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A recent investigation revealed associations between outdoor air pollution in urban areas and non-viral 

 exacerbations, as well as specific inflammatory pathways in the airways of children with asthma.

The prevalence and severity of asthma increased with the rise of urbanization, and according to the study, children in low-income urban centers have the highest rates of asthma. While the relationship has been observed in previous literature, the mechanisms involved are not understood, especially in comparison to those that facilitate the relationship between respiratory viruses and asthma exacerbation.

In the study, Matthew Altman, MD, Systems Immunology Division, Benaroya Research Institute, and investigators, focused on asthma exacerbations without the presence of respiratory virus, but the team also aimed to examine regional air pollutant concentrations, respiratory illnesses, lung function, and upper airway transcriptional signatures in children with asthma.

The Specific Inflammatory Pathways and Air Pollutants

The retrospective analysis evaluated data from the MUPPITS1 cohort from 2017, which enrolled 208 children aged 6-17 years from urban areas across 9 cities. The participating patients had exacerbation-prone asthma and were recruited between October 2015-October 2016, then their respiratory status was monitored. The final visit of the investigation took place in January 2017.

Investigators then validated their findings with the ICATA cohort, which recuited 419 patients with persistent allergic asthma, aged 6-20 years, that lived in urban areas across 8 US cities. Enrollment occurred from October 2006-March 2008, with the final visit dated December 2009.

For this assessment, investigators included patients who reported respiratory illness within the MUPPITS1 study duration. Patient data from the ICATA cohort were included if they had nasal samples collected at the time of respiratory illness or a scheduled visit.

Air quality index values and air pollutant concentrations for PM2.5, PM10, O3, NO2, SO2, CO, and Pb from the US Environmental Protection Agency spanning the years of both cohorts, were used to match values and concentrations of each illness for each participant. Then, investigators utilized an amalgamation of generalized additive models, case crossover analyses, and generalized linear mixed-effects models in order to identify associations between regional air pollutant concentrations and respiratory illnesses and asthma exacerbations, pulmonary function, and upper airway transcriptional signatures.

Influences of Asthma Without Viral Infection

The data demonstrated a rise in air quality index values, that resulted from increased PM2.5, O3 concentrations, showed a significant association with decreased pulmonary functions and the presence of asthma exacerbations without viral infection. The analysis consisted of 168 patients from MUPPITS1 (98 males; 70 females), and 189 patients from ICATA (115 males; 74 females).

Evidence of altered gene expression in coordinated inflammatory pathways was significantly linked to individual pollutants. This observation related to PM2·5 with increased epithelial induction of tissue kallikreins, mucus hypersecretion, barrier functions and O3 with increased type-2 inflammation, the team reported.

"Our findings suggest that air pollution is an important independent risk factor for asthma exacerbations in children living in urban areas and is potentially linked to exacerbations through specific inflammatory pathways in the airway," investigators wrote. "Further investigation of these potential mechanistic pathways could inform asthma prevention and management approaches."

Associations between outdoor air pollutants and non-viral asthma exacerbations and airway inflammatory responses in children and adolescents living in urban areas in the USA: a retrospective secondary analysis

This article was published by our sister publication HCP Live.

Articles

The specific mechanisms involved in associations between air pollution and respiratory illness without viral infection are not understood, especially compared with those of respiratory viruses and asthma exacerbation.

Air pollution in urban areas linked to asthma, inflammatory responses in children

The risk of sudden infant death syndrome (SIDS) is greater among siblings of children who died of SIDS, according to a recent study.

SIDS is defined as the death of an infant aged under 1 year after an extensive postmortem investigation. It is the leading cause of death in the first year of life, but its causes remain unclear. Hypothesized risk factors of SIDS include an exogenous stressor, a critical development period, and an underlying vulnerability.

As SIDS risk still cannot be predicted, determining the association between a family history of SIDS and subsequent SIDS is needed to identify children at risk of SIDS. A study was conducted to determine if SIDS risk increases in siblings of children who died of SIDS.

Health and administrative registries in Denmark were used to conduct the study. These registries contained registration data on parents and siblings of individuals born in Denmark, along with complete data on hospital diagnosis and cause of death. 

Information on those who had died from SIDS was collected from the Danish Cause of Death Register. If an infant aged under 1 year died to a cause unknown after thorough autopsy, their death was registered as SIDS.The Danish Medical Birth Registry was used to determine siblings of children who had died of SIDS. 

The study population included all births in Denmark between January 1, 1978, and December 31, 2016, aged under 1 year at the time of death. Stillborn babies and adopted children were excluded. Data was also collected on household income and mothers’ educational status.

Ninety percent of SIDS cases occurred within the first 6 months of life, with a median age of 3 months. Of children experiencing SIDS, 61% were male. 

While sex and mother’s age at birth did not lead to a significant difference in SIDS cases between the 2 study groups, sibling SIDS cases more often lived in low-income households and had mothers with only elementary school education.

Of 2,666,834 births, 1540 cases of SIDS were identified. The rate of SIDS was higher among siblings of children who died of SIDS compared to a general population. A 4-fold higher risk was found among this group, indicating that family history of SIDS should be considered when determining SIDS risk.

Glinge C, Rossetti S, Oestergaard LB, Stampe NK, Lynge TH, Skals R, et al. Risk of sudden infant death syndrome among siblings of children who died of sudden infant death syndrome in Denmark. 

2023;6(1):e2252724. doi:10.1001/jamanetworkopen.2022.52724

In a recent study, siblings of children who died of sudden infant death syndrome (SIDS) were at an increased risk of SIDS.

Risk of sudden infant death syndrome among siblings of victims

The rate of active postnatal care has a direct association with the survival rate of periviable infants, according to a recent study.

Multiple factors impact the decision on whether periviable infants born at 22 to 25 weeks’ gestation should be given active care, such as individual bias, fear of adverse outcomes, medical ethics, local and national policies, and communication between parents and caregivers. An individualized approach is recommended by professional societies in the United States.

There is little evidence on why infant mortality rates differ based on geographic variation, but data from Sweden has associated lower infant mortality rates among periviable infants in areas with higher rates of active perinatal care. Therefore, regional differences in mortality may be impacted by regional differences in rates of active perinatal care.

Investigators conducted a cohort study to determine the association between active perinatal care and infant mortality for periviable infants. Data on live births and infant deaths was gathered from a US Centers for Disease Control and Prevention database.

Infants were divided into subgroups based on gestational age. Subgroups included 22 weeks’ 23 weeks’ 24 weeks’, and 25 weeks’ gestation. The birth weight of included infants was 400 to 999 g.

Ten United States regions were included in the study. Active postnatal care involved using assisted ventilation, neonatal intensive care unit (NICU), surfactant replacement therapy, antibiotics for suspected neonatal sepsis, or seizures. Aside from seizures, these conditions indicated active postnatal care had been administered.

Race characteristics, insurance status, early prenatal care, and higher-risk pregnancy data were also collected. There were 41,707 periviable infants included in the study, 78% of which were of singleton birth and 46.7% of which were female.

The gestational age of 13.7% of infants was 22 weeks, 23 weeks for 23.1%, 24 weeks for 30.5%, and 25 weeks for 32.7%. About 19% of infants were Hispanic, and about 30% were non-Hispanic black. Established prenatal care by 3 months was seen from 69.5% of mothers, and 15.4% of pregnancies were considered higher risk. Medicaid covered about 42% of births.

There was evidence of active postnatal care in 83.9% of infants, with rates varying by region and gestational age. Infants born at 25 weeks’ gestational age were given active postnatal care more often than those born at 22 weeks’ gestational age, 93.5% and 41.5% receiving care respectively.

Survival through infancy was seen in 62.6% of infants overall, 18.9% born at 22 weeks’ gestational age, 50.8% born at 23 weeks’ gestational age, 70.7% born at 24 weeks' gestational age, and 81.7% at 25 weeks' gestational age. Survival rates differed between various regions.

A moderate positive correlation was found between region rate of active postnatal care and survival rate at 22 weeks’ gestation. Rates of active care did not have a significant effect on survival rate at 23 weeks’, 24 weeks’, or 25 weeks’ gestation. A positive correlation was also found between regional NICU admission and survival rate at 22 weeks’ gestation. 

While assisted ventilation immediately after birth also had a positive correlation with survival at 22 weeks’ gestation, a negative correlation was found at 25 weeks’ gestation. Surfactant administration therapy also had a negative correlation with survival at 25 weeks’ gestation. Antibiotics for suspected sepsis had no correlation with survival rate.

For perinatal care, a positive correlation was found between regional cesarean delivery rates and survival at 23 weeks’ gestation, but not 22 weeks’, 24 weeks’, or 25 weeks’ gestation.The correlation between antenatal corticosteroid administration and survival was moderately positive at 22 weeks’ gestation and moderately negative at 24 weeks’ gestation.

Silva ER, Shukla VV, Tindal R, Carlo WA, Travers CP. Association of active postnatal care with infant survival among periviableinfants in the US. 

 2023;6(1):e2250593. doi:10.1001/jamanetworkopen.2022.50593

In a recent study, the infant survival rate among periviable infants varied based on the type of active postnatal care received at certain gestational ages.

Active postnatal care associated with periviable infant survival rate

A sugary drinks tax in England was associated with a decreased prevalence of 

 among older primary school children, according to new research from the University of Cambridge.

The study estimates that approximately 5,000 yearly cases of obesity may have been avoided in year six girls (10 to 11 years old) with the introduction of the Soft Drinks Industry Levy.

However, investigators found no significant associations between the tax and obesity levels in year six boys or younger children from the reception class (4 to 5 years old).

“We urgently need to find ways to tackle the increasing numbers of children living with obesity, otherwise we risk our children growing up to face significant health problems,” said the study’s first investigator Nina T. Rogers, PhD, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science. “That was one reason why the UK’s soft drinks industry level was introduced, and the evidence so far is promising. We’ve shown for the first time that it is likely to have helped prevent thousands of children each year becoming obese.”

A global health problem, children who are obese are more likely to suffer from serious health problems including high blood pressure, type II diabetes, and depression in childhood and in later life. One in ten reception aged children in England is living with obesity and the figure doubles to one in five children in year six.

According to the UK-based investigators, young people consume significantly more added sugars than recommended, a large source of which is sugar-sweetened drinks. Children in deprived households are more likely to be at risk of obesity and to be heavy consumers of sugar-sweetened drinks.

The UK governments introduced a two-tier sugar tax on soft drinks in April 2018 to protect children from excessive sugar consumption and address childhood obesity. This tax was aimed at manufacturers of the drinks to incentivize a reduction in the sugar content of soft drinks.

Investigators from the Medical Research Council (MRC) Epidemiology Unit at the University of Cambridge tracked changes in the level of obesity in children in England in reception year and year six between 2014 and 2020. They compared changes in levels of obesity 19 months after the sugar tax was introduced, taking into account previous trends in obesity levels.

The findings show the introduction of the sugar tax was associated with an 8% relative reduction in obesity levels in year six girls, which was equivalent to the prevention of 5,234 cases of obesity per year in just this group. These reductions were greatest in girls whose schools were in deprived areas, with a 9% reduction.

The study observed no associations between the sugar tax being introduced and changes in obesity levels in children from the reception class. No overall change in obesity prevalence was observed in year six boys.

Despite finding an association and not a causal link, investigators say the study adds to previous findings that the tax was associated with a substantial reduction in the amount of sugar in soft drinks.

“It isn’t a straightforward picture, though, as it was mainly older girls who benefited,” Rogers said. “But the fact that we saw the biggest difference among girls from areas of high deprivation is important and is a step towards reducing the health inequalities they face.”

Associations between trajectories of obesity prevalence in English primary school children and the UK soft drinks industry levy: An interrupted time series analysis of surveillance data

A sugary drinks tax in England may have prevented over 5,000 cases of obesity a year in older girls, but had no significant association with obesity levels in year six boys or younger children.

Sugary drinks tax may be effective in preventing childhood obesity

Prolonged absences from school and other life activities following a concussion may cause harm to recovery in pediatric patients aged 5 to 17 years, according to a recent study.

Current guidelines recommend 24 to 48 hours of rest for students following concussion, before a gradual return to school (RTS). However, strong evidence supporting the period spent away from school is lacking. Studies have found 72% of children will miss at least 1 day of school, with many absent for 2 to 5 days.

While prolonged rest has been associated with a potential delayed recovery, 1 study showed higher symptom levels in students spending more time at school. However, there is also evidence that early return to physical activity improves symptom recovery.

Investigators conducted a study to determine the average duration of absence from school following concussion and the associations between RTS timing and symptom burden 14 days postinjury. Data was gathered from the Predicting Persistent Postconcussion Problems in Pediatrics study, examining pediatric patients following concussion.

Exclusion criteria for the original study included not having an injury based on trauma, having a Glasgow Coma Score of 13 or less, and requiring hospital admission for multisystemic injury or neurosurgical intervention. The recent study also required a valid and specific RTS date, with children whose injury occurred during common school closure periods excluded.

Demographic, developmental, and psychiatric data were gathered. Follow-ups occurred at 7, 14, and 28 days postinjury, where participants provided information on their RTS date and current symptom behavior. Patients aged 5 to 7 years had responses given for them by their parents. 

The Post-Concussion Symptom Inventory (PCSI) was used to report symptom severity. Symptom burden, the primary outcome of the study, was measured by PCSI score at 14 days postinjury. The number of school days missed was assessed, with 0 to 2 days missed considered early RTS and 3 or more days missed considered late RTS.

There were 1630 participants included in the final sample, about 38% of which were female. The average age of participants was 11.8 years, and individuals were divided into 3 age groups: 5 to 7.9 years, 8 to 12.9 years, and 13 to 17.9 years.

On average, students missed 3.74 school days following a concussion. Older children often missed more days than younger children. About 54% of participants experienced an early RTS, and about 46% experienced a late RTS. Those aged 13 to 17 years most often experienced a late RTS, followed by those aged 8 to 12 years, then those aged 5 to 7 years.

Overall, significant associations between early RTS and reduced average symptom levels 14 days postinjury were recorded in individuals aged 8 to 12 years and those aged 13 to 17 years. This association was stronger in individuals with a greater symptom burden. However, it was not recorded in children aged 5 to 7 years.

These results indicated younger children return to school sooner than older children on average, but early RTS could lead to reduced symptom burden and faster recovery.

Vaughan CG, Ledoux A, Sady MD, Tang K, Yeates KO, Sangha G, et al. Association between early return to school following acute concussion and symptom burden at 2 weeks postinjury. 

2023;6(1):e2251839. doi:10.1001/jamanetworkopen.2022.51839

In a recent study, children returning to school earlier following a concussion experienced reduced symptom burdens at 14 days postinjury.

Early return to school reduces concussion symptoms

Artificial neural network (ANN) may be an efficient tool for predicting neonatal metabolic bone disease (MBD) during prenatal and postnatal periods, according to a recent study.

MBD is often seen in infants born preterm and lacking fetal mineral accumulation. Hypophosphatemia, hyperphosphatemia, and skeletal demineralization are all characteristics of MBD. Osteopenia, osteoporosis, rickets, and pathologic fractures can also all occur in MBD, increasing bone fragility and potentially impacting short- and long-term bone growth.

While infants at risk of MBD receive screening, there is a wide variety of diagnostic methods, and early recognition can be difficult because of the late onset of clinical symptoms and a lack of specific biochemical markers. This has led to a need for predictive tools for MBD.

A flexible and accurate machine learning algorithm, the ANN, has been able to predict multiple diseases. Investigators developed serial ANN models for the risk of MBD to determine the most efficient and accurate model for prediction.

Pregnant Chinese women gave written consent to participate in a diagnostic study, conducted from January 1, 2012, to December 31, 2021. Recruitment occurred early in pregnancy, and follow-up continued until 1 month after parturition.

To be included, participants needed to have a singleton pregnancy, complete clinical data during the antenatal, delivery, and postpartum periods, and surviving infants with detailed values of alkaline phosphatase. A peak serum alkaline phosphatase level above 500 U/L 72 hours after birth was used to determine MBD.

Data on maternal and neonatal characteristics was gathered from electronic health records. These characteristics included demographic data and prior pregnancy history, nutritional conditions during pregnancy, complications and comorbidities, medication use during pregnancy, birth outcomes, and neonatal disorders.

Five predictive models were build using an ANN, with a receiver operating characteristic curve used to evaluate the model performance.

There were 10,801 Chinese women participating in the study, 65.8% of which were local residents, 98.1% of Han ethnicity, and 9.3% had uterine scanning. Of the infants, 55.1% were male and 44.9% female. MBD presented in 138 infants, only 6 of which were term infants. In comparison, 75.9% of control infants were term infants.

In putative predictive factors, offspring of women with inadequate folic acid during pregnancy were 2.31 times more likely to develop MBD, compared to 3.26 times higher when born to women taking calcium supplementation and 0.38 times lower when born to women taking iron supplements. 

MBD risk factors included magnesium sulfate use in pregnancy and infants with low birth weight, anemia, septicemia, or respiratory distress syndrome.

The area under the receiver operating characteristic curve (AUC) was calculated for ANN models. Model 1 showed the highest AUC, followed by model 5, model 4, model 3, and model 2. As model 1 had a net reclassification improvement of 0.205 compared to model 5, it showed an improved discriminative ability.

Results also indicated improved identification of neonates at high risk of MBD with less instances of misclassification in model 1. Overall, model 1 showed the best performance for significant prenatal and postnatal factors and model 5 for postnatal factors, making them viable for use in clinical practice.

Jiang H, Guo J, Li J, Li C, Du W, Canavese F, et al. Artificial neural network modeling to predict neonatal metabolic bone disease in the prenatal and postnatal periods. 

 2023;6(1):e2251849. doi:10.1001/jamanetworkopen.2022.51849

Artificial neural network models have been developed which are able to accurately and efficiently predict neonatal metabolic bone disease.

Artificial neural network promising for predicting neonatal metabolic bone disease

The Mama Bear Effect charitable organization has launched free Pediatric Kits for medical centers and pediatricians to support the education of medical professionals, parents, and children on child sexual abuse prevention.

The Mama Bear Effects was founded in 2012 and has been recognized as a national leader in child sexual abuse prevention education.

According to Adrianne Simeone, founder of The Mama Bear Effect, a conservative estimate predicts about 10% of children are at risk of child sexual abuse. This estimate could reach up to 16% of boys and 25% of girls.

2023 Parental and Caregiver Perspectives on Child Sexual Abuse Prevention study

, The Mama Bear Effects found that many parents and caregivers want education on sexual abuse prevention from pediatricians. Despite this, awareness of the child sexual abuse epidemic is only being spread by 10% of pediatricians and family practitioners.

A Pediatric Best Practices Guide, co-written with Martin Finkel, DO, professor emeritus of the CARES Center at the Rowan-Virtua School of Osteopathic Medicine, is included in each Pediatric Kit. Finkel has dedicated 40 years of his career to addressing the issues of child sexual abuse.

"It is clear that pediatricians and medical professionals serve a critical role in educating families to help prevent sexual abuse,” Finkel said. “We cannot effectively improve children's outcomes without addressing the risk of sexual abuse."

The Pediatric Kits were partially funded by kNot Today, an Indianapolis-based nonprofit founded by Linda and Frank Reich. Alyssa Van Vactor, Executive Director of kNot Today, stated that the key to protecting children from sexual abuse is starting conversations with parents and giving them resources.

. Medical centers can schedule a short meeting to discuss participation in a survey for receiving a free Pediatric Kit.

Pediatric resources for sexual abuse prevention launched by The Mama Bear Effect. The Mama Bear Effect. January 26, 2023. Accessed January 27, 2023. 

https://www.newswire.com/news/pediatric-resources-for-sexual-abuse-prevention-launched-by-the-mama-21938969

Pediatric Kits supporting the education of medical professionals, parents, and children on child sexual abuse prevention have been launched by The Mama Bear Effect.

The Mama Bear Effect launches Pediatric Kits for child sexual abuse prevention education

According to the Surgeon General, 1 child in 5 experiences significant problems due to a psychiatric disorder. The good news is that The REACH Institute can help many, if not most, of these youngsters. The real tragedy is that so few, less than 1 in 3, are receiving the comprehensive treatment they really need. Children and adolescents with emotional and behavioral problems, deserve access to the best possible mental health care. Unfortunately, such services are often difficult to obtain. Parents, however, can advocate for their children’s needs, and health care practitioners, such as pediatricians, can further the cause by offering their services, through training for children and adolescent with mental health care issues.

REACH’s flagship Patient-Centered Mental Health in Pediatric Primary Care (PPP) Program will be held in West Palm Beach, Florida, March 17- to 19th. This dynamic, interactive 3-day course is led by world class pediatricians, developmental-behavioral pediatricians, clinical nurse specialists, and child/adolescent psychiatrists. PCPs who want to increase their skills and confidence in diagnosing and treating common mental health issues like ADHD, anxiety, depression, and other behavioral health issues are encouraged to register for this course.

Primary care is one of the most affordable and accessible ways for families to get common mental health issues diagnosed & treated. Yet, many providers feel they aren't adequately prepared. REACH’s PPP training program provides PCPs with custom-designed guides, assessment instruments, dosing and side effect charts, medication comparison tables, and other valuable tools they can begin using in their offices immediately. By providing mental health training for primary care providers, The REACH Institute increases the nation’s capacity to help children with mental health disorders.

To learn more about this training course in West Palm Beach, upcoming virtual training options and to register, visit: 

https://thereachinstitute.org/training/#patient-centered-mental-health-in-pediatric-primary-care-ppp

The REACH Institute announces its first live mental health training since the beginning of the COVID-19 pandemic.

Patient-centered mental health in pediatric primary care (PPP) program in West Palm Beach

Participation in sports teams increases the risk of using electronic vapor products (EVPs) among high school students, according to a recent study published in 

An increase in EVP use among high school students has been observed in recent years, potentially because of an assumption that nicotine vaping does not cause similar levels of harm and addiction as tobacco products. However, longitudinal studies have indicated an increased risk of cigarette use among youths using e-cigarettes.

Cases of morbidity because of vaping have been reported, and suspected carcinogens released by EVP liquids indicate potential, unknown health consequences. With these outcomes in mind, studies have been conducted on how adolescent behaviors affect the risk of EVP use.

Participation in sports teams has been associated with decreased cigarette use, but some studies have associated sports team participation with increased e-cigarette use. However, this data was limited.

To determine the association between participation in sports teams and EVP use, investigators conducted an analysis of data from the Youth Risk Behavior Survey (YRBS), a survey of high school students in the United States.

Data was gathered from the 2015, 2017, and 2019 YRBS cycles. Questions in the survey asked students on their use of EVPs and cigarettes in the previous 30 days. 

Exclusive users of EVP, referred to as EVP users, were students who had not used cigarettes but had used EVPs in this time. Exclusive users of cigarettes, referred to as cigarette users, were students who had used cigarettes and not EVPs. Students who used both products were referred to as dual users, and those who used neither were referred to as nonusers.

Intermittent use of EVPs or cigarettes was defined as 1 to 19 days of use in the past 30 days, while frequent use was 20 days or more in the past 30 days. Sports participation was determined through a question asking how many sports teams students played in during the past 12 months.

There were 30,762 high school students who met the inclusion criteria for the study throughout the 3 YRBS cycles. About half of participants were female. Of participants, 75.1% were nonusers, 2.3% cigarette users, 16.1% EVP users, and 6.5% dual users.

No participation in sports teams was seen in 43.7% of participants, while 25.4% were on 1 team, 17.4% on 2 teams, and 13.5% on 3 or more teams. Of students participating on 1 or more sports team, 74.5% were nonusers, 1.7% cigarette users, 18.3% EVP users, and 5.5% dual users.

Among students not participating in sports teams during the prior 12 months, 75.9% were nonusers, 3.1% cigarette users, 13.4% EVP users, and 7.6% dual users. These students used EVPs less than those participating in sports teams but used cigarettes more.

Participation in sports teams reduced the odds of frequent versus intermittent use for cigarettes and EVPs among cigarette and EVP users respectively.

Based on these results, investigators recommended student athletes be educated on the health risks of EVP use.

Rapoport E, Zhu M, Pham D, Keim SA, Adesman A. Sports team participation and vaping among high school students: 2015–2019. 

2023;151(1):e2021055565. doi:10.1542/peds.2021-055565

High school students in sports teams were less likely to use cigarettes, but more likely to use electronic vapor products, according to a recent study. 

Sports participation increases vaping risk among high school students

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

Early in the COVID pandemic, surges of other seasonal respiratory viruses like influenza and respiratory syncytial virus (RSV) were far below normal levels, likely because of masking and other precautions that were in place to try and stifle the spread of SARS-CoV-2.

But in the third year of the pandemic, as the public has largely abandoned masking and other measures, public health experts warned of the threat of a “tripledemic” of COVID, flu, and RSV infections.

It’s still too early in the season to get a final tally on the toll of each of these viruses, but so far each has made a strong showing.

RSV cases got an early start, ticking up as early as May and peaking around fall, according to the Centers for Disease Control and Prevention (CDC).

COVID-19 infections were declining through most of 2022, but new the highly Omicron transmissible variant changed that. The version of Omicron that was circulating the United States in late 2022 and into early 2023—XBB.1.5—has proven to be highly contagious, but not necessarily leading to as many hospitalizations or severe illness as previous variants.

Influenza cases were still being reported at high numbers as of mid-January, but the CDC revealed that infections appeared to be trending down. Annually, there are between 9 million and 41 million cases of influenza reported in each flu season, according to the CDC.

 This year’s total so far is at about 24 million, the CDC reports.

 While this total places the year’s cumulative flu burden at an average level, it’s not uncommon for flu cases to continue into early spring.

The good news is that each of these viruses have seemingly taken turns reaching a peak, despite warnings that the U.S. was headed for a triple pandemic of flu, COVID, and RSV this winter. Although it may not seem like it for families who have battled one illness after another, the worst of the predicted “tripledemic” seems to have missed its predicted target.

Adam J. Ratner, MD, of Hassenfeld Children’s Hospital at NYU Langone and a member of the American Academy of Pediatrics’ committee on infectious diseases, says it seems like these viruses had the greatest impact on higher risk groups, including children with other comorbidities or those did not receive the available vaccinations.

“I think it’s been a really bad respiratory viral season all over the country, and different areas have seen different things,” Ratner says.

RSV and flu made up the bulk of infections—at least those that he saw requiring hospital admission—early in the season, Ratner says. Hospitalizations are on the decline, now, but there are still plenty of kids becoming sick enough with any of these viruses to need a hospital bed, he adds. New COVID variants caused a spike in cases over the holidays, he says, but for a variety of reasons, severe illness from COVID appears to be limited to high-risk individuals for the most part.

“Most people in the U.S. Have some immunologic experience, meaning they’ve had COVID, been vaccinated one or more times, or both,” Ratner says, adding that there are estimates that somewhere around 75% of children in the U.S. have now been infected with COVID at some point during the pandemic whether they knew it or not.

There have been some co-infections with more than one of these viruses at a time, too, Ratner says, but there isn’t really any data that shows co-infection is leading to more severe illness. On the other hand, Ratner says complications like bacterial pneumonia can happen after an initial infection with COVID, flu, or RSV.

Vaccinations, when available, remain the best defense, Ratner adds. COVID and flu vaccines are available, but effective RSV immunizations are still in trial phases. One maternal vaccine from Pfizer has shown promise, he adds, and there is good data on the efficacy of long-acting monoclonal antibodies.

Currently, oseltamivir remains the treatment of choice for influenza, Ratner says, and remdesivir can be used in children who need hospitalization from COVID-19 or require oxygen therapy. Nirmatrelvir/ritonavir, another COVID treatment option, is only approved for children aged 12 and up, Ratner says.

RSV is perhaps the most difficult to manage beyond supportive care. Monoclonal antibodies are more of a preventive tool than a treatment option, he says. This treatment is used in premature infants and young children with congenital lung diseases, and its given monthly for their first RSV season, Ratner says.

While the winter respiratory virus season is far from over, Ratner says hospitalizations do appear to be on the downswing, and the number of children requiring intensive treatments remains relatively low.

“Fortunately for kids, getting hospitalized and needing that level of support is much rarer for kids than adults,” Ratner says.

1. RSV Numerator Data for the U.S. Centers for Disease Control and Prevention. Accessed January 15, 2023. https://www.cdc.gov/surveillance/nrevss/images/trend_images/RSV14Num_Nat.htm. 

2. COVID-19: COVID data tracker weekly review. Centers for Disease Control and Prevention. Accessed January 16, 2023. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. 

3. Disease burden of flu. Centers for Disease Control and Prevention. Accessed January 17, 2023. https://www.cdc.gov/flu/about/burden/index.html. 

4. Weekly U.S. influenza surveillance report. Centers for Disease Control and Prevention. Accessed January 17, 2023. https://www.cdc.gov/flu/weekly/index.htm. 

Artificial neural network promising for predicting neonatal metabolic bone disease

The Mama Bear Effect launches Pediatric Kits for child sexual abuse prevention education

Patient-centered mental health in pediatric primary care (PPP) program in West Palm Beach

Sports participation increases vaping risk among high school students

Virus triple threat