Bisphenol A (BPA) has been linked to a number of adverse health outcomes and previous studies in animals have indicated that BPA has a tie to the development of pediatric asthma and allergic airway inflammation. However, the jury has remained out on whether BPA or its structural analogs bisphenol S (BPS) and bisphenol F (BPF) had ties to asthma morbidity. A 

Journal of Allergy and Clinical Immunology

Researchers collected 660 urine samples from 148 children who were predominantly low-income, Black, aged 5 to 17 years, and had established asthma. They quantified the concentrations of BPA, BPS, and BPF in each sample. The data on health care utilization, symptoms, and pulmonary function and inflammation were collected every 3 months over a year.

The investigators overall saw consistent positive association between exposure to BPA and measures of asthma morbidity. They saw increased odds of emergency department visits (adjusted odd ratio [aOR] = 2.12 [95% CI =1.28-3.51]), general symptom days (aOR = 1.40 [95% C = 1.02-1.92], and maximal symptom days (aOR = 1.36 [95% CI = 1.00-1.83]) per 10-fold increase in BPA concentrations. There was observed evidence of sexually dimorphic effects. Bisphenol A concentrations were tied to increased chances of health care use and symptom days among only the male participants. No consistent association with asthma symptoms and health care utilization was found with either BPS or BPF.

The study’s strengths included the fact that it was the first study to compare BPA, BPS, and BPF exposure in connection to the measures of asthma morbidity in the pediatric population. The study’s prospective design and evaluation of repeated exposure were also strengths as well as the prospective data collection that minimized the potential for recall bias. One of the limitations was the lack of information on pubertal stage as puberty could affect how BPA interacts with asthma morbidity.

The researchers concluded that their study’s findings indicate that exposure to BPA in a cohort that is mainly minority and low-income is linked with asthma morbidity. The link could differ by sex. They said that the studies should spur further studies because of widespread BPA exposure and asthma burden in the United States.

1. Quirós-Alcalá L, Hansel N, McCormack M, et al. Exposure to bisphenols and asthma morbidity among low-income urban children with asthma. 

. July 28, 2020. Epub ahead of print. doi:10.1016/j.jaci.2020.05.031

Articles

Animal studies have shown bisphenol A (BPA) has an impact on asthma morbidity. A new human study offers some further information.

Impact of BPA on asthma morbidity

Early in the COVID-19 pandemic, the US supply chain was stretched thin on many necessary products, including hand sanitizer. In response to this shortage, many health systems, manufacturers, and non-traditional institutions (eg, distilleries) sought to compound hand sanitizer to meet this need. To ensure safe compounding practices, in March 2020 the US Food and Drug Administration (FDA) released guidance for the temporary compounding of certain alcohol-based hand sanitizer products during the public health emergency.

 In addition, the United States Pharmacopeia (USP) provided recommendations on compounding alcohol-based hand sanitizer during the COVID-19 pandemic.

 These guidance documents provided recommendations regarding ingredients, facilities, and labeling in accordance with the World Health Organization’s (WHO) recommended recipe.

 These documents support the use of two formulas that result in either an ethanol antiseptic topical solution containing ethanol 80% (v/v) or an isopropyl alcohol antiseptic topical solution with a final concentration of 75% (v/v).1,2,3 According to the USP guidance, compounded hand sanitizers have a beyond use date of 30 days which is significantly shorter than commercially available products.

 The FDA does not recommend the public manufacture their own hand sanitizers due to risk for poor efficacy if made incorrectly and reports of skin burns.

 The hand sanitizer should be labeled with the alcohol percentage and can be stored at controlled room temperature.

The CDC recommends using alcohol-based hand sanitizer only when soap and water are unavailable. Therefore, it is crucial that the final concentration of hand sanitizer is at least 60% alcohol (ethanol or isopropyl alcohol) to avoid getting sick and spreading germs to others.

 Hand sanitizer should be used by covering all hand surfaces and rubbing one’s hands together, for approximately 20 seconds, or until they feel dry.

 Soap and water should be used whenever possible and always during food preparation, wound care, using the restroom, or caring for pets.

Hand sanitizer, when used by children, must be under the direct supervision of adults to prevent accidental ingestion.

 Numerous brands and types of hand sanitizers have emerged in the market place and they are NOT regulated by the FDA. It is extremely important to review all contents and their concentration to assure its effectiveness and safe use. The CDC and FDA are excellent resources for updated information for hand sanitizers (eg, potential harmful effects of methanol containing products). —Carlton Lee, PharmD, MPH, FASHP, FPPAG

Policy for Temporary Compounding of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency Immediately in Effect Guidance for Industry. U. S. Food and Drug Administration. 

https://www.fda.gov/media/136118/download

. Published in March 2020, Last Updated on June 1, 2020, Accessed on July 13, 2020.

Compounding Alcohol-Based Hand Sanitizer During COVID-19 Pandemic. United States Pharmacopoeia. 

https://www.usp.org/sites/default/files/usp/document/about/public-policy/usp-covid19-handrub.pdf

. Published on March 18, 2020. Last Updated on March 25, 2020. Accessed on July 13, 2020.

Guide to Local Production: WHO-recommended Handrub Formulations. World Health Organization. 

https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf

. Last Updated in April 2010. Accessed on July 13, 2020.

Q&A for Consumers: Hand Sanitizers and COVID 19: FDA. 

https://www.fda.gov/drugs/information-drug-class/qa-consumers-hand-sanitizers-and-covid-19

Show Me the Science – When & How to Use Hand Sanitizer in Community Settings, Centers for Disease Control and Prevention. 

https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html

. Last Updated on March 3, 2020. Accessed on July 13, 2020.

Hand Sanitizer Use Out and About. Centers for Disease Control and Prevention. 

https://www.cdc.gov/handwashing/hand-sanitizer-use.html

. Last Updated on April 13, 2020, Accessed on July 13, 2020.

FDA Updates on Hand Sanitizers with Methanol. U. S. Food and Drug Administration. 

https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-methanol?utm_campaign=FDA%20MedWatch%20-%20Hand%20Sanitizers%20with%20Methanol&utm_medium=email&utm_source=Eloqua#products

. Last Updated on July 2, 2020. Accessed on July 13, 2020.

Hand Sanitizers with Methanol: FDA Updates. MedWatch - The FDA Safety Information and Adverse Event Reporting Program. 

http://s2027422842.t.en25.com/e/es?s=2027422842&e=349602&elqTrackId=376c7bc788024cd5a73d955f2e3dcbdc&elq=2ea8b9246c7f46c89ae20013d2c01819&elqaid=13243&elqat=1

The COVID-19 pandemic led to a shortage of hand sanitizers and a push to make up the gap with compounded hand sanitizer ensued. Recommendations were released to ensure their efficacy.

Recommendations for compounded hand sanitizers during COVID-19

The best practices for advanced imaging in emergency departments has changed dramatically over the past decade, as the drive to reduce radiation exposure has intensified. A report in 

 offers a look at the trends in imaging.1

Researchers ran a cross-sectional study that examined 26,082,062 emergency department visits. They only included visits that involved a child aged 18 years and younger. The information came from the January 2009 to December 2018. The imaging techniques examined were computed tomography, magnetic resonance imaging, and ultrasonography.

The 26,082,062 visits involved 9,868,406 children who were seen in 32 emergency departments across the United States. The proportion of emergency department visits that had any advanced imaging increased from 6.4% in 2009 to 8.7% in 2018. During the same time, the proportion of visits that utilized computed tomography went from 3.9% to 2.9%. Meanwhile, ultrasonography increased from 2.5% to 5.8% and magnetic resonance imaging increased from 0.3% to 0.6%. The major decreases in computed tomography rates occurred with concussion (−23.0%), appendectomy (−14.9%), ventricular shunt procedures (−13.3%), and headaches (−12.4%). The increased use of nonradiating imaging modalities included magnetic resonance imaging for ventricular shunt procedures (17.9%) and ultrasonography for appendectomy (42.5%) and abdominal pain (20.3%). During the study period, emergency departments had a wide variation in the utilization of magnetic resonance imaging for ventricular shunt procedures and ultrasonography for appendectomy. In the study period, hospitalization and 3-day emergency department rates decreased and the length of stay in the emergency department did not change.

The study authors concluded that overall the use of advanced imaging went up from 2009 to 2018. Ultrasonography and magnetic resonance imaging increased during the period, but the use of computed tomography went down during the period. The variation in practice seen indicate a need to develop standardized imaging practices.

1. Marin J, Rodean J, Hall M, et al. Trends in use of advanced imaging in pediatric emergency departments, 2009-2018. 

. August 3, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.2209

Best practices for imaging in emergency departments has changed over the years. A new report offers a look at the trends in the past decade.

How advance imaging utilization has changed over 10 years

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

In an ideal world every child would live in home with a family who loves them and that child would never have to fear maltreatment or removal from the home. Unfortunately, we don’t live in that world and some children do have those worries. An 

 looks at whether children who have allegedly been maltreated and categorized at high-risk of being placed in foster care by a predictive risk model had an increased risk of emergency department and inpatient hospitalizations for injuries.

Investigators ran a retrospective cohort study that was based on a probabilistic link between hospital encounter data and child protection. The study was conducted in Allegheny County, Pennsylvania, and at the Children’s Hospital of Pittsburgh. The study’s participants were children who had been referred for either alleged neglect or alleged abuse in Allegheny County between April 2010 and May 2016.

There were 47,305 participants and 23,601 of them were girls. The average age at referral was 8 years and 28,211 of the participants were Black. Children who were rated as the highest 5% risk group by the predictive risk group were found to be more likely to have a medical encounter for treatment of an injury in the follow-up period that children who were in the low-risk group, which was the bottom 50% of risk. Among the children who were referred for maltreatment and who were classified as being at highest risk, the rate of experiencing an any-cause injury encounter was 14.5 per 1000. In comparison, the children at lowest risk had an any-case injury encounter rate was 4.9 per 1000. When the cause of injury was reduced to abuse-associated injury, the high-risk children had a rate of 2.0 per 1000 and the low-risk children had a rate of 0.2 per 1000. No link was found between risk scores and cancer outcomes.

The researchers concluded that children who are at high risk of foster care placement and who have also reported alleged mistreatment were at an increased risk of both emergency department utilization and in-patient hospitalization for injuries.

1. Vaithianathan R, Putnam-Hornstein E, Chouldechova A, Benavides-Prado D, Berger R. Hospital injury encounters of children identified by a predictive risk model for screening child maltreatment referrals. 

. August 3, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.2770

Not every child has a safe home. An investigation examines whether children with alleged maltreatment and who are at high risk of foster care placement have an increased risk of hospitalization for injuries.

Using maltreatment to predict hospitalization for injury rate

For many children, family means parents (as the primary guardians) and siblings. However, for 2% of children in the United States, the primary family guardians mean grandparents. There is little known about how grandparents as caregivers compares to parents as caregivers. A recent 

 provides some new information on how both compare in regards to caring for a child with attention-deficit/hyperactivity disorder (ADHD), caregiver aggravation and coping, child temperament, and adverse childhood experiences (ACEs).

The investigators used a combined data set from the 2016, 2017, and 2018 National Survey of Children’s Health. The data included children aged 3 to 17 years. They looked at composite and single-item outcome measures.

A total of 80,646 households, with 78,239 parent-headed and 2407 grandparent-headed were studied. In this sample, the children in grandparent-based households experienced more ACEs than the children in parent-headed houses (β = 1.22, 95% CI: 1.07 to 1.38). Children who were in preschool and school and lived in grandparent-headed households were found to be more likely to have ADHD than their peers in parent-headed homes (adjusted odds ratio = 4.29, 95% CI: 2.22 to 8.28; adjusted odds ratio = 1.72, 95% CI: 1.34 to 2.20). School-aged children in grandparent-headed homes had poorer temperament (βadj = .25, 95% CI: −0.63 to 1.14) and the caregivers in those homes showed greater aggravation (βadj = .29, 95% CI: 0.08 to 0.49). These differences were not noted after children who had ADHD were excluded from the sample. Differences were not noted between the 2 types of households for interactions with children, caregiver coping, and emotional support.

The researchers concluded that grandparents who are tasked with raising their grandchildren are coping with the stress of parenting as well as actual parents. The fact that they are often caring for children who have poorer temperaments than their peers as well as greater development problems than children in parent-headed homes speaks to the coping skills of grandparents who serve as parents. It also speaks to an area of stress that clinicians should be sensitive.

1. Rapoport E, Muthiah N, Keim SA, Adesman A. Family well-being in grandparent- versus parent-headed households. 

. August 3, 2020. Epub ahead of print. doi:10.1542/peds.2020-0115

For some children grandparents serve as parents. A new study looks at how grandparents cope with parenting when compared to parents.

How well do grandparents cope with parenting?

Dr Farber is a pediatrician in Woodbridge, Virginia.

Using only intensive clinical examination for initial identification of early-onset sepsis (EOS) in late preterm and term neonates substantially decreases laboratory testing and antibiotic use with no adverse outcomes. These were the ­findings of investigators who analyzed the effect of such an approach at their California hospital during a 5-year period.

As part of this approach, late preterm and preterm neonates who appeared well at birth remained with their mothers, even when the infants had perinatal risk factors for EOS. Nurses provided all these babies with enhanced clinical monitoring, and a neonatal hospitalist performed the initial clinical assessment of infants born to mothers with chorioamnionitis. Early in the study period, such chorioamnionitis-exposed infants were admitted to the NICU, but later on these babies instead remained with their mothers for the entire hospitalization if they appeared well.

Antibiotic treatment was administered only if the treating physician decided it was appropriate because the neonate was clinically ill at birth or later developed clinical signs of illness that posed a risk of sepsis. In addition, neonates were not routinely screened using sepsis laboratory testing, and when such testing was performed it was only once antibiotic treatment was started. Finally, routine evaluation for EOS did not include lumbar puncture for cerebrospinal fluid studies and culture. These tests generally were performed only in the presence of neurologic signs, such as mental status changes or seizures, at presentation or when the blood culture became positive.

Analysis of outcomes in 20,394 neonates ≥35 weeks’ gestation found that the percentage of neonates exposed to ampicillin decreased from 11.1% in the period before the clinical-examination approach was instituted to 4.1% during the intervention period. In addition, C-reactive protein testing declined from 15.3% to 6.3%. Overall, during an almost 5-year period, implementation of the clinical-examination approach reduced the use of antibiotics by 63% and sepsis laboratory testing by 59% (

Frymoyer A, et al. J Pediatr. 2020. E pub ahead of print

This paper is a potentially seminal article in my view. I was taught that at-risk newborns required work-ups and antibiotics; this is a drastic change. I expect it will take time to become standard; more seasoned physicians will not necessarily adjust their approach based on articles. In time, the next generation of pediatricians can show how it can be done safely.

Examining how an intensive clinical examination can change the approach to early-onset sepsis.

New approach to EOS reduces testing and antibiotics

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Children who are allergic to 1 type of nut allergy are more likely to have another, according to a recent report.

, evaluated coexistent nut and seed allergies in children across Europe, tracking prevalence and similarities between types of allergens.

 Researchers found that, overall, there were more coexistent nut and sesame seed allergies than previously reported.

Peanut and tree nuts are the most common food allergen, increasing by 2.1% in children in the United States over the past 30 years. Across Europe, the team found geographical differences in tree nut allergy prevalence based on pollen sensitization.

“Sensitization to nuts is affected by pollen sensitization because of cross-reactive allergens, and only a proportion of children sensitized to nuts will truly be allergic,” the report notes.

Peanut and tree nut allergies often cause severe, anaphylactic, and sometimes fatal reactions, and sesame seed allergies are also associated with severe reaction, the research team notes. These allergies often start early in life with a single tree nut or peanut allergy, and those children usually develop multiple nut allergies over time. A report from the United Kingdom found that 1 cohort of children had a 23.5-fold increase in multiple nut allergies over roughly a decade. Therefore, having peanut, tree nut or sesame seed allergies increases the risk of frequent food allergy reactions significantly, and quality of life drops as the number food allergies rise.

According to the report, 20% to 50% of individuals in the study self-reported co-existent peanut and tree nut allergies on a questionnaire at the start of the study. These results may not be accurate, though, the study notes, as individuals may overestimate allergy symptoms and cross-reactivity between peanuts and tree nuts.

Oral food challenges were done on study participants to get a more accurate number of co-existent allergies. Previous estimates of co-existent peanut and tree nut allergies after oral food challenges were around 30%, but more of these studies were limited and done retrospectively. Additionally, in prior reports, 58% to 84% of children with sesame seed allergies also had allergic reactions to peanuts, and about a quarter of children with peanut allergies also had sesame seed allergies.

The goal of the study was to evaluate these past observations against new testing with oral food challenges, examining reactions to peanuts, 9 different tree nuts, and sesame seeds in children with at least 1 proven nut or seed allergy. Children were assessed from different regions in Europe for comparison purposes—London, Geneva, and Valencia.

Children with life-threatening reactions in the past were excluded from the study, and a total of 159 across the 3 regions participated. Twenty-one later dropped out of the study for various reasons, including fear of a serious reaction. A total of 866 oral food challenges were performed on the remaining children, and 60.7% of the children in the study were allergic to more than 1 nut or seed. A single nut allergy was found in about 39% of the study group, and the maximum number of allergies any participant had was to 9 of the nuts or seeds tested.

Peanut allergies were the most common overall at 49%, followed by walnut allergies at 42.6% and cashew allergies at 34.3%. This number could be skewed, the researchers note, as the highest number of participants came from London, where peanut allergies were most prevalent. Cashew and pistachio allergies were most common among the Geneva group, and walnut and pecan allergies were most common in Valencia. If the number of children from each area were equal, the research team suggests that walnuts actually would have been the most common allergen, followed by peanuts and then pecans. Valencia had no cases of sesame seed allergies at all,.

Most children came to the study with their index, or presenting, allergy as the peanut, followed by walnut, hazelnut, and cashew. According to the research team, no children listed pecans as their index allergen. Sesame seeds, Brazil nuts, pistachios, almonds, macadamia, and pine nuts were sometimes, but seldom, listed as index allergens. The latter were among the most often consumed seeds and nuts before the study was conducted, the report notes.

In looking at common threads among children with multiple nut and seed allergies, researchers found that children older than 36 months of age had a higher chance of multiple nut allergies. In Geneva, there was also a connection between other non-nut food allergies and an increased risk of multiple nut allergies. This was not found in other areas. Age, and other conditions like asthma, were not associated with an increased risk of multiple nut allergies, the study notes. Researchers also found that allergies to certain nuts—macadamia, pistachio, and pecan­—were only present in children with 3 or more other nut allergies. Hazelnut and walnut allergies were present in most of the children with 3 or more nut allergies, too, according to the study. Children who could eat cashews, peanuts, walnuts, or pecans before the study were generally allergic to fewer nuts.

There were several other links noted between nuts in children with co-existent allergies, according to the report. Cashew and pistachio allergies were the most highly correlated, followed by walnut and pecan. The relationships varied though, as 97% of children with pistachio allergies were allergic to cashews, but only 83.3% of children allergic to cashews were allergic to pistachios. The case was similar for walnuts and pecans. Again, 97% of children with pecan allergies were allergic to walnuts, but only 75% of children with walnut allergies were allergic to pecans. Additional clusters and correlations are listed within a table in the study.

Oral food challenges can be difficult and stressful to conduct, and some children even dropped out of the study for fear of severe reactions to the food challenges as noted earlier. Overall, there were few severe reactions, but epinephrine was required for a lot of the positive food challenges. Reactions to almonds, macadamia nuts, and walnuts required epinephrine most often. Brazil nuts, sesame, and macadamia had the highest severity of symptoms during the challenges, with sesame seeds producing reactions in the highest number of organ systems in the London cohort.

Overall, the research found that the prevalence of multiple, co-existent nut allergies was about 20% higher than previously reported. Although oral food challenges present a lot of risk, they also allowed the study team to make connections between common allergen relationships. Children were encouraged to begin consuming nuts to which they didn’t develop a reaction during the study, despite the fact that current guidance is for children with 1 nut allergy to avoid consuming any nuts. The study team is working to see if the children in the study group followed this advice, and what their ongoing reactions have been. Ongoing results could be used to reduce the number of diet restrictions for individuals with nut allergies.

1. Brough H, Caubet J, Mazon A, et al. Defining challenge-proven coexistent nut and sesame seed allergy: a prospective multicenter European study. 

. 2020:145(4):1231-1239. doi:10.1016/j.jaci.2019.09.036

Children who are allergic to 1 type of nut are often allergic to multiple nuts or seeds, according to a recent report.

Multiple nut allergies more common than previously thought

Bacteria found in the digestive tract of pregnant women may have an effect in reducing the risk of food allergy development in their infants, according to a recent report.

 by Australian researchers, reveals that 

—a microbe found in the gut of people in most hunter-gatherer cultures—may be protective against food allergies during gestation.

Researchers used data from more than 1000 mothers and babies between 2010 and 2013, taking fecal samples from women at 36 weeks pregnant, and from their infants after they were born. Samples were taken from babies at 1, 6, and 12-months of age. DNA analysis performed on the samples revealed that women who carried the bacteria had babies who were significantly less likely to develop food allergies.

 bacteria may help prevent food allergy development by crossing the placenta and stimulating the developing baby’s immune system.

Lead author Peter J. Vuillermin, MBBS, BMedSci FRAC, PhD, a pediatrician and associate professor at Deakin University in Melbourne, Australia, says the study findings could possibly be used to help develop a supplement for pregnant women that may prevent food allergy development in their offspring.

 during pregnancy is strongly associated with protection against allergic disease in the offspring,” Vuillermin says. “

 carriage is virtually ubiquitous in pre-industrial, traditional communities and has become increasingly uncommon in Westernized environments.”

One of the reasons some cultures may lack this bacterium is difference in fiber sources. Vuillermin says diets in plant-derived fiber are thought to promote 

, but this was not demonstrated in the current study.

“The big factors we identified were that 

 was less common in smaller households and when women had been recently treated with antibiotics,” he says.

According to the report, the larger household size was first linked to food allergy prevalence more than 30 years ago. In the decades since, the “hygiene hypothesis” that guided initial theories developed into a deeper understanding of how lower microbial exposure in early years is a risk factor for allergy development, and that changes in the human microbiome may be to blame.

“It has been proposed that losses of specific bacterial species from out ancestral microbiota may be relevant to the increase in immune-related diseases, and that depletion in the compositional and functional diversity of the gut microbiome during pregnancy plays an important role in stimulating fetal immune development,” the report states.

Skin prick tests were used to evaluate allergies in infants compared with the DNA analysis from fecal samples. The research team found that 7%—18 out of 254—of the infants developed food allergies. In contrast, about 10% of Australians develop food allergies­—one of the highest rates in the world.

More research is needed to determine any potential adverse effects of the bacteria, such as possible colitis and insulin resistance in animal models. However, Vuillermin says the goal is to develop a novel probiotic that creates the same effect as 

. Additional studies are already being planned.

1. Vuillermin P, O’Hely M, Collier F, et al. Maternal carriage of 

 during pregnancy associates with protection against food allergy in the offspring. 

. 2020:11(1). doi:10.1038/s41467-020-14552-1


A recent study in Australia investigates whether a probiotic could help reduce food allergy development.

Gut bacterium linked to decreased food allergy risk

On the topic of ‘return to school’ this year, anxiety abounds for parents and children, as well as teachers, school staff and nurses, nurse practitioners (NPs), departments of health and legislators.

 Since school is considered “the work of children,”

 we must carefully consider all aspects of ‘return to school’ in light of the current, unprecedented COVID-19 pandemic. Many compelling questions emerge, but first and foremost the question to address is: 

Can children return to school and be in classroom environments that assure health and well-being for all?

The National Parent Union conducted an online COVID-19 survey of 500 parents with children from kindergarten through 12th grade on May 4 and 5, 2020.

 Lowe’s data revealed a significant level of anxiety among parents concerning return to school for their children. A 

 article reported that 6 of 10 parents are considering continuing with home learning rather than sending their children to school in Fall 2020.

 Some of the parental anxiety and decision making by parents may be attributed to uncertainty as the pandemic remains a viable threat throughout our country.

Planning, testing and masks are a critical component for safe return to school

Guidance from the Centers for Disease Control and Prevention (CDC) for opening schools was posted on the CDC website on March, 19, May 19, June, 3, and July 23, 2020.

 The guidance emphasizes the importance of school officials and administrators collaborating with local health officials for decision making regarding return to school and decisions about closing schools, while the most recent statement did stress the importance of reopening schools. The initial interim CDC guidelines

 did not address two major issues, masks and testing, that must be resolved either locally, or nationally by implementation of best available scientifically based health safety measures prior to any child’s/adolescents return to school. However, the CDC guidance on July 23, 2020 does recommend masks for children and staff in school settings, except those under 2 years old, and those with some medical conditions. Since wearing masks has been met with controversy, the work of health care professionals (HCPs) is to gain the support of parents, children and school personnel to wear masks during school. And, while recommendations presented in this paper are consistent with CDC guidelines and supports wearing masks, it also provides more stringent considerations for testing school personnel and children. All HCPs realize the ever evolving and changing health care recommendations as the pandemic moves across the country and the world. Thus, what is considered best practice today based on the available evidence, may be shown to be incorrect tomorrow. Making reasonable changes to tackle the twists and turns that emerge every day in this pandemic is a major challenge. Health care professionals at the local, state, regional, in helping non-HCPs make sensible decisions based on scientific data to protect all individuals. Return to school decisions must be based on the science with the overall goal of the health and well-being of the children/adolescents, the school personnel and the community as a whole. One size and one decision will not fit all.

The CDC guidance on COVID-19 from July 23, 2020 supports using “cloth face coverings” to prevent the spread of the COVID-19 virus, and includes in their practical recommendations that schools put “cloth face coverings on school supply lists and provide cloth face coverings as needed to students, teachers, staff, or visitors who do not have them.”

 Indeed, the scientific evidence from COVID-19 public health measures supports wearing masks as the new norm for all adults and for all children older than 2 years. Thus, we believe that wearing masks is an essential component of safe return to school. However, children with chronic illnesses, including pulmonary conditions, and those with disabilities may be advised by their physicians and NPs, not to wear face masks. Thus, some protection for children, who are too young to tolerate wearing a mask or are unable to wear masks, may be provided by other children and school personnel who can safely wear face masks in school settings.

The CDC guidance of July 23, 2020 also states that “[The CDC] does not currently recommend universal symptom screenings to be conducted by schools.”

 School NPs and school nurses are educated on public health screening measures and are ideally suited to appropriately screen students and all school personnel prior to entering school for the purpose of preventing exposure of individuals with COVID-19 or any communicable disease symptoms from spreading the virus to contacts at the school. The value of having a school nurse for every school was supported by the AAP policy statement in June 2016.

 In this pandemic, the school nurse is an essential part of the healthcare team (eg, private practice physicians, school based health centers, community clinics, and the department of health) overseeing the health of the children and school personnel and should be employed in every school.

Another major concern identified in the original CDC guidance

 is the recommendation to close schools for 2 to 5 days when there is a confirmed case of COVID-19 in the school system. Opening and closing schools for 2 to 5 days will be disruptive to everyone. Testing prior to return to school may prevent schools from opening and closing in a chaotic fashion.

Plans to reopen schools must be based on local and state public health data as well as primary and secondary prevention strategies that minimize the potential for viral spread, and avoid a cycle of frequent opening and closing of school systems due to outbreaks of COVID-19.

 The authors believe that testing of students and school personnel prior to reopening schools is the cornerstone of primary and secondary prevention strategies. And while the most recent CDC guidance does not recommend universal testing of children and staff, it however, proposes other testing strategies based on local and state data.

When the pandemic began, data from other countries led health care providers to believe that children were less affected by COVID-19 but may be asymptomatic carriers.

However, as the pandemic spread in the United States and Italy, there were news reports of chronically ill children hospitalized with severe symptoms. The most troubling occurrence is the new presentation of the COVID-19 complication of the syndrome, Multisystem Inflammatory Syndrome in children (MIS-C).

 The etiology of MIS-C remains unclear. According to reports from the CDC, children who developed MIS-C may have been infected weeks before the appearance of MIS-C symptoms, and/or were symptomatic carriers.

Thus, based on these presentations of COVID-19 in children, testing strategies for children must be considered on all levels to protect all children, school personnel, and the communities in which they live. As of this writing, data for widely testing children for COVID-19 in the United States is non-existent.

Innovation is an outcome of a crisis. New, non-invasive methods for testing for COVID-19 in children should be developed. Saliva sample testing may be a reasonable solution that can be developed, and, as of this writing, is under investigation as a point-of-care test.

Once testing policies and methods are in place, only then can we proceed with developing other policies that address a safe school environment for children and adolescents, and all school personnel that work every day to educate and care for our children/adolescents.

Screenings are critical to safely reopen schools

Children have been out of school since March 2020 and may not have had their usual access to health care throughout this pandemic. Screenings to identify problems in physical, emotional, social, and behavioral health are a critical strategy for the design and implementation of effective strategies for healthy children. Thus, we encourage all HCPs, including school nurses, to assume a leadership role in the design and implementation of screenings for the identification of children and school personnel who may present with problems that may have arisen during stay-at-home orders (eg, anxiety, school phobia, etc.).

Screening is a critical part of the process for prevention of transmission of COVID-19 within school systems. An innovative, reliable method for screening children and school personnel prior to going to school each day should be implemented. Some health care systems and other clinical practices have already implemented the use of a web-based application or ‘app’ that can be used to screen for temperature and emerging symptoms one-hour before reporting to work each day. This screening tool asks the individual to report the morning temperature, and also asks other pertinent questions about symptoms and possible exposure to an individual with COVID-19. If negative, the employee reports to work. If any portion of the screening is positive, the individual does not report to work that day. For parents who do not have access to cell phones or apps on their devices, a plan should be in place for the parents to call into the school and report the information to be reviewed by the school nurse prior to the children leaving for school. Once at work (school) and before entering the workplace (school environment), a second temperature screening is recorded. Such an app for school-based screenings for children and school personnel can easily be developed and implemented as best practice for early identification of possible COVID-19 exposure and/or infection for healthy children.

It has been theorized that COVID-19 viral shedding may persist for longer periods of time through the gastrointestinal tracts of in children.

 It is believed that children may be asymptomatic carriers and may shed the virus for days or even weeks, but too little testing has been done. Schools must be vigilant in preparation of the bathroom space of children and school personnel, preparing for the worst-case scenario. It is important for school systems to be proactive, rather than reactive. Leadership of school nurses and nurse practitioners is essential in policy preparation and enactment of policies for bathroom use.

Frequent cleaning and maintenance of modern bathrooms will reduce risks shedding and must be instituted prior to opening schools, and continue throughout the school day. Measures to help children become comfortable in the bathroom must be part of the curriculum. Soap, running water, and a clean toilet must be established.

 Bathrooms may increase risk of disease transmission without structural change (proper toilet design, adequate soap and water, frequent cleanings). Proper implementation of a plan will enable children and staff to better understand how to prevent other diseases (including influenza and other common gastrointestinal diseases), which should also help change attitudes and establish new norms.

COVID-19 brought to the forefront nationwide educational inequality. As HCPs, we know the importance of being lifelong learners and the importance of early childhood education and continued excellence in education throughout the K through 12 years. It was distressful to hear many parents report that their children did not have access to computers, tablets and/or the internet at home to continue their education virtually. To achieve meaningful societal change, social justice and educational parity, we encourage educators, parents, and all community members to analyze the local educational needs and to plan accordingly to meet the needs of all students.

As Erik Erickson said, “School is the work of children.”

 We value the education our children receive throughout the US each year preparing the children to develop into healthy, kind, valuable, innovative and productive members of society in whatever careers and professions they choose. The immediate closing of schools at the onset of the COVID-19 pandemic has further enlightened everyone on the value of educators and the school systems. All HCPs want children to return to school safely and free of the threats of contracting COVID-19 within the school environment. Thus, our recommendations are based on the best available evidence as of this date and time. Screening, non-invasive testing, masks for all children over 2-years old, eye protection, social distancing, cleaning, transportation, and bathroom use are critical to the health and well-being of the children, all school personnel, their parents, family members and the community in which they live and grow.

1. Lowe, B. New poll: Two-thirds of parents support keeping schools closed ‘until they are certain there is no health risk’. Published May 11, 2020. Accessed June 3, 2020. 

https://www.the74million.org/new-poll-two-thirds-of-parents-support-keeping-schools-closed-until-they-are-certain-there-is-no-health-risk/

2. Erikson, EH. Childhood and society (2nd ed.). 1963. W. W. Norton & Company.

3. The Editorial Board. How to reopen America’s schools. The New York Times. Published June 6, 2020. Accessed June 17, 2020. 

https://www.nytimes.com/2020/06/06/opinion/coronavirus-schools-reopen.html?referringSource=articleShare

4. Center for Disease Control and Prevention. Interim Guidance for Administrators of US K-12 Schools and Child Care Programs Plan, Prepare, and Respond to Coronavirus Disease 2019 (COVID-19). Published April 12, 2020. Accessed June, 3 2020 

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html

5. Center for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Coronavirus Disease 2019 (COVID-19). Considerations for Schools. Published May 19, 2020. Accessed June 3, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/schols-childcare/schools.html

6. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). K-12 Schools and child care program. Published June 3, 2020. Accessed June 17, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools-faq.html?deliveryName=USCDC_2067-DM29945

7. AAP Council on School Health. Role of the School Nurse in Providing School Health Services. Pediatrics. Published June 2016. Accessed July 12, 2020. Accessed from 

https://pediatrics.aappublications.org/content/137/6/e20160852

8. Center for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). Interim considerations for K-12 school administrators for SARS-CoV-2 testing. Published June 30, 2020. Accessed July 12, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-testing.html

9.Center for Disease Control and Prevention. For Parents: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19. Published May 20, 2020. Accessed June 10, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/mis-c.html

10. Hindson J. COVID-19: faecal-oral transmission?. 

. 2020:17(5):259. doi:10.1038/s41575-020-0295-7

11. WHO Water, Sanitation and Hygiene strategy 2018-2025. Geneva: World Health Organization; 2018 (WHO/CED/PHE/WSH/18.03). License: CC BY-NC-SA 3.0 IGO Published 2018. Accessed June 28, 2020. 

https://apps.who.int/iris/handle/10665/274273

As fall approaches, one of the biggest questions is: Can children return to school and be in classroom environments that assure health and well-being for all?

Safe return to school: A call to action

Telemedicine has become a buzzword during the COVID-19 pandemic and mobile therapy services have become a popular way for many people to get the mental health care they need. A 

 looks into whether acceptance and commitment therapy–based group intervention via videoconferencing can be effective in lessening posttraumatic stress symptoms in parents who are caring for very ill children.

The investigators ran a randomized clinical trial. The trial was a single-site study that was conducted in a tertiary pediatric hospital in Australia. The parents of children aged 0 to 18 years who had been admitted for a life-threatening illness or injury to the cardiology, pediatric intensive care unit, or oncology departments were eligible to be included. The parent was screened for eligibility in the first month after diagnosis or admission and was randomized to either the intervention group or the waited listed control group 4 to 10 months following diagnosis or admission. The intervention was a group therapy program called Take a Breath, a 6-session parent-mediated psychological intervention provided by online videoconference over 8 weeks. The control group were given treatment as normal and offered the intervention 3 months after being randomized.

There were 1232 assessed for eligibility and 313 who were randomized. One hundred sixty-one of the parents were randomized into the waiting list control group and 152 were allocated to the intervention group. The postintervention questionnaire was completed by 37 parents in the intervention group and 44 parents in the waiting list group. In this group, 32 parents were in the oncology group, 25 parents were in the pediatric intensive care unit group, and 24 were in the cardiology group. Overall, the intervention group showed significantly greater improvement in posttraumatic stress symptoms, with the average Posttraumatic Stress Disorder Checklist–Version 5 scores decreasing from 23.3 to 17.8 in the intervention group and 31.7 to 26.2 in the waiting list control group.

The researchers concluded that using acceptance and commitment therapy can reduce posttraumatic stress symptoms in parents of very ill children. Additionally, the results indicate that the videoconferencing setup worked and can provide the therapy to hard-to-reach populations.

1. Muscara F, McCarthy M, Rayner M, et al. Effect of a videoconference-based online group intervention for traumatic stress in parents of children with life-threatening illness. 

. 2020:3(7):e208507. doi:10.1001/jamanetworkopen.2020.8507

Technology can help improve access to care. A new report examines whether videoconferencing group therapy can help the parents of seriously ill children.

Impact of videoconferencing group therapy in parents of seriously ill children

Disease caused by severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2), otherwise known as COVID-19, has rapidly emerged as an international public health emergency with over 12 million cases, 650,000 deaths,

 and varying states of lockdown among countries worldwide since the virus first appeared in December 2019. The novel coronavirus classically presents in symptomatic patients with signs of upper or lower respiratory tract infection (URI, LRI), varying in degree of severity and multi-organ involvement

Recent literature has reported a variety of dermatologic manifestations among children and adults associated with COVID-19 infection. In general, children with the virus reportedly have milder clinical manifestations and lower incidence of critical cases compared to adults

 Cutaneous manifestations seen in children may often differ from those seen in infected adults. Findings most commonly seen in children include chilblains-like lesions (or “COVID toes”) and viral exanthem variations (erythema multiforme-like, papulovesicular eruption, varicella-like eruption among others), as well as prominent mucocutaneous involvement in the more severe Kawasaki-like disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C). In this review, we aim to highlight the various pediatric cutaneous findings associated with COVID-19 thus far, in context of infection timeline and utility of recognizing these manifestations to alert suspicion of SARS-CoV-2 infection.

Vascular-related manifestations: the debate over COVID toes

One of the dermatological findings to first gain traction among COVID-19-related manifestations is chilblains-like lesions, or commonly referred to as “COVID toes” or pseudo-chilblains. Chilblains, also known as perniosis, is a localized vasculopathy that involves vasoconstriction of small arterioles and venules triggered by cold, most commonly affecting those with chronic exposure to low temperatures, damp exposure or poor peripheral circulation, in children, young women, and elderly patients. Lesions present as either single or multifocal erythematous, purplish edematous papules, nodules, macules or less commonly bullae, that may be pruritic, tender or accompanied by a paresthesia, commonly on the extremities such as the fingers, toes (Figure 1), and less commonly on nose and ears

COVID-19 has been seen as primarily a disease impacting the lungs, but more of the body's systems have been shown to be impacted by the disease. Here's a look at how the disease impacts the skin.