting, not displacing it.
Whatever we may learn about what young children can or cannot learn from the screens in their lives, what we know is that they need human contact and interaction — and there’s a real worry that screens may take up time and space in babies’ and toddlers’ lives and replace some of what they most need.
But Dr. Dimitri Christakis, a pediatrician who directs the Center for Child Health, Behavior and Development at Seattle Children’s Research Institute, who was one of the authors of the existing guidelines, argued in a 2014 editorial in JAMA Pediatrics for the value of high-quality electronic experiences even for very young children, and for up to an hour a day of what might be considered playing with educational digital toys.
What we should be emphasizing for older children, he said, is that parents need to make sure that they get true nonscreen time built into their days. That means, in part, no screens in the bedroom, and cellphones left for the night in a different room. Families need to create a couple of hours of high-quality offline time each day.
Dr. Strasburger noted that the content of what children watch is very significant. “Media violence will never be good for kids; sexual content at a young age will never be good for kids; first-person shooter games will never be good for kids,” he said. “The research is very clear, and it will never change.”
Even high-quality educational electronic content shouldn’t crowd out the other parts of childhood. “Unstructured, unplugged playtime is very important for all children and especially very young children,” said Dr. Benard Dreyer, the president of the American Academy of Pediatrics and a professor of pediatrics at N.Y.U. “This does not negate the previous recommendations,” he told me. “We still don’t think kids under 2 should be watching TV; we still don’t think older kids should be spending more than two hours a day watching TV.”
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