Ask Dr. Lia Erickson to list the four most important reasons children need to have annual checkups and she’ll surprise you with her first.
“The biggest thing we pick up on is mental health,” said Erickson, a pediatrician with Novant Health Waughtown Pediatrics in Winston-Salem. “We screen all patients over age of 12 for depression and it's been surprising how many of them have tested positive. Sometimes we even pick up on suicidal thoughts.”
Suicide was the second-leading cause of death for teens ages 10 to 19 in 2017, according to the Centers for Disease Control and Prevention (CDC).
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2: Plotting growth
No. 2 on Erickson’s list is plotting a child’s growth on a chart that pediatricians have been using since the late 1970s to identify anomalies that might indicate a health problem.
Just this year, growth charts helped Erickson diagnose and treat two potentially life-threatening conditions in children.
“Over the past six months, we had two kids who had not grown much,” Erickson explained. “One was a 6-year-old boy that had an undiagnosed congenital problem with his stomach, where it was actually located in the chest cavity. He had to be admitted to the hospital for surgery. The other was a 12-year-old boy who had a chronic infection in his stomach that caused him to be anemic and not grow. Despite all the screening we do now, the only symptom we saw was when they fell off the growth chart.”
Both children are now doing well, thanks to surgery and other therapies, as well as continued monitoring by Erickson.
Congenital anomalies – health problems a child is born with – are a leading cause of death in children 14 and under, and the No. 1 cause of death in babies under 12 months.
3: Screening for issues that can cause chronic diseases
Next on the list is screening for what health care providers call “comorbidity,” which occurs when a patient has two or more conditions that raise their risk of becoming obese, having high blood pressure and developing type 2 diabetes, heart disease and other chronic illnesses, each of which is a leading cause of death in the United States.
Most pediatricians also measure BMI, or body mass index, on all patients starting at the age of 3.
“We know that obesity, or BMI that is higher than the 95th percentile for age, increases the risk of developing comorbidities,” said Erickson. “In children with obesity, these can include obstructive sleep apnea, elevated blood pressure, elevated cholesterol, abnormal liver function and prediabetes. We often think of these as being diseases that affect adults, but we are starting to see them more often in adolescents.”
4. Screening for social determinants of health
Finally, Novant Health Waughtown Pediatrics has embraced standard screening for so-called “social determinants of health,” a practice that puts it at the leading edge of American pediatrics.
At every well visit, clinicians ask the children and their parent whether they had enough money for food, or felt they were going to run out of food, in the last month. The clinic has a high percentage of low-income patients. If patients answer yes, clinic staff members refer them to food banks and other community resources that may be able to help. The clinic also screens mothers for signs of postpartum depression and domestic violence.
Social determinants of health are conditions in which people are born, live, learn, work, play, worship, and age and they account for many health disparities in the United States.
In 2015, for instance, Hispanic adults were four times less likely to have finished high school, twice as likely to live below the poverty line and 20 times less likely to speak proficient English than non-Hispanic whites. A 2018 study estimated that, despite big gains since the Affordable Care Act was fully implemented in 2014, Hispanics were still three times more likely to be uninsured that non-Hispanic whites.
Each of these is associated with higher health risks and together they tend to increase stress, which can itself contribute to overeating and high blood pressure.
“We probably have more complicated social situations we are trying to help navigate, than many clinics,” Erickson said.
The long shadow of COVID-19
The importance of screening for mental health, comorbidities and social determinants of health has only become more important due to the stress and indirect health consequences of COVID-19 – particularly among communities of color.
“We are seeing many kids who have gained a lot of weight and shown signs of depression in last six months related to being cooped up in the house all day, being bored, eating unhealthy food and being relatively inactive,” Erickson said. “Even though children are not being affected as much by COVID-19 from a clinical standpoint, they are experiencing more stress. Kids are afraid their parents are going to get sick and die, and older siblings are having to mind younger siblings while trying to attend class online.”
Those fears are not entirely misplaced. A recent study of 38,000 patients at John Hopkins Health System found 43% of Hispanics tested positive for COVID-19 compared to 9% for non-Hispanic Whites and 18% of Blacks.
“We want all parents to know regular checkups are always important for children, but especially now,” said Erickson. “We also want them to know that Novant Health is going above and beyond to ensure the clinic is a safe place to go during COVID.”
“This is not a time to delay care if they have something they are concerned about,” Erickson concluded. “It's a time to be more vigilant.”