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WRITE Excellence in Teaching Award

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Congratulations Dr. Merrill-Steskal for being awarded the WRITE Excellence in Teaching Award for the Eastern/Central Washington region.

“This award aims to recognize and honor preceptors with a track record of excellence in teaching medical students as well as those that serve as a leader in their community. Nominations were collected from WRITE students across WWAMI. A selection committee then reviewed all nominations based on five criteria: commitment to student success, effective teaching methods, positive impact in the community, excellence as a role model for students, and commitment to continuous improvement. You have clearly demonstrated the qualities we look for in outstanding preceptors and recipients of this award.” – University of Washington School of Medicine

Avoiding Picky Eating in Kids

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Contributor Dr. Elise Herman

Most parents are familiar with the ‘picky eater’- the child who is suspicious of new foods, has strong favorites, and may refuse to eat what the rest of the family is eating. Picky eating is very common in young children, but usually improves by age 5 years. This behavior occurs in part to exert some control over mealtime (and parents) in a way that is often attention-getting.

Regarding feeding your child, it is a parent’s job to offer healthy foods and decide the time and place for eating; it is the child’s job to decide what to eat and how much. Remember that children will eat when they are hungry, and with enough opportunities (it may take 15 ‘exposures’ to something new), will accept and eat most foods. Pressuring a child to eat creates conflict and can make mealtime stressful actually resulting in the child eating less. It is OK if your child occasionally misses a meal because they refuse to eat what is served.

There are things parents can do to minimize “picky eating” and encourage good eating habits that last a lifetime:

  • Offer a variety of foods including vegetables as soon as your child starts solids in infancy.
  • Have set mealtimes and decide how long meals will last; most kids can sit at the table for about 15 minutes for breakfast and lunch, and 20-30 minutes for dinner.
  • Sit down for meals and do not allow kids to come and go from the table; if they are ‘done’, the plate and any uneaten food is removed.
  • The kitchen is ‘open’ for planned meal or snack time and otherwise is ‘closed’; no other eating or drinking (except for water) as it may decrease the appetite for the next meal. Kids need 3 healthy balanced meals and 1-2 small snacks daily.
  • Get your child involved–gardening, preparing food/ helping with cooking (keep this age appropriate), planning the meal, or setting the table.
  • No separate meals; you are not running a restaurant! You can have a ‘boring’ option available (for example, plain bread) occasionally, but ignore whining or tantrums about food.
  • Give new foods in very small amounts so it is not intimidating.
  • Do not offer crackers, cookies, chips, etc. to get your child to eat ‘something’; if they are truly hungry, they will eat some of what is served.
  • Do not use dessert as a bribe to eat a meal.
  • Model healthy eating habits and keep discussion of eating neutral; no elaborate praise if they eat ‘well’ and no criticism if they refuse to try a new food. Keep conversation light and upbeat so mealtimes are positive.

If you have concerns about your child’s ability to eat or swallow normally, or if you worry they may not be getting enough nutrition, talk to your child’s health care provider.

Resources

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

The Benefits of Awe-Inspiring Experiences for Kids

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Contributor Dr. Elise Herman

We have all known the sensation of wonder and amazement when we experience something “awesome” like a spectacular rainbow. It turns out that ‘awe’- the overwhelming feeling of respect and amazement, often created by something vast and mysterious- is an important emotion with lots of benefits. Sources of awe might be nature, art, music, spirituality, or a demonstration of courage.

Experiencing awe has been well studied in kids and adults and has been shown to increase creativity and curiosity, which fuel learning. Awe increases positive feelings, decreases negative feelings, and helps with emotional regulation and the ability to handle stress. Awe inspiring moments give children stronger feelings of connection and cooperation, especially if shared with others. Family bonds are strengthened by family members witnessing something ‘awesome’ together.  Prosocial behavior (behavior that benefits others) has been shown to be more likely after experiencing awe.

In the face of something vast like a starry sky or beautiful ocean, we may feel more humble, understanding how small we really are in the world. This feeling of humility can put our own issues and struggles in perspective and encourage us to think beyond ourselves. This is particularly important now given social media use with its constant attention on us as individuals and how we appear to others.

When nature is the source of wonder, kids tend to feel more comfortable and confident in the outdoors. Nature-inspired awe also can decrease PTSD and overall stress. Feeling awe after doing something brave or challenging can increase a child’s resiliency and ‘grit’.  

The benefits of awe have a biologic basis.  Research shows that feelings of awe decrease cytokines, chemicals in the body which are related to inflammation, illness, and depression. Awe can also cause the release of oxytocin, a hormone associated with love and empathy.

There are relatively simple ways to encourage more awe, terrific for both our kids and ourselves:

  • Slow down and take time to notice the little things such as birds in flight, changing leaves, or a butterfly
  • Have more unstructured time, less rushed time and put away the phones and devices
  • Expose your child to art (such as galleries and museums), dance, and music; there are many local opportunities for this
  • Look for science activities that inspire wonder, such as going to a planetarium or a science museum
  • Get out in nature more, taking the time to comment on and express curiosity about what you see and hear
  • Notice and discuss courageous and kind behavior
  • Read books about brave and pioneering individuals
  • Create experiences at unusual times such as an early walk at sunrise or stargazing late at night (yes, after bedtime!); these can be very impactful
  • Consider doing journaling or artwork about awe-inspiring experiences
  • Although in-person is best, watching nature documentaries can also create feelings of awe
  • Express awe yourself- get excited about wondrous things and share those feelings with your child

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

Pedestrian – Vehicle Accidents

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Contributor Dr. Elise Herman

Walking is a great way to exercise for adults and kids alike, but there is a concerning 11% increase in child and adolescent pedestrian fatalities in the US in the last 10 years, resulting in about 600 deaths per year. In response to this, the American Academy of Pediatrics (AAP) released a new policy statement in June 2023. It discusses not only what we can all do to keep our kids safe while walking near cars but addresses how communities can change roads and driving to help prevent pedestrian injuries.

There may be multiple reasons for this spike in pedestrian accidents involving children and youth. Both drivers and walkers tend to be more distracted than in the past, mostly by cell phones. Wearing earbuds makes walkers less aware of their environment. More kids are also walking to school (a good thing) but need to do so safely.

The risk of being hit by a car or other vehicle is greatest in rural areas, according to the AAP, and boys are more likely than girls to be victims. Vehicle speed is the most important factor. In general, the faster the vehicle is going, the greater the risk of a collision with a pedestrian and the more severe the injury. For this reason, it is recommended by the American Academy of Pediatrics that communities change policies and planning regarding roads. Speed bumps, roundabouts, and lower speed limits all work well to slow vehicles down. Photo speed limit enforcement, particularly in school zones, is very effective. Simply extending curbs is an easy way to help protect pedestrians.

There are steps we can all take to help kids be safe when around cars, both in advising our children and being safer drivers ourselves.

  • Pedestrians should be on a path or sidewalk if at all possible; if walking on the shoulder, walk facing oncoming traffic
  • Hold your younger child’s hand when crossing the street, cross at designated intersections or crosswalks, and always observe traffic safety laws. You are a role model– no jaywalking!
  • Teach your child to cross the street: look left, right, and left again, and keep looking around while crossing
  • Kids should not play in driveways or areas next to driveways
  • Children 10 and under should have adult supervision when walking near traffic
  • Pedestrians should not wear earbuds or look at smartphones
  • Increased visibility is important; brightly colored clothing, hats, and backpacks help anytime, and a flashlight or headlamp is crucial at night
  • Drivers should not be distracted by smartphones or interacting with the touchscreen on the dashboard
  • It is the law to allow walkers to cross a crosswalk completely before beginning to drive
  • Use the rear-view camera in addition to car mirrors when backing up and keep the camera clean and ice-free

Resources

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

Wildfire Smoke Exposure and Children

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Contributor Dr. Elise Herman

As climate change causes a longer and more severe wildfire season, exposure to wildfire smoke in children is an increasing problem. Wildfire smoke is felt to be more dangerous than typical air pollution and kids (especially those under 5 years) are more vulnerable for multiple reasons. Children’s smaller airways are more adversely affected by swelling and inflammation from smoke. Kids also breathe more rapidly than adults, thereby taking in more of the dangerous particles. Children who have underlying lung problems including asthma are at increased risk and are more likely to need medical care.

Children typically have coughing, sneezing, and increased congestion with wildfire smoke exposure. They may also have burning or discomfort of their eyes, nose, and throat. If there is more serious exposure, a child may become lethargic or have shortness of breath. Signs of trouble breathing in kids include breathing rapidly, the ribs sticking out with each breath (“retractions”), and the abdomen moving a lot with breathing (“belly breathing”). Babies may also have head bobbing and grunting as signs of respiratory distress.

Being aware of the air quality can guide your actions. Airnow.gov is a good site to check; if the AQI (air quality index) is over 150, avoid any outdoor activity if possible. Kids 2 years and over can wear a mask to somewhat reduce smoke exposure. NIOSH N95 or KN95 masks are 80-95% effective at reducing smoke exposure (depending on the fit of the mask) but do not come in sizes for younger kids. Surgical masks are only 20% effective and therefore are not ideal. Cloth masks really do not help filter smoke.

Here are steps child you can take to protect your child if there is wildfire smoke in your area :

  • Ideally, temporarily relocate to an area free of smoke
  • If the AQI is over 150, stay inside and close windows and doors
  • If possible, use a HEPA air filter or MERV13 filter (this is a rating for a filter’s effectiveness) on your air-conditioning unit; the Environmental Protection Agency (EPA) also has information on creating a DIY air cleaner that is effective
  • Set your air conditioning to ‘recirculate’
  • If you do not have air-conditioning and the weather is very hot, consider going to a cooling center (a place with air conditioning to provide temporary respite from the heat)
  • Avoid lighting candles, vacuuming, or using a gas stove which can worsen indoor air quality
  • Rinse your child’s eyes with water if they are stinging or itchy
  • If your child has a lung condition like asthma, make sure you have enough medication, especially a rescue inhaler
  • Call your healthcare provider if your child feels short of breath, or complains of dizziness or chest pain
  • Seek emergency care if you see signs of shortness of breath as listed above or if your child seems less alert or very lethargic

Resources

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

2023 Community Health Improvement Week

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Dr. Martin and Robin Read share how their organizations are working together to make a healthier future for our county.

This year, Community Health Improvement Week runs June 12 – 18.

Vehicular Heat Stroke in Children

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Contributor Dr. Elise Herman

As summer approaches and the outdoor temperature increases, a danger looms for children- vehicular heatstroke (VHS), which is heat injury due to being in a hot car or other vehicle. These deaths are so preventable, and as a parent you may wonder how such a thing could happen, but vehicular heatstroke claims an average of 38 children’s lives a year in the US, with almost a thousand deaths since 1998.

Heat stroke is the most severe heat-related illness and occurs when the core body temperature is over 105.8 degrees Fahrenheit with signs of nervous system injury including confusion, seizures, and coma. Dehydration along with heat exposure can cause deadly heat stroke. Children are more at risk because they sweat less than adults and can overheat more quickly.

Vehicular heatstroke most often occurs when an adult ‘forgets’ a child in a car, often when the adult is on the way to work, intending to stop at childcare first. A change in routine such as a different parent doing the drop-off can also increase the risk. Parental stress or sleep deprivation can be contributing factors. Vehicular heat stroke can also occur if kids are playing in a car and accidentally lock themselves in.

The outside temperature does not need to be extremely high for vehicles to become dangerously hot. VHS has happened with outside temperatures as low as 57 degrees. A car can heat up 20 degrees in 10 minutes on a sunny day, and 72 degrees outside can become 117 degrees in a vehicle within 1 hour. Cracking the window or parking in the shade make little difference in term of the car heating up. Climate change also means more hot days and more extreme heat.

There are steps we can take to minimize the risk of this tragedy:

  • Never leave a child in a vehicle unattended even briefly
  • Make it a habit to open the back door of the car when you park, just to check the backseat.
  • Put some important item you need for your day- purse, iPad, employee badge, etc. in the back seat near your child.
  • Keep a stuffed animal or something similarly eye-catching in the car seat when empty and move it to the front passenger seat when the car seat is in use as a reminder.
  • Remember the phrase “Look before you lock”.
  • Instruct your childcare provider to contact a parent if a child is not dropped off as scheduled.
  • Keep car keys out of reach of kids, and teach them to never play inside cars, trunks, etc.
  • Teach your child to honk the horn if they are trapped inside a car.
  • If a child is missing, check all vehicles and trunks immediately.
  • If you ever see a child alone in a locked vehicle, call 911.

Resources

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

Social Media & Teens

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Contributor Dr. Elise Herman

Parents of teens know that this is a tough time for their kids, and many experts point to smartphones and social media as contributing to the worsening mental health of young people. Recent research has shown that social media is not just related to depression, anxiety, and loneliness, but can cause these issues. It should be noted that no one should be on social media until age 13 (it is against the rules as well as potentially harmful), and the later a teen starts with it, the better.

When phones and social media became common around 2012, kids began spending less time with friends just ’hanging out’, which is felt to contribute to feelings of isolation. So what are kids doing instead of hanging out with their peers? They are, of course, on their phones. 95% of all American teens have smartphones and they are on their phones over 7 hours a day (excluding for academics or homework). It is well known that all that phone and social media time is interfering with sleep, and inadequate sleep is tied to anxiety and depression in teens.

The negative effects of social media include bullying, kids comparing themselves to other people’s “perfect lives”, and a sense of FOMO (Fear of Missing Out). There may also be exposure to violent or sexual content. Instagram and other social media can promote body image issues in teen girls who may already be struggling with self-esteem. Social media (including TikTok, Instagram, Snapchat, and YouTube) is engineered to be addictive, and 2/3 of teens age 13-17 years use it, 16% admitting to using social media “almost constantly”.

There are some clear positives of social media, however. Most teens say it can make them feel more connected to peers, and those with a disability or feeling marginalized may find support on a social media platform. It can provide an outlet for creativity, and most would agree on its potential for being entertaining.

Given that there are some positives, and most teens are very plugged in to their social media, what can parents do to help their kids regulate their usage? Although banning social media outright seems tempting, this is unlikely to be successful. Knowing that just decreasing the amount of social media can help kids with body image, depression, anxiety and self-esteem, it is better to make a mutually agreed upon plan with your teen to limit it.

This plan should have scheduled downtime daily without the phone and social media, including mealtimes and the hour before bed (and ideally no phones in the bedroom). Social media should be allowed only after homework is done; this can be implemented via parental controls if needed. Setting a daily time limit for social media apps is easily done on the phone; ideally your teen should do this and look at it as helpful reminder although parental controls are again an option. Encourage taking a longer break for activities like camping, traveling, and special times with friends or family. It is good to see how much more engaged we are when we don’t have our phones and social media to distract us.

Discuss with your child what on social media makes them feel better or worse; if something makes them feel worse, they should avoid it (good advice for us adults, too). Sympathize with your teen if you have a love/hate relationship with your social media and that limiting this may be difficult for you, too. Handling social media can be something you do together as a family. The American Academy of Pediatric has a new version of their free Family Media plan which can guide parents in media usage individualized for each family member (see Resources, below).

Parents should be familiar with social media platforms and know which ones their child is using. Encourage frequent conversations with your teen about relationships, social media, and emotional well-being so it will be easier for them to come to you if they have concerns. If social media is affecting your teen’s mental health, it is time to take a break and consider talking to your child’s healthcare provider and/ or a counselor.

Resources

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

Bringing Music into Your Child’s Life

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Contributor Dr. Elise Herman

Children seem to love music right from the start, which makes sense since babies in the womb can hear sound beginning around the fourth to the fifth month of pregnancy. Research has shown the many positives of music for kids, so making music part of your child’s life will reap benefits over their lifetime. Music involvement includes listening to music, playing an instrument, singing, and dancing.

Music exposure for young children increases brain development, according to research done at the University of California at Santa Cruz in 2016. This was particularly noted in the areas of language and reading skills. Other research has shown that participation in music classes can increase IQ and standardized test scores along with achievement in English and mathematics. Involvement with music improves patience and listening skills and, therefore, school readiness for young children. Experiencing music and dance of different cultures expands a child’s world view and appreciation of other people.

Music has been shown to decrease stress hormones and anxiety, so much so that it is used in hospitals before surgeries and in dental offices. It increases positive emotions and encourages self-regulation and a sense of calm– obviously beneficial for children of all ages. Playing an instrument and dancing help develop motor skills and encourage self-expression and creativity. Being part of a music or dance class teaches kids how to participate in a group and work with others; kids learn valuable social skills in these settings.

It is never too early to bring music into your child’s life. Sing to your unborn child and continue this from infancy onward. Talent doesn’t matter, so don’t avoid this if you are not a gifted singer (few of us are). Sing lullabies to your infant, and attach certain songs to activates for your toddler, such as songs for cleaning up, nap time, and bedtime. Nursery rhymes and clapping along are delightful to young children. Preschoolers love silly songs and lots of repetition (think “The Wheels on the Bus”). Quiet background music (at times) is a great way to expose your child to music of different types.

Keep simple musical instruments in your child’s play area, like a tambourine and shakers. You can also make your own ‘instruments’, such as using a wooden spoon to beat pots and pans and putting beans in a childproof small plastic container for a shaker.

Older kids enjoy music classes in school and benefit from music and dance lessons outside of school as well. Watching dance videos with your child and trying to learn dances together is a fun musical activity. Going to concerts and dance performances connects kids with others and encourages attention and listening skills.

So, start early by filling your child’s life with music and dance of all types. Have fun, and let it awaken the child within you, too. Look online to find lots of local opportunities for music and dance, both for classes and live events. We are also fortunate to have the outstanding music department at Central Washington University, which offers many concerts which are family-friendly.

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

Parenting Your Teenager

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Contributor Dr. Elise Herman

As kids get older, the joys and challenges of parenting change. Teenagers can be wonderful people—enthusiastic, very involved with friends, and with passionate opinions and feelings. However, they can also be impulsive, take risks and feel invulnerable, creating a setup for poor decisions. In addition, teens are working on independence, which can mean pushing back against authority (i.e., us parents). It is all-natural but can create some tension in the household.

Many parenting goals now are the same as when your child was younger, such as encouraging a healthy lifestyle. This includes good nutrition, family meals, getting outside regularly, and adequate sleep. Teens generally need 8-10 hours of sleep nightly but often want to stay up late and then sleep in or have difficulty getting up for school. “Sleeping in” on the weekends should be no more than 1-2 hours later than usual, and naps should be avoided. There should be no caffeine later in the day (this includes pop). Phones or other devices should not be used within an hour of bedtime; ideally, phones are out of the bedroom at night to limit temptation. If you feel this won’t work, parental controls can also be used to manage data access.

Safety is a big topic for teens— so many new things are happening! Driving, dating, possible alcohol and drug use, mental health concerns. Find moments to chat with your teen about some of these issues in shorter conversations, possibly when the two of you are in the car or making a meal. If something is in the news, such as cyberbullying, use that as a start to a discussion (not a lecture). Acknowledge that things are more complicated and high-pressured for them than when you were a teen and that you would like to know more about their world.

Encouraging autonomy means having clear, consistent rules and expectations (ideally agreed upon by your teen) for driving, dating, curfew, etc., gradually giving them more freedom. Acknowledging their successes helps build confidence and will make you comfortable giving them more responsibility. Consequences for poor behavior should be “firm and fair” and be understood by your child beforehand. Give your child a more significant voice on decisions such as meals, activities, and family plans; weekly brief family meetings are a great time to let your teen know their input is valued.

Teens are really in training for adulthood, and you need to give them life skills to succeed. Having chores, learning to set a budget, and being able to cook and clean are crucial. A part-time job encourages responsibility and teaches your teen to balance work, school, and other activities. Learning to drive can be challenging and perhaps worrisome to parents, but it is necessary to become independent. Teens should know how to do essential home repairs, change a tire and deal with small emergencies (such as power outages or grease fires in the kitchen). Teach them essential money management, such as using a credit card responsibly and spending wisely within their means. Learning to regulate emotions is also a necessary part of growing up. Model this by trying to remain calm, talking about your feelings, or taking a break from an uncomfortable situation.

The teen years can be challenging for you and your child as they strive for more independence. Mistakes may be made, but let them know you are there to support them. Don’t be afraid to tell them you love them, even if it sometimes feels awkward. They may not always act like it, but adolescents still want to know they are loved unconditionally, so even a brief hug or high five is reassuring when life may feel stressful and confusing.

Resources

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.