The American Academy of Pediatrics (AAP) has taken the lead on protecting immigrant children, as the Trump administration issued a series of executive orders shortly after taking office in January that included raids by Immigration and Customs Enforcement (ICE) police from the federal Department of Homeland Security. There were also children denied entry who were refugees, vetted with their families for years and already cleared to enter.

“The mission of the American Academy of Pediatrics is to protect the health and well-being of all children — no matter where they or their parents were born,” wrote Fernando Stein, M.D., AAP president, in a Jan. 25 position statement. “Immigrant families are our neighbors, they are part of every community, and they are our patients. The Executive Orders signed today are harmful to immigrant children and families throughout our country. Many of the children who will be most affected are the victims of unspeakable violence and have been exposed to trauma. Children do not immigrate, they flee. They are coming to the U.S. seeking safe haven in our country and they need our compassion and assistance. Broad scale expansion of family detention only exacerbates their suffering.

“Far too many children in this country already live in constant fear that their parents will be taken into custody or deported, and the message these children received today from the highest levels of our federal government exacerbates that fear and anxiety. No child should ever live in fear. When children are scared, it can impact their health and development. Indeed, fear and stress, particularly prolonged exposure to serious stress — known as toxic stress — can harm the developing brain and negatively impact short- and long-term health.

“The American Academy of Pediatrics is non-partisan and pro-children. We urge President Trump and his Administration to ensure that children and families who are fleeing violence and adversity can continue to seek refuge in our country. Immigrant children and families are an integral part of our communities and our nation, and they deserve to be cared for, treated with compassion, and celebrated. Most of all, they deserve to be healthy and safe. Pediatricians stand with the immigrant families we care for and will continue to advocate that their needs are met and prioritized.”

Advice to pediatricians

Medscape interviewed Julie M. Linton, M.D., co-chairperson of the AAP Immigrant Health Special Interest Group and a pediatrician in Winston-Salem, North Carolina, about immigration. Linton cares for many immigrant children. The interview was published Feb. 8 under the title “The Black Cloud of Deportation and Stress in Immigrant Children.”

Medscape: How can primary care providers who have immigrant kids in their practice recognize and assess these children? These families may be afraid to disclose their immigration status to anyone, even the pediatrician. What questions can or cannot be asked, and how can clinicians be respectful of the family’s need for privacy?

Dr Linton: This is a very real phenomenon and something with which we commonly struggle in clinical practice. Providing culturally effective care from the start is critical for families who prefer languages other than English. Having skilled interpreters to help us to communicate directly with families is essential, unless you are an official bilingual provider in the child or family’s preferred language and are able to successfully communicate with them. Very clear interpretation for communication is critical when you are talking about any issue related to health, and particularly when you’re talking about sensitive issues. If we are going to ask families about stress as it relates to immigration, it’s very important that we make it clear to the family that the reason we are asking these questions is because these are all things that can affect their child’s health. I often say something along the lines of ‘I’m going to ask some personal questions to understand your family’s journey. Many of the children and families I care for face chronic stress that can impact health. I want to understand how stress may be affecting your child’s health and how we may be able to help you.’

Medscape: What about documenting the care of these children? Is it safe to document a child’s citizenship status within the health record?

Dr Linton: If an immigration officer or team contacts a pediatrician for patient information, the pediatrician should be aware that all medical information, including documentation, is multifaceted and protected by the Health Insurance Affordability and Accountability 1996 (HIPAA) Act of 1996. It can be helpful to seek assistance from the legal department at the healthcare facility, or from the solo practitioner’s own legal counsel.

“Citizenship is relevant to health, and clinicians want to document these conversations in the confidential medical record. The AAP firmly believes that medical records should not be used in any immigration enforcement action; that’s part of our immigrant child health policy statement that was published in 2013. The question about how to best document these conversations in the medical record should be deferred to legal colleagues, but I can share some insight into how I approach this issue. For more information, the AAP’s Immigrant Health Toolkit has answers to some of these legal questions. For even more up-to-date information about legal issues that affect immigrant families, the National Immigration Law Center (NILC) is an outstanding resource for providers and families. It tends to be directed toward legal providers but has information that can be extrapolated to healthcare as well. I often use that as my resource because the NILC keeps its information up to date more than any other group and is very sensitive to advocacy issues that pertain to these populations.

Medscape: Here is the most important question: If you have an immigrant child in your practice who is experiencing the negative health effects of stress, what can you do? What are some best practices?

Dr Linton: First and foremost in the setting of fear and stress, children need buffering support from loving parents or caregivers. We know that enduring, supportive relationships with caregivers help children to overcome stress and build healthy brains. For many of the immigrant children whom I see in clinic, supportive family relationships create a buffer for ongoing stress. As pediatricians, we have a crucial role in supporting families as they support their children. Some of the things that we can celebrate in that process include enhancing the ‘serve and return’ — interactions with children that are supportive and encourage brain development. These include reading, talking, and singing with children; spending quiet time; and engaging in conversations that answer a child’s questions at the right level.

Medscape: What about the ‘bystander’ child and family in diverse communities who fear for their friends and neighbors?

Dr Linton: This is a very real issue. Children worry about bad things happening to their friends. We are all connected to one another, and the more that we can support all children in coping with uncertainty and fear, the more likely it is that we can support positive brain development and achieve collective prosperity for the future of our country. I wish that I didn’t have to use the precious little time I have with families to discuss the potentially harmful effects of stress on their child’s developing brains. As a pediatrician, my role is to help children grow, develop, and reach their full potential to contribute to our collective America. I hope that we can continue to work together to support children in reaching their full potential to contribute to our economy, to our community, and to our country.”

Editor’s note: This article touches also on the plight of refugee children, denied entry from seven countries by a Trump executive order. Their fate, as well as that of others from those countries, is in the hands of the courts.