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June 16, 2021

Marvin So

Ruth Richardson, JD

Johannah M. Scheurer, MD, FAAP

In May 2018, Idil Abdull found her 16-year-old non-verbal autistic son crying on the floor of his classroom in Bloomington, Minnesota.  A disruption in routine had caused him great anxiety and stress, prompting the school to suspend him for five days. As Abdull put it, “What could they possibly do wrong that you want to teach them at that age that they’re not welcome in school?”

Exclusionary discipline practices such as detentions, suspensions, and expulsions should be a concern for pediatricians. Students who are Black, Native, or have disabilities are more likely to be suspended or expelled relative to peers, even after accounting for students’ degree of behavioral infarction. Multi-level factors may contribute to this disproportionality, which emerges as early as preschool. For example, educators may subconsciously expect challenging behaviors more from Black children, particularly Black boys, and receive inadequate training on developmentally-appropriate student emotional and behavior management. Punitive practices such as “zero-tolerance” policies and school resource officers were developed to optimize learning environments, yet such approaches have not improved school safety or academic achievement.

Instead, exclusionary discipline can create academic, health, and social challenges for students. Being excluded is associated with reduced academic performance, levels of school engagement, and graduation rates. It can sever ties to supportive peers and adults, impair perceived worth and belonging, and heighten anxiety or mistrust which may collectively worsen mental health.6 Finally, exclusionary discipline involvement predicts a higher likelihood of school dropout and justice system contact, the so-called school-to-prison pipeline.

Such outcomes are likely unsurprising to pediatricians, as we know that childhood experiences set the foundation for lifelong health and social well-being. Moreover, it is clear that children’s behavio

r and biology are often patterned by factors beyond the individual child, such as the presence of sensitive caregiving or stable housing. Physicians can play their role by conducting thorough histories of challenges with learning, behavior, and school discipline, and attending to contributing factors (e.g., parent mental health). They can also collaborate with school staff and administrators to better support students with behavioral needs through individualized education plans or broader initiatives to shift schools towards more restorative, supportive disciplinary approaches. Models such as positive behavior support, restorative practice, and social-emotional learning discern the root causes of student behavior, providing a tailored continuum of support to address student needs and amend harms.5 Finally, pediatricians can use their voice as trusted professionals to advocate for reforms such as increased accountability mechanisms and banning Pre-K through grade 4 suspensions.

For too long, over-reliance on punitive policies have caused exclusionary discipline to fall primarily on the shoulders of children with marginalized identities. As providers for society’s most vulnerable, let us work to lift our children up, not push them out.

References:

 Phaneuf T. Looking to reduce discipline disparities, House bill would ban preschool suspensions in Minnesota. MinnPost. March 22, 2019.

 U.S. Department of Education Office of Civil Rights. 2013-2014 Civil Rights Data Collection: A First Look. 2016.

 Welsh RO, Little S. The School Discipline Dilemma: A Comprehensive Review of Disparities and Alternative Approaches. Rev Educ Res. 2018;88(5):752-794.

 Gilliam WS, Maupin AN, Reyes CR, et al. Do Early Educators’ Implicit Biases Regarding Sex and Race Relate to Behavior Expectations and Recommendations of Preschool Expulsions and Suspensions? Yale Child Study Center. 2016.

 Lamont JH. Out-of-school suspension and expulsion. Pediatrics. 2013;131(3).

 Jones EP, Margolius M, Rollock M, et al. Disciplined and Disconnected: How Students Experience Exclusionary Discipline in Minnesota and the Promise of Non-Exclusionary Alternatives. America’s Promise Alliance. 2018.

About the Authors

Marvin So, MPH, is a medical student at the University of Minnesota and Public Health Advocacy Fellow with the Twin Cities Medical Society. 

Ruth Richardson, JD, is Minnesota state representative for District 52B. 

Johannah M. Scheurer, MD, FAAP, is a medical educator and neonatologist in the Department of Pediatrics, University of Minnesota.

Seema Kumar, MD, FAAP

Severe obesity is affecting increasing numbers of youth. While overall rates of childhood obesity are plateauing, severe obesity is on the rise. Nearly 10 percent of 12-to-15-year-olds and 14 percent of 16-to-19-year-olds have severe obesity. An increasing number of these young people are developing what are considered adult diseases: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, fatty liver disease, and bone and joint dysfunction.  

Lifestyle modifications remain a cornerstone for weight reduction in children with obesity, as noted in research by Armstrong and others in Pediatrics in 2019. However, lifestyle modifications have only modest success, particularly in youth with severe obesity. 

And so far, the role of medications in achieving weight loss in adolescents with severe obesity is not defined. There is little data on the long-term safety and efficacy of weight-loss medications in children.

Bariatric surgery as an option for adolescents  

In adults with obesity, bariatric surgery is the most effective option to achieve weight loss and remission of several comorbid conditions. Recent studies are finding similar results for adolescents. 

Bariatric procedures (laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) have shown good efficacy in achieving weight loss in adolescents with severe obesity. Bariatric surgery in adolescents has been associated with remission or improvement of several obesity-related comorbidities, including type 2 diabetes, hypertension and dyslipidemia. In fact, adolescents who have bariatric surgery experience higher rates of improvements in type 2 diabetes and hypertension than adults who undergo similar surgery. 

The American Society for Metabolic and Bariatric Surgery and the American Academy of Pediatrics have updated guidelines on bariatric surgery for adolescents with severe obesity. Guidelines recommend bariatric surgery be considered for youth with:  

Body mass index (BMI) percentile ≥ 120 percent of the 95th percentile or BMI ≥ 35 kg/m2 (whichever is lower) or more with concurrent obesity related comorbid diseases 

Body mass index (BMI) percentile ≥ 140 percent of the 95th percentile or BMI ≥ 40 kg/m2 (whichever is lower), even in the absence of any obesity related comorbid diseases 

The guidelines, published in 2018 in Surgery for Obesity and Related Diseases, no longer recommend using skeletal growth and pubertal staging to determine eligibility for surgery. The guidelines also suggest consideration of surgery in special cases, such as for children with syndromic obesity or hypothalamic obesity or for patients with limited decision-making capacity.

As these guidelines indicate, surgery should be considered as a treatment option for adolescents with severe obesity – just as surgery would be considered for many other health conditions. Bariatric surgery helps young patients lose weight and stave off weight-associated diseases. The procedure compares in safety to gallbladder surgery.

As with adults, weight regain after surgery is a challenge for adolescents. Close follow-up with a multidisciplinary team helps achieve long-term efficacy. Telemedicine can be very effective to maintain contact with adolescents both before and after surgery. 

For more information:

Armstrong SC, et al. Pediatric metabolic and bariatric surgery: Evidence, barriers, and best practices. Pediatrics. 2019;144:e20193223.

Pratt JSA, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surgery for Obesity and Related Diseases. 2018;14:882.

About the Author

Seema Kumar, MD, FAAP, is chair of Pediatric Endocrinology and Metabolism at Mayo Clinic Children’s Center in Rochester, Minnesota. She is part of the multidisciplinary Adolescent Bariatric Surgery Program at Mayo Clinic. The program is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. 

Mark R. Schleiss, MD, FAAP

Considerable interest has been engendered nationally for developing and implementing testing of newborn infants for congenital infection with cytomegalovirus (CMV). Currently, newborn screening in Minnesota consists of three simple tests: blood spot screening, hearing screening, and pulse oximetry screening. In Minnesota, the newborn dried blood spot tests over 60 disorders, examining for a variety of metabolic, genetic, and immunological disorders. However, the sum total of all abnormal screening tests still represents fewer babies annually than the total number of cases of congenital CMV. In Minnesota, it is estimated that 300-350 infants are born annually with congenital CMV. Up to 15 percent of these babies are at risk for long-term neurodevelopmental disorders and sensorineural hearing loss, which may not be present at birth but may develop by age 3. Indeed, congenital CMV is the most common infectious disease in Minnesota responsible for long-term disabilities.

So, why is universal congenital CMV screening not performed in the United States? One concern has been the lack of sensitivity of testing for CMV in the newborn blood spot. In studies performed in the early 2000s, the sensitivity of such testing, using PCR testing for CMV DNA, was no better than ~30 percent. However, in a recent publication in JAMA: Pediatrics, I demonstrated a substantially enhanced sensitivity of blood spot testing, between 85-90 percent, in a newborn nursery study performed at five Twin Cities hospitals. This substantial improvement in sensitivity creates an opportunity to establish a universal testing program in Minnesota. Using the dried blood spot allows state health departments to tap into established infrastructure using this resource  to potentially add CMV PCR to the testing panel and precludes the need to collect additional swabs and samples, such as urine and saliva, in most newborns.

Testing for congenital CMV infection in the newborn period identifies infants who can benefit from careful neurodevelopmental evaluation, in particular careful audiological evaluation – since most CMV-associated hearing loss occurs beyond the immediate newborn period. Depending upon the results of diagnostic evaluation, some infants may benefit from antiviral therapy. I presented a summary of the clinical characteristics of the Minnesota universal congenital CMV screening cohort in an oral poster symposium in May at the annual Pediatric Academic Societies meeting. Long-term developmental studies are described at the UMN congenital CMV resource web site (cmv.umn.edu). Many state health departments are considering the addition of congenital CMV testing to their screening panels, and the Department of Health and Human Services is considering addition of CMV to the Recommended Universal Screening Panel. Increased knowledge and awareness of congenital CMV, particularly among young women of child-bearing age, can play a role in prevention, until such time that a vaccine is licensed. 

The UMN will be a testing site for a phase III efficacy study for an investigational CMV vaccine for young women. The study will being in late 2021. Those interested in learning more about the study can email cmv@umn.edu.

About the Author

Mark R. Schleiss, MD, FAAP,  is the American Legion and Auxiliary Research Professor at the UMN Medical School. Dr. Schleiss received his medical degree from the Oregon Health and Sciences University and completed his residency at Doernbecher Children’s Hospital, and his Pediatric Infectious Diseases fellowship at Seattle Children’s Hospital/Medical Center. He also completed a fellowship in Molecular Medicine studying cytomegalovirus (CMV) molecular genetics at the Fred Hutchinson Cancer Research Center, Seattle, Washington.

MNAAP’s long-time lobbyist and policy advocate Eric Dick passed away suddenly in January 2021. Eric was deeply committed to improving the health and wellbeing of every child in Minnesota and he not only personally fought for policies to achieve this goal, but also engaged so many beyond himself in the legislative process. Through the annual MNAAP Pediatricians’ Day at the Capitol, Eric shared his incredible skill as a connector and coach, teaching our members how to turn their own stories and experiences into actionable, effective legislative meetings and messages. He was especially passionate about working with residents and medical students and relished every opportunity he had to spend time with them, both at the Capitol and in their individual programs. In that spirit, MNAAP and MAPF have established a scholarship fund in his memory

The Eric Dick Memorial Advocacy Scholarship will be awarded annually to one or more residents or medical students each year to engage in legislative advocacy projects aimed at improving the health and wellbeing of children in Minnesota – particularly those focused on eliminating health disparities. 

With a generous 10-year financial commitment from one of our board members to seed the scholarship fund, we invite you to join us in honoring Eric’s memory with a contribution of your own.

You can do so by clicking the donate button on the Foundation’s webpage at mnaap.org/mapf or by mailing a check, made payable to the Minnesota Academy of Pediatrics Foundation, to the address below. Please include “Eric Dick Memorial Advocacy Scholarship” in the memo line.

Minnesota Academy of Pediatrics Foundation

c/o Jeff Bauer, Executive Director

1609 County Road 42 W. #305

Burnsville, MN 55306

Mobile Giving With Your Smart Phone Camera 

Supporting the Eric Dick Memorial Advocacy Scholarship only takes a few minutes, thanks to the custom QR code you see below. You can connect to the donation page in 2 easy steps:

1 – Open your smartphone camera app

2 – Hold the phone over the QR code so the code shows up in your camera viewfinder.

Your phone will either automatically take you to the donation page or prompt you to click the DonorBox.org link it displays. 

 

The chapter’s new Anti-Racism Task Force and the existing Poverty and Disparities Work Group have merged to create a brand new group: the Anti-Racism and Disparities Work Group.

At its first meeting in May, the group covered a lot of ground. Members focused the conversation around ways in which the newly formed collaborative could address issues that intersect in anti-racism and disparities work to remove systemic barriers for BIPOC infants, children and teens in Minnesota.

The Anti-Racism and Disparities Work Group is co-chaired by Kate Sadak, MD, FAAP (who led the Anti-Racism Task Force Work along with MNAAP President-elect Eileen Crespo, MD, FAAP) and Valeria Cristiani, MD, FAAP (who served as Poverty and Disparities co-chair with Rachel Tellez, MD, FAAP). 

Previously, the Poverty & Disparities Work Group had established its priorities as:

1) Educating members about health disparities, poverty/ homelessness, food deserts, etc.

2) Identifying community and state-level partners

3) Advocating for increased access to care, food, housing, and transportation.

The newly formed work group plans to tackle areas such as literacy, redlining and homeownership, and connecting with programs such as Child & Teen Check Ups. Members will work in sub-groups. The group also wants to increase member education about anti-racism and disparities by scheduling speakers for presentations.

The Anti-Racism and Disparities Work Group plans to meet monthly as members ramp up to take on this work. The next meetings will take place Monday, July 19, and Monday, August 16, both via Zoom from 12:15 to 1 p.m. If you’d like to get involved, contact MNAAP Executive Director Jeff Bauer at bauer@mnaap.org.

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