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

Childhood cognitive performance is very likely not set in stone and could in fact be modifiable in a number of ways. One of the key inequalities could be linked with racial disparities. An 

 looks at what modifiable factors could help improve cognitive test scores.

Researchers ran a longitudinal pregnancy cohort study that looked at mother-child pairs who were enrolled in the University of Tennessee Health Science Center–Conditions Affecting Neurodevelopment and Learning in Early Life study, which ran from December 2006 to July 2011. The children were examined every year until they were aged 4 to 6 years. Environment-wide associations were examined through 155 prenatal, perinatal, and postnatal exposures. The cohorts sample of mothers included pregnant women who were recruited when they were at 16 to 28 weeks of gestation and were receiving care at 4 hospitals in Shelby County, Tennessee. High-risk pregnancies were excluded from the study.

There were 1055 children included in the study. Twenty-four factors were examined. The researchers noted links between child cognitive performance and parental education as well as breastfeeding. With each increase of 1.0 standard deviation in exposure, positive links were seen with fostering cognitive growth from maternal reading ability (β = 1.42; 95% CI, 0.16-2.68) as well as observed parent-child interactions (β = 1.12; 95% CI, 0.24-2.00). A negative association was found with parenting stress (β = −1.04; 95% CI, −1.86 to −0.21). The researchers found that a moderate increase in the beneficial exposures were linked with a noted improvement in estimated cognitive testing scores when using marginal means (0.5% of a standard deviation). Overall black children had fewer beneficial cognitive performance exposures.

The investigators concluded that there were a number of beneficial cognitive performance exposures that were modifiable and also linked with mean differences in cognitive performance by race. They believe that the study could guide other studies that are focused on decreasing racial disparities found in childhood cognitive performance.

1. LeWinn K, Bush N, Batra A, Tylavsky F, Rehkop D. Identification of modifiable social and behavioral factors associated with childhood cognitive performance. 

. September 21, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.2904

Articles

A new investigation looks at the modifiable factors that can impact childhood cognitive performance.

How modifiable is childhood cognitive performance?

Childhood is filled with many things, including spending time with family, going to school, and forming the foundation for adult life. Unfortunately for some children, there can also be marginalization from peers. Little research has been done on how this peer rejection impacts long-term health outcomes. A 

 looks at the impact of peer status on circulatory outcomes in adulthood.

The researchers included participants who were born in 1953 and who also resided in the greater metropolitan area of Stockholm, Sweden in 1963. The study was based on the Stockholm Birth Cohort Multigenerational Study. Cohort members had their peer status assessed sociometrically at age 13 years. Inpatient care registers with information about circulatory diseases was linked to the survey material.

Investigators found that being marginalized by peers at age 13 years was linked with a significantly higher risk of circulatory disease in adulthood among both females (hazard ratio [HR] 1.33; 95% CI 1.04 to 1.70) and males (HR 1.34; 95% CI 1.09 to 1.64). Additionally, the researchers found a graded relationship between circulatory disease and peer status in the female participants (p=0.023). The same was not found with the male participants because only the lowest social status position was linked to a significantly increased risk of circulatory disease. The links between peer status and circulatory disease was significant, even after adjusting for other conditions.

The study had a number of strengths, including the use of longitudinal data that was linked to register data. There was also a high level of participation, which helped reduced biases that were linked to attrition or non-response. The homogenous nature of the study’s cohort also allowed certain influences, such as immigration, could be ruled out by the researchers. Limitations included very little information about the health and health-related behaviors in childhood. The timing of the presentation of health problems was also unable to identify.

The investigators concluded that circulatory disease in adulthood could potentially be traced to being marginalized by peers in childhood. Peer status in late childhood, which is when the child starts the process of social integration that will form the basis of adolescence and adulthood, can be a long-term stressor that could contribute to circulatory disease in a number of ways.

1. Miething A, Almquist Y. Childhood peer status and circulatory disease in adulthood: a prospective cohort study in Stockholm, Sweden. 

. September 15, 2020. Epub ahead of print. doi:10.1136/bmjopen-2019-036095

Many things in childhood can have a lifelong impact. A new study sheds light on how peer marginalization can impact cardiovascular outcomes in adulthood.

Social marginalization in childhood can impact circulatory health in adulthood

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

A nutritional assistance program aimed at improving diets of pregnant mothers, infants, and young children, may have benefits for older children in the household, too—even after they age out of the program, according to a new report.

Journal of the American Academy of Dietetics and Nutrition

, studied the unintended benefits of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) on older children in participating households.

Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a federal program that offers supplemental foods, education on nutrition and breastfeeding, breastfeeding support, access to health care and social services, and pregnancy and postpartum support to women and their children up to age 5 years. Eligibility for this program is based on nutritional risk and income level. Gross income has to be at or below 185% of the federal poverty level and be deemed by a health professional to be at nutritional risk to participate in WIC. Families and individuals who already participate in the Supplemental Nutrition Assistance Program (SNAP), Medicaid, or Temporary Assistance for Needy Families (TANF) are automatically eligible for WIC enrollment.

 participated in the WIC program in 2019, with California and Texas having the most number of residents enrolled. Annual 

 for the WIC program nationwide were just over $3 billion in 2019, with an 

 of about $40 per person. Although this program is costly, the benefits have been well-demonstrated. Previous research has shown an association between participation in the WIC program and healthier eating habits in children up to age 5 years. What has not been investigated before is how the WIC program could potentially help older children living in WIC households.

The new study focused on examining the dietary behaviors of children who were no longer eligible for the WIC program due to age, but lived in households with other children who were enrolled in WIC. Data were collected from 2 independent household surveys collected in 2010 and 2014 as part of the New Jersey Child Health Study.

More than 600 children who were too old to participate in WIC but who lived in households with incomes below 200% of the federal poverty level were included in the study. Nearly 400 of those children lived in homes that participated in the WIC program because of other children in the household.

The research team asked questions about specific foods, including daily fruit and vegetable intake, consumption of 100% juice or sugar-sweetened beverage, and how often sweet and salty snacks were eaten.

Overall, the study team didn’t find a big difference in the diets of children between the ages of 5 and 18 years, regardless of whether anyone else in their household was enrolled in the WIC program. There were some healthy patterns observed for children who were too old for WIC but lived in WIC households. Children in the 12- to 18-year-old age range who were ineligible for WIC due to age but lived in WIC households consumed more vegetables that their peers who lived in non-WIC households. Additionally, girls in WIC households who were ineligible for the program consumed 100% fruit juices more often than those in non-WIC households. The report also found that age ineligible children in Hispanic WIC households consumed less sugar-sweetened beverages that children in the same demographic from non-WIC households.

The study concluded that as children age out of WIC eligibility, they may still benefit from the program through younger siblings or household members. Researchers suggest that future revisions to WIC programming should consider the implications and benefits of extending the program to other children in eligible households, according to the report.

1. Steeves S, Acciai F, Tasevska N, DeWeese R, Yedidia M, Ohri-Vachaspati P. The special supplemental nutrition program for women, infants, and children spillover effect: do siblings reap the benefits?. 

. 2020;120(8):1288-1294. doi:10.1016/j.jand.2020.02.013

2. Benefits.gov. Special supplemental nutrition program for women, infants and children (WIC). Accessed September 21, 2020. 

Even though they may be too old to participate in Special Supplemental Nutrition Program for Women, Infants and Children (WIC), a new study shows that the program can help older kids eat better, too.

WIC can benefit older siblings too

 investigated whether participating in programs aimed to supplement food supplies for low-income families could help improve food security and healthy outcomes. Published in the 

Journal of the Academy of Nutrition and Dietetics

, the goal of the study was to investigate food spending in households that participating in the Supplemental Nutrition Assistance Program (SNAP).

The Supplemental Nutrition Assistance Program is a federally funded program that helps low-income families with food expenses at home. The program is administered by individual states, and about 14 million households received SNAP benefits in 2018, according to the US Census Bureau.


Previous reports have shown a positive relationship between SNAP participation, and at-home food spending. However, what research hasn’t shown is how this is affected by food pricing in difference areas.

The new study investigated more than 2500 SNAP and non-SNAP households whose cash income was at or below 185% of the Federal Poverty Level. According to the US Census Bureau, SNAP participation requires household incomes to be below a certain threshold, and benefits then depend on the size, income, and demographic of the household. The average monthly SNAP benefit in 2018 was $251, the census bureau reports. About half of all SNAP households include at least 1 child aged younger than 18 years and a third of those households included a person aged 60 years or older.

The median household income for SNAP families in 2018 was $61,937 per year, according to the US Census Bureau, with the highest levels of SNAP participation in New Mexico and West Virginia. About 13% of the nation’s SNAP households are below the poverty limit. Additionally, most SNAP households are white rather than minorities—with 76% of households being white; 13.5 being Hispanic or Latino; 12.4 being black alone; and less than 5% Asian. Eligibility for SNAP is a bit more generous when disabilities are involved, according to the report, noting that about a quarter of all SNAP participants have at least one person with disabilities in the household.

Researchers compared spending on food at home to maximum SNAP benefits based on household size alongside consumer price indexes. The result was a positive spending difference between SNAP and non-SNAP spending on average.

Households that had a lower household income and higher SNAP participation had spending relative to maximum SNAP benefits that was 29 to 30 percentage points more than low-income, non-SNAP households. These trends were similar in areas with varying price indexes.

The research team concluded that families enrolled in the SNAP program spent more overall on food at home than non-SNAP, low-income families. More research is needed to understand how SNAP participation can help improve food security and overall health outcomes, the report notes.

1. Ismail M, Ver Ploeg M, Chomitz V, Wilde P. Differences in food-at-home spending for SNAP and non-SNAP households given geographic price variation. 

. 2020;120(7):1142-1150.e12. doi:10.1016/j.jand.2019.12.017

2. Loveless T. Supplemental Nutrition Assistance Program (SNAP) Receipt for Households: 2018. Census.gov. Published June 1, 2020. Accessed September 21, 2020. 

https://www.census.gov/content/dam/Census/library/publications/2020/demo/acsbr20-01.pdf

For low-income families, securing an adequate supply of nutritious foods can be a challenge. There are public programs to help supplement grocery budgets, such as the Supplemental Nutrition Assistance Program (SNAP) but do these help needy families improve their overall nutrition?

Impact of SNAP on food spending

An extremely low birth weight can be linked with many less than optimal outcomes in life. A 

 examines whether extremely low birth weight combined with early hypoxemic respiratory failure to impact survival and neurodevelopmental impairment in young children aged 18 to 26 months.

 The study also examined whether exposure to inhaled nitric oxide improved the outcomes for African American infants who had early hypoxemic respiratory failure.

The researchers used the Neonatal Research Network to find infants who had a weight ≤ 1000g, had a gestational age ≤ 26 weeks, had maximal oxygen ≥ 60% on either day 1 or day 3, were labeled early hypoxemic respiratory failure, and were born between 2007 to 2015. They used a propensity score regression model to analyze the outcomes.

There were 7639 infants with extremely low birth weight who were born ≤ 26 weeks. In this group, 22.7% of the infants had early hypoxemic respiratory failure. The investigators found that early hypoxemic respiratory failure was linked with a mortality of 51.3%. They also found the incidence of moderate-to-severe neurodevelopmental impairment was 41.2% in infants at 18 to 26 months of age. Among the infants who were treated with inhaled nitric oxide, the mortality was found to be 59.4%. Intact survival was linked to a complete course of antenatal steroids (adjusted odds ratio [aOR]: 1.6, 95% CI: 1.1–2.2), being female (aOR: 2.4, 95% CI: 1.8–3.3), and having a birth weight ≥ 720 g. Infants who were African American were found to have a similar incidence of early hypoxemic respiratory failure, 21.7% versus 23.3%. However, they were found to have lower exposure to inhaled nitric oxide, 16.4% versus 21.6%. Intact survival, which meant no death or neurodevelopmental impairment, had no significant difference between African-American infants and other races (aOR: 1.5, 95% CI: 0.6–3.6), when looking at infants with hypoxemic respiratory failure who were exposed to inhaled nitric oxide.

The researchers concluded that early hypoxemic respiratory failure in infants with ≤ 26 weeks is linked with both high mortality and high neurodevelopment impairment at 18 to 26 years. Additionally, the use of inhaled nitric oxide was not found to decrease either mortality or neurodevelopment and those outcomes were not different among African American infants.

1. Chandrasekharan P, Lakshminrusimha S, Chowdhury D, et al. Early hypoxic respiratory failure in extreme prematurity: mortality and neurodevelopmental outcomes. 

. September 17, 2020. Epub ahead of print. doi:10.1542/peds.2019-3318

Extreme low birth weight is linked to suboptimal outcomes. A new report looks at how early hypoxemic respiratory failure and extreme low birth weight can influence survival.

Impact of extreme low birth weight and early hypoxemic respiratory failure on survival

Poll

Do providers feel like they have successfully adapted to providing telehealth services, as compared to the beginning of the pandemic?

How comfortable are providers with telehealth?

Pediatric nurse practitioners (PNPs) often evaluate infants, children, and adolescents with a variety of dermatologic presentations that provide supporting evidence for the differential diagnoses and the subsequent final diagnosis. In their article, 

Dermatological findings associated with COVID-19 in pediatric patients

 Dr Schmidt and Ms Chen provide a detailed description of cutaneous manifestations in children and adolescents that most likely are associated with a diagnosis of COVID-19, even in the absence of positive polymerase chain reaction (PCR) or antibody test results.

It is important for PNPs to become familiar with these newly described dermatologic findings to accurately differentiate these skin presentations from ‘somewhat look-alike’ presentations that are more familiar to all providers in pediatric primary care clinical practice, urgent care centers, or emergency departments. Pediatric nurse practitioners need to recognize these newly identified skin manifestations and the relationship to a diagnosis of COVID-19. The conditions identified by Dr Schmidt and Ms Chen included pseudo-chilblains, erythema multiforme-like lesions, multisystem inflammatory syndrome in children, Kawasaki disease, and other non-specific viral exanthems. The authors provide photographs for each of these conditions. Pediatric nurse practitioners should become familiar with each of these photos to diagnose the dermatologic findings in a timely manner and/or make a referral to a dermatologist or other health care providers, as appropriate.

The authors discuss the open registry now available, identified as the Pediatric Dermatology Research Alliance COVID-19 Response Task Force (PDCRTF). This analysis of dermatologic presentations in COVID-19 will be a valuable resource for pediatric providers to identify as many presentations as possible for children who are suspected of having COVID-19 even in the absence of positive PCR, antigen, or antibody testing.

Since the beginning of the COVID-19 pandemic, there have been considerable disagreements about testing for COVID-19. The fact that children are presenting with dermatologic findings that are highly suspicious of being related to COVID-19 and available data showed that many children with these manifestations have tested negative on PCR and antibody testing is a major concern. Were these children living in households where adults were exposed to the virus, and the children were not tested until the dermatologic manifestations were evident? Have children only been tested if they presented with respiratory systems or fevers suggestive of COVID-19?

The lack of a comprehensive national testing plan for adults and children has adversely affected the ability of health care professionals, scientists, and researchers to control many outbreaks that have occurred and are occurring throughout the United States. As children and adolescents return to school, testing is a critical component for the equation of a safe return for the children, adolescents, school personnel, and teachers. Yet, there is no consistent plan for testing. We have already seen some high schools and colleges closing almost immediately after opening and the one commonality has been no testing plan in place. We, as pediatric health care providers, must advocate for a testing plan for children to assure the safety of the children and adolescents, the school personnel and teachers and as they return home each day, for their family members as well.

Growing evidence indicates that COVID-19 impacts more than the respiratory system. Clinicians should keep an eye out for dermatologic conditions that may be associated with the illness.

Emerging dermatologic conditions in the presence of COVID-19 pandemic

A mother’s health during the end of pregnancy and the first weeks following delivery can have an impact on not only her health outcomes, but her offspring’s as well. A 

 looked at the effect that maternal perinatal depression and anxiety had on the offspring’s development in the first 18 years of life.

The investigators used 6 databases: CINAHL Complete, Cochrane Library, Embase, Informit, MEDLINE Complete, and PsycInfo, to search for studies that reported information on the link between perinatal maternal mental health problems and offspring development. They included studies that were published in English, had a human sample, collected quantitative data, utilized a longitudinal design, examined measures of perinatal depression as well as development in the offspring, and investigated whether there was a link between perinatal depression or anxiety and childhood development.

The researchers found 191 unique studies that met their criteria, which created a combined sample of 195,751 unique mother-child pairs. They found that maternal perinatal depression and anxiety were linked with poorer development in the following areas:

cognitive (antenatal period, r = −0.12 [95% CI, –0.19 to –0.05]; postnatal period, r = −0.25 [95% CI, –0.39 to –0.09])

language (antenatal period, r = −0.11 [95% CI, −0.20 to 0.02]; postnatal period, r = −0.22 [95% CI, −0.40 to 0.03])

adaptive behavior (antenatal period, r = −0.26 [95% CI, −0.39 to −0.12])

offspring social-emotional (antenatal period, r = 0.21 [95% CI, 0.16-0.27]; postnatal period, r = 0.24 [95% CI, 0.19-0.28])

motor (antenatal period, r = −0.07 [95% CI, −0.18 to 0.03]; postnatal period, r = −0.07 [95% CI, −0.16 to 0.03])

The investigators found that this went beyond only the infant years and lasted into both childhood and adolescence. The robust nature of the results was confirmed through meta-regression.

They concluded that maternal anxiety and depression in the perinatal period did have a negative association with the child’s development. The results indicated that preventing depression and anxiety in this period as well as utilizing early interventions could have positive impact on the development of many children.

For more on maternal depression's impact on a child's development, click 

1. Rogers A, Obst S, Teague S et al. Association between maternal perinatal depression and anxiety and child and adolescent development. 

. September 14, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.2910

A mother’s health during pregnancy and in the first weeks following delivery can have an impact on her future health. A new report looks at how her mental health could also impact her child’s development through not only infancy, but childhood and adolescence.

Impact of a mother’s perinatal depression on a child’s development

There is no level of lead exposure that is without risk. Exposure to lead in childhood leads to irreversible neurodevelopmental deficits, which sets children up for a lifetime of suboptimal outcomes. Unfortunately, lead exposure prevention is only secondary in nature. An investigation in 

 assesses whether a machine learning model was better than regression in predicting childhood lead poisoning.

Researchers ran a prognostic study that used data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program linked to the Chicago Department of Public Health. The participants came from a development cohort of children and a validation WIC cohort. Blood lead levels were assessed until December 2018.

There were 6812 children in the WIC validation cohort, which was comprised of mostly Hispanic and non-Hispanic Black children. The median year for house construction in the cohort was 1919. The machine learning prediction model’s area under the curve was 0.69, whereas the logistic regression’s area under the curve was 0.64 (difference, 0.05; 95% CI, 0.02-0.08). When the models were used to predict the 5% of children who were at the highest risk of having elevated blood lead levels, the machine learning model had a positive predictive value of 15.5% and the regression had a predictive value of 7.8% (difference, 7.7%; 95% CI, 3.7%-11.3%). In this same group, the sensitivity was 16.2% for machine learning and 8.1% for the regression (difference, 8.1%; 95% CI, 3.9%-11.7%) and the specificity was 95.5% and 95.1%, respectively (difference, 0.4%; 95% CI, 0.0%-0.7%)

The investigators concluded that the machine learning model was better at predicting childhood lead poisoning than regression. The machine learning was particularly good at identifying children who were at the highest risk of being exposed to lead. The findings are particularly important because many agencies have limited resources to proactively prevent lead exposure. The study’s results indicate that predicting lead exposure is difficult, but utilizing the machine learning model could help agencies use proactive measures to prevent exposure among children who are at the greatest risk.

1. Potash E, Ghani R, Walsh J, et al. Validation of a machine learning model to predict childhood lead poisoning. 

. 2020;3(9):e2012734. doi:10.1001/jamanetworkopen.2020.12734

No level of exposure to lead is safe and predicting exposure can be difficult. An investigation assesses the effectiveness of a machine learning model in predicting lead exposure.

Predicting lead exposure with a machine learning model

The 2020-2021 school year is going to be an unusual one. Some children are still solely learning virtual and some have returned to in-class learning. Then there are the children who are getting a hybrid education, with some virtual and some on-site teaching . Regardless of where and how a child is learning, there are many hurdles for families to get over to get the most out of school. The American Academy of Pediatrics has come up with 

 to help every child have the best year possible.

Create and maintain a built-in routine for each weekday. Maintain this routine both when the child has virtual learning and when the child has in-person education.

For the child who is learning virtually, make sure he/she/they has a quiet place to attend school and that they have the supplies and login information needed for necessary accounts.

For the child who is learning in-school, make sure the child has multiple face masks that are labelled with the child’s name. Rehearse proper mask technique with child.

Ensure the child is up-to-date on all vaccinations. If vaccinations are needed or there is uncertainty about whether a child has all needed vaccinations, the parent should contact the child’s pediatrician.

Encourage the child to take ownership of his or her learning. Parents should provide help only when absolutely necessary.

Discuss mental health with the child and watch out for signs that more mental health help may be needed. If the child is having trouble with school, contact the school and the child’s pediatrician.

Talk to the child’s teacher about how the child is handling the situation. Be sure to bring up any specific concerns.

Watch out for signs of struggle with school work. If a child is struggling, contact the child’s pediatrician to schedule an appointment for a learning disability evaluation or to see if the struggles are linked to something else.

Do not send the child to school if he or she is showing any sign of illness. Contact the pediatrician to talk about the next steps.

For children with disabilities, discuss an individualized plan with both the pediatrician and educators.

Ensure that parents have some time to themselves, when they don’t have to worry about caring for their child.

1. American Academy of Pediatrics. AAP offers back-to-school tips amid COVID-19. 

. Published September 1, 2020. Accessed September 16, 2020. 

https://services.aap.org/en/news-room/news-releases/aap/2020/aap-offers-back-to-school-tips-amid-covid-19/

The current school year will be an unusual one and will present many hurdles for families to cross. The American Academy of Pediatrics (AAP) has some tips to ensure each child has the best school year.

How comfortable are providers with telehealth?

Emerging dermatologic conditions in the presence of COVID-19 pandemic

Impact of a mother’s perinatal depression on a child’s development

Predicting lead exposure with a machine learning model

AAP offers 11 tips for the 2020-2021 school year