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Recently, I talked to Contemporary Pediatrics' Editorial Advisory Board member Candice W. Jones, MD, FAAP, about her new book, "High Five Discipline: Positive Parenting for Happy, Healthy, Well-Behaved Kids," published by the American Academy of Pediatrics. 

Candice Jones, MD, discusses her new book, "High Five Discipline: Positive Parenting for Happy, Healthy, Well-Behaved Kids"

Julianne Lapsa is a pediatric emergency fellow at Johns Hopkins Children’s Center in Baltimore, Maryland.

Thuy Ngo is an assistant professor of pediatrics at Johns Hopkins University School of Medicine in Baltimore, Maryland.


A female aged 13 years with morbid obesity (body mass index, 56.7 kg/m

) and recent hospitalization for pyelonephritis presented to the pediatric emergency department with abdominal pain, tachycardia, and shortness of breath. She completed a course of oral antibiotics for the pyelonephritis about 4 days prior and initially felt well. Two days later, she started to experience diffuse abdominal pain accompanied by nonbloody, nonbilious emesis and watery diarrhea. The patient also complained of increased thirst and new bowel and bladder incontinence. That morning she developed difficulty breathing with tachypnea and a generalized feeling of weakness, which prompted her presentation to the pediatric emergency department. She denied fever, dysuria, or malodorous urine since completing the above antibiotics. She also denied being sexually active. She had operative pinning for a slipped capital femoral epiphysis about 3 months earlier, for which she has no residual pain or swelling, but she still uses crutches and has been sedentary since the procedure.

Triage vital signs show a temperature of 36.6 °C with a heart rate of 177 beats per minute; blood pressure, 104/84 mmHg; respiratory rate, 30 breaths per minute; pulse oximetry, 98% on room air; and capillary refill time of 3 seconds. She is generally ill appearing and moaning in pain. Her exam is also notable for dry mucous membranes and otherwise significant for tachycardia without murmurs, tachypnea with clear breath sounds, and a soft and nondistended but diffusely tender abdomen. She has no rashes, joint swelling, or swelling of lower extremities.

Immediate interventions to treat the tachycardia and early signs of shock include intravenous (IV) fluid resuscitation with improvement in heart rate, cap refill time, and blood pressure. A blood culture was drawn followed by administration of empiric IV ceftriaxone and metronidazole. Antibiotics were selected for broad-spectrum coverage in this patient who fits systemic inflammatory response syndrome criteria and for additional polymicrobial coverage for possible intra-abdominal infection (Table 1). An electrocardiogram (ECG) was obtained to evaluate for right heart strain, and ischemia was notable for sinus tachycardia. Computed tomography angiogram (CTA) of chest and CT abdomen/pelvis with IV contrast imaging were ordered.

Given the patient’s ill appearance, abnormal vital signs, and multiple sources for possible infection, the following broad laboratory work-up was pursued. An initial glucometer reading was 119 mg/dL. Additional results returned as follows: complete blood count with leukocytosis of 30 K/mm

 with 8% bands; hemoglobin, 10.7 g/dL, hematocrit, 33.6 g/dL, platelets, 649 K/ mm

; C-reactive protein, 56 mg/dL (<0.5 mg/dL); lactate, 2 mmol/L (normal <2.3 mmol/L). D-dimer was elevated at 19 mg/L FEU (normal <0.5 mg/ dl FEU). A comprehensive metabolic panel, venous blood gas, troponin, lipase, urinalysis, and urinary pregnancy test were all within reference range.

The greatest initial concern and most immediately life-threatening diagnosis was a pulmonary embolus (Table 2). Although less common in the pediatric than adult population, the patient had several risk factors, including obesity, minimal ambulation for the past several months, surgical procedure, and recent hospitalization. A high index of suspicion is also needed for patients on oral contraceptive therapy, recent travel, malignancy, or a family history of hypercoagulability. The physical exam of acute distress, tachypnea with clear breath sounds, and significant tachycardia supported this possibility. No unilateral leg pain or swelling was seen, although this can be difficult to assess in patients with an obese body habitus. Patients typically present with chest pain, but abdominal discomfort can also be referred. ECG findings may be normal or demonstrate sinus tachycardia, right bundle branch block, ST-segment elevation in V1 and aVR, and low amplitude QRS complexes. The Simplified Wells Score and Pulmonary Embolism Rule-Out Criteria (PERC) are often used to risk- stratify patients with possible pulmonary embolism. The Wells Score rates patients on symptoms, likelihood of diagnosis, and history of hypercoagulability; patients with more than 1 risk factor should have immediate imaging. Those with a score of 1 or less can then be further assessed via PERC. PERC applies some of the same factors as Wells and also accounts for medication use and physical exam. If there are no PERC criteria met in addition to a Wells score of less than 2, no further evaluation is indicated. If any PERC signs are present, further stratification with D-dimer testing is suggested. Although this can be helpful to supplement clinician decision-making, both have not been validated for patients less than 18 years old. Thus, these should be used only as a guide and not to replace physical exam and clinical suspicion.

Although the patient had no reported fevers, sepsis must always be considered in a patient with persistent tachycardia. She had many possible intra-abdominal sources for sepsis, most notably a recurrent pyelonephritis complicated by a renal abscess. Her body habitus limited physical exam localization of pain to a specific abdominal quadrant; additional possible etiologies include cholecystitis, pancreatitis, appendicitis, and tubo-ovarian abscess (TOA). Other infectious sources are a lower lobe pneumonia with diaphragmatic irritation resulting in abdominal pain or an osteomyelitis from her recent hip surgery requiring hardware placement. Her vital sign improvement with IV fluid resuscitation, the significant leukocytosis with increased bands, and her elevated inflammatory markers further supported an active infection as the diagnosis. The elevated D-dimer indicated a possible blood clot, but this is also a nonspecific finding and usually elevated in sepsis, as well. The treatment of suspected sepsis includes IV fluid hydration and early broad-spectrum antibiotics following collection of all relevant cultures. If patients have hemodynamic instability despite aggressive fluid resuscitation, the vasoactive agent of choice according to recently updated pediatric sepsis guidelines is norepinephrine or epinephrine.

A history of new onset polydipsia and urinary incontinence raised the suspicion of an endocrine etiology. Although the patient was an adolescent, her body habitus suggested an increased risk of type 2 diabetes mellitus with resulting hyperosmolar hyperglycemic state (HHS). HHS is a consequence of hyperglycemia, significantly elevated serum osmolarity, and severe dehydration. It is typically a complication of uncontrolled type 2 diabetes or may be triggered by an underlying infection leading to dehydration. It can lead to fatal cerebral edema and cardiovascular collapse. HHS is diagnosed by clinical findings of dehydration, lethargy, and altered mental status. Laboratory evaluation includes elevated glucose greater than 600 mg/ dL, elevated plasma osmolarity of 320 mOsm/L or higher, and no ketoacidosis.

 Management requires aggressive IV hydration at twice the maintenance rate and administration of only subcutaneous insulin rather than a continuous infusion.

Unexplained tachycardia in the pediatric population may also indicate myocarditis. Myocarditis is an inflammation of the cardiac muscle usually caused by a recent viral infection. Additional signs and symptoms include tachypnea, fatigue, vomiting, hepatomegaly, and an S3 gallop on exam. ECG may show sinus tachycardia and elevated ST segments. Lab work-up usually is associated with an elevated troponin. A chest x-ray may show an enlarged cardiac silhouette and pulmonary edema. Patients typically do not tolerate IV fluids well and should be emergently transferred to a facility with pediatric cardiology services.

Radiographic testing revealed the diagnosis of the patient. A CTA chest was negative for pulmonary embolus, and the CT abdomen/ pelvis with and without IV contrast demonstrated a large fluid collection in the right lower quadrant (Figure) that was most consistent with a TOA. There was also extensive reactive bowel inflammation that likely caused her associated diarrhea and incontinence.

CT abdomen/pelvis with and without contrast demonstrates large tubo-ovarian abscess

Upon diagnosis of TOA, general pediatric surgery service was consulted. The patient was admitted to the pediatric intensive care unit following the surgical procedure. Pediatric infectious disease and gynecology services were consulted to guide IV antibiotic therapy. Antibiotics were then further broadened to vancomycin and piperacillin-tazobactam. Blood cultures remained negative. Her intra-abdominal culture grew multiple organisms. Gonorrhea and chlamydia polymerase chain reaction were negative. The patient had a prolonged hospital course of several weeks. She required 2 additional operative interventions for repeat drain placement and ultimately a right salpingectomy. She was discharged with multidisciplinary follow-up, including physical therapy and weight loss clinic. The patient continuously denied any sexual activity or sexual abuse. Her infection was attributed to a combination of recent urinary system infection and poor genitourinary hygiene.

TOA is an intra-abdominal infection that usually results as a late complication of pelvic inflammatory disease (PID). It typically presents with abdominal pain, vaginal discharge, adnexal mass, and leukocytosis in sexually active females of reproductive age. Up to 50% of infected patients may be afebrile with an ill appearance. As the infection is caused by ascension of bacteria from the lower genital tract, etiology of micro-organism is usually polymicrobial.

 The predominant cause is anaerobic bacteria rather than 

, and aerobic streptococci.3 Risk factors for TOA are reproductive age, intrauterine device use, multiple sexual partners, and past PID infections.

Physical exam usually notes pelvic tenderness, often with evidence of peritonitis. Bimanual exam may re- veal cervical motion tenderness and adnexal tenderness and/or mass. Radiographic testing will confirm the diagnosis, and multiple modalities are acceptable including ultrasonography, CT scan, and MRI.

Although TOA is almost always caused by further ascension of bacteria from PID, it can result spontaneously without history of sexual activity and as a complication of hysterectomy. In the pediatric population, it has been rarely seen as a sequela of inflammatory bowel dis- ease. There are also case reports of TOA in adolescents resulting from a combination of obesity, constipation, recurrent urinary tract infection, and poor hygiene.

After initial recovery, later complications include chronic pelvic pain, infertility, ectopic pregnancy, ovarian vein thrombosis, and recurrent PID.

TOA can be managed both medically and surgically. All patients should be admitted to the hospital with a gynecology consult. If the TOA has not yet ruptured, antibiotics can be trialed.

 The initial recommended regimen includes IV cefotetan or IV cefoxitin and IV doxycycline, IV ampicillin with IV gentamicin loading dose followed by IV clindamycin, or IV ampicillin-sulbactam and IV doxycycline. IV medications can be transitioned to oral once patients have defervesced, resolution of leukocytosis, clinical improvement in pain, and improvement in size of abscess on imaging.

Surgery may be pursued as source control for unstable patients, large abscess size, or failure of antibiotics. If patients have worsening symptoms or no improvement after 2 weeks of oral therapy, surgery is recommended. Surgical options include intervention- al radiologic percutaneous drainage or laparoscopy/laparotomy for drainage and possible salpingectomy.

Given the significant associated complications, TOA prevention is important when it comes to adolescent health. Health care team members should counsel patients on safe sex practices, PID, and TOA risk factors before a patient develops these conditions.

1. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. 

. 2020;21(2):e52-e106. doi:10.1097/PCC.0000000000002198

2. Adeyinka A, Kondamudi NP. Hyperosmolar hyperglycemic nonketotic coma. National Center for Biotechnology Information. StatPearls. Accessed August 4, 2021. 

https://www.ncbi.nlm.nih.gov/books/NBK482142/

3. Curry A, Williams T, Penny ML. Pelvic inflammatory disease: diagnosis, management, and prevention. 

4. Chernick LS. Tubo-ovarian abscesses in nonsexually active adolescents: A rare but consequential miss. 

. 2019;65(2):175-176. doi:10.1016/j.jadohealth.2019.04.006

5. Hartmann KA, Lerand SJ, Jay MS. Tubo-ovarian abscess in virginal adolescents: exposure of the underlying etiology. 

. 2009;22(3):e13-e16. doi:10.1016/j.jpag.2008.03.006

6. Jiang X, Shi M, Sui M, Wang T, Yang H, Zhou H, Zhao K. Clinical value of early laparoscopic therapy in the management of tubo-ovarian or pelvic abscess. 

. 2019; 18(2):1115-1122. doi:10.3892/etm.2019.7699

Articles

A female aged 13 years with morbid obesity (and recent hospitalization for pyelonephritis presents with abdominal pain, tachycardia, and shortness of breath. What's the diagnosis?

An adolescent female with abdominal pain and tachycardia

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

In an ideal world, everyone would eat well-balanced, home cooked meals packed with nutrients, but in reality, fast food and convenience meals are a fact of life for many people. A 

 from C.S. Mott Children’s Hospital in Ann Arbor, Michigan, asked 2019 parents about their family’s eating habits and examined how those habits varied in conjunction with the perception of their child’s.

When it came to how parents viewed whether their children were of normal weight, underweight or overweight, the vast majority of parents indicated that they believed their child was the right weight, but 13% felt their child was overweight and 10% thought their child was underweight. Lower income parents were more likely than higher income parents to say their child was overweight (21% vs 10%).

In terms of what kind of food caregivers and children ate, the pandemic led to major changes in the daily diet of the family and where the food came from. Half of the parents stated that their families had been eating more home cooked meals since the start, whereas 1 in 5 said that fast food meals had become a more regular meal option. Parents who said their child was overweight were more likely to increase fast food meals than the parents with children who were the right weight (28% vs 18%). When stressed for time, 72% of the parents agreed that fast good was a good option. Furthermore, 1 in 3 think that fast food provides good value for money and nearly a quarter of parents believe that it’s less expensive than cooking meal in the home.

Nearly all parents agree that fast food is unhealthy for children, but a roughly equal number of parents believe that it’s okay in moderation. When children do get fast food, 88% of the parents allow them to choose their meals and only 33% of parents read the nutritional information. Some parent did try to steer their child to healthier options (67%) and to reduce the number of unhealthy options like french fries (59%). Parents who think their child is overweight were more likely to say that their child had soda with their fast food than those who felt their child was the right weight.

Over the past few months, 66% of parents said that family meals had been healthier than they had been previously and 20% said that their child had at least 2 fast food meals a week. When asked what prevented parents from making home cooked meals, being too busy to cook (43%) and too much stress (22%) were the 2 top reasons. Moreover, those barriers were more commonly reported in parents who had an overweight child.

Clinicians should ask questions about family meals during visits. To help families that may be experiencing financial hardships and who may struggle to easily get to the grocery store, pediatric providers should be aware of programs in their area that can help families. If the parent indicates lacking the time to cook meals, pediatricians should use the time as family time, allowing younger children to help with preparation and encourage older children to experiment or even prepare a whole meal on their own.

1. C.S. Mott Children’s Hospital. Parent views on fast food and family meals. 2020;39(2). Published September 20, 2021. Accessed September 20, 2021. Available at: 

https://mottpoll.org/reports/parent-views-fast-food-and-family-meals

What’s on the dinner table varies widely from family to family. A new poll offers insight into what factors lead some of those meals to be fast food.

What leads families to choose fast food for family meals

Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics.

In 2007, Steve Jobs changed the world—and medical care—by introducing the iPhone. The iPad followed in 2010, and the Apple Watch in 2015.

 We now have hundreds of smartphone-based medical applications; we can dictate into the medical record using our phones, and can utilize “connected” devices, such as digital stethoscopes, pulse oximeters, continuous glucose monitors, and others to improve patient care. Here’s a look at some of the most useful connected devices/wearables, and smart applications for pediatric practice.

The Apple Watch: Implications for personal health

Although the Apple Watch followed the introduction of the iPhone by 8 years, it has had an enormous impact on health care. The current version of the Apple Watch, Series 6, can detect and monitor a patient’s heart rate, and alert if atrial fibrillation or an unusually fast heart rate is detected.

 With numerous patients, the Apple Watch has documented episodes of tachycardia that resulted in an evaluation by a pediatric cardiologist. Moreover, pediatric cardiologists are now advising patients to use their Apple Watch (or similar smart watch) to monitor their heart rate. Additionally, this series of the Apple Watch includes a pulse oximeter, which correlates surprisingly well with home fingertip oximeters. Therefore, the Apple Watch can be used to monitor asthma exacerbations or monitor the condition of children with respiratory infections. With watch OS 8 installed, the watch will be able to monitor sleep respiratory rate. The watch can be configured to detect falls from syncope or seizures and can auto dial 911 to summon help.

The next version of the Apple Watch is reported to include a body temperature sensor, and many speculate that, at some point, the device will be able to monitor blood pressure and continuously monitor blood sugars.

Connected spirometry for improved asthma management

As we all know, many children with asthma do not take their medications as prescribed. Therefore, many patients may have exacerbations or may be unaware that they are not optimally managed. When such patients begin to wheeze, patients may not seek care from their primary care physicians, preferring to be seen at more convenient urgent care clinics or, all too often, at an emergency room. VitalFlo is a company that will enable physicians to better care for their asthmatic patients. The VitalFlo system consists of a high-tech spirometer that communicates with an application on a smartphone. The application is easy to use, includes a tutorial for using the spirometer, a brief survey of symptoms, and directs the patient to produce 3 good blows into the device.

 Patient results are transmitted to a portal that can be viewed by the patient or clinician, and recommendations can be discussed with patients via office or telehealth visits. Depending on disease severity, the provider makes recommendations regarding the frequency of testing. The VitalFlo system is a prescription-based service that costs a practice $35 per patient per month (less if the patient purchases the spirometer). The provider can generate revenue by charging for monitoring a patient using the VitalFlo system.

An application for ADHD and anxious patients

A parent recently informed me about Mightier, a smart tablet–based system for treating children with attention-deficit/hyperactivity disorder (ADHD) or anxiety.

 It is a biofeedback program that teaches children coping and calming skills that can yield tangible results in a matter of months. It is appropriate for children with ADHD, oppositional defiant disorder, and anxiety disorders. Once a parent subscribes to the Mightier program, their child is provided with a gaming tablet and a heart rate monitor that is worn on the arm. The child plays video games while wearing the heart rate monitor, and as the heart rate increases, the difficulty of the games increases as well. When the heart rate reaches a certain level, the game is interrupted and the child is taught a variety of coping skills from a cartoon character. Mightier teaches children to implement coping strategies when they recognize the physiologic consequence of negative thoughts and emotions, ie, an elevated heart rate, associated with dysregulation. An integrated award system reinforces the adoption of coping strategies, and children look forward to participating in the program.

The program was developed at Boston Children’s Hospital and has been used by thousands of children since its release 7 years ago.

 The system is affordable at $40 per month, with discounts offered for prepayment. It is directed at children aged 6 to 12 years, and a child should commit to at least 45 minutes of play time per week to see results from the program.

Although our diabetic patients are usually managed by pediatric endocrinologists, pediatricians should be aware that there are 2 connected systems now available for monitoring patients’ sugars continuously. The FreeStyle Libre 2 system from Abbott Diabetes Care is approved for use in children 4 years of age and older.

 A 14-day sensor is inserted on the back of the arm. The sensor has a thin filament that sits under the skin and tracks glucose measurements every minute. A handheld monitor/reader is used to scan the sensor and displays the glucose measurement as well as a trend indicator graph that depicts the latest 8 hours of glucose history.

Measurements are also uploaded to a smartphone-based FreeStyle LibreLink application, which displays information like that of the reader and stores data for 90 days.

The Dexcom G6 Continuous Glucose Monitoring System is indicated for children 2 years and older.

 In contrast to the FreeStyle Libre, the Dexcom subcutaneous sensor lasts for 10 days and uses a Bluetooth transmitter attached to the sensor to communicate with either a handheld monitor or a smartphone application.

Masimo has also produced several devices for use by patients. The $300 MightySat has been a reliable medical-grade fingertip oximeter that is used for monitoring a pulse, pulse oximeter readings, and perfusion indexes.

 It has been upgraded and is now the only fingertip pulse oximeter that can report a patient’s respiratory rate. The MightySat integrates with a Masimo Personal Health application to track all readings.

 Masimo also sells an $80 sleep monitoring application that monitors a patient’s heart rate, oxygen level, and respiratory rate during sleep and integrates with a sleep monitoring application on smart devices. Each sensor can be used for 10 nights, and low oxygen readings suggest the patient may be experiencing sleep apnea, indicating that the patient should be referred for a formal sleep study.

Additionally, the Masimo Radius-T sensor is applied to the chest of a child 5 years and older and can monitor temperatures for as long as 8 days, and temperatures are recorded on a smart- phone application. For $50, Masimo provides 3 Radius-T sensors.

Furthermore, Withings will soon start selling a ScanWatch, which will enable users to screen for sleep apnea by recording electrocardiogram, pulse oximeter measures, and heart rates.

Best smartphone applications for pediatric practice in 2021

Over the years, I have installed a select few applications on my smartphone. Here is a quick look at my current top recommendations:

 This application facilitates rapid look-up of pediatric drug dosages for most frequently prescribed medications and has a terrific web-based version that can be accessed from a desktop. Epocrates provides extensive features beyond just drug dosages. It provides free continuing medical education online courses, a disease compendium, a drug interaction checker, a pill identifier, a comprehensive list of medical calculators, and a library of current medical guidelines. The basic version is free, but users can subscribe to upgrade and access Epocrates’ additional features.

 This platform enables me to help patients determine the lowest cost medications in our local area, listing all area pharmacies. In many circumstances, GoodRx prices are lower than insurance company co-pays.

I always recommend this application to all new—and old—parents to provide guidance regarding symptoms, when to call the doctor or seek medical assistance, as well as medication dosages for antipyretics and other commonly prescribed OTC medications, including acetaminophen, ibuprofen, and diphenhydramine. It also provides handy parenting advice and first aid measures that discuss common injuries, and even what to do in life-threatening emergencies.

 Version 5 of this application is now in beta testing. This has always been at the top of my best applications list for pediatricians. Its appearance has improved substantially and, as in the past, it provides a quick way to convert pounds to kilograms, a bilirubin risk calculator, and a formulary of commonly prescribed medications. It also includes useful calculators, including an age calculator based on date of birth, a body mass calculator, an adjusted midparental height calculator, as well as growth charts, recommendations for intravenous fluid administration, tables of topical steroids, and links to useful websites for pediatricians. It was created by W. Kent Bonney, MD, in 2010 and continues to be the first application I place on the front screen of my new smartphone whenever I upgrade!

The above are but a few of the devices and applications that will revolutionize health care over the next few years. Smart devices were once only an idea we saw in science fiction movies and television shows. Now they are an integral part of our high-tech practices and enable physicians to improve the health of patients.

1. Kheit J. Apple innovation timeline — revolutions keep on turning. The Mac Observer. July 12, 2016. Accessed August 2, 2021. 

https://www.macobserver.com/columns-opinions/editorial/apple-innovation-timeline-revolutions-keep-turning/

2. Apple Watch Series 6. Apple. Accessed August 2, 2021. 

https://www.apple.com/apple-watch-series-6/

3. Gallagher W. Apple Watch body temperature sensor research underway since at least 2019. Apple Insider. June 17, 2021. Accessed August 2, 2021. 

https://appleinsider.com/articles/21/06/17/apple-watch-body-temperature-sensor-research-underway-since-at-least-2019

4. Unsurpassed remote respiratory monitoring. VitalFlo. Accessed August 2, 2021. 

https://www.vitalflohealth.com/healthcare-providers

5. Mightier is a fun, proven way for kids to manage their emotions. Mightier. Accessed August 2, 2021. 

6. FreeStyle Libre. Abbott. Accessed August 2, 2021. 

https://www.freestyle.abbott/us-en/home.html

7. The Dexcom G6 CGM System. Dexcom. Accessed August 2, 2021. 

9. Wearable health you’ll want to wear. Withings. Accessed August 2, 2021. https://www.withings.com/us/en/watches

12. Self Care Decisions. Accessed August 3, 2021. 

13. Pedi QuikCalc. Accessed August 2, 2021. 

http://www.pediquikcalc.com/PediQuikCalc/Welcome.html

14. Apple heart study launches to identify irregular heart rhythms. News release. Apple. November 30, 2017. Accessed August 2, 2021. 

https://www.apple.com/newsroom/2017/11/apple-heart-study-launches-to-identify-irregular-heart-rhythms/

15. Miller C. Apple Watch and other wearables can detect long-term effects of COVID-19, early research suggests. 9 to 5 Mac. July 7, 2021. Accessed August 2, 2021. 

https://9to5mac.com/2021/07/07/apple-watch-long-covid-effects/

16. Mishra T, Wang M, Metwally AA, et al. Pre-symptomatic detection of COVID-19 from smartwatch data. 

. 2020;4(12);1208–1220. doi:10.1038/s41551-020-00640-6

17. Radin JM, Quer G, Ramos E, et al. Assessment of prolonged physiological and behavioral changes associated with COVID-19 infection. 

. 2021;4(7):e2115959. doi:10.1001/jamanetworkopen.2021.15959

A look at the latest apps, smart watches, and more for better health.

From watches to apps: Connected tech for better health care

A female aged 13 years with morbid obesity (and recent hospitalization for pyelonephritis presents with abdominal pain, tachycardia, and shortness of breath. What's the diagnosis?

A new policy statement from the American Academy of Pediatrics examines how supportive relationships can promote resilience that can prevent toxic stress.

Plus, a look at some of the most useful connected devices/wearables, and smart
applications for pediatric practice.


A look at what to expect from Contemporary Pediatrics this week

What's new on Contemporary Pediatrics: September 20 to 24

A COVID-19 vaccine for children aged 5 to 11 years is 1 step closer to reality with the 

 from Pfizer/BioNTech for their vaccine, named COMIRNATY following the US Food and Drug Administration (FDA) approval of the vaccine for people aged 16 and older.

 The results from the Phase 2/3 trial showed the vaccine was safe, well tolerated, and promoted a robust response.

The trial had 2268 patients aged 5 to 11 years. They were given a 10 µg dose, which is smaller than the dose given to people aged 12 and old, in a 2-dose regimen. Following the second dose, the geometric mean titers taken showed strong immune responses a month after receiving both doses. The geometric mean titers also compared well to those seen in participants aged 16 to 25 years who had been used as the control group for the analysis. Overall, the side effects were comparable to those seen in the control group participants.

Pfizer/BioNTech plan to share these results with the FDA and other regulatory bodies around the world in the immediate future. Topline data from the 2 to 5 years of age and 6 months to 2 years of age cohorts are expected to be released at some point in the fourth quarter.

1. Pfizer. Pfizer and BioNTech announce positive topline results from pivotal trial of COVID-19 vaccine in children 5 to 11 years. Published September 20, 2021. Accessed September 20, 2021.

 https://www.pfizer.com/news/press-release/press-release-detail/pfizer-and-biontech-announce-positive-topline-results

Initial results from the trial indicate it was well-tolerated and promoted a good immune response.

Pfizer/BioNTech announce COVID-19 vaccine topline results for kids 5 to 12 years

Roughly 20% of all babies born in the United States are supplemented with formula in their first few days of life.

 Although they may be exclusively breastfed later on, a new study raises questions about how early exposure to cow’s milk proteins might help shape future allergies.

the Journal of Allergy and Clinical Immunology

 was done using a multilocation randomized control trial across 4 hospitals in Japan. During the trial, early formula feeding practices were investigated to determine if there were safe and practical ways to prevent the development of cow’s milk allergy.

Researchers examined when infants were exposed to cow’s milk proteins, for how long, and whether they later developed cow’s milk allergies. They concluded that early cow’s milk formula introduction—along with consistent exposure—may help prevent the development of cow’s milk allergy. When formula is used for the first few days, even as a supplement, and then discontinued, this could have the opposite effect and increase the chances of cow’s milk allergy development later on, the study notes.

The significance of the study results, according to Tetsuhiro Sakihara, MD, lead author and a pediatrician at Heartlife Hospital in Okinawa, Japan, is that the strategy doesn’t compete with breastfeeding. Instead, research suggests that small-dose supplementation of cow’s milk formula—not enough to replace breast milk nutritionally—may have a protective effect against cow’s milk allergy development.

Cow’s milk allergies affect between 0.5% and 3% of infants globally by age 1 year. Genetics play a role in the development of some of these allergies, and cow’s milk allergies often appear alongside other food allergies. However, a number of environmental factors during the prenatal and postnatal periods can also have an impact.

In this study, none of the 31 participants who avoided cow’s milk formula for the first 3 days of life later developed a cow’s milk allergy, suggesting that avoiding this type of formula in the days after birth could help prevent future allergies. However, when cow’s milk formula was used, continued exposure until at least 3 months of age—even in small doses—appeared to help prevent a later reaction, Sakihara said.

“We guess that early discontinuation of cow’s milk formula ingestion might be associated with the development of cow’s milk allergy,” said Sakihara.

A subgroup was investigated during the study involving infants who developed a cow’s milk allergy at 6 months of age. The research team broke these infants into categories, comparing those who stopped using cow’s milk formula before 1 month of age, at 1 to 2 months of age, and between 3 and 5 months of age. The group that stopped using cow’s milk formula the earliest had the highest rates of allergy development, according to the study.

“Early discontinuation of cow’s milk formula ingestion, particularly in the first month of life, increased the risk of cow’s milk allergy in infants who received cow’s milk formula in the first 3 days of life,” Sakihara says.

The research team used its study to come up with the suggestion that ingesting 10 milliliters or less of cow’s milk formula daily between 1 and 2 months of age could help prevent the development of cow’s milk allergies later on. The small volume means that this strategy doesn’t have to compete with breastfeeding as a nutrition source, Sakihara adds.

In fact, Sakihara says this strategy might be particularly helpful at helping infants who may have had supplemental formula feedings in the first few days of life avoid cow’s milk allergies once they become more exclusively breastfed.

1. Centers for Disease Control and Prevention. Breastfeeding Report Card. Updated September 17,2020.


https://www.cdc.gov/breastfeeding/data/reportcard.htm

2. Sakihara T, et al. Randomized trial of early infant formula introduction to prevent cow’s milk allergy. 

Food Allergy and Gastrointestinal Disease

. 2021;147(1):224-232. doi: 10.1016/j.jaci.2020.08.021

3. Flom JD, Sicherer SH. Epidemiology of Cow's Milk Allergy. 

. 2019;11(5):1051. doi: 10.3390/nu11051051

Early exposure to peanuts has been shown to reduce the risk of peanut allergy. Is the same true with cow's milk?

Can early and continued cow’s milk formula exposure prevent food allergies?

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

It isn’t enough to try and prevent traumatic events in childhood. Supporting healthy growth also means helping children identify stable and supportive relationships in their life. These relationships can buffer bad experiences and promote resiliency, according to a recent policy statement from the American Academy of Pediatrics (AAP).

The policy statement updates previous data on the lifelong effects of toxic stress in children with information on the value of a nurturing relationship with at least 1 stable adult.

“Childhood toxic stress is a public health crisis that demands an integrated public health response. With a social isolating pandemic, a widening of disparities, and a reckoning with centuries of systemic racism, the concept of toxic stress has never been more relevant,” said Andrew Garner, MD, PhD, FAAP, a pediatrician from Westlake, Ohio, and clinical professor of pediatrics at Case Western Reserve University in Cleveland.

Garner, a member of the AAP committee that developed the report, explained that toxic stress can permanently remodel a child’s brain at the cellular level, resulting in behavioral changes that become biologically embedded. Addressing these stresses is 1 step to helping children at risk, but Garner said the policy focuses on what pediatricians can do to be proactive.

“Toxic stress is a deficits-based model in that it defines the problem. Toxic stress explains how many of our society’s most intractable problems—disparities in health, education and economic stability—are rooted in our shared biology but divergent experiences and opportunities,” he explained. “Conversely, relational health is a strengths-based model in that it defines the solution. Relational health explains how the individual, family, and community capacities that support the development and maintenance of safe, stable, and nurturing relationships also buffer adversity and build resilience across the life course.”

In 2012, the AAP outlined the dangers of toxic stresses—early childhood experiences that become biologically embedded and impact life-long development—in a policy statement. The 

 updates the lessons from that report, focusing on how relational health can be used to buffer and support growth and resiliency in spite of toxic stress.

Toxic stress refers to a wide range of childhood experiences that have physical, behavioral, and even cellular impacts on a developing child. Many of these experiences are the result of relationship challenges like the lack of a nurturing support system, and things like homelessness or insecurity over food and housing. These stresses can damage the entire trajectory of a child’s life, according to the policy statement, and may be to blame for some of the most challenging disparities that develop in adulthood.

The statement outlines new research that suggests that positive childhood experiences can have a protective effect against toxic stress, even working to reverse the effects of damaging experiences.

Safe, stable, and nurturing relationships are key to promoting relational health, according to the paper, because they not only buffer toxic stresses but they also help build resiliency. The policy statement therefore advocates for a new focus on not just preventing toxic stress, but also on promoting relational health.

“Promoting relational health and preventing toxic stress are 2 sides of the same coin. Toxic stress is a deficits-based model that describes what goes wrong in the absence of nurturing relationships,” Garner wrote in a 

 “Conversely, relational health is a strengths-based model that describes what goes right when children are afforded safe, stable, and nurturing relationships and positive early experiences.”

Building relational health is a process that can take at least 2 generations, he added, noting that it takes multiple layers of family and community effort to support a child’s emotional needs. When a child’s support system functions in “survival mode” because of their own stresses, they aren’t able to provide a positive childhood experience or a background of supportive relational health for future generations.

“Understanding that process allows us to see how many ‘adult-onset’ diseases are actually ‘adult-manifest’ diseases with their origins in childhood,” he added.

Addressing these issues, which Garner called a public health crisis, requires both vertically and horizontally integrated efforts. Vertical efforts are rooted in a public health approach that supports stable relationships throughout childhood. Horizontal efforts can include policy and societal changes designed to support families and community health.

Garner said pediatricians are uniquely positioned to universally promote relational health; identify and address potential barriers to relational health; and utilize the common factors approach and refer to evidence-based therapies when relationships are strained. Some examples of universal promotions include educating parents about development, promoting lots of developmentally appropriate play, and supporting emotional intelligence by helping kids tap into their passions when distressed or bored.

“Potential barriers to relational health that the pediatrician might identify and address include: parental adversity as a child; parental mental illness or substance abuse; or the child’s exposure to poverty, violence, or racism,” Garner added. “Attachment and Biobehavioral Catch-up, Parent Child Interaction Therapy, and Child Parent Psychotherapy are all evidence-based interventions to support relational health, and pediatricians are well placed to advocate for the local development of these services.”

According to the report, another challenge is the fact that our society as a whole is moving toward increased division and social isolation, leading to even more barriers to the formation of stable, healthy relationships that can support relational health. AAP is working to develop practices and policies that can help support healthy relationships despite these challenges. A few starting points that have been identifies include:

 This is a core function of the family-centered pediatric medical home and a focus of the statement. How to promote relational health in families is a hot topic in pediatric research, and pediatric primary practices may be the perfect place to focus intervention efforts.

 Addressing family stressors such as financial circumstances or ill family members—even in adult members who are not normally included in the pediatric care spectrum—can go a long way toward overcoming barriers that increase toxic stress and make it more difficult to promote relational health. Clinicians can suggest programs that could help either ameliorate or solve such stress points.

 Offering support for core life skills like executive function and self-regulation is something pediatricians are used to doing for children, but not other members of their families. Including parents and caregivers in these efforts by doing things like providing education on basic child-rearing and the importance of establishing daily routines.

More research is needed to develop best strategies for these efforts, and work is also needed to stress the importance of relational health in physician training programs and residencies. Pediatricians also need to advocate more aggressively to increase community support for programs that foster good relational health—and for payment reforms that will allow clinicians to be reimbursed for the time and effort they need to devote with this level of care.

Creating change when it comes to addressing toxic stress and relational health will require major shifts in the entire pediatric care model, Garner added.

“Most of medicine utilizes a deficits-based framework. It assumes that the patients are ‘broken,’ and that the primary role of the health care professionals is to reactively respond and to fix them. Pediatricians, however, are intuitively strengths-based. We are all about proactively going up-stream and trying to get things right the first time, instead of trying to repair or remediate much larger problems later,” Garner said. “This policy statement is trying to pivot from the deficits-based framework of toxic stress towards the strengths-based framework of relational health. As the policy statement argues, doing so is a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy.”

1. Garner A, Yogman M, Committee on psychosocial aspects of child and family health, section on developmental and behavioral pediatrics, council on early childhood. Preventing childhood toxic stress: partnering with families and communities to promote relational health. 

. August 2021; 148(2). doi: 10.1542/peds.2021-052582.

2. Garner A. Almost a decade after policy on toxic stress, ‘relational’ health seen as key approach. 

 Published July 26, 2021. https://www.aappublications.org/news/2021/07/26/toxicstress072621

Toxic stress can have lifelong negative effects. A new policy statement from the American Academy of Pediatrics (AAP) examines how healthy relationships may serve as a buffer.

AAP: Healthy relationships can help offset toxic stress

 launched its inaugural Resident Writers Award program, where residents and fellows throughout the United States were invited to submit one of their most challenging cases, worked on during their residency or fellowship program.

 spoke with several of the entrants about why they submitted their particular cases and what best practices and takeaways were the result of treating their patient. In the next interview of the series, Matthew Metzger, MD, PGY2, who is a resident  at the Herman and Walter Samuelson Children's Hospital in Baltimore, Maryland, discusses his case of 4-year-old who had a fever, headache, and a diffuse rash. Dr. Metzger discusses how the case highlights the need to be aware of how location can impact what's included in the differential diagnosis.

Matthew Metzger, MD, PGY2, discusses his case submission for the Resident Writers Award program. 

Case highlights importance of knowing diseases common to area of practice

During the 4 decades that I have practiced pediatrics, our specialty has evolved in many ways. Thirty years ago, we gave epinephrine injections for children coming to the office with asthma attacks, recommended ipecac for poison ingestions, and often would perform septic workups in the office prior to hospitalizing febrile babies.

During this time, pediatricians made rounds at the hospital, attended cesarean deliveries, and were frequently paged during days and nights on call. After an office visit, parents would pay at the time of service and submit receipts for reimbursement. We performed strep and urine cultures in the office. In all, it was far less complicated than it is today.

What does the future hold for pediatric practice?

I wrote my predictions for the future of pediatric practice over 20 years ago in the January 2000 issue of 

I correctly predicted that pediatricians would adopt electronic health records (EHRs) and patient portals. However, this did not occur until the enactment of the Health Information Technology for Economic and Clinical Health Act (HITECH), which was part of the American Recovery and Reinvestment Act (ARRA) of 2009.

 Likewise, I predicted touch-/stylus-enabled computer screens and the ability of computers to populate fields in an EHR, either via patient or staff input, and the ability of “connected” devices to rapidly take vital signs and perform patient screens. I also correctly predicted the use of biometrics to confirm the identity of patients— although few practices have implemented this—and the availability of a nasal vaccine (which was introduced for influenza in 2003).

 However, I was incorrect in predicting that people would begin carrying a medical card containing their health care related data. At the time, I did not foresee the impact of smart devices on health care, the rise of cloud computing, and how patients would utilize patient portals to make office visits, ask questions, and pay their bills.

Additionally, like so many others, I certainly never saw a global pandemic coming, or that insurance companies would continue to wreak havoc on health care. I’d like to think that the COVID-19 pandemic will lead to an overhaul of our present health care system, and hopefully expedite much needed health care reform.

As an optimist who has seen how technologies have slowly improved health care over the course of many years, I believe that future pediatricians will have many new tools at their disposal that will improve patient care. For example, we will see Drs Alexa, Siri, and Google evolve and have the ability to remind diabetic patients to measure and record their sugars, suggest healthy eating habits and exercise for children who are overweight, and remind families of upcoming health care visits. They will facilitate booking appointments and facilitate telehealth visits, if needed. Translation systems are improving and soon will let you converse with foreign language-speaking patients in real time, with both users merely wearing headphones.

I am hopeful that in the future we will have a patient-focused health care system where government involvement has been minimized and providers can direct patient care with limited oversight by insurance companies.

1. Schuman A. Beyond 2000: tomorrow’s office technologies today. 

2. US Department of Health and Human Services. HITECH Act enforcement interim final rule. Revised June 16, 2017. Accessed August 5, 2021. https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html

3. Piedra PA, Gaglani MJ, Kozinetz CA, et al. Trivalent live attenuated intranasal influenza vaccine administered during the 2003-2004 influenza type A (H3N2) outbreak provided immediate, direct, and indirect protection in children. 

. 2007;120(3):e553-e564. doi:10.1542/peds.2006-2836

Over 20 years ago, Dr. Andrew J. Schuman predicted what lay ahead for medicine and pediatrics. He revisits those predictions and looks toward what the next 10 years may hold.

The future of the pediatric practice

Mayne Pharma has announced the FDA approval of halobetasol propionate foam, 0.05% (Lexette; Mayne Pharma) for the treatment of plaque psoriasis in adolescent patients 12 years and older.

The US Food and Drug Administration has approved halobetasol propionate foam, 0.05%, a potent topical corticosteroid, for the treatment of plaque psoriasis in adolescent patients.