Use well infant and child exams to identify toxic stress

This December, the American Academy of Pediatrics endorsed more than two decades of research indicating that toxic stress leads to permanent changes in the developing child's brain structure and function.

Evidence now supports an idea that most medical professionals considered obvious — exposure to elevated stress hormones, primarily cortisol, influence structural changes in the developing brains of the fetus and infant. Unlike behaviors, which can be augmented, these structural changes are permanent, irreversible and contribute to chronic physical and mental health concerns in adulthood.

This evidence is key for family nurse practitioners delivering care to under-served U.S. populations, in which poverty seems to potentiate a toxic environment. Early interventions for children living in this setting are often necessary to promote health. One of our most utilized interventions, anticipatory guidance is an essential component of well infant and child exams. But is it enough?  

Now that the effects of toxic stress on brain structure are known, a shift in the current delivery of U.S. health care is urgent, away from the provider's office and toward the home environment. Community outreach programs committed to public-health initiatives are vital to ensure preventive rather than reactive health-care delivery models.

Preventing stress is an unlikely intervention, but providing access to resources that can help with stress management is not. Perhaps the nurse practitioner's most important role when caring for under-served populations is just that — improving access and starting early. But this daunting task cannot be accomplished without continued and increased support from the government for primary care and assistance programs.  

As more research becomes available, the importance of prenatal care and well infant and child exams will continue to expand. These pivotal periods provide the best time to identify children and families at risk for toxic stress exposure. This is the best opportunity nurse practitioners have to intervene and prevent potentially life-long adverse health effects.

Leigh Montejo, MSN, FNP-BC, provides health care to underserved populations at the Metropolitan Community Health Service's Agape Clinic in Washington, North Carolina.

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