2018-19 TOW #47: Tuberculosis screening

We are fortunate to live in an increasingly diverse city with immigrants from around the world. At this time of year families are often planning summer travel to visit family members abroad, so this is a good time to think about how to screen for TB after travel. Materials for this week:

Key take-home points:

  1. What are the rates of TB in the US, and what are the risk factors among children? TB has been declining in the US and reached an historic low of 3.2 cases per 100,000 in 2012. The biggest risks are being born outside the US, or traveling to another country, especially for >1 week and staying with family. For children, additional risks include living among family members or visitors born in endemic countries, or living with high risk adults (including those affected by homelessness, incarceration, drug use or HIV). Those with chronic diseases, immunodeficiency, and/or those using high-dose steroids are also at higher risk of developing TB.
  2. Who do we need to screen for TB in clinic? It’s recommended to start screening for latent TB infection (LTBI) from the first time we meet patients and annually at well visits, or 10 weeks after return from travel (although considered acceptable to wait for annual check-ups). To assess LTBI risk factors, there are 4 validated questions: 1) Has a family member or contact had TB? 2) Has a family member had a positive TB test? 3) Was the child born in a high-risk country (i.e., outside US, Canada, Australia, New Zealand or Western Europe)? 4) Has the child traveled to a high-risk country for more than 1 week? (and SCH ID team adds: or has child had household visitors from a high-risk country?)
  3. Which screening tests do we use? Screening tests vary by age group: per the CDC, tuberculin skin test (TST or PPD) is still preferred for children less than 5. The preferred test for ages 5 and older is a blood test, the interferon gamma release assay (IGRA, e.g., QuantiFERON -TB Gold). IGRA tests measures interferon gamma response to mycobacterial antigens so are relatively specific to M. tuberculosis. They do not require a return visit, and are not cross-reactive with BCG vaccine. We can use a combination of tests to help establish diagnosis when there are indeterminate results, or concern for false positives or negatives.
  4. What happens if there is a positive TB screen? To establish a diagnosis of latent TB, rule out active disease through a chest x-ray, history and exam. The initial preferred treatment for positive latent TB is with isoniazid (INH) for 9 months (there are alternative schedules to this based on special patient needs).
  5. How common is BCG vaccine? How does BCG vaccine affect interpretation? Bacille Calmette-Guerin (BCG) immunization is widely used in TB endemic countries; the WHO estimates that 83% of the world’s population has received this vaccine. Most countries recommend giving the vaccine at birth, and the majority of children receive it before age 5. Because of the varying effects of BCG on interpreting TB tests, we use a conservative approach, and BCG status is not used in interpreting PPD reactions, and is not a contraindication for receiving PPD. Quantiferon gold testing is not affected by cross-reactivity with BCG, however the test has been less accurate for younger children, and may be more difficult to administer due to phlebotomy requirement.

2018-19 TOW #38: Child abuse recognition

April is child abuse prevention month, an important reminder to discuss this always challenging but critical topic. Our role in primary care encompasses strategies to build resilience, promote strong relationships, link families to resources, and screen and refer for concerns as mandated reporters. SCH’s Protection, Advocacy and Outreach team has 3 prevention programs: Period of PURPLE crying, Medical-Legal Partnership, and Positive Parenting (which funds our Promoting First Relationships (PFR) training).

Materials for this week:

Take-home points for child abuse recognition:

  1. How many children are affected by maltreatment? We are likely to encounter child maltreatment in our practices: 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. How are “neglect” and “verbal abuse” defined? Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child; it includes lack of adequate nutrition, hygiene, shelter, and safety. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. “Verbal abuse” refers to nonphysical forms of punishment intended to cause shame and humiliation.
  3. What is the AAP stance on corporal punishment and why? As of fall 2018, the AAP opposes any form of corporal punishment, including spanking, as it is not effective for changing long-term behavior and is associated with many adverse outcomes, including aggressive behavior and mental health problems. Here’s a very informative infographic on the psychology of spanking. Dr. Sege, who co-authored the AAP statement, discusses how you can talk to parents who were spanked themselves in this podcast (here’s the interview transcript).
  4. Which children are at highest risk for child abuse? Children in all SES levels are at risk, and in ~80% of cases, parents are perpetrators. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired or multiple gestation pregnancy. Parent-level risk factors include poverty, multiple children under 5, substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for development.
  5. What is the most overlooked form of abuse? Bruising is the most frequently missed form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and referral to CPS. Before being diagnosed with child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury.

2018-19 TOW #36: Learning disabilities

Our role in addressing child development extends into the school years as we help children when there are concerns about school performance. I had a long discussion with a school psychologist this week who helped identify important needs for one of my patients. This is a really important topic for us to be knowledgeable about to support families and partner effectively with schools.

Materials for this week:

Take-home points:

  1. How many children are affected by learning disabilities? The lifetime prevalence of learning disabilities in US children is 5-10%, so should be considered when children are having school difficulties. Learning disabilities are heritable, but specific genes are still being identified. fMRI studies show children’s brains with learning disabilities differ in structure and  function.
  2. How do we define a learning disability and what are the types? A learning disability is a disorder that affects a child’s ability to read, use and understand language, write, or do mathematical calculations. Learning disabilities have been described as a significant discrepancy between academic achievement and intellectual potential, despite receiving appropriate instruction. Two main types are verbal/language (affecting ~80% of those with learning disabilities including dyslexia, i.e., difficulty reading and dysgraphia, i.e., difficulty writing) and non-verbal (dyscalculia, including problems with visual-spatial relations, math, and problem solving). There is a lot of overlap, and children often have both types.
  3. What’s the pediatrician’s role in diagnosis? Usually, behavior problems are the first presenting symptoms. Children may act out or withdraw because they cannot meet the demands or may have difficulty paying attention to material they don’t understand. We should first identify or exclude other causes that impact academic performance such as psychosocial (e.g., abuse, neglect), medical (e.g., prematurity, drug exposure, hearing/vision problems) and developmental issues (e.g., ADHD). Formal testing required to confirm a specific diagnosis is typically the school’s role. We can refer the child to the school’s committee on special education for evaluation. The request should be in made in writing by the parent, and we can often be helpful by including a note outlining specific concerns. We can also refer for advanced evaluation by a psychologist or developmental-behavioral pediatrician.
  4. What’s our role in monitoring? Our role includes being an advocate for the child in interfacing with school personnel, assisting the family in understanding the diagnosis, and monitoring progress. We should routinely screen for associated problems that can arise such as new behavioral difficulties, anxiety, and depression.
  5. How should we interface with schools? First, we have to obtain permission with a signed Release of Information form from the parents. An important law to be aware of is the Individuals with Disabilities Education Improvement Act (IDEA) part B, a federal law ensuring that all students ages 3-21 receive a free and appropriate public education under the least restrictive environment, regardless of disability. If a child is found to qualify for special education services under IDEA laws, an individualized education program (IEP) is created, outlining the plan for special education service. We can access the Medical-Legal Partnership if we feel that children are not receiving services for which they qualify under the law.

2018-19 TOW #8: Early learning

This topic is one that makes me hopeful for the world when we see the progress made in recognizing the importance of early learning for children and local and nationally advocacy to improve it. There’s a long way to go for universal access, but Harborview Pediatric Clinic has done a great job with Dr. Abby Grant’s leadership to strengthen an integrated referral approach to early learning. I am so excited to share the newer resources that social work students put together to help us identify where to refer our patients.

Take-home points about early learning:

  1. Our role: We as pediatricians have an opportunity to advocate for our patients through early learning settings: referrals to quality child care, preschool and Head Start programs, and also supporting work on policies and funding for these programs.
  2. Why preschool matters: Robust research shows that children who participate in high-quality preschool programs have better health, social-emotional, and cognitive outcomes than those who do not participate. Participating in quality early learning can boost educational attainment and income later in life – some studies have followed up participants into their 40s and 50s. A key factor in the most successful programs is very high-quality offered by well-trained staff.
  3. Preschool helps address disparities: Children from low-income families on average start kindergarten 12 to 14 months behind their peers in pre-literacy and language skills – they have the most to gain from preschool programs.
  4. We can do better: Only 41% of children from low-income families are enrolled in preschool compared to 61% of more affluent peers.
  5. Next steps: While most pediatricians inquire about early education, only a small proportion assist families in completing Head Start applications. Read the attached to learn more about options for publicly funded programs for your patients. Please remember to advocate for quality early learning settings for your patients and in our local and state policy decisions.

2018-19 TOW #5: Water Safety and Drowning Prevention

Summer is a great time to review water safety, especially in Seattle where we have access to so much beautiful open water and sunshine to enjoy it. Safety around water is critical, as drowning is actually a leading cause of injury death for children. Seattle Children’s has partnered with community organizations through programs like Everyone Swims to develop materials and advocate for policy changes to prevent drowning, including contributions from our own residents.

Check out this week’s teaching resources here:

Take-home points for understanding drowning and promoting water safety:

  1. Epidemiology of drowning: Death from drowning is a top 3 cause of injury death in childhood. It is the leading cause of injury death for 1-4 year olds and the 2nd leading cause for 5-14 year olds. Unfortunately, it disproportionately affects minority children. Children can drown in only 1-2 inches of water. Adolescent males have a 10-fold increased risk of drowning compared to females. They have higher risk exposure, more risky behaviors (e.g., swimming alone and at night), and are more likely to drink alcohol in aquatic settings.
  2. Drowning definition: Drowning is no longer defined as death from submersion. The WHO defines it as “a process of experiencing respiratory impairment from submersion/immersion in liquid” and outcomes are classified as death, morbidity, or no morbidity.
  3. Risk reduction: Drowning can be prevented by many strategies including 1) adult supervision within arm’s reach, 2) life jackets, 3) pool fencing that encloses the pool and is at least 4 feet high, 4) swimming at lifeguarded areas, and 5) swimming lessons. The American Academy of Pediatrics (AAP) recommends children begin to learn to swim by age 4. In one study, taking formal swimming lessons was associated with an 88% reduction in drowning risk (Brenner et al. Arch Ped Adol Med 2009).
  4. Drowning prevention: Pediatricians have a role in helping prevent drowning. Screen for swimming ability at age 4-5 and refer to swim lessons (see pool info handouts on Everyone Swims tab on the SCH drowning prevention page). Discuss water safety with families and provide information, including handouts here: http://www.safekids.org/watersafety

2018-19 TOW #3: Well child care/ health supervision

The beginning of the academic year is a great time to review our central tenets in providing effective well child care (WCC). WCC can be very rewarding as a pediatrician, especially if you have the right tools and knowledge. We all recognize that providing comprehensive WCC is difficult in a 15-20 minute visit, so we have to prioritize. We are also being called upon to consider new models of care to truly impact social determinants of health and chronic diseases over the lifetime, as one of our own amazing gen peds faculty, Dr. Tumaini Coker, discusses below and is actively researching.

Materials for this week:

Take-home points for this week:

  1. Why well child care? Through WCC visits, we have a unique opportunity to identify and address important social, developmental, behavioral, and health issues that can have significant and long-lasting effects on children’s lives into adulthood. Pediatricians provide the vast majority of WCC to children in the US, which differs from other countries’ health systems where general practitioners or nurses provide it. As society changes, one of our current pediatric challenges is to adapt WCC to better address issues that most impact adult health including poverty, low education, environmental exposures, and ACEs (Adverse Childhood Experiences). Newer models of care including the medical home with integrated care, group visits, home visitation programs, and health navigators are all being utilized and studied to improve WCC.
  2. What ages do we recommend WCC visits and why? We have >20 visits recommended with children between ages 0-18. Currently there are 6 visits recommended between birth to age 1 (newborn, 2-4 weeks, and 2, 4, 6 and 9 months). Visits are spaced out over the next 2 years (15, 18, 24, 30 months) and then annually after age 3. The timing for these has been largely influenced by providing vaccines, which is the most evidence-based prevention strategy we use in pediatrics; and by Bright Futures, developed by the maternal and child health bureau in the 1990s to standardize recommendations and care.
  3. How do we prioritize topics for WCC? For each recommended well child check from newborn to age 21, Bright Futures includes guidelines for screening and a “menu” of 5 possible anticipatory guidance topics. Even with these pared down, there’s a lot to cover, so we often still have to do more focusing. There’s some data that parents can only retain up to 3-4 recommendations from a visit. It’s also not just what we say, but how we say it that matters. To support parents feeling engaged and supported, we can use the tools of Promoting First Relationships in primary care. We can show we welcome parents’ concerns and acknowledge their needs and efforts. Through specific positive feedback, we can highlight what we see them doing well to engage in responsive parenting, recognize their child’s needs, and to find joy in interacting with their child.
  4. What’s the evidence for effective components of anticipatory guidance? Unfortunately, the studies are difficult to do and the data is limited. Because of this, the US Preventive Services Task Force often gives a Category 1 (Insufficient Evidence to Evaluate) rating to pediatric screenings, such as for lead, and cannot say whether outcomes are improved because of the intervention. There are several pediatric preventive health interventions with good supporting evidence including Reach Out and Read, promotion of breastfeeding, the “back to sleep” campaign, and avoidance of physical discipline.
  5. In the limited time we have, what’s most important to cover? Most important is that we address parents’ concerns and set an agenda with them. While I confess I don’t love or routinely remember mnemonics, “CHECUP” is a good list for basics to review that is more or less mapped to the order of topics in the visit, starting with parent concerns.
  • C – Concerns (or questions)
  • H – History (interval hx, past medical, birth, family, social)
  • E – Environment (home, typical day, nutrition, sleep)
  • C – Child (development, growth, voiding)
  • U – Unanswered questions (inquire about further concerns)
  • P – Prioritized anticipatory guidance

TOW #50: Marijuana Use

Among 12th graders, daily use of marijuana is now more common than cigarettes. As a legalized marijuana state in Washington, we should know about important implications for adolescents, and for pregnant and breastfeeding moms, as reviewed below.

Materials for this week:

Take-home points for marijuana use among adolescents:

  1. What are the active components of marijuana? Over 200 mixtures of cannabinoids come from the cannabis plant. One of the cannabinoid chemicals, tetrahydrocannabinol (THC), has psychoactive properties that has led to its recreational use. Cannabidiol (CBD) – a non-psychoactive cannabinoid, is another of the active chemicals for medicinal use. There are varying amounts of THC and CBD in any given plant.
  2. How prevalent is marijuana use?  The National Survey on Drug Use and Health showed the prevalence of past-month marijuana use in the US more than doubled between 2001-2002 and 2014-2015, with 8.3% of those aged 12 or older reporting past-month marijuana use. According to the NIH’s Monitoring the Future Survey, in 2015 34.9% of 12th graders in the US reported past-year use of marijuana. The 2015 survey also found that daily marijuana use exceeded daily tobacco cigarette use among 12th graders for the first time since the study’s inception (in the 1970s; 6% vs. 5.5%).
  3. What are the short-term effects of useWhat are long-term effects on developing brain? Side effects of marijuana use included impaired attention, concentration, and executive functioning. Tachycardia and systolic hypertension are two consistent physical effects. Other short-term effects include drowsiness, ataxia, increased appetite/thirst, conjunctival injection, dry mouth, anxiety, insomnia, hallucinations and short-term memory loss. In the long run, heavy marijuana use in the adolescent period interferes with synaptic pruning and myelination, causing changes in the hippocampal region, prefrontal cortex and white matter volume, which correlates with impaired cognitive functioning. These changes can affect attention span, concentration and problem solving, as shown in studies analyzing functional MRIs of marijuana users. Additionally, there is emerging data supporting increased risk of psychosis and predisposition to developing schizophrenia in adolescent marijuana users.
  4. What are differences between legalization and decriminalization? Legalization refers to allowing legal cultivation, sale, use, and/or possession of marijuana. Decriminalization means eliminating criminal penalties for possessing or using small amounts of marijuana. Both concepts have been debated, particularly for how it affects the adolescent population. The biggest support for decriminalization is shifting from law enforcement to a public health approach that emphasizes medical treatment for drug dependence or addiction. One of the problems with legalization (as we are seeing in WA) is the belief among adolescents that regular use does not cause harm. Nationally in 2015, 68.1% of 12th graders did NOT view regular  marijuana use as harmful.
  5. What are the effects of levels of THC for pregnant and nursing mothers? Breast milk can be up to 8 times as concentrated as the serum levels of chronic users, and THC is readily absorbed and metabolized by infants. The American College of Obstetricians and Gynecologists (ACOG) and Academy of Breastfeeding Medicine recommend stopping marijuana use (either recreational or medicinal) during pregnancy and breastfeeding given animal studies that suggest negative effects on brain development and lack of safety data in humans. It is important we discuss these risks with moms.

TOW #49: Adverse Childhood Experiences (ACEs)

We are fortunate to be in a time in pediatrics when the neuroscience is catching up with what we have long known about social determinants of health affecting children’s development. The original study on Adverse Child Experiences (ACEs) was published 20 years ago in a collaboration between the CDC and Kaiser. Growing understanding of the science behind toxic stress outcomes is generating renewed interest and investment in early childhood programming, such as here in King Co with the Best Starts for Kids program, and nationally in programs like the AAP Resilience Project, among others.

A big thanks to the fantastic advocacy of Drs. Colleen Gutman (Chief ’17) and Abby Grant who helped prepare these resources to inform your clinic practices. These materials also build on and relate to the approaches we have discussed in Promoting First Relationships (PFR).

Resources for this week:

Take-home points on ACEs/Trauma-informed care:

  1. Ecobiodevelopmental framework (EBD) – As reviewed in the AAP Technical Report, “an emerging, multidisciplinary science of development supports an EBD framework for understanding the evolution of human health and disease across the life span.” Science has shown significant associations between the “ecology of childhood” and many developmental outcomes and life course trajectories.
  2. ACEs definition: Adverse childhood experiences (ACEs) are experiences in early life that have detrimental effects on child development and adult health outcomes including abuse, neglect, being exposed to intimate partner violence, mental illness, and drug addiction. In addition, poverty and racism can exacerbate the effects of other ACEs.
  3. Toxic stress definition: Adversity and maltreatment in childhood are thought to affect development and health through chronic exposure to stress. This repeated and ongoing activation of stress response pathways is termed “toxic stress”, in contrast with normal, healthy, physiologic stress response mechanisms. Children experiencing adversity and maltreatment have been shown to have elevations in inflammatory cytokines and dysregulation of their HPA axis, and their brains may develop differently.
  4. Protective factors: Thankfully, the presence of a positive, nurturing adult is powerful in protecting against the negative effects of toxic stress. While there is great variability in genetic susceptibility to stress reactivity, nurturance mediates and protects against the negative effects of toxic stress and adversity (not just in humans, but across animal species, too).
  5. Pediatricians’ role in addressing ACEs/toxic stress: we are being called upon to take more active roles in developing and implementing science-based strategies to reduce toxic stress in early childhood, and hopefully thereby tackle some of the pressing disparities in learning, behavior, and health. We can become knowledgeable about the concepts and resources on trauma-informed care (as above). We can take a “universal precautions” approach and treat everyone with respect and humility. We can be aware of somatic symptoms that may be signals of untreated stress/trauma. We can also give special attention to care provided to those who are affected by trauma to help build nurturing and resilience, and avoid retraumatizing children and/or caregivers.

TOW #48: Fatherhood

In honor of Father’s Day next weekend, we are going to review the role of dads and how to expand beyond our traditionally mother-centric perspective of child-raising to be intentional about engaging fathers (and other support parents) in the care of children. Many more children are being raised in families where parents are not married, where mothers are working, and/or where the father is the primary parent, so supporting fathers to be actively involved as parents is increasingly important. Indeed, we have some great father role models in our program!

Materials for this week:

Take-home points on fathers’ role in parenting:

  1. Definition of father has expanded: a father can be any male adult who is most committed to, caring for, and supportive of the child including a stepfather, grandfather, adolescent father, father figure, or a co-parent in a gay relationship, regardless of living situation, marital status, or biological relation.
  2. Barriers to fathers’ involvement in child’s health care: 4 major barriers include employment (lack of flexibility, etc), interpersonal (cultural barriers, mother not wanting father to be involved, or not living in home), personal (lack of knowledge, comfort), and health care system (lack of access to records, appt times, etc).
  3. Fathers’ involvement matters: The presence of fathers positively impacts health, mental health, and educational achievement of children. We can encourage single mothers to increase the involvement of dedicated male role models in a child’s life. Additionally, we can discuss the importance of an involved father figure and parenting tips directly with fathers whenever possible. We can help dads know what a difference they make.
  4. Dads may need coaching and encouragement: Men are less likely to have babysat or helped care for siblings when growing up compared to women. We need to address dad, learn his name, make eye contact with him, and include him when providing information about parenting. We also need to ask him direct questions and remind mom of the importance of involving dad. We can help foster the mentality of teamwork as the best way to support the child. Doing this at the nursery and newborn visits is especially helpful to set the tone from the start, like handing the baby to the dad or asking dad to help change the diaper. Specific ways for us to encourage dads to be part of care include doing the bedtime routine (the sleep expert Dr. Craig Canapari emphasizes a simple sleep routine that one parent can do solo), and doing night-time feedings.
  5. Advocate for parent-leave policies: Data from countries like Denmark that have generous paternity leave policies show impressive outcomes: dads become involved from the beginning, and it’s better for the country’s overall productivity, as it supports more moms to return to work when both parents engage and share in child-rearing. We can all advocate through the AAP and other pediatric organizations to have more family-friendly leave policies in the US; encouragingly, our local tech employers seem to be setting the stage for adopting them, and we can hope the trend finally spreads!

TOW #20: Child poverty

As we head into the holiday season, this is an opportune time to reflect on the impact of poverty and how to serve our vulnerable children. With the help of many wonderful faculty and residents including Dr. Abby Grant and REACH Pathway residents, we have a comprehensive list of resources to draw upon to support families.

Materials for this week:

Take-home points:

  1. How many children live in poverty? Unfortunately, children represent the group with the highest poverty rates in the US, with 22% living below the federal poverty level (FPL). In 2017, the FPL is $24,600 in annual income for a family of 4. If you include those living at 200% of the FPL, or “near poor”, that represents 43% of children – almost half – I find this statistic quite shocking. Since 2013, the majority of children enrolled in public school live in poverty. The FPL method was developed in the 1960s, and many argue that it is outdated and understates the true scope of poverty in the nation. There are major inequities in poverty rates, with non-white children experiencing much higher rates of poverty. The PBS series “America by the Numbers” highlights the striking disparities in health related to poverty.
  2. What are the effects of poverty on health? Poverty represents one of the biggest threats to children’s health. The effects are far-reaching: “Poor children are almost twice as likely to be in fair or poor health, are 1.7 times more likely to be born low birth weight, are 3.5 times more likely to suffer from lead poisoning, are twice as likely to experience stunting, and are more likely to be diagnosed with severe chronic health conditions. Poor children are 1.7 times more likely to die in infancy and 1.5 times more likely to die in childhood.” – Bauman Pediatrics 2006
  3. Where can we learn more about the science of poverty and its effects on children? The Academic Pediatric Association (APA) Task Force on Child Poverty developed the U.S. Child Poverty Curriculum​, a series of 4 stand-alone modules to promote understanding of the impact of poverty and other social determinants of health on child well-being, the biomedical influences of poverty, and advocacy. The AAP resident section conducted a FACE poverty campaign and developed many teaching tools and resources specific to residents.
  4. How do we tackle poverty in the office? Dr. Benard Dreyer, past president of the AAP, helped develop the AAP’s first policy statement on poverty and recommended that pediatricians screen for poverty risk factors. As we reviewed last week, I-HELP is a screening tool to remember ways we can address concrete needs by asking and linking to resources for Income, Housing, Education, Legal (immigration), Personal & Family stability. Other screening tools including for food insecurity are reviewed here. We can also help parents develop positive relationships with their children that are protective and build resilience, such as those approaches taught in the Promoting First Relationships curriculum. It’s also exciting to consider more sweeping structural changes including revamping primary care delivery, providing home visitation, care coordination, and parenting programs, all described by Drs. Beck et. al (see above).
  5. What can we do to address poverty at a policy level? We can advocate with our national organizations for policies that benefit families including benefits and tax support-many outlined by Dr. Dreyer in his Case For Ending Childhood Poverty.