COVID-19 Special Edition: Superheroes of Pediatric Care: Moving Beyond the Challenges of COVID-19

Speakers

Joining us on today’s podcast is Dr. Rahil Briggs, National Director of ZERO TO THREE’s HealthySteps program. Rahil, thanks so much for being here with us today and just for timing, I’m going to jump right into our first question. What can we tell parents and caregivers about the potential effects the pandemic lifestyle changes could have on development, particularly on infants and toddlers?

Dr. Briggs: Thank you Sally, and thanks for having me. I know this question is on a lot of people’s minds. We’re a year into this and what’s been the effect? For some of these kids, it’s half of their life that they’ve lived within the COVID pandemic. But for parents of babies and toddlers, I think we mostly have really good news. Because they are learning through serve and return interactions, it doesn’t need to occur in one particular kind of learning environment or even a specific variety of environments for them to continuously be learning. So, parents can rest assured that babies and toddlers who are having that regular interaction with their primary caregivers in loving, supportive, nurturing ways with all sorts of serve and return moments all day long are still learning a lot. So, reading books, singing, playing music, just observing what’s going on around them. We often talk about—you know nobody expects that you’re going to put your life on hold and read 20 books to your kids every hour, but can you just comment on what you’re doing as you’re cooking dinner? Now I’m putting the water in the pot, and now I’m putting the rice in, and let’s watch it boil—and just really narrating or sportscasting that day.

I’ll say it again and again and again, you know, it’s about really taking care of oneself—avoiding toxic stress, bringing in mindfulness if you can. And I don’t mean that we all become yogis and meditate every day. That is not realistic right now. We’re trying to juggle 12 different things every minute.

It’s about self-care of adults. Self-care is not selfish as we’ve discussed before. Reducing that caregiver stress will reduce baby and toddler stress, and when babies and toddlers are less stressed, they learn better just like us, right? We learn better when we’re less stressed and it’s exactly the same for them. And of course, if there’s one thing we’ve all learned in this last year, it’s that stress can’t be avoided per se, but it’s about regulating. And so, for parents and caregivers it’s about self-regulating or asking for help. And when you do those things, either self-regulate or ask for help, you model really important social-emotional skill that babies will eventually learn through that example.

Sally: Rahil, I really appreciate that connection you just made between the health of caregivers and the health of children. I think it’s something that can easily be overlooked, especially with everything going on. And I’m wondering, are there concrete examples of things that caregivers should look out for? Something that might indicate that their child has been negatively impacted by the uncertainty and chaos surrounding the pandemic?

Dr. Briggs: Sure, so we know that the difference between a one-year-old and a two-year-old say in developmental terms is pretty remarkable. It’s quite different than the difference between a 33-year-old and a 34-year-old, for example. And so, developmental regression is something that you might look at and you might look for. So, is a child who used to be toilet-trained now going back to having accidents or asking for diapers? Or a child who used to be, you know, fully weaned from a bottle, or breastfeeding or a pacifier, suddenly going back in that direction? Those can be signs of them just saying like “Hey, this is all a bit overwhelming for me right now and I want to go back to a place where things are a little bit easier, and I get a lot more soothing and a lot more care.”

From some of the wonderful work of people like Joan Luby and others, we know that preschool age children can be unfortunately depressed. They can be reliably diagnosed with depression, meaning that a number of different professionals would agree: “yes, this looks like depression.” And not too unlike ourselves in the adult phase of life, you know. It could be impacting sleep, diet, interest in everyday things. So, I would say that’s a great time to really reach out to your pediatrician and say, “This is what I’m seeing. Does this feel like the new normal and just what I should expect because of how we’ve all been? Or does this feel like something that needs a little bit more attention?” And so, any prolonged or substantial changes might be something to bring to a pediatrician.

We know that lots of families have been worried about going to the pediatrician. I saw just this week, the American Academy of Pediatrics has put out a new call that parents are superheroes when they bring their children to the pediatrician to get up to date on vaccinations, but it’s also those times to ask those questions and really double-check like is this okay? Is this something to be expected? Or is this something to be worried about?

Sally: So, the pediatric system, like many had to adapt rapidly to the pandemic. What do you think has worked well and what has not worked well?

Dr. Briggs: So, talk about superheroes. When I think about my colleagues in pediatric care at Montefiore and around the country and all through healthcare, the lengths to which people have gone to support families is remarkable. We’ve heard about just pediatric practices, sort of turning themselves inside out and becoming one-stop-shops for families—diapers, formula, and the like. So, just gratitude to everyone in pediatric healthcare. They’ve been stressed, to say the least, and so that pediatric system has had to get retooled to serve adult patients. There have been some children’s hospitals where full floors have become adult-focused out of need, and of course, as people have gotten sick or been less available, we’ve seen that as well.

So, the pediatric system was stressed to say the least. We saw and we continue to see dips in well-child visits. We see dips in vaccinations—not COVID, but all those other diseases that we have these wonderfully evidence-based vaccinations for—and it’s around the country. We’ve also heard about pediatric practices closing, just not being able to stay open for business because the volume was down or because the workforce issues. There’s been a slow rebound on all of these points, but I’d say we’re not quite back yet to pre-pandemic levels and so that means that families are missing out. They’re missing out on that really important care that happens at the pediatric office.

If we don’t reverse this and quickly, that will be concerning. I think about it, especially from an equity lens. When all babies and toddlers have a strong start, and when they can get that start through a partnership through a high performing pediatric practice, the entire country is better, right? Pediatric primary care is like the only setting we have in this country that almost universally reaches all babies, all toddlers, and their families no matter what your income is, no matter, you know where you’re living.

So, I’d say some of the transitions we saw, you know, as folks got to recognize that this new normal was going to be around for a lot longer than they had anticipated. We saw our HealthySteps practices really adhere to the guidance that was put out by the American Academy of Pediatrics and by the CDC. And so, for many practices that meant postponing visits for older kids and only seeing kids birth to age 2 in person. That was some early American Academy of Pediatrics guidance. Some practices experimented with drive through vaccinations, others went fully remote and started seeing families virtually. Telehealth in pediatrics is not quite as seamless as it may be for us in the adult world, right? That was a really big adjustment for people. I think it’ll be here to stay in some form, but lest you think it’s easy, try to imagine a baby or a toddler on the other side of that telehealth visit and telling them, “please sit there for the next three minutes and don’t move and show me the inside of your wrist.” Right? It’s like “uhh no.” So, not always the most compliant.

You know, but for a lot of folks, for families and providers, seeing their patients virtually was better than not seeing them at all. Again, though, I think about equity here. And so many of those inequities that we saw pre-COVID are still relevant. Perhaps more relevant than ever, and they really come to light when we think about telehealth and folks who don’t have multiple computers in the home and the one that they do have is needed for the school-age child to do online schooling. They don’t have unlimited Internet access or cell phone data. And then, when we close the public spaces, previous options like using a computer at the library or the like aren’t really feasible. We’ve heard from our practices in rural areas that broadband access is a huge issue. This was again pre-COVID, and that affects telehealth and of course, remote learning for older children and work.

As we become vaccinated, many of us, you know, practices are mostly back to in-person with the safety precautions that they need, which is really promising. And I would say we’ve all learned a lot. We’ve learned we are more flexible than we knew we could be, and we have been reminded about the inequities that existed pre-COVID because they have been magnified. My real hope is that we renew a focus on changes that really last for families—committed to health, well-being, school readiness of all babies and toddlers. Our work at HealthySteps continues with I’d say even more urgency than we had earlier. And hopefully, the world and the community at large can join us with really that mission to give all babies and all toddlers that incredibly strong start.

Sally: Yeah, you started talking about this a little bit, but I’m curious when families are really stressed and they’re starting to say like, “Well, a well-child visit might be something that I can skip because there’s so much going on and I’m worried about exposure.” What would you say to those families and how would you kind of help them think through what that might mean?

Dr. Briggs: It’s a great question. In terms of skipping well-child visits, we have data that suggests that there are negative outcomes when you skip well-child visits. So, what are some things that can happen? Well, developmental delays can go undiagnosed, and we all know that the earlier we catch those developmental delays and the earlier that we provide evidence-based treatment, the better the outcome for children, sometimes erasing what was a delay in only just a year.

We also know about the incredibly lifesaving importance of vaccinations. We all are pretty well, you know, the number of people who can talk about what an mRNA vaccination does these days is remarkable and hopefully they remember that we’ve got vaccinations for lots of other really life-threatening diseases, and it’s critical—early childhood is the moment when you’re getting vaccinated, right?  Almost every visit there’s some combination of vaccinations. They’re just so important.

Growth is an obvious one. Not everybody has a perfect infant scale at home, and so being able to make sure that babies are gaining back that early birth weight and then gaining weight at the rate we would expect really has significant implications for development and well-being overall. So, it’s really one of those visits that feels pretty darn worth it to mask up, to call ahead about safety protocols, and to know that each and every one of those health care providers is going in there every day just as worried about their own health and well-being and that of their families and wouldn’t do anything to put their patients in danger.

Sally: You always make me feel better when I talk to you, Rahil. I love those concrete examples too, I think that’ll be really helpful.

I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, Instagram @developingchildharvard, and LinkedIn: Center on the Developing Child at Harvard University. Brandi Thomas is our producer. Dominic Mathurin is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. This podcast was recorded at my dining room table.