The Well Child Issue by mo-afp

SUMMER 2021

MISSOURI FAMILY PHYSICIAN VOLUME 40, ISSUE 3

FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

CONTENTS

BOARD CHAIR Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT-ELECT John Burroughs, MD (Liberty) VICE PRESIDENT Kara Mayes, MD (St. Louis) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

4 The Well Child

BOARD OF DIRECTORS

9 Virtual KSA Sessions Available

DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron) ALTERNATE Mike Feuerbacher, MD (Maryville) DISTRICT 2 DIRECTOR Vacant ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis) DIRECTOR Dawn Davis, MD (St. Louis) ALTERNATE Lauren Wilfling, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald) ALTERNATE Jennifer Allen, MD (Hermann) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia) ALTERNATE Amanda Shipp, MD (Versailles) DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville) ALTERNATE Justin Cramer, MD, FAAFP (Marshall) DISTRICT 7 DIRECTOR Beth Rosemergey, DO, FAAFP (Kansas City) DIRECTOR Afsheen Patel, MD (Kansas City) ALTERNATE Wael Mourad, MD, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Andi Selby, DO (Joplin) ALTERNATE Barbara Miller, MD (Buffalo) DISTRICT 9 DIRECTOR Douglas Crase, MD (Licking) ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau) ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Lees Summit) Josephine Glaser, MD (St. Louis) Krishna Syamala, MD (St. Louis)

6 Screen Time and Its Effect on Childhood Obesity

10 The Importance of Parental Influence in Combating Childhood Obesity and How Physicians Can Help 12 Safe House Project 14 Preventing Abuse by Integrating Sexual Health into Your Practice 16 School Leaders Focus on Student Wellness 18 Safe Schools Have Vaccinated Students 22 Post-Pandemic Sports Injuries 26 FHFM Fitness Challenge 28 Members in the News 30 References

RESIDENT DIRECTORS

John Heafner, MD, SLU Morgan Murray, MD, UMKC (Alternate)

STUDENT DIRECTORS

Noah Brown, UMKC Kelly Dougherty, UMC (Alternate)

AAFP DELEGATES Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF

MARK YOUR CALENDAR August 27-28 Transition to Practice Conference for Residents and Students Capitol Plaza Hotel, Jefferson City September 18 Rural Health Conference with Illinois AFP Regency Conference Center in O’Fallon, IL October 17

EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey

Virtual KSA: Health Counseling & Preventive Care More info on page 9 November 12-13

The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

29th Annual Fall Conference and Annual Business Meeting Big Cedar Lodge — More info on pages 5 & 27 December 12 Virtual KSA: Diabetes More info on page 9

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org MO-AFP.ORG 3

The Well Child

mong the many joys of being a rural family physician in Marshall, Missouri is the ability to provide care to families from conception to death. Delivering this full spectrum of care has allowed me to see the impact healthy children can have not only on their own families, but also on the community. Reflecting on over 25 years of practice, it has Jamie Ulbrich, MD, FAAFP been so rewarding to see babies I delivered and Board Chair, Marshall ones I took care of at birth, develop through their childhood years to graduate 8th grade, high school, start new families of their own and finally begin new career paths (not necessarily in that order, of course). I have also had a not so easy time sharing with some of these same families the new diagnosis of type 1 diabetes by some young boy or girl showing up to the office in DKA. Having one of my adorable young girls coming in not feeling well and being diagnosed with leukemia. Experiencing and supporting one of my very close young family friends that was diagnosed with liver cancer several years ago. While others with significant learning and mental health disorders that we continue to work hard to support both child and family.

Mission Statement:

Most children that you see however, come from well child visits. Assessing developmental milestones to checking growth charts, to finding out the concerns of both the patient and their family is still probably one of the most fun and rewarding things I get to do in my practice today. The “simplistic innocent honesty” that you receive from children is both humbling and refreshing. They have no trouble telling you exactly what mom said when they spilt something in the car on the way to the office that morning only to the embarrassment of their red-faced mother. Or simply asking you a question that you know came out of their mouth without rehearsing to the surprise of their parents. And don’t forget about the time spent promoting healthy practices and vaccinations. As we transition from the pandemic-laden world of the past 12-18 months, seeing these children again gives me hope for the future and, if I’m honest, a lot of joy. My hope and prayer for each MAFP member is that you continue to find joy in your practice and reflect on your blessings however busy you are. In addition, never forget the importance of the words you use with your children and adolescent patients as you encourage them through their growth and development, trials and tribulations. I assure you they won’t.

The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.

MISSOURI FAMILY PHYSICIAN July - September 2021

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Screen Time and Its Effect on Childhood Obesity

O Shahed Faruk, MD Joplin, MO

besity has become a prevalent problem in childhood all over the world in the last few decades. It is estimated that 12 to 13 million children and adolescents are overweight or obese in the United States (US)1. There is also now an increased risk of severe obesity amongst some children2. The reasons for increased risk of obesity vary from child to child. Regardless of the causes behind obesity, there are many detrimental implications including health issues later in life as well as psychosocial complications related to obesity4. This article will discuss some of the general causes of obesity among children and focus on how the increase in screen time can play a part in this growing hazard. As with adults, in children, body mass index (BMI), an indirect calculation of body fats, is used to gauge normal weight to obesity. BMI is calculated by using weight in kilogram/height in meter2 (kg/ m2). The cutoff for normal, overweight and what is considered obese vary based on gender and even age of the child2. Per CDC and other standard guidelines, BMI of 5th to 85th percentile is normal weight, 85th to 95th percentile is overweight and over 95% is considered very obese 2. Many factors can play a role in increasing the risk of obesity that

MISSOURI FAMILY PHYSICIAN July - September 2021

extend from birth to adulthood. Prenatal history can play a factor. This can be seen in infants born to mothers with obesity and/or gestational diabetes who may suffer from macrosomia. An elevated weight at an early age may also place these children at risk for increased weight and obesity later in life. Maternal smoking can also increase risk for future weight problems. Children with overweight and obese parents are at increased risk as well, possibly suggestive of genetics playing a role in obesity. Moreover, parents play a major part in obesity in children as they can influence food selection and eating behaviors2. A percentage of obesity in youths is caused by medical conditions, including certain genetic conditions, hypothyroidism, polycystic ovarian syndrome and other less common conditions4. On the other hand, environmental reasons of weight gain can range from a socioeconomically disadvantaged background, lack of access to playgrounds and parks, living in dangerous neighborhoods, poor food quality and other various environmental factors 1, 2. For external causes of obesity, a major theme in studies has been that screens may be a large factor in the recent increase of childhood obesity in the continued on page 8

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Shape the Future of Family Medicine Our Medical Students Need You Our state has a critical need for clinical training sites for students. Share your knowledge and skills. To volunteer to host clinical rotations, contact the department of family medicine at a medical school near you.

MO-AFP.ORG 7

continued from page 6

world. Most of these studies grouped screen time as a general of fullness. However, while this relationship has been shown category, which may include time watching television, playing both experimentally and longitudinally in adult populations, the video games or any time spent on a computer. Studies have seen effect of these endocrine regulators, sleep, and obesity are not a dose wise increase in weight based upon the number of hours yet clear on children, and should be further investigated 6. of screen time. The cause for increase in weight for children Additionally, screen time has been linked to reduction in with more screen time can be due to an assortment of factors. physical activity, which in turn may increase risk of weight gain Studies used for this article focused on increases in screen time in children. In a study with participation of multiple early care and its effect on eating and habits related to sleep and physical and education centers (ECE) with children ages three to five, it activity in children as the primary correlative causes. One such was found that higher computer access resulted in less physical study, which consisted of children four to seven years old, activity and more sedentary time5. However, this relationship implemented an electronic time manager in order to reduce between screen time and physical activity is still being screen time for seven months, and followed these children investigated. Previous studies have posited this relationship as over the course of two years. The researchers found that the a factor to childhood obesity, but longitudinal studies have yet group with limited screen time presented with decreased BMI to show a direct link between screen time and physical activity7. or less BMI gain than the control group3. Regardless of the cause of this increase Some possible theories behind these in weight, elevated weight in children findings were that children tended to eat can increase risks of cardiovascular, more calorie dense food while passively endocrine and metabolic syndrome8. Specific conditions such as hypertension, watching screens and that children were “Parents should hypercholesterolemia, and insulin more exposed to advertisements during model and resistance are now being diagnosed in screen time. This constant viewing of practice the those with childhood obesity2. Overweight advertisements was shown to influence and obese children are also at risk for the type of food children chose to eat or behaviors they major psychiatric problems including ask their parents to purchase. Children would like increased risk of developing depression, exposed to screen time tended to eat their children dissatisfaction with their bodies, less fruits and vegetables and instead to imitate by unhealthy weight loss intervention, consumed more snacks, high calorie and poor self-esteem4. It is important beverages and fast food3. These children also having less that there are effective interventions to also tended to eat when they were not screen time.” combat this increased weight gain due to hungry and ate for a longer period of time. these potential complications. There are Additionally, eating in front of a screen medications and surgeries that may help, also distracted children from the feeling but behavioral and lifestyle-modifications of fullness, contributing to an increase in may have the best long-term benefits. BMI3. Meta-analyses of studies on parental Increases in screen time also reduced sleep time in children, which led to weight gain3. Studies influence show that parental behaviors and practices have a showed that children who tended to stay awake later, usually major impact on child weight gain, indicating that it is especially due to increased screen time, also tended to wake up later. This important that parents also demonstrate appropriate physical is significant since some findings in these studies suggested activity levels, sedentary behaviors, and screen time9. Thus, that late bedtime, rather than low sleep duration, was more parents should model and practice the behaviors they would associated with increases in weight of children. Additionally, like their children to imitate by also having less screen time. children who slept late due to increased screen time also were Additionally, parents should reinforce and support their children observed to eat dinner later, which could be a contributory factor to be physically active. Moreover, parents should not place a in weight gain in children3. On the other hand, shorter sleep television in their child’s room and limit screen time to less than also has been found to play a role in childhood obesity in that one hour per day. Early child and education centers should also it appears that shorter sleep times have been associated with reduce access to screen time and encourage more physical activity children choosing higher calorie and less nutritious foods. Thus, in those settings to promote healthy behaviors and decrease children with decreased screen time, longer sleep durations, weight gain in children5. Childhood obesity is a growing nationwide problem that is and early dinner times were seen to have less incidence of obesity and weight gain1. Although the exact mechanism of derived from multiple factors. Combatting childhood obesity will why decreased sleep induces weight gain has not yet been require help from various sources in a child’s life such as parents, elucidated, many have suggested that shorter sleep times may physicians, other medical providers, and educational facilities in alter endocrine homeostasis by increasing cortisol and ghrelin order to decrease screen time, increase physical activity, and secretion, and decreasing leptin levels1. This would result in promote more nutritional food choices in children. an increased hunger sensation as well as decreased feelings References found on page 30

MISSOURI FAMILY PHYSICIAN July - September 2021

Virtual KSA Sessions Available

he Missouri Academy of Family Physicians, in partnership with the Maryland, Ohio, and Wisconsin chapters of the American Academy of Family Physicians, is excited to announce two virtual, American Board of Family Medicine (ABFM)-endorsed Family Medicine Certification knowledge self-assessment (KSA) group study sessions focused on health counseling and preventative care and diabetes. Set for Sunday, October 17 and December 12, beginning at 4:30 p.m. CDT (typically takes 4 hours for completion), this program has limited registration. This innovative program will use a robust web-based system that will allow family physician learners from across the country the opportunity to complete the KSA while engaging their peers and an expert content leader from a location of their choosing. Completion of each KSA will provide participants with 10 certification points towards their ABFM certification requirement. In addition, this activity has been reviewed and is acceptable for up to 8 live prescribed continuing medical education credits by the American Academy of Family Physicians. For up-to-date information on registration and each event, visit www.mo-afp.org/cme-events/ksa/.

Health Counseling & Preventive Care Sunday, October 17, at 4:30 p.m. CDT ABFM Family Medicine Certification: Virtual Knowledge Self-Assessment (KSA) Group Study

Diabetes Sunday, December 12, at 4:30 p.m. CDT ABFM Family Medicine Certification: Virtual Knowledge Self-Assessment (KSA) Group Study

We are a non-profit, statewide, recruitment and retention resource for healthcare professionals who are looking for careers in Missouri, including our rural and medically underserved areas. Ask us about: how to find a job, resume or CV development, loan repayment/forgiveness, scholarship programs, and more. We’re here to help!

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MHPPS is non-profit and located within the Missouri Primary Care Association

CONTACT US TODAY TO FIND OUT MORE! Joni Adamson Director of Recruitment jadamson@mo-pca.org | 573-636-4222 mhpps.org MO-AFP.ORG 9

The Importance of Parental Influence in Combating Childhood Obesity and How Physicians Can Help

Cameron Burr, OMS I KCU, Joplin, MO

Jordan Matekal, OMS I KCU, Joplin, MO

n 2011, Lindsey Murtagh and David Ludwig published a controversial article in the Journal of the American Medical Association detailing possible law changes involving childhood obesity. They argue that, while diet, exercise, and other societal influences put children at risk of becoming obese, parents need to take an equal portion of the blame. In their eyes, having excessive junk food in the home and failure to support a physically active lifestyle are defects in successful parenting. Murtagh’s and Ludwig’s argument leaves readers with an important question. Given the factors of genetics, personal choice, advertising, and other forces on a child’s health, what is the influence of parenting on a child’s weight? How much responsibility should parents take for what has become a nationwide problem of epic proportions2? This article will explore three ways parental habits can have an influence on a child’s weight. First, we will examine how parent’s work schedules influence childhood obesity. Second, we will discuss how parent’s cooking skills play a role in their child’s weight. Third, we will review how parent’s examples set the tone for their children’s diet. Lastly, we will assess the physician’s role in preventing childhood obesity using questionnaires and weight monitoring.

What is the Influence of Parents’ Work Schedules on Children’s Weight? Today, more families than ever before have both parents in the workforce1,6,7,8,13. Mothers are typically viewed as those responsible to make meals for their children8. However, the increase in the number of families with both parents working means more mothers have entered the workforce 1,2,12,. About 75% of American women with children between ages 6-17 are in the workforce 1. This has

MISSOURI FAMILY PHYSICIAN July - September 2021

Samuel Heywood, OMS I KCU, Joplin, MO

John Paulson, DO, PhD, FAAFP KCU, Joplin, MO Department Chair, Primary Care

created a new household dynamic in American homes – with more women entering the workforce, children do not have a parent in the home as often as previous generations have 1,2. This has also put a new stress on parents who must successfully balance professional and family lives. 86% of working mothers reported feeling stressed over trying to balance being a good employee and a good mother14. In a study by Storfer-Isser and Musher-Eizenmann13, working parents reported not having enough time to grocery shop, prepare, and clean up after meals. Working more hours per week positively correlated with children’s consumption of packaged, processed foods9. More working hours also led to more meals eaten outside of the home at fast-food restaurants 6,7,12,13. Both factors – consuming prepackaged foods and eating at fast-food restaurants – have been shown to increase the prevalence of childhood obesity7,12. Increased working hours also lead to a decrease in the number of meals eaten together as a family. In a study by Fulkerson et al.,6 only 41% of families reported eating together more than five times a week. Family meals represent an excellent time for parents to monitor what their children eat and provide an example of healthy eating6. Research shows that the more family meals a child takes part in, the more likely they are to eat healthy foods and the less likely they are to drink sugary drinks and eat high fat foods6,13. Thus, a decrease in family meal frequency due to work schedules can lead to a higher likelihood of childhood obesity6. Working parents also frequently reported being too tired upon returning home to prepare healthy meals for their families7,13. As a result, they stock their kitchens with easy to make, processed meals and snacks6,7,13. Reported fatigue correlated positively with the amount of unhealthy food a child consumed13. Surveys show

that parents feel hesitant to give their children prepackaged foods because they know they are not nutritious, but the timesaving and easy cleanup aspects of these foods often outweigh their hesitation. Obviously, the increased consumption of nonnutritious meals leads to a higher prevalence of obesity 6,7,9,12,13.

What is the Influence of Parents’ Cooking Skills on Children’s Weight? To maintain a healthy weight, children should be eating a variety of vegetables, fruits, whole grains, and lean protein. They should also avoid sugar, solid fats, and excess sodium4. Because over 70% of a child’s daily calories are consumed within the home, it is of vital importance that healthy foods are readily available in the home. Studies have shown that children are more likely to eat healthy if nutritious food is readily available5,6,7,9,12,13. Studies by Horning et al.7 and Martin et al.9 show that healthy food is less likely to be available to children in the home if their parents do not know how to prepare it. Fulkerson et al.6 concluded that only 34% of American families give their child a vegetable for their evening meal every day. Findings also suggest that the lower a parent’s cooking abilities, the higher the prevalence of ultra-processed foods there are in the home 7,9 . Pre-packaged and processed foods offer an easy alternative to parents who have low cooking self-efficacy – they are readily available, require little time and energy, are easy to clean up, and are relatively inexpensive. However, they contain high amounts of sugar, sodium, and fat 7,9. These findings suggest that increasing cooking skills could be an effective prevention method against childhood and adolescent obesity 7,9. The development of cooking skills and effective meal planning strategies could drastically increase the amounts of healthy foods available to children in the home6,10.

environment in which they feel positive emotions, they are more likely to eat them again. However, they will avoid foods that were presented to them at a time they were experiencing negative emotions6,12. Further, when parents spend more time eating with their children, the amount of healthy food consumed has been shown to increase. When parents eat quickly to get to their next task, healthy food consumption decreases6.

What is the Physician’s Role in Childhood Obesity Prevention? The primary way physicians can help prevent and treat childhood obesity is by screening and monitoring a child’s height and weight through routine visits13. Starting at two years old, physicians should begin discussing healthy weights and body mass indexes with a child and their parents3. Physicians should counsel with parents about the importance of obesity prevention and treatment in the home – such as limiting sugary and fatty foods and increasing activity levels11. In addition, physicians can offer waiting room questionnaires to help parents evaluate the health of their diet and the eating habits of their children. Questions can assess a child’s eating behaviors and activity levels, as well as how parents feel about food preparation, their schedule, the environment they provide for their child, and how ready they are to make changes to promote a healthy weight11. Physicians can help motivate parents, set goals, and follow up with them in subsequent visits11. Physicians should develop strong communication skills and understand that conversations and questionnaires about children’s weight may be uncomfortable, but they have been proven to help children maintain a healthy BMI13.

Conclusion

Research shows that, as hypothesized by Murtagh and Ludwig,

What is the Influence of Parents’ Example on parental habits have a profound impact on a child’s weight and Children’s Weight? likelihood of becoming obese. Specifically, data supports that

Parental modeling of fruit, vegetable, and other healthy food intake is key in the development of children’s eating habits5,6,12. Parents serve as the ultimate models for eating – if they do not eat a certain food, it is unlikely that their children will12. A study by Eck et al.5 found that the main reason children consume sugar-sweetened beverages, the leading cause of added sugar in the American diet, is because their parents do. Children learn eating habits by observation6 and have been shown to drink more sugar-sweetened beverages if they are readily available in the home5. Parents reported recognizing that their children want to drink what they drink but say limiting sugar-sweetened beverages can be difficult because they enjoy drinking them5. When a group of children was surveyed, their number one suggestion for how to limit their consumption of sugar-sweetened beverages was to tell their parents not to drink soda5. Parents also establish the environment their children eat in. If children are exposed to new fruits and vegetables in an

parents working more hours per week increased children’s consumption of unhealthy foods7,9,12,13. Studies also show that if parents do not know how to prepare nutritious foods, then they are less likely to be found in the home, thus increasing the amount of sugary and fatty food consumed by children6,7,9. Research also supports that children learn eating habits through parental modeling, and they are less likely to eat unhealthy foods if their parents also avoid them5,6,12. To promote a healthy weight and combat the childhood obesity epidemic, it is paramount that parents and physicians work together. Physicians should provide parents with opportunities for honest assessments of their own habits and those of their children13,11. Parents must remain open to adjusting their work schedules, improving their cooking skills, and changing their dietary habits to endorse healthy weights. The combination of these factors could alter the future of the childhood obesity epidemic. References found on page 30

MO-AFP.ORG 11

SAFE HOUSE PROJECT W Brittany Dunn, Chief Operations Officer Safe House Project

hen I first heard the statistic that nearly 50% of human trafficking survivors have contact with a medical professional during their trafficking, I was not surprised. When I learned that number jumped to 90% when the age of the victim dropped below eighteen, I was equally unsurprised. As the Chief Operating Officer of a nonprofit organization, Safe House Project , whose mission is to eradicate child sex trafficking by 2030, I have had the opportunity to walk alongside many survivors. I, along with my team, have heard countless stories straight from survivors about medical professionals who either missed the indicators of their trafficking, or were unsure of how to engage with them in order to offer them assistance. One of the survivors we work with, Claire, had multiple interactions with medical professionals during the course of her trafficking. She had this to say, “During the course of my trafficking

MISSOURI FAMILY PHYSICIAN July - September 2021

experience, I was taken to multiple primary care physicians, emergency departments, and a number of specialists. I was diagnosed with multiple sprains, subluxations, and dislocations. My traffickers always had an excuse for my injuries. I was asked if I was born prematurely, as evidenced by physical, emotional, and social developmental delays. My delays in development were from severe emotional neglect, physical abuse, and long-term starvation. I attempted to tell the staff what was happening to me, but when I was not believed, I shut down. Because of this, clinicians later in my treatment did not have the knowledge they needed to properly diagnose and treat me.” Claire is not the only survivor whose story reads this way. Of the survivors we have worked with since the founding of Safe House Project, most of them have had a number of experiences with medical professionals and a noteworthy number of them suffer with chronic health conditions caused

by their trafficking. It is the goal of Safe House Project that every and teenagers who play sports come in for physicals. Sick and child who finds themselves in a doctor’s office, urgent care, or injured children pass through doctors’ offices for treatment. emergency department will be met with staff who know what Training medical professionals on the signs and indicators of sex to ask and when to ask it in order to be a resource for victims of trafficking is an imperative step in the eradication of it. child sex trafficking. The first step in this process has been the launch of a Children’s Another survivor we work with, Anna, was a first grader Hospital Executive Guide outlining relevant research, survivor when her trafficking began. In order to keep up appearances, experiences, and suggested competencies that are relevant her traffickers allowed her to play soccer at her local elementary for any practicing medical professional working with children. school. Every year Medical professionals throughout elementary reviewing this document school, her trafficker and meeting with the Safe brought her in to her House Project team are an pediatrician for a physical integral step in adopting for soccer. Her physician best practices for survivor watched her go from a care, increasing survivor bright, talkative child to identification above 1%, a shy, withdrawn one. and leading communities A child who once had toward eradicating child sex drawn attention to every trafficking in America. scrape and bruise, telling In addition to the the story of each tumble Children’s Hospital Executive that caused them, now Guide, Safe House Project held her long sleeves offers training for medical tight in her hands to cover professionals on how to spot them. He watched as she the indicators of trafficking, went from strong and prevent trafficking by athletic to almost frail. knowing warning signs and Her stepdad spoke for vulnerabilities in patients, her. She would no longer and what to do if you expect look him in the eye. She a patient is being trafficked. visibly tensed when he The training can be relevant walked in the room. This for all staff members within combination of warning a practice, from reception to signs is an indicator of nursing staff and physicians. child sex trafficking. Healthcare workers should Anna’s doctor, had he had follow their hospitals policies - Brittany Dunn, COO of Safe House Project the training he needed and procedures for reporting to spot trafficking, could suspected trafficking. If you have intervened on Anna’s behalf. Without the training, Anna need additional assistance or resources, Safe House Project, an was left to go home with her trafficker year after year. organization operating in all 50 states, is able to provide assistance Thirteen-year-old Jack is another survivor of sex trafficking. in placing survivors in restorative care programs once proper law He was a pitcher for his baseball team, so when he broke his enforcement agencies have been notified. Safe House Project’s arm, he was devastated. His coach took him to the local urgent team can be reached at (202) 596-2073. care for an x-ray. A nurse witnessed the coach rubbing Jack’s Finally, community members can learn more on how to shoulders while they waited. As Jack walked past his coach, spot, report, and prevent trafficking at OnWatch , a free oneanother nurse witnessed him pat Jack on the butt. Jack shrugged hour training, which empowers individuals to report suspected it off as “something they just do in baseball,” but he was clearly trafficking to the National Human Trafficking Hotline at 1-888embarrassed by it. The abuse escalated from there. The coach 373-7888. was a fixture in Jack’s life as his single mom raised him and his National Human Trafficking Hotline sister. Those who saw oddly sexual behavior let it go, and due to that, no one intervened on Jack’s behalf. Jack’s coach would go on to traffic him throughout the baseball season. Jack’s trafficking could have been prevented if the nurses who witnessed Jack’s Info@safehouseproject.org coach touching him in a provocative manner had had the for more information about training or education they needed to spot the signs and respond. to engage in the fight against child sex In many cases, doctors are a first line of defense for victims trafficking in your community. of trafficking, particularly in children. Children who attend school must come in for the required vaccinations. Children

“In many cases, doctors are a first line of defense for victims of trafficking, particularly in children. Children who attend school must come in for the required vaccinations. Children and teenagers who play sports come in for physicals. Sick and injured children pass through doctors’ offices for treatment. Training medical professionals on the signs and indicators of sex trafficking is an imperative step in the eradication of it.”

1-888-373-7888

References found on page 30 MO-AFP.ORG 13

Family physicians have many health priorities to address with patients and families in every well-visit. While some physicians incorporate ageappropriate conversations about sexuality and development into pediatric well-visits, there is evidence that these conversations should be happening more - especially as these conversations have been linked to preventing childhood sexual abuse. 14

MISSOURI FAMILY PHYSICIAN April July - -September June 2021 2021

Prevalence and Impact Data

In a review of health maintenance visits, 1 of 3 adolescent patients did not receive any information on sexuality from their physician; and, if they did, the conversation lasted less than 40 seconds (Boekeloo, 2014). While we would like for sexual abuse to be a rare occurrence, 1 in 5 girls and 1 in 20 boys is a victim of child sexual abuse (Douglas & Finkelhor, 2005). Additionally, children are most vulnerable to child sexual abuse between the ages of 7 and 13 (Douglas & Finkelhor, 2005). That means that a high number of pediatric patients will experience sexual abuse and waiting until adolescence to discuss sexual health or sexual abuse may be too late for many of our children. After experiencing child sexual abuse, children may experience symptoms within three days of the events. These symptoms may include: increased arousal (difficulty falling asleep or staying asleep), re-living experiences (nightmares, intrusive thoughts, flashbacks), negative mood and cognitions (“I can’t trust anyone”), and avoidance (of people, places, activities, as well as thoughts, feelings, and behaviors). Beyond these immediate impacts, children who had an experience of rape or attempted rape in their adolescent years were 13.7 times more likely to experience rape or attempted rape in their first year of college. Compared to those with no history of sexual abuse, young males who were sexually abused were 5 times more likely to cause teen pregnancy, 3 times more likely to have multiple sexual partners, and 2 times more likely to have unprotected sex (Homma, Wang, Saewyc, Kishor, 2012). The impact of child sexual abuse can lead to many difficulties throughout the lifespan including increased rates of health issues (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome), increased likelihood to report current and early age smoking, severe obesity, physical inactivity, alcohol or drug use, and sex with >50 partners, difficulties in interpersonal

relationships, and increased mental health problems such as PTSD, depression, psychosis, and substance use disorders.

Next Steps for Family Physicians

In order to effectively prevent child sexual abuse, children should hear safety messages from multiple adults, such as parents, grandparents, teachers, doctors, and nurses. Talking about sexual abuse prevention reduces the likelihood that it will happen and can even delay the early initiation of sexual activity. When sexuality is discussed frequently and openly in a physician’s office, conversations about the topic can be easier and more comfortable for parents to initiate. Physicians can explore parents’ expectations for sexual development while offering factual information. Screening rates for STIs, pregnancy, and partner violence can improve as barriers to discussing sexuality diminish. Not only can family physicians assist in identifying factors that place children at risk for maltreatment, they can assist in integrating sexuality education into the relationships they build with children, adolescents, and families. While children and adolescents often receive sexuality education classes in school, physicians’ efforts can complement their education in unique ways. With their physician, children and adolescents can ask questions, discuss embarrassing experiences, reveal personal information, and discuss their sexuality and sexual activity privately. To integrate this education, family physicians can: 1) incorporate sexuality education into every visit beginning early in the child’s life, 2) encourage parents to discuss developmentally appropriate sex-related issues with children and adolescents, and 3) utilize their relationship and lifelong perspective of sexuality education to have conversations that may otherwise be difficult with children and teens.

“...Children are most vulnerable to child sexual abuse between the ages of 7 and 13”

Jennifer Holzhauer, MSW, LCSW Trauma Response Program Washington University School of Medicine-Child and Adolescent Psychiatry

Shae Strom, MSW, LMSW Trauma Response Program Washington University School of Medicine-Child and Adolescent Psychiatry

Angela McManis, MSW, LMSW Community-Based Services Director Jewish Family Services

References found on page 30

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Susan Crooks, President, Missouri Association of School Administrators In collaboration with David Luther, Director of Communications

School Leaders Focus on Student Wellness

here is a Latin phrase one hears occasionally in K-12 education circles: in loco parentis. School leaders, including superintendents, principals, teachers and others are “in the place of parents” from the time the student is picked up by the bus until they are dropped at home at the end of the day. Every school leader knows his or her first priority is the health and welfare of the children who attend their schools, and this extends beyond the school day to extracurricular events and special school-related functions. Students are the focus for all educators, and we are fortunate to have a close relationship with those in the medical field who are equally dedicated to the well-being of the many people they serve of all ages. As the superintendent of the Leeton R-X School District, a small, rural district, my approach to student wellness has been to maintain a positive climate and culture where students feel safe. Safety comes in many forms. If a student is struggling with an issue, they must

MISSOURI FAMILY PHYSICIAN July - September 2021

know they can speak to any staff member; they must feel respected; and they must know we are working to meet their needs. When we are successful in this approach, students thrive.

Availability of Resources

Before delving into how schools provide student health services, it’s important to understand that resources can vary significantly from one district to the next. A district’s location often dictates the level and type of support it receives from local, state and federal sources and can make a real difference in what can be done to help a child. A child attending school in a metropolitan area may benefit from the district’s partnerships with local medical, dental and vision outlets. For example, the Springfield Public Schools have a relationship with Trudi’s Kids, a mobile medical unit provided by Jordan Valley Community Health Center (JVCHC), which includes vision exams and glasses. The district also has access to a mobile Tooth Truck provided by Ronald McDonald House Charities (RMHC). While rural

Nutrition & Food Insecurity

In Missouri, during the school year, approximately 3.5 million reimbursable (free/reduced) lunches are served (“Missouri Food and Nutrition Services, National School Lunch Program Total Reimbursable Lunches Served School Year 2020-2021.” https://dese.mo.gov/sites/default/files/FNS-totallunch-20-21. pdf). Students may also participate in school breakfast and afternoon snack programs. However, beyond the school day (and the school year), food insecurity is a very real concern. School districts have found a variety of ways to help address this issue. Dr. John Link, superintendent for the Jackson School District, noted that part of their Whole Child Strategy includes their Power Pack Program. “Through this program, we feed over 300 students beyond the school day, and provide holiday meals for over 150 families.”

The Mental Wellness Crisis

schools may not have ready access to such partnerships, there are often other means available to help students, including telehealth programs.

Physical Well Being and Getting Creative

Regardless of the size of the school district, students benefit from a variety of offerings related to their physical wellbeing. During the fall, students receive health screenings that address hearing, vision, blood pressure, and scoliosis. It is also common for students in kindergarten through eighth grade to receive a dental check-up, and if there is a concern, parents will be notified so they can seek additional assistance. Many school districts offer voluntary flu clinics for all students in the fall and vaccination clinics for incoming eighth graders and seniors. Naturally, physical fitness is important for all students. Whether it is recess, physical education classes, or participation in extracurricular sports, students need to move, and sometimes this calls for creativity. Dr. Jim Wipke, superintendent of the Ladue School District (St. Louis) shared that during the 2020-21 “COVID” school year, students at the middle school worked in cohorts as a means to reduce additional contact. As a result, there was limited classroom to classroom movement. So, staff developed the concept of “learning walks” where the cohorts would walk the campus while discussing the concepts they were studying. Dr. Wipke noted, “This has not only been a great way for students to get a little exercise, but it has also helped to build stronger relationships with friends and staff.”

In recent surveys of school leaders across Missouri, one of the greatest concerns expressed is student mental wellness (2019-2020 and 2020-2021 MASA Membership Surveys). Anxiety, depression, suicidal thoughts, and self-harm are increasing at an alarming rate, and many districts do not have the resources to adequately address the situation. School leaders cite unstable homelife, food insecurity, and family financial hardships (including homelessness) as key factors impacting children. Negative interaction on social media, including bullying and intimidation, also plays a significant role in student anxiety and stress. To help address mental wellness issues, we have hired a teacher who meets with at-risk students throughout the day to work on social and emotional skills, deal with negative peer pressure, encourage positive expectations for themselves, and set personal goals. And there are many other mental health success stories across the state. Dr. Allan Markley, superintendent for the Raytown C-2 School District, (Kansas City) shared that when a teacher contacted a parent to express that his child was exhibiting suicidal thoughts, the warning was initially dismissed. Dr. Markley said, “We then learned that the father and mother were not parenting together and the family was facing many challenges. The teacher continued to check with both parents and they ultimately did reach out for help. The parents made their child’s mental health their priority. The parents followed up with the school staff person to share that counseling was going well, and they all shared tears of joy and happiness for how the family was reunited and had overcome their challenges.” As leaders of school districts, we must continually strive to provide students with a safe environment in which they can learn and grow. When our districts develop programs and initiatives that successfully help children, we must build on them and share the ideas with our peers. We must seek out all available resources to address our students’ physical and mental wellbeing, and we must engage with our elected representatives to help them understand the need for additional resources. We can never forget that at times we are in loco parentis, and this must guide us as we strive to do what is best for the children in our care. MO-AFP.ORG 17

SAFE SCHOOLS

MISSOURI FAMILY PHYSICIAN July - September 2021

HAVE

VACCINATED STUDENTS (Opinion Piece)

Nathan Beckett, MD Missouri Immunization Coalition

he first global pandemic in generations unceremoniously disrupted nearly every element of American life during the last year. Nothing stressed the social fabric more than the interruption to regular schooling for our kids. We all want a return to safe, sound, and normal schools. Our youth are stressed, depressed, feeling isolated, and not learning in the capacity they should. Some estimates report as many as 3 million American children lacked school access, and many fear these students won’t return in significant numbers. continued on page 20 MO-AFP.ORG 19

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We should take a moment to recognize Missouri’s relative success. Teachers were prioritized in Phase 1B for the State of Missouri’s COVID-19 Vaccine Plan, enabling 98% of Missouri schools to offer some form of in-school instruction this spring. Missouri ranks 6th in the lowest proportion of remote learners in the country and 5th in the highest proportion of in-person student learning . Thus, in many cases, the obligation to navigate the pandemic was transferred to school districts to prepare and execute mitigation strategies and provide some semblance of normalcy in the era of COVID-19. Not surprisingly, this transition has not been without its own share of confusion and angst for all shareholders. As physicians for school-aged children, we want to know schools are as safe as possible for all who congregate in these spaces. We aim to provide our patients with the best opportunity to grow, discover, and explore their world in an environment not unduly burdened with stress and disease. We want our teachers teaching, our learners learning, and our school administration and districts focusing on those things like infrastructure, achievement, retention, and advancement. One of the most valuable contributions we can make in this equation is to strongly recommend to our families that we vaccinate every child against vaccine-preventable diseases. America is in an unfortunate moment with a growing number of people questioning the utility and safety of immunization. It’s almost unfathomable that leaders in the United States largely squandered the opportunity of a global pandemic to educate the general population about the monumental success and importance of vaccination. On a societal level, our collective trust in our institutions is eroding. However, as doctors, we are in a unique and enviable position to speak directly with families and advise parents about why vaccines are needed. There are stories we can share and things we can do to compete with the misguided pretext that vaccines are unsafe or unnecessary. Reflective of the times, all physicians need to be better messengers and tell more compelling narratives when called upon to do so. We need to be both creative and consistent. We will not overcome dangerous misinformation, misunderstanding, and underestimation of the diseases that vaccines prevent if we are not unified in facing this crisis. 20

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Why must we find better ways to connect with people who question our medical recommendations? To be effective in our messaging, we must demonstrate competence, confidence, and superior understanding of health on both an individual and a societal basis. Conceptually, this is a tradition and framework within which we are already comfortable and accustomed. But vaccine hesitancy requires us to tailor our delivery, and the most fundamental aspect of this challenge is to carefully listen to and consider objections as they arise. More importantly, this moment requires us to be humble, deferential, and open-minded with families bringing concerns to us about immunization. Nobody is refusing vaccines to intentionally cause harm. Acknowledging and empathetically exploring a parent’s reticence will not only help them pinpoint their frustrations or concerns, but will help us communicate our conceptualization of the patient’s situation, and ultimately, provide a better opportunity to address the unvaccinated child. We may have to be willing to dive into a few rabbit holes and shouldn’t be surprised when we find the common ground below the surface. There’s also the obvious added benefit that we will form deeper and more meaningful relationships with our patients and their families, which I find inexorably tied to my own job satisfaction.

“One of the most valuable contributions we can make in this equation is to strongly recommend to our families that we vaccinate every child against vaccinepreventable diseases.”

Of course, we could spend hours with each vaccine-hesitant individual trying to persuade their authorization for a childhood vaccine, but we don’t often have time carved out to allow for this effort. We need to choose simple, impactful language. We should be nonjudgmental, but persistent. We need to have a personal story prepared; one or two that we have practiced frequently. Often this is best accomplished by focusing on a single disease that vaccines prevent. Tell a story of a patient who contracted pertussis, hepatitis, pneumococcus, or Haemophilus influenzae. Talk about the remarkable historical context when we conquered polio and smallpox. Find your voice in your personal narrative, and honestly reflect on how it impacts you on a personal level. There are 15 Missouri counties below or at risk of falling below the threshold for herd immunity to measles; 3% of Missouri’s schoolchildren are at risk of contracting a vaccine-preventable disease due to existing vaccine exemptions. It is great to have a few statistics in your arsenal if used strategically, but people aren’t numbers, so be careful how you choose to communicate data. As much as I don’t want to be alarmist, I believe we need to be alarmed about the momentum that vaccine hesitancy has gained in our state. At this time, the Missouri School Immunization Requirements provide that immunizations should continue to be administered according to the Advisory Committee on Immunization Practices (ACIP) schedule. Furthermore, unimmunized children may be excluded from school during vaccine-preventable disease outbreaks. However, this year a bill was proposed that would allow a huge increase in the number of exemptions to school vaccine requirements. The language of House Bill 37 (HB37) was considered on the floor of the Missouri House of Representatives, after it was inserted as an amendment to another bill; one which had a better chance of passing through to the Missouri Senate. On April 28th, the amendment was voted on and lost 79-67, with 13 abstentions. This underlying math should put all pediatric providers on notice. The language of HB37 would certainly decrease the rate of vaccinations for Missouri schoolchildren, making our schools less safe. Speaking privately with vaccine-hesitant families and publicly in support of immunization, as experts on the subject, will provide legislators the political capital they need to vote for sound policy. A unified collective voice is quite powerful. At the time of this writing, the law is unchanged. Furthermore, most vaccine-preventable disease outbreaks remain infrequent occurrences, as our vaccination rates have mostly not fallen below critical thresholds. But it is crucial that we recognize the direction we are headed as a state and try to prevent any further regression. Although it would be ideal for all students and staff to be protected from COVID-19 through immunization before they return to school in the fall, Missouri state education leaders don’t plan to require the COVID-19 vaccine. Any such direction would have to clear internal hurdles at the Missouri Department of Health and Senior Services as well as the Missouri legislature, and only after the vaccines are fully approved by the FDA. The COVID-19 pandemic already sharply reduced the number of childhood vaccinations we are giving; now is the time to redouble our efforts to halt the decline. Physicians remain the most important voice for families about vaccines. Our presumptive recommendations informing parents that shots are due makes a proven difference in childhood vaccination rates . What we do in this moment with our leverage will reverberate for generations to come. MO-AFP.ORG 21

Kevin Gray, MD, CAQ-SM, FAAFP Clinical Assistant Professor, UMKC Family Medicine Residency and Sports Medicine Fellowship

Post-Pandemic Sports Injuries

Joshua Go, DO Chief Resident, UMKC Family Medicine Residency

Zahn Raubenheimer, MD Chief Resident, UMKC Family Medicine Residency

ith COVID related school closures a measure of months past, organized sports activity participation is again rising. Family medicine physicians should be aware of common sports injuries as well as means for diagnosis. The aim of this review is to revisit common sports injuries and populationbased injury trends based on age, sex, and mechanism of injury in order to help with differential diagnosis and treatment of the respective injuries. Overuse injuries are very common in the pediatric population because of continued musculoskeletal growth and development in these patients. One can commonly expect to see pain, swelling, and compensation to avoid excess stress placed on these areas. Sever’s disease (calcaneal apophysitis) occurs from repetitive heel strikes from any activity, although it is most common in runners and jumpers. The calcaneus bears the brunt of stress, causing inflammation of the growth plate in the heel. Pain will localize to the posterior heel and can be reproduced with a calcaneal squeeze test. Sever’s can be treated with sport avoidance, NSAIDs, and stretching exercises.

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Osgood-Schlatter disease presents as frontal leg pain at the tibial tubercle. Traction from the quadricepts tendon, through the patella, causes inflammation as a result of the shear forces which occur at this junction. Patients present with pain localized to this area and reproduction of pain with palpation of the tibial tubercle. Treatment includes relative rest from painful activities, stretching, NSAIDs, and rarely immobilization. Jumper’s knee (patellar tendinopathy) occurs from repetitive stress to the patellar tendon from sports requiring jumping such as basketball or track and field, resulting in inflammation of the tendon. The treatment is activity modification including rest from jumping, ice to the area, offloading with patellar tendon strap, and occasionally complete rest. Bone stress injuries including stress fractures, as the name implies, result from repetitive stress to an area. These tend to be in the weight bearing areas of the body (legs, feet). Exam shows localized pain with palpation to the area and with stress to the bone such as the fulcrum test. Stress fractures may also occur in the spine (spondylolysis) with sports where lumbar

extension and hyperextension are common such as baseball pitchers and gymnasts. X-ray imaging should include oblique views to evaluate the pars interarticularis in a “Scottie dog” view. Treatment includes complete rest from painful activities, oftentimes including a short period of nonweightbearing to the affected limb. Total treatment may require 6-12 weeks of abstinence from the offending activity in order to properly heal. Throwing injuries such as Little Leaguer shoulder, Little Leaguer’s elbow, and Osteochondritis dessicans (OCD) of the elbow are seen more frequently in overhead throwing and hitting activities such as baseball and tennis. Little Leaguer’s Shoulder represents a Salter Harris I type injury to the proximal humeral physis commonly seen in adolescent male pitchers. Little league elbow is a term encompassing several pathologies which may cause pain to the medial elbow including medial epicondyle apophysis stress injury, Ulnar Collateral Ligament (UCL) injury, and flexor-pronator mass pathology (tendinopathy, strain, etc.) OCD lesions occur when cartilage and bone become avulsed during compression from repetitive throws, causing pain to the area. These lesions are seen more commonly in adolescent male throwers, but are also seen in gymnasts. Stress fractures of the olecranon may also be seen in overhead athletes. Rest from throwing is the primary treatment; however, preventive efforts including time away from sport and pitch counts are paramount to reducing injury risk. Injuries to growth plates or near growth plates must be promptly diagnosed and treated. With timely and proper treatment, reductions in repeat injury, more severe injury, and impaired growth are seen. Sport specialization, or participating in a single sport, has

been a hot topic in recent years. Several meta-analyses of sports specialization have demonstrated significant increased injury risk from repetitive stress injuries as noted above. Cross training has been found to be beneficial for patients in allowing different patterns of muscle use that are important in each different sport, and has been proposed to disperse forces across a larger area, which tends to decrease repetitive injuries. Sports injury profiling has a unique complexity within the pediatric population due to sex, growth, biomechanical differences of the athlete and the activity required by the sport, genetics and intensity of sports participation. Early assessment of possible injuries affords improved outcomes before neuromuscular deficits become more difficult and resistant to intervention. When looking at retrospective studies among pediatric athletes age 5-17, female athletes were found to have a higher percentage of overuse injuries compared to traumatic injuries while the opposite was seen in males. More specifically, females were more likely to have lower extremity, spine, hip/ pelvis and soft tissue injuries, while males had slightly higher rates of upper extremity injuries and trends to more traumatic bone related injuries. Data showed three fold greater findings of patellofemoral knee pain in females, with two fold risk in males for osteochondritis dissecans and fractures. These findings could however be largely related to increased participation in contact/ collision team sports by males, while females are often more involved with track and field/cross country, soccer, softball, gymnastics and dance. Valasek et. al, dove deeper into age and sex and found increased frequency of lower extremity injuries (72.9%) with more than half of injuries occurring to the knee (60.2%). Among continued on page 24

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upper extremity injuries, two thirds of which occurred at the shoulder. Previous research noted young females to be at greater risk of ACL injuries secondary to earlier puberty with rapid growth periods of the tibia and femur and a shifting center mass superiorly compared to males. These changes apply a significant amount of torque to the knee joint and its ligaments, thus, increasing knee forces with less body control. Male pubertal growth often lends to more muscle mass which acts to balance stress placed by increasing height and changing center of mass. When studying early adolescence, male athletes under the age of 12 sustain ACL injuries almost twice as frequently when compared to age matched females. The difference could be a result of increased sports participation by young boys prior to puberty as a predominant risk factor. Overall, the divergence in pubertal transformations place females at greater risk of severe injury requiring surgery. Pediatric apophyseal injury patterns show highest risk of injury during periods of growth. Ages 5-9 years had increased incidence of apophysitis, and were predominantly located in the lower extremities. Conversely ages 15-18 years had higher proportions of tendon, bone and bursa injuries located at the pelvis, spine and upper extremity. Compared to the younger and older age ranges, 10–14-year-olds demonstrated higher rates of articular cartilage injuries due to proposed repetitive microtrauma in ages 10-14. Greater than 80% of each age group continued participation despite reporting pain prior to their evaluations. It is crucial to understand injury profiles that occur with biomechanical predisposition (ligamentous laxity, flexibility, strength), genetics, age and sport. Nonsurgical treatment is the mainstay of treatment; however around 40% of patients will require surgery. Unfortunately, these treatments are often not definitive. As many as 25% of young athletes with ACL injuries will experience a subsequent ACL injury within 1 year from returning to sports after surgery.

And nearly 70% of all patients with ACL injuries will suffer osteoarthritis within 10-15 years. It is crucial for physicians caring for young athletes to place prevention at the forefront of injury treatment to allow children to continue to play safely without pain. This begins at the preparticipation examination. In recent years, an unsettling trend in ACL injuries after concussion has been explored. Findings of these multiple studies suggest a 60% increase in ACL risk for up to 3 years following sports related concussions. Primary care physicians continue to hold the greatest potential for injury prevention and early diagnosis beginning with preparticipation evaluations and within well child checks. The majority of pediatric sports related injuries are not diagnosed with radiographs and rely on careful history and physical examination. Prevention and early diagnosis and treatment limit morbidity from these injuries. References found on page 30

Local Public Health Orders and Vaccine Passports Signed Into Law

B 271 establishes greater accountability for local leaders when imposing public health orders and prohibits local COVID-19 vaccine passports. Governor Parson signed this measure in mid-June. Under HB 271, political subdivisions may only issue public health orders that directly or indirectly restrict access to businesses, churches, schools, or other places of assembly for 30 calendar days in a 180-day period when the governor has declared a state of emergency. Orders may be extended more than once with a simple majority vote by the local governing body. If a state of emergency has not been issued by the governor, political subdivisions may only issue orders that limit access to 24

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businesses, churches, schools, or other places of assembly for 21 calendar days in a 180-day period. These orders may be extended more than once with a two-thirds vote by the local governing body. Additionally, HB 271 prohibits county or municipal governments that receive public funds from requiring documentation of COVID-19 vaccination in order for residents to access transportation systems or other public services. Todd Shaffer, MD, Lee’s Summit, testified on behalf of the MAFP at the hearing on multiple bills that addressed the authority of local health departments. He emphasized that local health departments need to respond quickly in times of health emergencies, especially with the uncertainty of a new virus or pandemic.

Governor Parson Signs SB 63: Creating Statewide Prescription Drug Monitoring Program in Missouri

he MAFP has long advocated for a prescription drug monitoring program in Missouri. As the last state to have a statewide program, we finally did it! Governor Mike Parson signed SB 63 into law, which creates a statewide prescription drug monitoring program in Missouri. “Establishing a statewide prescription drug monitoring program has been a top priority for my administration, and I want to thank Senator Holly Rehder and Representative Travis Smith for working to get this landmark legislation across the finish line,” Governor Parson said. “SB 63 will help provide necessary information to health care professionals and empower them to make decisions that better serve their patients and assist in fighting the opioid epidemic in Missouri.” SB 63 establishes the Joint Oversight Task Force of Prescription Drug Monitoring, responsible for collecting and maintaining the prescription and dispensation of prescribed

controlled substances to patients within the state. This legislation will assist healthcare professionals in better monitoring the dispensation of opioids and other prescribed controlled substances to their patients. Patient information is protected health information under the Health Insurance Portability and Accountability Act (HIPAA) and will continue to be maintained as such in accordance with the federal law under SB 63. SB 63 further states that patient information is considered a closed record under state law and will not be provided to law enforcement agencies, prosecutorial officials, or regulatory bodies for purposes not allowed under HIPAA. SB 63 can be viewed online at https://www.senate.mo.gov/21info/BTS_Web/Bill.aspx? SessionType=R&BillID=54228843.

Family Physicians’ Voices Heard at AAFP’s Virtual Advocacy Summit More than 280 family physicians and medical students participated in this year’s virtual AAFP Family Medicine Advocacy Summit, May 18-19. MAFP was well represented with 13 family physicians sharing personal experiences with their US Senators and Representatives: Michele Sun, MD, Resident; Kara Mayes, MD; Elizabeth Garrett, MD; John Heafner, MD, Resident; Josephine Glaser, MD; Margaret Oliver, MD, Resident; Kelly Dougherty, Student; Peter Koopman, MD; Sarah Cole, DO; Megan Landis, DO, Resident; John Burroughs, MD; Afsheen Patel, MD; and Todd Shaffer, MD. We met with staff from the following offices: Senator Josh Hawley, Senator Roy Blunt, Representative Ann Wagner, Representative Vicky Hartzler, Representative Emanuel Cleaver, and Representative Sam Graves. FMAS attendees pressed Congress to adopt Medicaid payment parity, establish permanent telehealth policy, and eliminate cost barriers to primary care for high-deductible health plan enrollees. Kara Mayes, MD, St. Louis, MAFP Vice President, participated and stated, “This was my first year to be able to attend AAFP’s Family Medicine Advocacy Summit, as timing didn’t work well for me in previous years. I was happy to be able to attend the virtual Advocacy Summit this year, and enjoyed getting to speak to the staff of our elected officials about many important issues facing healthcare, while still being able to see my patients throughout the day in between meetings. While I look forward to traveling

to Washington DC in future years, the virtual summit was a great introduction to national lobbying for me.” The MAFP encourages all members to reach out to their US and Missouri legislators about issues that are important to you and your practice. You can find your legislators by visiting https://www.senate.mo.gov/LegisLookup/Default.aspx. MO-AFP.ORG 25

FHFM Fitness Challenge

he Family Health Foundation of Missouri (FHFM) held a Fitness Challenge Fundraiser through the month of May. The fundraiser was conceived by FHFM President and MAFP Board President, John Paulson, DO. The FHFM Fitness Challenge consisted of participants making a donation of any amount they felt appropriate to FHFM and completing the recommended 150 minutes of moderate activity per week for every week in May. The contest resulted in over 13,000 minutes of logged activity! Those that completed and logged enough activity every week were entered into a drawing for unique prizes including: Person You Should Know Feature (below), Preferential Seating at Annual Fall Conference, Six Free AFC 50/50 Drawing Entries, and a Complimentary Annual Fall Conference Registration. As a reminder FHFM, allows the next generation of family medicine physicians to attend MAFP conferences free of charge,

provides scholarships for the top student from medical school entering family medicine, provides a summer externship scholarship, provides cash awards for the Annual Fall Conference Poster Contest, and other support for family medicine residents and medical students. Founded in 1988 by the Missouri Academy of Family Physicians as its philanthropic arm, the Family Health Foundation of Missouri (FHFM), is dedicated to improving the health of Missouri families by supporting scientific, educational, and charitable activities through the field of family medicine. The FHFM is a 501 (c)(3) organization and donations are taxdeductible. Donations are accepted at anytime at https://www. mo-afp.org/foundation/fhfm-donation-form/, by mailing a check to FHFM, 722 W. High St., Jefferson City, MO 65101, or by calling the MAFP office.

FHFM Fitness Challenge Winner

Cameron Burr, OMS I KCU, Joplin, MO Why Do You Love Family Medicine?

“

You get to have relationships with patients that not a lot of other physicians get. You get to take care of the entire family for a variety of needs. A good family doc has the chance to be an awesome influence in the community.

”

Either / Or Missour-ee Sunrise Invisibility Walk

Missour-ah

Pizza

Windows Up

Tacos

Windows Down

Sunset Ability to Fly Run

MISSOURI FAMILY PHYSICIAN July - September 2021

Summer Virtual Vegetables

Early Bird Cat

Night Owl Dog

Ocean Headphones

Winter

Urban

Rural

In-Person

Inside

Outside

Meat Mountains Speakers

Hospital Pediatrics Biology

Clinic Geriatrics Chemistry

Dr. Kraemer giving testimony

Left to right: Ed Kraemer, MD; Rep. Brenda Shields; Carol Suit, PA; Sarah Mannix, PA Student

Preceptor Workforce Program Let’s Try Again Next Year

B 689, introduced by Representative Brenda Shields (District 11), travelled through committees and the House, but did not make it over the finish line this year. This bill would have created a tax credit for primary care physicians or physician assistants who precept medical and physician assistant students in underserved areas. The $1,000 tax credit would have been awarded for 120 hours of preceptorship and up to three tax credits could be awarded in one year (and not transferrable to past or future taxes due). Funding for this program would have been a license fee increase of $7 for physicians and $3 for physician assistants. Representative Shields guided this bill through the legislative maze and was a true champion. The bill was passed out of the House Workforce Development Committee early in the session. The next step was on to the House Rules-Legislative Oversight Committee and was easily voted out of this committee. It was then off to the House floor where the full chamber debated the bill. It was at this time that “rural” was removed from the eligibility requirements of the bill. We all know the physician shortage in rural areas; however, underserved areas remained in the bill and encompasses most of the state. This was an amendment we agreed to and it passed the House…and then on to the Senate. By now, the clock was ticking and time was getting short with

the end of session less than a month away. Other pressing issues were before both chambers, such as the state budget. HB 689 was scheduled to be heard by the Senate Economic Development Committee; however, Senate floor debate precluded the committee hearing which was eventually cancelled, and rescheduled for the following week. Our champions who presented testimony made the journey back to Jefferson City to present testimony before the Senate committee. An amendment was added to the bill that would have expanded the scope of practice for nurse practitioners, and was voted out of committee. All was not lost. Even though we could not support HB 689 with this amendment, our governmental consultants, Brian Bernskoetter and Randy Scherr, were strategically working to have our bill added to other bills with a similar focus and in the queue for a vote. As the last week of session moved on, none of these measures made it across the finish line. The Senate adjourned early on the last day of session and did not take up any other business. HB 689 was so close – it just needed to be brought up on the floor of the Senate for debate and vote. There is always next year! Kudos to our champions who presented in person and written testimony at the House and Senate hearings. It is a challenge to rearrange your schedules on such short notice to testify before a committee. Thank you!

Annual Meeting Notice: November 13, 2021 You are invited to the Missouri Academy of Family Physicians Annual meeting held in conjunction with the 29th Annual Fall Conference. The meeting will be on November 13th from 11:45 a.m. – 1:45 p.m. at Big Cedar Lodge in Ridgedale, MO. This meeting is open to all members. The agenda for this meeting will include annual reports from the MAFP officers, election of the 2021-22 slate of

officers, proposed bylaws changes, and the annual awards and installation ceremony. More information about the meeting can be found on the website at: https://www.mo-afp.org/ members-only/. For more information about the Annual Fall Conference, please visit www.mo-afp.org/cme-events/afc. MO-AFP.ORG 27

MEMBERS IN THE NEWS

Left to right: Desztiny Howard, MD PGY-2 UMKC, Emma Connelly MS-6 UMKC, Jason Onwenu, MS-2 from KCU Joplin (Summer Extern) Joshua Go, DO PGY-3 UMKC, Todd Shaffer, MD, MBA, Professor UMKC during rounds at UMKC.

2021 Summer Externship Program The Family Health Foundation of Missouri (FHFM) in partnership with the AAFP Foundation offered six Missouri medical students the opportunity to participate in a Summer Externship at a Family Medicine Residency Program this summer.

The six recipients are: • • • • • •

Megan Bastain, MS1, SLU – Mercy Family Medicine Residency Dagny Gould, OMS1, KCU – Research Family Medicine Residency Stephen Jones, OMS1, KCU – UMKC Family Medicine Residency Karstan Luchini, OMS2, KCU Joplin – Mercy Family Medicine Residency Jason Onwenu, OMS1, KCU Joplin – UMKC Family Medicine Residency Catherine Stout, OMS1, KCU Joplin – Research Family Medicine Residency

Congratulations to each recipient! Look for stories about their experiences in a future issue of Missouri Family Physician magazine. 28

MISSOURI FAMILY PHYSICIAN July - September 2021

Ann Abbott, DO, MA, from Kansas City University

Top Graduating Medical Students The Family Health Foundation of Missouri (FHFM) awards $500 scholarships to the top graduating medical students who are entering a Missouri Family Medicine Residency program. This year’s award recipients are: • Ann Abbott, DO, MA – Kansas City University • Chyleigh Harmon, MD – Saint Louis University • Tori Applegren, MD – University of Missouri Columbia • Claire Wolber – University of Missouri - Columbia • Rikki Koebler – A.T. Still University

Congratulations to each recipient!

You can donate to the FHFM and help support these programs for Missouri’s family medicine residents and medical students by visiting https://www.mo-afp. org/foundation/.

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review. We love to hear from our members!

MU COVID-19 Vaccine Committee The University of Missouri (MU) Health Care COVID-19 Vaccine Committee oversees clinical operations of employee and community vaccination, including implementation of a High-Throughput Vaccination Site for the State of Missouri, and continues to lead the transition from “mass vaccination” to clinic and pharmacybased vaccine distribution. This committee is co-chaired by Laura Morris, MD, MSPH, FAAFP, and Margaret Ann Day, MD, FAAFP, who also teach in the Family Medicine Residency at MU. Together, Dr. Morris and Dr. Day provide clinical oversight for the team of pharmacists, nurses, and staff, design and approve clinical policies and procedures, and provide education for their organization as well as many others. They have participated in hundreds of media interviews on radio, local and regional television newscasts, newspaper and print media stories, and hour-long productions on network TV as well as Facebook Live events to educate the public about the COVID-19 vaccine and spread public health messages.

Laura Morris, MD, MSPH, FAAFP

Medical Director, Family Maternity Care Medical Director, Rural Track Associate Residency Program Director Associate Professor, Family & Community Medicine University of Missouri School of Medicine

Margaret Ann Day, MD, FAAFP

Associate Clinical Professor Medical Director, Ambulatory Services University of Missouri School of Medicine

Continuum Family Care Partnership Brings New Healthcare Tech to Northwest Missouri

Spire’s Health Tag

Continuum Family Care, a family health practice based in Maryville, has partnered with Spire Health to provide industryleading medical technology and remote patient monitoring. Continuum Family Care is the first practice in Missouri to adopt such technology, and the clinic looks forward to providing peace of mind to patients with chronic respiratory diseases like COPD. An easily wearable device, Spire’s Health Tag captures and reports medical-grade data around the clock, including respiratory rate, pulse rate and physical activity. The technology’s remote monitoring system notifies medical staff of potential health

concerns – often days before a patient experiences or reports symptoms – to enable early interventions and potentially prevent hospitalizations. “We pride ourselves on the comprehensive approach we take to preventive health care, and we’re excited to further this initiative through our partnership with Spire Health,” said Continuum owner Dr. Chip Fillingane. “With its capacity to remotely monitor patients, Spire’s Health Tag technology aligns perfectly with our mission to aid patients through the entire continuum of their care.”

MO-AFP.ORG 29

References

Screen Time and Its Effect on Childhood Obesity — pages 6, 8 1. Venkatapoorna CMK, Ayine P, Selvaraju V, Parra EP, Koenigs T, Babu JR, Geetha T. The relationship between obesity and sleep timing behavior, television exposure, and dinnertime among elementary school-age children. J Clin Sleep Med. 2020;16(1):129–136. 2. Kohut T, Robbins J, Panganiban J. Update on childhood/adolescent obesity and its sequela. Curr Opin Pediatr. 2019 Oct;31(5):645-653. 3. Thomas N. Robinson, Jorge A. Banda, Lauren Hale, Amy Shirong Lu, Frances Fleming-Milici, Sandra L. Calvert, Ellen Wartella. Screen Media Exposure and Obesity in Children and Adolescents. Pediatrics. Nov 2017, 140 (Supplement 2) S97-S101 4. Brown CL, Halvorson EE, Cohen GM, Lazorick S, Skelton JA. Addressing Childhood Obesity: Opportunities for Prevention. Pediatr Clin North Am. 2015 Oct;62(5):1241-61 5. Amanda E. Staiano, Elizabeth Kipling Webster, Andrew T. Allen, Amber R. Jarrell, and Corby K. Martin. Childhood Obesity. Sep 2018.341-348. 6. Hagen, E. W., Starke, S. J., & Peppard, P. E. (2015). The association between sleep duration and leptin, ghrelin, and adiponectin among children and adolescents. Current Sleep Medicine Reports, 1(4), 185-194. 7. Fakhouri, T. H., Hughes, J. P., Brody, D. J., Kit, B. K., & Ogden, C. L. (2013). Physical activity and screen-time viewing among elementary school–aged children in the United States from 2009 to 2010. JAMA Pediatrics, 167(3), 223-229. 8. Vukovic Rade, Dos Santos Tiago Jeronimo, Ybarra Marina, Atar Muge. Children With Metabolically Healthy Obesity: A Review. Frontiers in Endocrinology. 2019; 10. 9. Huilan Xu, Li Ming Wen, Chris Rissel, “Associations of Parental Influences with Physical Activity and Screen Time among Young Children: A Systematic Review”, Journal of Obesity, vol. 2015, Article ID 546925, 23 pages, 2015. The Importance of Parental Influence in Combating Childhood Obesity and How Physicians Can Help — pages 10-11 1. Bureau, U.S. Census. “Number of Children Living Only With Their Mothers Has Doubled in Past 50 Years.” The United States Census Bureau, 12 Apr. 2021. Retrieved from https://www.census.gov/library/stories/2021/04/number-ofchildren-living-only-with-their-mothers-has-doubled-in-past 50 years.html 2. Bureau, U.S. Census. “The Choices Working Mothers Make.” The United States Census Bureau, 12 Mar. 2021, www.census.gov/library/stories/2020/05/thechoices-working-mothers-make.html 3. Burr, C., Matekel, J., Heywood, S., Paulson, J. Parental Influence on Childhood Obesity. Poster presented at: Kansas City University Research Symposium; 2021 April 6-9; Joplin, MO. 4. Centers for Disease Control and Prevention. (2016, December 15). Childhood obesity facts. Centers for disease control and prevention. Retrieved from https://www.cdc.gov/obesity/childhood/causes.html 5. Eck, K. M., Dinesen, A., Garcia, E., Delaney, C. L., Famodu, O. A., Olfert, M. D. Shelnutt, K. P. (2018). “Your Body Feels Better When You Drink Water”: Parent and School-Age Children’s Sugar-Sweetened Beverage Cognitions. Nutrients, 10(9), 1232. doi:10.3390/nu10091232 6. Fulkerson, J. A., Kubik, M. Y., Rydell, S., Boutelle, K. N., Garwick, A., Story, M., Dudovitz, B. (2011). Focus groups with working parents of school-aged children: what’s needed to improve family meals?. Journal of nutrition education and behavior, 43(3), 189–193. doi:10.1016/j.jneb.2010.03.006 7. Horning, M. L., Fulkerson, J. A., Friend, S. E., & Story, M. (2017). Reasons Parents Buy Prepackaged, Processed Meals: It Is More Complicated Than “I Don’t Have Time”. Journal of nutrition education and behavior, 49(1), 60–66.e1. doi:10.1016/j.jneb.2016.08.012 8. Lee, G., & Kim, H. R. (2013). Mothers’ Working Hours and Children’s Obesity: Data from the Korean National Health and Nutrition Examination Survey, 2008-2010. Annals of occupational and environmental medicine, 25(1), 28. doi:10.1186/2052-4374-25-28 9. Martin, C.A., Machado, P.P., Costa Louzada, M.L., Levy, R.B., Monteiro, C.A.

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(2019). Parent’s cooking skills confidence reduce children’s consumption of ultra-processed foods. Appetite, 144. doi:10.1016/j.appet.2019.104452 Murtagh L, Ludwig DS (2011). State intervention in life-threatening childhood obesity. JAMA. 2011;306(2):206–207. doi:10.1001/jama.2011.903 Resnicow, K., Davis, R., Rollnick, S. Motivational Interviewing for Pediatric Obesity: Conceptual Issues and Evidence Review, Journal of the American Dietetic Association, Volume 106, Issue 12, 2006, Pages 2024-2033. Savage, J. S., Fisher, J. O., & Birch, L. L. (2007). Parental influence on eating behavior: conception to adolescence. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics, 35(1), 22–34. doi:10.1111/j.1748-720X.2007.00111.x Storfer-Isser, Amy & Musher-Eizenman, Dara. (2012). Measuring parent time scarcity and fatigue as barriers to meal planning and preparation: quantitative scale development. Journal of nutrition education and behavior. 45 (10). doi:1016/j.jneb.2012.08.007. “The Harried Life of the Working Mother.” Pew Research Center’s Social & Demographic Trends Project, Pew Research Center, 10 Sept. 2020, www. pewresearch.org/social-trends/2009/10/01/the-harried-life-of-the-workingmother/.

Safe House Project — pages 12-13 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070690/ 2. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequencesof-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf 3. https://www.safehouseproject.org/ 4. https://safehousepartners.org/cheg/ 5. https://www.iamonwatch.org/ 6. https://humantraffickinghotline.org/ Preventing Abuse by Integrating Sexual Health into Your Practice — pages 14-15 1. Boekeloo BO. Will you ask? Will they tell you? Are you ready to hear and respond? Barriers to physician-adolescent discussion about sexuality. JAMA Pediatr. 2014;168(2):111–113pmid:24378601 2. Douglas, E. M., & Finkelhor, D. (2005, May). Child Sexual Abuse Fact Sheet. www. unh.edu. http://unh.edu/ccrc/factsheet/pdf/childhoodSexualAbuseFactSheet. pdf. 3. Homma Y, Wang N, Saewyc E, Kishor N. The relationship between sexual abuse and risky sexual behavior among adolescent boys: a meta-analysis. J Adolesc Health. 2012;51(1):18-24. doi:10.1016/j.jadohealth.2011.12.03 Post-Pandemic Sports Injuries — pages 22-24 1. Bloom DA, Wolfert AJ, Michalowitz A, Jazrawi LM, Carter CW. ACL Injuries Aren’t Just for Girls: The Role of Age in Predicting Pediatric ACL Injury. Sports Health. 2020 Nov/Dec;12(6):559-563. doi: 10.1177/1941738120935429. Epub 2020 Aug 11. PMID: 32780637; PMCID: PMC7785901. 2. Cassas, K. J., & Cassettari-Wayhs, A. (2006, March 15). Childhood and Adolescent Sports-Related Overuse Injuries. American Family Physician. https://www.aafp. org/afp/2006/0315/p1014.html. 3. McPherson AL; Shirley MB; Schilaty ND; Larson DR; Hewett TE. Effect of a Concussion on Anterior Cruciate Ligament Injury Risk in a General Population. Sports medicine (Auckland, N.Z.). https://pubmed.ncbi.nlm.nih. gov/31970718/. 4. Stracciolini A, Casciano R, Levey Friedman H, Stein CJ, Meehan WP 3rd, Micheli LJ. Pediatric sports injuries: a comparison of males versus females. Am J Sports Med. 2014 Apr;42(4):965-72. doi: 10.1177/0363546514522393. Epub 2014 Feb 24. PMID: 24567251. 5. Valasek AE, Young JA, Huang L, Singichetti B, Yang J. Age and Sex Differences in Overuse Injuries Presenting to Pediatric Sports Medicine Clinics. Clin Pediatr (Phila). 2019 Jun;58(7):770-777. doi: 10.1177/0009922819837360. Epub 2019 Mar 22. PMID: 30897956.

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Visit cdc.gov/projectﬁrstline to learn more about infection in control practices.