This article was originally published in The Notebook. In August 2020, The Notebook became Chalkbeat Philadelphia.
Here’s how it’s supposed to work.
Responsibility for a newborn child’s medical care is assigned to a pediatrician soon after birth.
Any conditions, such as vision problems, that could threaten the child’s learning are quickly spotted and explained to the parents or guardians. Checkups screen not only for physical ailments, but also for issues with language development and learning. The child sees a pediatrician at least once a year for a regular examination.
Prescribed medications are taken regularly. Parents monitor the child for signs such as sitting too close to the TV, which could mean nearsightedness, or persistent lethargy, which could signal something as serious as lead poisoning from flaking paint.
Later, if a condition flares up when the child is at school, a nurse is there to deal with it, and often the child can return to class. If it’s more serious, the parents are informed, and they notify their pediatrician and seek appropriate care.
Sitting at the nurse’s desk at William Dick Elementary School in North Philadelphia, where she has worked for almost a decade, Pat Westerfer talked about how it actually works in a low-income, urban district.
“Sometimes the nurse in the building is the only medical practitioner the kids see,” said Westerfer, who is at Dick only on Tuesdays and Fridays.
She has had cases when a sick child comes and tells her, “My mom told me to come to school so I could see the nurse.”
It’s possible that the child has no regular pediatrician and neither the parent nor the child fully understands prescribed medications.
And even with children who have a pediatrician, getting them there can be difficult for a parent who may work at a low-wage job with no paid sick days.
“I’ve seen more of that [recently] because of the job situation,” Westerfer said. “Maybe they have to take three buses to get to St. Christopher’s,” the nearest children’s hospital.
Colleen McCauley, health policy director for Public Citizens for Children & Youth, said that although most children, other than those who are undocumented, can get health care through either Medicaid or the Children’s Health Insurance Program (CHIP), many parents don’t know how to sign up or how to navigate the system once enrolled. (Any health center or pediatrician’s office should be able to help.)
Daniel Taylor, a pediatrician at the Center for the Urban Child at St. Christopher’s, said, “There’s an epidemic of missed appointments.”
All this connects to literacy. A child’s health is important to support proper brain development. A pioneering 2003 study showed that some children growing up in impoverished environments hear 30 million fewer words in their first four years of life than peers in more privileged settings, due to the types of interactions with adults in their lives.
Medical professionals like Taylor have become involved in promoting with parents the importance of reading to children, talking with them, and listening to them. Through the Reach out and Read program, Taylor makes sure that families have reading materials and learns what he can about the child’s home environment.
“The [health] choices a family has to make get embedded in a child’s brain,” he said.
He is also on the lookout for missed developmental milestones that can act as warning signs. By 2 months, a child should smile in response to a parent. The child should have at least said one word by age 1. By 5, he or she should be able to speak in complete sentences. A stranger should be able to understand what the child is saying, and the child should be able to draw a square, play with others, and begin to understand the letters of the alphabet.
Many parents don’t know what to look for, so teachers and child-care professionals should act as another set of eyes.
Pat Westerfer and other school nurses also encounter many children who have undiagnosed medical issues.
The worst problem, she said, is that the nurses are not there every day.
“When I come into the building on a Friday,” she said, “one of the kids might say, ‘Where were you yesterday? I needed you to take care of me.’"
“If they don’t feel well, they’re not going to learn anything.”
Another downside of a school having no nurse on duty is that children are often sent home as a precaution when they could be safely treated – or just observed – and sent back to the classroom.
And Westerfer said she sometimes finds that parents are keeping a child home when the condition doesn’t call for it. A student who has a cast for a broken arm was one example she cited.
Nationwide, 45 percent of schools have a full-time nurse, said Beth Mattey, president of the National Association of School Nurses. The average in densely populated areas is higher, she said.
After nurse layoffs in recent years, the staffing situation in the School District of Philadelphia has become more difficult. How much more difficult is hard to estimate.
Nurses staff 218 District schools and 95 city private and parochial schools.
In January, the District reported having 183 certified school nurses on its payroll. That is 100 fewer than just four years earlier, according to District budget documents.
District officials did not respond to Notebook queries about nurse staffing levels in District schools. They also declined to make anyone available for an interview, providing only a short, prepared statement from Health Coordinator Shannon Smith that gave a general description of nurses’ duties.
Having a full-time nurse in a school “makes all the difference in the world,” said Mattey, who works in the Brandywine School District, which serves a portion of Wilmington, Del. She said that even a part-time nurse might be more likely to send a child home in a borderline situation when she doesn’t know the child well.
“You get to know the kids. … They become more comfortable with you when you know your school and community,” she said. “It could be kids being bullied, kids who are depressed. A kid might sit in the nurse’s office if they can’t deal with [the noise in] the cafeteria.”
Brianna Scogna, a full-time nurse at Mastery Thomas Elementary, a charter school in South Philadelphia, asked, “How do you function every day without a nurse with so many children with chronic conditions? A lot more kids have asthma now.”
For a child with diabetes, she said, “You might have to vary insulin doses based on what a child is doing, exercise. You have to educate the children. … You do it kid by kid.”
Both Westerfer and Scogna see themselves as teachers. So does Taylor, who founded the web-based advocacy program CAP4Kids (Children’s Advocacy Project), which offers resources for accessing and utilizing health care.
Although a child of any background can be born with a medical problem involving hearing or eyesight, Taylor said that conditions in a low-income neighborhood like the one surrounding St. Christopher’s are more likely to result in that problem interfering with learning. Chronic absence is a major cause of lags in literacy development.
“About 80 percent of medical conditions have a social origin,” he said.
Taylor said that when he takes a new patient, he finds himself “taking more of a social history than a medical history.”
Roughly 20 percent of the children he sees have asthma, he said, “mostly because of social issues such as unsafe housing or secondhand smoke exposure.” And poorly treated asthma results in sleep deprivation during formative periods of brain development after age 3, Taylor said.
Iron-deficiency anemia, which can cause extreme fatigue, is related to poor diet and is most common in “food deserts” – neighborhoods without supermarkets, where fresh fruits and vegetables are harder to find.
Lead poisoning, caused by flaking paint in older homes, can cause vomiting and irritability. At high levels, it can affect brain development.
Taylor worries especially about parents who don’t catch symptoms in the child’s preschool years even when they are told what to look for.
“A lot of our families have had significant trauma in their lives,” he said. “They don’t have the energy to maybe even notice the subtle stuff.”
Fabiola Cineas contributed reporting.