Sklice (ivermectin) lotion, 0.5% has been approved for over-the-counter (OTC) use by the US Food and Drug Administration (FDA) in children aged 6 months and older.

The toll of COVID-19 and quarantine on college students’ mental health

The impact of COVID-19 on mental health is hard to measure. A report offers a look at how quarantine impacted the mental health of university students.

Impact of preoperative blood transfusion on postoperative outcomes in newborns

Many newborns get a blood transfusion because of surgery, but could preoperative blood transfusion do more harm than good?

Toll of environmental exposures on teen psychosocial stress

A new report looks into how environmental exposures can negatively impact an adolescent’s perceived stress.

Articles

It was a very busy week for the Contemporary Pediatrics team.

In case you missed it: October 26 to October 30

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

Eggs are one of the big 8 food allergens and much like with peanuts, using oral immunotherapy has been used to achieve desensitization and sustained unresponsiveness. An 

Journal of Allergy and Clinical Immunology

 looked at the potential benefits of baked egg therapy for egg allergy, which the researchers noted had not been well studied previously.

The researchers enrolled children aged 3 to 16 years who were baked egg-tolerant but unbaked egg reactive. Each participant was randomized to receive 2 years of treatment with either egg oral immunotherapy or baked egg therapy. They administered double-blind, placebo-controlled food challenges following 1 and 2 years of treatment to assess for desensitization. Another challenge was administered after 2 years of treatment, followed by 8 to 10 weeks without the treatment, to assess sustained unresponsiveness. Additionally, some children who were baked egg-reactive were given egg oral immunotherapy and given identical double-blind, placebo-controlled food challenges to be used as a comparator group.

A total of 50 children were included in the study. The investigators found that sustained unresponsiveness occurred in 3 of the 27 children who were assigned to the baked egg therapy group versus 10 of the 23 participants who had been assigned to receive egg oral immunotherapy (

 = .009). Within the comparator group, 7 of the 39 children were able to achieve sustained unresponsiveness. The dosing symptom frequency was similar for both baked egg therapy and egg oral immunotherapy among the children who were baked egg tolerant, but were more frequent in the comparator group. The investigators found that egg white–specific immunoglobulin E skin testing and basophil activation decreased in a similar fashion following baked egg therapy and egg oral immunotherapy.

The researchers concluded that treatment of unbaked egg allergy with oral immunotherapy was much more likely to help a child achieve sustained unresponsiveness than baked egg therapy.

1. Kim E, Perry T, Wood R, et al. Induction of sustained unresponsiveness after egg oral immunotherapy compared to baked egg therapy in children with egg allergy. 

. 2020;146(4):851-862.e10. doi:10.1016/j.jaci.2020.05.040

Oral immunotherapy has been an effective way to treat peanut and egg allergies. Can baked egg therapy improve food allergy outcomes in children who can tolerate baked eggs?

Looking at the efficacy of baked egg therapy at improving egg allergy outcomes

When treating acutely ill children, are all fluid therapies created equal? An investigation in 

 examines whether commercially available plasmalike isotonic fluids lead to a risk of electrolyte disorders in this population.

The researchers ran an unblinded, randomized clinical pragmatic trial that was performed at a pediatric emergency department in Finland. The patients included in the study were aged 6 months to 12 years, were hospitalized because of an acute illness, and required intravenous fluid therapy. Exclusion criteria included a need for renal replacement therapy; severe liver disease; pediatric cancer requiring protocol-determined chemotherapy hydration; inborn errors of metabolism; a plasma sodium concentration of less than 130 mmol/L or greater than 150 mmol/L on admission; a plasma potassium concentration of less than 3.0 mmol/L on admission; clinical need of fluid therapy with 10% glucose solution; or a history of diabetes, diabetic ketoacidosis, or diabetes insipidus. Each patient was randomly assigned to receive either commercially available plasmalike isotonic fluid therapy (140 mmol/L of sodium and 5 mmol/L potassium in 5% dextrose) or moderately hypotonic fluid therapy (80 mmol/L sodium and 20 mmol/L potassium in 5% dextrose).

A total of 614 children were included in the study’s cohort, with an average age of 4.0 years. Investigators found that a clinically significant electrolyte disorder was more common in the children who received the plasmalike isotonic fluid therapy (61 of 308 patients) than in the children who received moderately hypotonic fluid therapy (9 of 305 patients; 95% CI of the difference, 12%-22%; 

 < .001). Overall the risk of developing an electrolyte disorder was 6.7-fold greater in children who were given isotonic fluid therapy. Among the patients who received the plasmalike isotonic fluid therapy and developed an electrolyte disorder, hypokalemia developed in 57 patients and hypernatremia developed in 4 patients. Additionally, weight change was greater in patients who received the isotonic, plasmalike fluid therapy in comparison with the children who received mildly hypotonic fluids (mean weight gain, 279 vs 195 g; 95% CI, 16-154 g; 

Investigators concluded that using commercially available plasmalike isotonic fluid therapy led to a marked increase in the risk of a clinically significant electrolyte disorder in acutely ill children. The same was not true when using moderately hypotonic fluid therapy containing 20 mmol/L of potassium, which had been the widely used fluid therapy previously.

1. Lehtiranta S, Honkila M, Kallio M, et al. Risk of electrolyte disorders in acutely ill children receiving commercially available plasmalike isotonic fluids. 

. October 26, 2020. doi:10.1001/jamapediatrics.2020.3383

Recent guidelines recommend using commercially available plasmalike isotonic fluid therapy, but could this have a negative impact on acutely ill children.

Can isotonic fluid therapy lead to electrolyte disorders in acutely ill kids?

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

How does the frequency of grocery shopping trips impact a household’s diet quality? Researchers in Chicago sought to answer this question in a new study examining both grocery shopping habits and household food inventories.

Journal of the Academy of Nutrition and Dietetics

, collected data from the Study on Children’s Home Food Availability Using TechNology between 2014 and 2016.

 Ninety-seven low-income families from African-American and hispanic families participated in the study. Diets were scored using home food inventories and a 24-hour history of what individuals in the household ate. Household food quality was matched to grocery shopping frequency—monthly, twice per month, three times per month, or weekly.

Researchers sought to investigate how the frequency of grocery shopping in a household impacted the overall diet of that household, and individually the members within that household—specifically young children.

“Grocery shopping frequency could be an important contributor to the types and quality of foods families bring into their homes,” says Angela Kong, PhD, MPH, RD, co-author of the study and clinical assistant professor of nutrition at the University of Illinois at Chicago College of Applied Health Sciences. King is also a researcher and fellow at the Institute for Health Research and Policy. “We found that the diet quality of foods in the home, based on the Healthy Eating Index Score, was poorer in households that grocery shopped once a month compared to households that shopped more frequently.”

The National Health and Nutrition Examination Survey, conducted from 1999 to 2016, found that although diets overall have improved with time, the majority of Americans still have poor diet quality. Higher income Americans have fared better, but there needs to be more work on improving diets overall—and specifically those of young children who eat the majority of their meals at home.

More frequent grocery shopping is associated with a higher intake of fruits and vegetables, but little else is known about overall diet quality in regard to grocery shopping frequency. The researchers analyzed grocery shopping patterns and household food inventories to get a bigger picture view, and found several trends.

In children, sodium scores were higher in households that shopped for groceries twice a month, but fruit and vegetable consumption was higher in households that shopped three or four times per month rather than those who shopped once per month. Overall, in households where grocery shopping happened more often, diet scores for the household were better.

“There were a greater number of households that were Black/African-American that reported shopping only once per month. The number of monthly shoppers who could drive themselves to the store was significantly less than households that shopped more frequently,” Kong says, adding that adjustments were made for these variables in the study analysis.

What the study did not investigate was whether grocery shopping frequency was impacted by availability—a problem in food deserts where it can be difficult to get access to fresh, healthy foods.

“Most of the households in our study resided in similar neighborhoods. We think transportation access could be a key contributor to a household’s ability to shop more frequently,” she says, adding this would require further investigation.

Researchers also did not ask why families shopped when they did. Was it a transportation problem? Scheduling? Budgets? That question hasn’t been answered yet, Kong says.

“We were able to conclude that shopping less frequently causes households to bring foods of poorer diet quality into their homes,” Kong says. “Future research is needed to understand this relationship better. Also, we would like to examine the potential influence car access has on shopping frequency and diet quality.”

Kong says she hopes the study highlights the fact that how often a household can grocery shop has a big impact on the types of food they bring into their home.

“In the context of clinical practice, it could be a conversation worth having between providers and patients,” she says.

1. Banks J, Fitzgibbon M, Schiffer L, et al. Relationship between grocery shopping frequency and home- and individual-level diet quality among low-income racial or ethnic minority households with preschool-aged children. 

. 2020;120(10):1706-1714.e1. doi:10.1016/j.jand.2020.06.017

A new report investigates how grocery shopping frequency impacts diet quality.

More frequent grocery runs tied to healthier household diets

Over the past decade the incidence of suicide among children and adolescents has increased and the incidence is higher among those who live in rural areas than in urban areas. Additionally, the need for health care professionals in those rural areas continue to be high. A 

 looked at the tie between rurality and the availability of suicide prevention services at mental health facilities.

The researchers used the Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Services Locator to find mental health treatment facilities in the United States. The facilities included in the research included outpatient, inpatient, and residential treatment and were located in all states and the District of Columbia. The rurality of the facilities was determined using the rural-urban commuting area codes according to ZIP Code Tabulation Areas and by county using the rural-urban continuum codes.

Across the 41,083 ZIP Code Tabulation Areas, 5637 of them had at least 1 mental health facility that provided care to children and teenagers. Among those that had such facilities, 2968 metropolitan areas had a facility; 666 micropolitan areas had a facility; 615 small town areas had a facility; and 265 rural areas had a facility that offered care for pediatric patients (nonparametric test for trend, 

 < .001). A similar trend was seen with facilities providing suicide prevention services. In this regard, 1936 metropolitan areas had such services; 535 micropolitan areas had them; 472 small town areas had suicide prevention services; and just 202 rural areas had such services (nonparametric test for trend, 

 < .001). Using the other determining factor that looked at counties, the researchers found that among 3223 counties, 2053 counties had at least 1 mental health facility that served children and adolescents. A smaller ratio of highly rural counties had at least one mental health facility that offered pediatric services than urban counties. Additionally, there were more mental health facilities offering suicide prevention services in counties that were in the middle of the rural-urban continuum than counties that were more urban or rural.

The researchers concluded that overall areas that were highly rural had fewer mental health facilities and suicide prevention services than other areas. They did note limitations such as the research didn’t look at service use and relied on the facility’s self-report. They emphasized that greater availability of such services are needed in rural areas to help combat the higher suicide rates found there.

1. Graves J, Abshire D, Mackelprang J, Amiri S, Beck A. Association of Rurality with availability of youth mental health facilities with suicide prevention services in the US. 

. 2020;3(10):e2021471. doi:10.1001/jamanetworkopen.2020.21471

Suicide is on the rise among children and teenagers. Access to mental health care isn’t always as accessible in rural areas as it is in urban centers. Are pediatric patients in these regions lacking much-needed suicide prevention services?

How available are suicide prevention services in rural areas?

Millions of Americans live in areas where fresh, healthy foods are hard to come by, and where government nutrition programs offer little or no access. A new report investigates how living in a food desert impacts participation in the Special Supplemental Program for Women, Infants, and Children (WIC) nutrition program, and what might help improve access to these programs.

, investigated how enabling WIC participation at discount stores could help expand access to the national program.

“Many low-income neighborhoods do not include a full-service grocery store. In these communities, discount variety stores (DVS) can be convenient points of food access,” says Lauren A. Wallace, DrPH, MPA, assistant professor in the Department of Public Health Sciences at the University of North Carolina Charlotte and lead author of the study. “However, to our knowledge no identified DVS are authorized to accept WIC benefits.”

The problem the research team investigates centers around an access issue. About 

—or areas where it is difficult to get access to affordable and healthy foods like fresh fruits and vegetables. In these areas, grocery stores are limited, and discount stores that have few fresh foods or fast food restaurants dominate. Roughly half of the people who live in food deserts are also low income, making it that much more difficult to travel or have food delivered from areas outside their immediate residence, according to the 

. This leads to higher rates of food insecurity and more nutrition-related health problems, like diabetes.

For the most vulnerable populations, like pregnant women and infant children, living in a food desert where there are few stores that participate in programs that can help—like WIC—makes the problem of access even more pronounced.

“Beneficiaries of WIC are low-income by definition. Many low-income folks live in low-income communities. Currently, most WIC authorized stores are grocery stores that often operate in middle- and higher-income communities,” Wallace explains. “As a result, WIC beneficiaries must travel outside of their community to benefit from WIC. Extending the types of stores that offer WIC access provides participants with increased access to WIC benefits.”

The WIC program is the third largest nutrition assistance program in the United States, according to the report, with more than 7.3 million participants receiving free supplemental food packages each month. The package comes in the form of vouchers that participants can use at grocery stores to receive infant formula or nutrient-dense foods. The WIC benefits can’t be used on everything, and people who have trouble accessing the healthy foods the program is supposed to supply will also have trouble participating in the program.

Participation in the WIC program has been dropping since 2011, according to the report. This decline has been blamed in part to access problems, as there are few large food stores that participate in WIC in the low-income communities the program is meant to serve. Discount variety stores like pharmacies, convenient stores, and dollar stores are more common in many of these areas, but none of these carry much in the way of fresh products.

There are also administrative issues in the WIC program that could exacerbate the access problem. State agencies that manage the WIC program are responsible for authorizing WIC vendors that participate in the program. New rules have been put in place for this authorization process, including a requirement to carry more fresh fruits and vegetables, and more dairy items. These requirements can be a challenge for smaller stores to meet, especially if they don’t have the space or consumer demand to make it worthwhile to carry these products. These added requirements can make it more difficult for smaller stores to participate in WIC, therefore preventing many of the stores located within food deserts to be authorized as a WIC location.

Beyond these issues, Wallace says there are even challenges for larger food stores, should participants be located near to one. The WIC regulations vary from one state to the next, and even larger national or regional grocers can have trouble navigating WIC rules in more than one state. Finally, she says that WIC state agencies sometimes have limited capacity to handle vendor compliance, and this might limit the state from recruiting additional food stores into the WIC program.

The research team followed one discount store chain through the process of joining the WIC program, providing insight on many of the challenges, drawbacks, and benefits to participating in the program. Wallace says the study highlights the need for more research on how availability of stores that accept WIC who participate in the program—as well as how to make it easier for stores and participants to utilize WIC.

Pediatricians can help, too, by helping to point families who can benefit from WIC in the right direction in terms of participation and ways to use the program in their area.

“It’s is a cost-effective program that improves maternal and child health,” Wallace says. “However, WIC participation has been declining in recent years. If clinicians could screen for and encourage WIC enrollment, that could lead to healthier birth outcomes and better nourished children.”

1. Wallace L, Morris V, Hudak K, Racine E. Increasing access to WIC through discount variety stores: findings from qualitative research. 

. 2020;120(10):1654-1661.e1. doi:10.1016/j.jand.2020.03.001

Access is a problem when it comes to Special Supplemental Program for Women, Infants, and Children (WIC) participation, with many low-income families living in food deserts where WIC-approved goods are hard to find.

Increasing WIC participation by improving access

Time and resources are a problem for clinicians when it comes to implementing new guidelines on peanut allergy prevention.

 reviews how clinicians have fared when it comes to implementing new recommendations on ways to prevent the development of peanut allergies.

 The recommendations, released in 2017, were developed as a result of new data on allergy prevention, but there have been some roadblocks when it comes to putting these guidelines into practice.

Addendum Guidelines for the Prevention of Peanut Allergy

National Institute of Allergy and Infectious Diseases (NIAID)

. Since these guidelines were released, however, there has been no follow-up to examine how clinicians are using them in practice. A team of researchers sought to answer that question by sending a 33-item electronic survey to pediatricians and allergists in 2018—just 1 year after the new guidelines were released. Of the eligible responders to the survey, 97.1% were aware of the guidelines. How the guidelines were used differed by specialty.

According to the report, 30% of pediatricians used the guidelines as published, and 64% used only a portion of the guidelines. Seven percent of pediatricians were not using the guidelines in their practice at all. Almost the exact opposite was true for allergists. Out of all the allergists surveyed, 64% of them were using the guidelines exactly as they were published, whereas only 34% were using portions of the guidelines and not others. Only 1% of allergists were not using the guidelines at all.

When pressed further on why the guidelines were or were not used, the surveys revealed several trends.

Some of the barriers to implementing the guidelines included pushback on the methods and concern about allergic reactions from parents (47.6%), clinician concerns about allergic reactions (21.8%), a lack of referral to allergists (33.6%), parents who were not interested in early feeding (28.2%), and a lack of clinic time to review the guidelines with parents (20.9%). Clinicians also reported some factors that were not specified in the guidelines that caused them to deviate from full implementation, and these were family histories of allergies and skin prick test results in children who were not at high risk. Nearly half of all the clinicians who completed the survey—45.7%—said they would also like more education or training on implementing the new guidelines.

The report also uncovered a great need by clinicians for more education material to provide to parents and caregivers when discussing the guidelines. Clinic visits during the time period that early feeding should begin are notoriously packed with vaccinations, education, assessments, and more. Electronic sources or printouts that could be given to parents at these visits to further explain the new guidelines and early feeding strategies were requested by many the survey respondents. Clinicians asked for scripts to use when talking to parents about the guidelines, guidance on how to introduce peanut-containing foods in the clinic, advice on how to conduct assessments or give recommendations, a frequently-asked-questions handout, instruction on feeding peanut-containing foods at home, and a more detailed explanation of the guidelines overall.

Although the release of the guidelines in 2017 was a good first step at combating the development of peanut allergies, the report made it clear that clinicians need more help when it comes to full implementing the recommendations. Moving forward, the report identify some key areas for continued work.

Pediatricians should discuss early peanut introduction in practice with parents and caregivers of low-risk infants.

Clinicians should be ordering immunoglobulin E testing and making referrals to allergists for infants who are at high risk of developing peanut allergies.

Stakeholders need to help clinicians develop and use more resources on early introduction feeding methods to help parents implement these changes at home.

1. Johnson J, Gupta R, Bilaver L, et al. Implementation of the addendum guidelines for peanut allergy prevention by US allergists, a survey conducted by the NIAID, in collaboration with the AAAAI. 

. 2020;146(4):875-883. doi:10.1016/j.jaci.2020.07.020

Peanut allergies are a big concern for parents when it comes to infant feeding. How can clinicians help?

Report grades clinicians on implementation of guidelines to avoid peanut allergies

The US Food and Drug Administration (FDA) has 

 Sklice (ivermectin) lotion, 0.5% for nonprescription, or over-the-counter (OTC), use through a process called a prescription (Rx)-to-OTC switch.

 It was initially approved as a prescription drug for the treatment of head lice infestation in patents aged 6 months and older in February 2012.

Sklice contains ivermectin 0.5% as the active ingredient and is a single-use lotion. It is meant for the topical treatment of a head lice infestation. It is meant only for external use and should only be applied to the scalp and dry hair, which is noted on the label directions. It is not approved for any other use. For patients who currently have a prescription version of Sklice, they should reach out to their health care provider for guidance.

In a press release for the approval Theresa Michele, MD, acting director of the Office of Nonprescription Drugs in the FDA’s Center for Drug Evaluation and Research said, “the Rx-to-OTC switch process aims to promote public health by increasing consumer access to drugs that would otherwise only be available by prescription. Today’s approval expands access to another effective topical treatment for the thousands of people with head lice.”

1. US Food and Drug Administration. FDA approves lotion for nonprescription use to treat head lice. US Food and Drug Administration. Published October 27, 2020. Accessed October 28, 2020. 

https://www.fda.gov/news-events/press-announcements/fda-approves-lotion-nonprescription-use-treat-head-lice

FDA approves Sklice for OTC use

Using blood transfusions in newborns is not uncommon, even though there are no guidelines providing guidance for transfusion thresholds. Additionally, there is little information on the postoperative outcomes of newborns who are given preoperative blood transfusions. A 

The researchers used the American College of Surgeons National Surgical Quality Improvement Program–Pediatric Participant Use Data Files from 2012 to 2015. They found all of the newborns who underwent a surgical procedure during the period. Both mortality and composite morbidity, which was labelled as any postoperative complication, were examined for newborns who received a preoperative blood transfusion within 48 hours of surgery and then compared to newborns who did not get a transfusion.

There were 12,184 newborns identified in the data and 1209 of those newborns were given a preoperative blood transfusion. Researchers found that the newborns who had received a transfusion had worse postoperative outcomes as well as higher rates of preoperative comorbidities (composite morbidity: 46.2% vs 16.2%; 

 < .01). Following multivariable regression analysis, they found that postoperative blood transfusions were independently linked with an increased 30-day morbidity (odds ratio [OR] = 1.90; 95% CI: 1.63–2.22; 

 < .01) and mortality (OR = 1.98; 95% CI: 1.55–2.55; 

 < .01). Similarly, in propensity score–matched analysis the transfusions continued their association with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29–1.81; 

 < .01) and mortality (OR = 1.58; 95% CI: 1.24–2.01; 

The investigators concluded that preoperative blood transfusions were independently linked with both increased mortality and morbidity among newborns who underwent surgery. They believe that further prospective data are required to better illustrate how red blood cell transfusions impact patients in the neonatal population.

1. Dukleska K, Vinocur C, Brenn B, et al. Preoperative blood transfusions and morbidity in neonates undergoing surgery. 

. October 21, 2020. Epub ahead of print. doi:10.1542/peds.2019-3718

As the COVID-19 pandemic stretches into its 8th month in the United States, with many people still maintaining the self-isolation from the earliest months, the mental health toll has become an increasing topic of discussion. A 

 offers some insight into the mental health state of the students and the factors that are linked to developing mental health symptoms.

The researchers asked all French universities to send an email to their students to complete an online questionnaire. Each participant was asked about a variety of mental health concerns including suicidal thoughts, stress, anxiety, and depression. They were assessed with the 22-item Impact of Events Scale–Revised, the 10-item Perceived Stress Scale, the 20-item State-Trait Anxiety Inventory (State subscale), and the 13-item Beck Depression Inventory. Care seeking data were also collected.

From a targeted population of 1,600,000 students, 69,054 students completed the survey. Most of the respondents were women (50,251 [72.8%]) and many were first-year students (32,424 [47.0%]). The students reported a prevalence of suicidal thoughts 11.4% (7891 students), severe distress (22.4% (15,463 students), high level of perceived stress 24.7% (17,093 students), severe depression 16.1% (11,133 students), and high level of anxiety 27.5% (18,970 students). Among the 29,564 students who reported at least 1 mental health outcome, 3675 of them said they had seen a health professional. Reporting at least 1 of the mental health outcomes was associated with a number of factors, including:

female gender (odds ratio [OR], 2.10; 95% CI, 2.02-2.19; 

nonbinary gender (OR, 3.57; 95% CI, 2.99-4.27; 

precariousness (loss of income: OR, 1.28; 95% CI, 1.22-1.33; 

 < .001; low-quality housing: OR, 2.30; 95% CI, 2.06-2.57; 

 < .001), history of psychiatric follow-up (OR, 3.28; 95% CI, 3.09-3.48; 

symptoms compatible with COVID-19 (OR, 1.55; 95% CI, 1.49-1.61; 

social isolation (weak sense of integration: OR, 3.63; 95% CI, 3.35-3.92; 

 < .001; low quality of social relations: OR, 2.62; 95% CI, 2.49-2.75; 

low quality of the information received (OR, 1.56; 95% CI, 1.49-1.64; 

The researchers concluded that university students reported a high rate of mental distress during the COVID-19 quarantine, with certain populations at greater potential risk. They believe that their results highlight the need to maintain contact with students, ensuring that they are in a safe place. Additionally, promoting access to care should be encouraged.

1. Wathelet M, Duhem S, Vaiva G, et al. Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic. 

. 2020;3(10):e2025591. doi:10.1001/jamanetworkopen.2020.25591.