>> Challenges to the health of kids and adolescents are rapidly changing.

Fortunately, so has the practice of pediatrics.

Stay with us as we talk with pediatrician doctor Bethany Hodge about changes in pediatric health care delivery.

Next on Kentucky health.

>> Kentucky health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Our children are our precious resource.

For years, we have trusted and depended upon pediatric primary health care providers to ensure their health and development such that they may reach their true potential.

In 2014, the European Confederation of Primary Care Pediatricians released its core curriculum.

This curriculum emphasized that the pediatric primary care providers should one focus on infants, children, and adolescents.

Two deal comprehensively with their health and well-being in the context of their family, community, and culture.

Three respect the autonomy of the child and recognize that the child is the prime subject of care and that their personal well-being precedes all other considerations.

And four while at the same time sets a framework for the involvement of parents, guardians, and or custodians as integral parts of the unit of care.

If we fast forward ten years to a piece written by Fred Wilson in Press Maverick, we see new and novel issues of facing the pediatrician.

At the forefront are how to incorporate telemedicine, artificial intelligence, wearable monitoring devices, and genomics to tailor an individualized care.

A growing mental health crisis is impacting pediatric practice.

This is addressed in an August 2020 article in the American Academy of Pediatric News, which had the headline Rising mental health problems and specialist shortages necessitate Mental health screening in primary care practices.

Finally, a more pernicious problem in one with which many of us in health care are ill equipped to address, is the politicalization of health care.

Again, it is the pediatrician who is at the front line in discussions over vaccines, health care access and the effects of environmental pollution.

To discuss the changes in delivery of pediatric health care, we have as our guest today, Doctor Bethany Hodge.

Doctor Hodge is a graduate of Indiana University School of Medicine, where she also completed her residency in pediatrics.

She then completed a master's in public health at the University of North Carolina.

Doctor Hodge is currently a professor of pediatrics and vice chair for Clinical Services and Population Health in the Department of Pediatrics at the University of Kentucky School of Medicine.

Doctor Hodge.

Bethany, thanks for being with us today.

>> Thank you so much for having me.

>> Now, are you sure they let you come up here knowing your connection to North Carolina?

I thought.

>> Apparently they did.

>> Nobody knows about that.

>> Just the degree part, I think.

>> Tell me about your journey.

How did you wind up being a pediatrician, and especially one who has an emphasis in public health issues?

>> Well, I think a lot of us started living in a very small town in rural Indiana.

There weren't a lot of different people with various professions, and I was, unfortunately at the doctor's office an awful lot as a kid.

Strep throat and other kinds of things.

He was someone that I knew well in my community.

And so when I was interested in medicine, it was pretty clear from the start that I'd be interested in pediatrics.

Within pediatrics, we sort of operating with the child in the context of their family and the context of their community and their household and things surrounding them.

So it's a pretty short leap for most pediatricians to start thinking in a public health kind of manner.

I did think it was really great to get a different perspective on health and health care, with some formal training in public health, and also to be able to work with those professionals over time to see what they're doing for the community.

>> Not to be silly, but when does pediatric care begin and when is the end point?

>> Well, you know, we definitely get handed the baby right in the delivery room and we take over from there.

We would prefer and we'd love working with our obstetrics colleagues to take good care of moms, because healthy moms, vaccinated moms give birth to healthier babies.

So I think there is a continuum there.

But definitely from that first minute of life up usually until age 18, but sometimes beyond for for people who are technically adults but have childhood conditions.

>> So sometimes you may see the pediatrician taking care of that person into young adulthood, either because that bond is so strong.

>> Yes, yes.

And sometimes, you know, we're the experts.

The better that we do our job, the more we are able to grow people that maybe did not survive until adulthood as adults.

And so we we have to transition care at some time.

But we're really bad at letting go.

>> When we think in terms of physiologic development and or using medications.

Are kids just little adults or they're an entirely different species.

>> Altogether, an entirely different species?

Okay.

A lot of times the medications and how they work, how we can deliver them, their dosages, they all have to be really tailored to them.

So also that aspect of customization of medicine, we do that every day too.

It has to be the right consistency, like a liquid.

It has to be the right flavor.

Sometimes you have to do a silly dance, but we do whatever we have to to get the medication in.

>> You made an interesting point about the number of pediatricians that are involved in public health.

And I think clearly pediatrics has led the charge in terms of well, well health care.

So tell me about that transition from sick to prevention.

>> I think there are a lot of built in parts of pediatric care that are the preventive visits, the well-child checks that start around two weeks of age.

And then, you know, you're going to the doctor every few weeks or every month in that early childhood period to check on growth and development, to get vaccines completed, things like that.

And then once you reach that kindergarten visit, it starts spacing out a little bit more.

We really like to stay involved so that we can be preventive after that.

So even after that kindergarten check off, we really like it when people come back to their pediatrician for preventive visits so that we can discuss things like normal development, so we can help the child start to understand their own health and take charge of aspects of their health.

And that's something that we do through later childhood and adolescence.

>> With so much emphasis now being placed upon the things that people are taking in that may impact them.

And I speak of food and also things of which we're breathing in.

How do you get involved in affecting and or at least being aware of, environmental and external influences that are affecting the child?

>> I think at those well-child visits there are a lot of checklists and trying to check in on awareness and family practices and things like that.

It's an opportunity to provide a lot of education as well.

Studying children gets a little bit trickier.

They don't like to fill out surveys.

Turns out to let us know exactly what they're up to.

So it's about observing them and seeing trends in the populations and listening to all the people that are taking care of them.

So we incorporate information from school teachers, from parents, from everyone to have a better idea about how kids are doing.

>> You know, I'm thinking about someone I knew who had a child that had really bad asthma and other respiratory problems, yet they lived in an area where there was a large amount of environmental pollution.

They had a lot of animals in the house with a lot of dander going on.

How do you interact them?

What do you tell somebody when they keep having their child having asthmatic episodes?

>> Right.

So I'm a pediatric hospitalist.

So if your asthma is bad enough that you landed in the hospital, that's when you'll you'll see me.

And we do have, again, checklists to kind of go over things.

What type of flooring is in the house?

Things like that.

What are the animals and allergy testing?

I sometimes will have discussions with the families as well about just particulates in the air, trying to be a little bit more neutral and not shame people for practices like smoking around their kids.

But to point out that there are problems when there are things that put particulates in the air.

It was also really interesting to see, when I was in Louisville at the time, that during the Covid 19 pandemic shut down, when there was so much less road traffic on our major highways there, our asthma admissions plummeted.

And so I think there is some also other things you can watch with what's happening in the world and the environment about when we're seeing trends in pediatrics that point to these larger issues of things happening in the world really do affect kids.

We and we don't necessarily have to take it for granted that it always has to be that way.

>> You mentioned that you're a hospitalist, and that's perhaps a foreign term to some of us, especially when we think about the pediatrician.

So not that you've been doing this a whole long time, but how has how has the practice of pediatrics changed over time?

>> Well, I will say that my cohort graduating from residency, we were some of the first people to come out and say, we want to be hospitalist for our entire career.

And so hospitalist medicine means that I just see patients while they're in the hospital, that office.

Pediatricians are often so busy that they need to be in their offices.

And so we work together as a team with them to take care of those immediate and acute issues that are landing a child in the hospital until they're well enough to go home and be transitioned back to the community for the rest of their care.

So it's fairly new in pediatrics.

It's now has its own board certification and everything.

It's true.

I have that.

And and it's emerging as a specialty so that we can be more efficient.

We can give higher quality care and really develop new practices for kids.

>> We know about the rise in diabetes in young folks, in kids and adolescents.

Are we seeing, in addition to that, other chronic illnesses at an earlier age?

And why do you think that is?

>> Well, a lot with the diabetes.

It depends on what type of diabetes we're talking about.

If we're talking about type two or diet related kinds of issues, we are seeing more of those things.

And kids, and definitely every case is seen as an issue.

This is something that we would hopefully want to be in front of with that preventive care, so that we don't reach that that point.

Some issues with hypertension and things like that as well.

But a lot of it too, is that we notice that our, our children who are struggling with obesity start having actual organ changes to their liver and to their heart.

That's something that we're studying.

And that their mental health often suffers as well when they're not able to be active or be engaged in things that kids usually like to do, like play and run around and be very active.

>> You brought in mental health there, which I thought was interesting.

I never think about that in terms of what a child can or cannot do.

But are we seeing more problems or unaddressed issues with mental health now in children than what we used to see, or are we just more aware of it?

>> Probably some of both, but it definitely feels very real to all of us that are working in pediatrics, that it's something that we're looking for or something that we're finding a lot, and something that we're seeing is tied into overall health outcomes, that children who start struggling with anxiety or depression earlier in life have more issues their whole the whole rest of their life, and that families that are struggling with those things in their household are also affected.

As far as the opportunities that that child has for normal growth and development, socialization and all those things that are going to help them future in their life as well.

>> Bring that together.

For me, when you're the child is the primary focus, but they're not in a, you know, isolated environment.

You have this entire family unit, other children, parents, etc.

how do you bring that whole thing together for the well-being of this child?

>> You have to see it as a team sport.

There is no other way to play pediatrics that it's it's the resources and strengths of the family that you want to understand and highlight, and then the gaps that exist for everybody in the family affect the well-being of the child.

So that's, I think, one of the reasons why we were very early in tracking things like food insecurity and social determinants of health in pediatrics, because all those things that surround the child really affect their health.

>> But you got an 11 year old who comes into your office.

And I say that because I remember as an 11 year old, I told my mom, thanks, you can stay outside.

>> I got this.

>> So you get an 11 year old.

And with all these psychosocial issues that are going on nowadays, do you get to talk to the child alone or is it always with somebody there?

>> It really depends on the family.

We try to do a lot of those more sensitive discussions in both contexts, because sometimes there are kids that are willing to talk to us more or in a different way when their parents are there.

But sometimes the parents are also very aware that their child has a need and wants to make sure that it's addressed.

And as I said, you know, the team is even bigger.

It can be school teachers, it can be other people that let us know that a child is struggling in some way, and then we can try to again work as a team to figure out what to do about it.

>> I want to put you to put your public health hat on.

Tell me, what is the role of gathering data in decision making regarding pediatric care.

>> Public health and data gathering?

It's a lot about making the unseen seen, right?

>> What do you mean?

>> Well, because by gathering the information, the concrete data, this case happened, this thing happened, or these trends or apparent that we can start to have discussions that maybe are better informed and hopefully less political to say, this is why we're concerned.

We're concerned based off of the data, and we're constantly monitoring for tons of different things.

It's also how far you know when, what's the earliest that we can know something so that we can then flip to that preventive stance.

If, you know, when we're seeing rises in Covid 19, numbers across the state is getting that information to people, does that change their behavior?

Do they wear a mask or not go to the grocery store if they know that they're an immunocompromised person or things like that?

Can they do things acting off that information?

Or when we're seeing things like the rise of vaccine preventable diseases in children, we want to have those discussions, even though they're hard, even though they're difficult.

If we have deaths in children related to vaccine preventable diseases, which we've had in the state of Kentucky this year, that puts a finer edge on that discussion to say, I'm trying to give you information so that you can do the best for your child, and I'm compelled to tell you these things.

>> You jumped into it.

So now you got to finish.

>> It, okay?

>> But I don't want my child vaccinated.

Right?

What is I think people and people do have a legitimate concern over vaccination.

But you as the pediatrician, you as the one who's looking at the data, what does that discussion look like?

>> It can really look very different depending on the family.

And I think that's part of how we can have better conversations about vaccines, is understanding what it is about the whole situation that's giving them pause, because it's a much different discussion.

If it's, well, I'm really scared of needles.

That's why I don't want to get a flu shot.

That's a different discussion than I have fundamental concerns about the components.

I want to see more science.

I want to, you know, the people that are maybe driven by sitting down with actual studies and numbers and telling them, or people that say, well, I just don't think it's a problem.

That's when I bring in the public health data and say, well, it's more of a problem than it used to be.

So to to bring whatever information that they feel like they're lacking or that they want to be able to make a decision into that discussion, it doesn't always work, but that's how I approach it.

>> Well, right now as we're taping this show, there are 121 kids who are being quarantined in South Carolina because of measles and because of this quarantine.

They're going to be out of school for 21 days.

That's 21 days of learning.

Now that's hard to make up.

Is that something when you talk to parents, say, do you want your child to miss school?

Or.

>> I think it's helping them be informed of the consequences, you know, not only of contracting the disease and what they may go through with that situation, but the the rules, the those are the rules.

Ours are in Kentucky are set by legislation in some ways, what it means to be vaccinated and for school requirements that they are well informed that those what the rules are and all the potential consequences.

I think that whole question of missing school that was seen as such a negative part of Covid.

But yet last year we had multiple school closures across the state because there were too many sick people and too many sick teachers to hold school.

So you just want to say, well, if we don't want that, what are we going to do differently this time so that we don't experience another winter with school closures, or that you don't experience that quarantine?

I think there's a perception that not vaccinating has no risks associated with it.

Vaccinating has risks, but not vaccinating does not have risks.

And that's part of the discussion that we need to flesh out.

>> So you're really balancing out which one which risk is greater for the individual and for everybody.

>> Yes, exactly.

>> One of the other things you do is you're involved in genomics.

So tell this old guy what is genomics and how does that influence your care of a patient.

>> I think well, genomics or genetics in children, it helps me to know more about them and how they may react to medications, what how their development may go.

So, you know, a lot of times I will get handed information that the family knows this about their child, but they don't know what it what it means or how it's going to play out.

And so we try to make some sense of that and set appropriate milestones and expectations for that child.

>> But put it together for me in terms of the algorithm of care.

How does all this stuff.

So you have all this data and you have, well, I guess you're looking at the genetic material of the kid or how in anticipating how they'll respond.

How does it all work?

>> Well, I think, you know, there is zooming in and zooming out, constantly happening in my practice that I'm taking a look at the kid in front of me and trying to help the family zoom out to see their child in the context of their community and their situation, to know what are realistic risks and benefits of the different stuff we're talking about, and then zooming in to know for your particular child, this is how I might change a recommendation or what we might want to try, or people that I might want to connect you with who are going through similar things that might be of benefit to you.

>> Where are you with the wearable devices and things that people use to try to model for themselves?

>> As a mother of a seven year old, I cannot imagine one more thing to keep track of, you know, and I think, too, in pediatrics they're less common.

Some things are highly are highly useful for specific populations, like type one diabetics.

I think they're wearable devices and insulin pumps and things like that really are very good.

But for general use in some ways, I don't want to be too data focused and lose sight of my kid.

So like for instance, there are wearable devices for oxygen monitoring of kids, of infants especially, and nervous moms, which I was one of them to would it give me reassurance if I could somehow know my kid's oxygen concentration at all times?

It seems to play out differently for different families.

Sometimes the device gives you so much information you're not quite sure what to do with it, or if the if the machine says this but the kid looks fine, which one do I act on?

If the machine says they're fine but the kid does not look fine, I still want them to bring them in, so I don't want the data to get in the way of people feeling like they have an ability to know their child, and to use some of their instincts to seek care when they when they want to, and things like that.

So I think because kids can't always tell us as much about their symptoms and report out and things like that, sometimes the data can give us extra information, but I think nothing kind of beats a child.

Having someone take care of them, who knows them well and can advocate for them when they do need health care.

>> Now, I am certain that if we go to your house and look into your kitchen, we'll see nothing but whole food products.

We'll find nothing canned, no chips and bags and snacks and sweets and all that.

>> That's true.

True.

>> So tell me, we have put a great deal of emphasis in putting more on it to get away from foods with a lot of preservatives and things, which I think we're putting.

Well, it's a good thing we're putting a lot of guilt on some other things, because sometimes something is better than nothing, especially in this harried world where people are trying to get.

How do you talk about nutrition at this age.

>> For, you know, nutrition really changes drastically across a child's lifespan.

I do think that if we want to talk about food as medicine from an infancy standpoint, we need to talk about breastfeeding.

We need to talk about those healthy moms again.

And ability.

>> Tell me about breastfeeding.

So cool.

>> You mentioned.

>> How long and when does it obviously start at the beginning.

How long do you.

>> Carry it?

The AAP recommends exclusive breastfeeding up until about age six months, and no transition to cow milk until after a year.

I also do global health and breastfeeding practices across the world are much different, and breastfeeding until age 2 or 3 is definitely possible and can be beneficial.

But you have to support moms in a radically different way than some of our structure does for them to be able to do that.

But it is one of those things that's associated with really good outcomes and good evidence for weight control, for allergy prevention, for brain growth, all kinds of things that are beneficial to children.

>> Are you a reader of the label?

Do you tell your parents you need to look at the label of the stuff you're giving your kids?

>> Yes and no.

You know, I think it has to be family dependent and you have to be aware of their financial situation and how much control they have over the food that enters their house.

I think you can help them play the between these two choices.

What's my best option?

And those types of things.

And and work with them to figure out what's feasible for their family as far as preparing meals, not relying as much on packaged foods and things like that.

And I think it's really important that we continue these conversations with schools.

Kids are at school during their childhood.

A lot of the time.

And so the quality of the food that we offer through our programs is really actually very important to their health as well.

>> I know this will vary from kid to kid going on, but typically speaking, how often should we be taking our children to see the pediatrician?

>> Once a year would be great.

Once we get past that five year prekindergarten check, then, you know, once a year for just prevention, not trying to add in 20 other things.

So you can actually discuss those prevention things is really great to do.

There are guidelines in the Bright Futures AAP guidelines for for things like that.

And then other things are directed by what they need.

So if you are concerned about your child's mental health or a condition, then going in frequently enough to have discussions on that can be good as well.

>> With about a minute and a half left, if you would.

What are three things that you really want us to take home and remember when it comes to dealing with the pediatrician?

>> Well, dealing with the pediatrician.

We're here to help a pediatric disease.

Pediatricians are on your side.

I think that's one thing we're asked to do a lot, and we are willing to do a lot to talk about the well-being of kids.

I think the other thing is whether or not you are currently parenting or plan to parent, you're still part of the community of the children of our that are living in Kentucky, and you have a role in what you are putting into the community that can benefit their well-being.

How we're considering things like large policies over food environment, all those sorts of things that you play a role in promoting the well-being of children, and that pediatricians are also there to help you understand those issues and to make choices that will benefit your community.

>> Do we have enough pediatricians right now or we have a shortage?

>> I feel like we never have enough and we're foreseeing potential shortages.

So we're trying to drive interest in our in our field for sure.

>> How are we seeing the who's coming in to help and fill some of the gaps?

>> Well, advanced practitioners of various sorts.

But also, again, we're playing a team sport, community health workers and other social workers.

All kinds of people are part of our team, and we need more of those that are willing to work with children as well.

>> Are we winning the battle or are we just trying to keep even as far as keeping kids to live their best lives?

>> We could be doing better.

We could be doing better.

But maybe that's my constant perfectionism.

I think, again, if you say that children are the most precious thing that we have in our society, how are we manifesting that with what we're doing with our money, time and resources?

And if you think we could be doing more, then maybe we should be.

>> Did I just hear you say we should put our money where our mouth is?

>> Maybe.

>> Yeah.

That was great.

Bethany.

Doctor Hodge, thank you very much for being with us.

I enjoy talking to you.

I think you've given us some good information.

And thank you for being with us today.

I think that we all have a better idea of the challenges, and, more importantly, the opportunities to maintain the health of our children.

Tried and true techniques used to maintain health are being augmented with newer modalities such as genomics, community wide health data, and consideration of environmental factors.

Working together with our pediatric health professionals, we can protect our most precious resources.

As you have said, if you wish to watch this show again or watch an archived version of past shows, please go to ket.org.

Forward Slash Health.

If you have a question or comment about this or other shows, we can be reached at Chi health at ket.org.

I look forward to seeing you on the next Kentucky Health.

And please, if you haven't formed the good relationship with your pediatricians, please do so.

Get those little folks seen so that they can become great adults in the future.

Thank you very much.

Doctor.

>> Has Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.