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

In April 2020, the first cases of multisystem inflammatory syndrome in children (MIS-C) were found. The current hypothesis is that MIS-C is mostly post-infection and distinct from coronavirus 2019 disease (COVID-19) because many of the cases had COVID-19 negative respiratory samples and MIS-C also peaked after reported COVID-19 cases. An 

examines how the characteristics and outcomes of MIS-C compare with severe COVID-19.

Investigators created a case series of patients aged younger than 21 years who were hospitalized between March 15, 2020, and October 31, 2020, at 66 hospitals in 31 states in the United States. The last date of follow-up was January 5, 2021. The patients with COVID-19 had a positive reverse transcriptase–polymerase chain reaction (RT-PCR) and severe organ system involvement. Patients with MIS-C had inflammation; multisystem involvement; fever; and a positive severe acute respiratory syndrome coronavirus 2 RT-PCR test or antibody test results or recent exposure with no alternate diagnosis.

A total of 1116 patients were included and 539 diagnosed with MIS-C and 577 diagnosed with COVID-19. When compared with patients who had COVID-19, patients with MIS-C were more likely to be non-Hispanic Black (32.3% vs 21.5%; absolute risk difference [RD], 10.8% [95% CI, 5.6%-16.0%]; adjusted risk ratios [aRR], 1.43 [95% CI, 1.17-1.76] vs White) and be 6 to 12 years of age (40.8% vs 19.4%; RD, 21.4% [95% CI, 16.1%-26.7%]; aRR, 1.51 [95% CI, 1.33-1.72] vs 0-5 years). Additionally, they were more likely to have cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% [95% CI, 4.7%-10.6%]; aRR, 2.49 [95% CI, 2.05-3.02] vs respiratory involvement), cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% [95% CI, 42.4%-52.0%]; aRR, 2.99 [95% CI, 2.55-3.50] vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% [95% CI, 2.3%-7.3%]; aRR, 2.29 [95% CI, 1.84-2.85] vs respiratory involvement) when compared to patients with COVID-19. The MIS-C patients also had a higher C-reactive protein level (median, 152 mg/L vs 33 mg/L; 

 < .001), a higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7,

 < .001), and a lower platelet count (<150 ×103 cells/μL [212/523 {41%} vs 84/486 {17%}, 

 < .001]). Three hundred ninety-eight of the patients with MIS-C required admission to the intensive care unit in comparison with 253 patients with COVID-19 who were admitted to one. Eight patients with COVID-19 died during hospitalization and 10 MIS-C patients died in the hospital. Among the patients with reduced left ventricular systolic function and coronary artery aneurysm, roughly e 91.0% (95% CI, 86.0%-94.7%) and 79.1% (95% CI, 67.1%-89.1%), respectively, normalized within 30 days.

Investigators concluded that their case series illustrate patterns of organ involvement and clinical presentation that could potentially distinguish between patients who have severe acute COVID-19 and those with MIS-C.

1. Feldstein L, Tenforde M, Friedman K, et al. Characteristics and outcomes of US children and adolescents with multisystem inflammatory syndrome in children (MIS-C) compared with severe acute COVID-19. 

. February 24, 2021. Epub ahead of print. doi:10.1001/jama.2021.2091

Articles

A case series offers insight on how to separate multisystem inflammatory syndrome in children (MIS-C) and severe acute coronavirus 2019 disease (COVID-19).

Differentiating between MIS-C and severe COVID-19

In an update how the agency was responding to the coronavirus 2019 disease (COVID-19), the US Food and Drug Administration

 abbreviated new drug applications, a warning letter, and an update on testing.

The 2 drugs approved for the abbreviated new drug applications, piperacillin and tazobactam for injection, are indicated for treatment of intra-abdominal infection in pediatric patients aged 2 months and older as well as adults and nosocomial pneumonia in children aged 2 months and older and adults. The drugs also have other indications for adults including skin and skin structure infections, female pelvic infections, and community-acquired pneumonia. Diarrhea, constipation, nausea, headache, and insomnia were the most common side effects.

The agency issued a warning letter to Dr. Paul’s Lab for selling an unapproved product called COVID-Aid Tincture that had fraudulent claims. The letter requested the company take immediate action and cease the sale of the product and any other unapproved and unauthorized products for the mitigation, prevention, treatment, diagnosis, or cure of COVID-19.

The testing update indicated that there are now 331 tests and sample collection have been authorized for use by the FDA through emergency use authorizations. This includes 37 molecular authorizations that can be used with samples collected in the home. It also includes an antigen prescription at-home test, an over-the-counter at-home antigen test, and one molecular prescription at-home test.

1. US Food and Drug Administration. Coronavirus (COVID-19) Update: February 19, 2021. Published February 19, 2021. Accessed February 24, 2021.

 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-february-19-2021

The US Food and Drug Administration (FDA) discussed its latest drug and testing efforts to respond to coronavirus 2019 disease.

FDA offers updates on COVID-19 response

The move to spending every day in the home, with little exposure to others, during the coronavirus disease 2019 (COVID-19) pandemic has led to many concerns about what it means for socialization, education, nutrition, and how children who need additional resources in school will fare. A

JAMA Otolaryngology – Head & Neck Surgery 

examines how the lockdowns as a result of COVID-19 impacted the amount of exposure to spoken communication that children with cochlear implants had.

The researchers recruited children with cochlear implants from a tertiary pediatric hospital in Ontario, Canada. The cochlear implants monitor and create datalogs of the levels and types of sound during hourly use each day. The datalogs of pre-COVID-19, which was February 1, 2020 to March 16, 2020, were collected and then during the initial easing of lockdown restrictions, peri-COVID-19, were collected. The hours of sound were categorized into 6 input levels: <40, 40-49, 50-59, 60-69, 70-79, ≥80 A-weighted dB sound pressure level. The sound was also put into 6 auditory scene categories: quiet, speech, speech-in-noise, music, noise, and other.

A total of 45 children were included in the study. The investigators found that there was similar daily use of cochlear during both time periods (9.80 mean hours pre–COVID-19 and 9.34 mean hours peri–COVID-19). However, despite a similar amount of daily use, there was significant quieting of input sound levels peri–COVID-19 by 0.49 hour (95% CI, 0.21-0.80 hour) at 60 to 69 dBA and 1.70 hours (95% CI, 1.42-1.99 hours) at 70 to 79 dBA with clear reductions in speech exposure by 0.98 hour (95% CI, 0.49-1.47 hours), which translated into a reduction of speech:quiet from 1.6:1.0 pre–COVID-19 to 0.9:1.0 during lockdowns. The greatest percentage reduction in daily speech were found in school-aged children (elementary, 12.32% [95% CI, 7.15%-17.49%]; middle school, 11.76% [95% CI, 5.00%-18.52%]; and high school, 9.60% [95% CI, 3.27%-15.93%]). An increase in daily percentage of quiet was found to be most prevalent in children who had fewer numbers of people in their household.

The researchers concluded that the lockdowns for COVID-19 were linked to a reduction in exposure to spoken communication. As children with hearing loss are already at risk of less than optimal outcomes for language, this additional reduced exposure could have increased risk of poorer outcomes. Making parents aware of the reduction and encouraging increased spoken language during the pandemic could help mitigate the results.

1. Gordon K, Daien M, Negandhi J, et al. Exposure to spoken communication in children with cochlear implants during the COVID-19 lockdown. 

JAMA Otolaryngology–Head & Neck Surgery

. February 18, 2021. Epub ahead of print. doi:10.1001/jamaoto.2020.5496

The lockdowns caused by the pandemic have led to many potential negative effects on children. An investigation looks into how they’ve impacted the exposure to spoken language for children with cochlear implants.

Impact of lockdowns on language exposure for kids with cochlear implants

Multiple guidelines recommend that teenagers get between 8 and 10 hours of sleep every night. Worries about a lack of adequate sleep have driven the call to push the school start time for middle school and high school later than the common 7:00 to 7:30 am now used. Further challenging the need for quality sleep in this age group is research showing how electronic devices can have a negative impact on teenagers’ sleep hygiene. However, insomnia can also be a problem in this age group and an

 looks into whether a prevention program was effective in reducing insomnia in those at risk.

The investigators ran a randomized controlled trial that compared a nonactive control group with a weekly insomnia prevention program. Each participant was assessed at the study’s baseline as well as 6 and 12 months following the intervention. Those assessing the participants had been blinded to the randomization.

There were 242 teenagers who had a family history of insomnia and subthreshold insomnia symptoms included in the study. They were randomly assigned into the control group (n = 121; mean age = 15.0 ± 1.7; female: 62.0%) and intervention group (n = 121; mean age = 14.7 ± 1.8; female: 51.2%). When compared to the control group, a lower incidence rate of both acute and chronic insomnia disorder was found in the intervention group (5.8% vs 20.7%; 

 = .002; number needed to treat = 6.7; hazard ratio = 0.29; 95% CI: 0.12–0.66; 

 = .003) over the course of the 12 month follow-up. Additionally, the teenagers in the intervention group had reduced vulnerability to stress-related insomnia (

 = .03) as well as decreased insomnia symptoms (

 = .03) both after the intervention and over the course of the 12 month follow-up. Postintervention, the researchers also noted better sleep hygiene practices (

 = .04), and increased total sleep time (

 = .05). Additionally, at the 12 month follow-up, the group that had undergone the invention recounted fewer depressive symptoms than the control group (

The investigators concluded that a brief cognitive behavioral program was effective in preventing the onset of insomnia. Given the sleep needs of adolescents, using such programs could be an effective way of getting affected teenagers back to healthier sleep schedules.

1. Chan N, Li S, Zhang J, et al. A prevention program for insomnia in at-risk adolescents: a randomized controlled study. 

. February 24, 2021. Epub ahead of print. doi:10.1542/peds.2020-006833

It is crucial that teenagers get adequate sleep, but unfortunately some may battle insomnia. Could a brief intervention help improve outcomes?

Using a program to combat teen insomnia

Although many people looked forward to the end of 2020 and the start of 2021, the pandemic continues with new variants starting to spread and the vaccine rollout stumbling in some locations. A recent poll indicates that many people aren’t expecting to return to a prepandemic life until at least the middle of the year, going from 37% when the poll was run in December 2020 to 55%. In fact, only 8% think it could resolve in a few months and 2% think that it can end in just a few weeks.

It appears that one of the biggest reasons for this change in hopefulness is general dissatisfaction with the rollout of the vaccine, with 68% of the respondents saying that they are very dissatisfied with it. However, there was some positive news with the number of people thinking the pandemic is getting worse going from 63% to 39%.

With the authorization of 2 vaccines in late 2020 it seemed like a corner had been turned with the pandemic. A recent poll offers insight into how the public feels like the pandemic is going and when the disruptions caused by it might end.

How people think the pandemic is going

In the summer of 2020, many health care professionals (HCPs) were concerned about the potential devastating effects of individuals contracting coronavirus disease 2019 (COVID-19) and influenza. For young pediatric patients, adding respiratory syncytial virus (RSV) to the ‘mixture’ of offending respiratory organisms was a major concern. Dr. Carnazzo discusses these issues in her article entitled, 

The perfect storm: Influenza and RSV during the season of COVID-19

The author provides a comprehensive presentation for COVID-19, influenza, and RSV with comparisons to one another that will enable HCPs to accurately diagnose the ill child presenting to an office-based practice or hospital settings. 

I believe that the concerns expressed prior to influenza season by all HCPs laid the foundation for parents and adults to make informed decisions about vaccinating themselves, their family members, and most importantly for the pediatric populations for parents to have their infants, children, and adolescents vaccinated against influenza each year. Media coverage also supported influenza vaccinations to prevent the ‘perfect storm’ of COVID-19 colliding with influenza resulting in higher rates of respiratory illnesses and deaths.

It always concerns me that pediatric and adult patients die during the influenza season, when we have a primary prevention strategy: administering the influenza vaccine, to prevent influenza, community spread of influenza, and deaths. The Centers for Disease Control and Prevention has recommended an annual influenza vaccine. And yet, in the 2019-2020 influenza season, there were 38 million illnesses, 18 million medical visits, 405,000 hospitalizations, and 22,000 deaths related to influenza.

 Additionally, during the 2019-2020 influenza season, there were 254 children aged between 0-4-years and 180 children/adolescents aged between 5-17 years who died from influenza.

In New York State, there are no reported pediatric deaths from influenza during the 2020-2021 influenza season as compared to the 2019-2020 influenza season in which 14 deaths were reported.

 Vaccinations, a primary prevention strategy, are an effective measure for the prevention of so many vaccine preventable diseases. Pediatricians and nurse practitioners should employ scientifically based strategies to support parents in their decision making prior to the influenza season and for all vaccines on the immunization schedule.

At this time, Pfizer and Moderna are enrolling or planning to enroll children aged older than 5 years in studies to determine the efficacy of COVID-19 vaccines in the pediatric populations. Once the studies are completed and emergency use authorization from the Food and Drug Administration is issued, pediatricians and nurse practitioners will play a critical role in helping parents make the decision to vaccinate their children against COVID-19. Time will tell if the COVID-19 vaccine, once approved for children, will prevent multisystem inflammatory syndrome in children, the severe presentation of COVID-19 disease, that has presented in some children, especially in Black and Hispanic populations.

1. Center for Disease Control and Prevention. Estimated influenza illnesses, medical visits, hospitalizations and deaths in the United States – 2019-2020 influenza season

Updated October 6, 2020. Accessed February 19, 2021.

 https://www.cdc.gov/flu/about/burden/2019-2020.html

2. New York State Department of Health. Weekly influenza surveillance report

 Updated February 6, 2021. Accessed February 19, 2021.

 https://www.health.ny.gov/diseases/communicable/influenza/surveillance/2020-2021/flu_report_current_week.pdf

3. Hester, M. Certain groups may be at greater risk of MIS-C. Published December 4, 2020. Accessed February 10, 2021. 

https://www.contemporarypediatrics.com/view/certain-groups-may-be-at-greater-risk-of-mis-c

As the 2020-2021 influenza season loomed, many in health care worried that the seasonal disease would add to the extraordinary burden of coronavirus disease 2019 and create a perfect storm. Have various prevention strategies helped prevent this potential issue?

Are primary prevention strategies altering the course of the perfect storm?  

Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN, discusses her frustration with the uptake in influenza vaccinations in recent years and what she hopes to see when the vaccine for coronavirus disease 2019 becomes authorized for use in a wider range of children.

The move to educating over Zoom has led to many questions about what it means children who required additional resources that aren’t available in the home. A new study looks at how the lack of exposure to language is affecting children with cochlear implants.

Plus, more of the latest news in pediatrics.

A look at what to expect from Contemporary Pediatrics this week

What's new on Contemporary Pediatrics: February 22 to February 26

As research has confirmed the long-reaching impact of a child’s health in later life, a number of programs have been created to provide children from low-income families with access to nutrition and care to support better health outcomes. This drive has included the creation of school-based vision screenings and programs that give eyeglasses to low-income children who need them. An

 looks into whether such programs lead to children consistently wearing the glasses, which can help with academic success.

Researchers conducted a longitudinal cross-sectional study of eyeglass wear compliance among children aged 3 to 5 years who attended 51 Bay Area Head Start preschools in San Francisco, California. The research was conducted in the 2017 to 2018 school year and included students who had failed their vision screening and met predetermined refractive criteria following cycloplegic refraction. The children were given eyeglasses through the See Well to Learn program. Eyeglass wear compliance was measured through weekly reports from the teacher for the school year. Consistent eyeglass wear was defined as wearing the eyeglasses for more than 50% of every school day, which was designated as a compliance score of 4.

A total of 188 students were included in the study and 133 of those children had an average compliance score of 4 or higher throughout the school year. Additionally, compliance prevalence was relatively stable over the course of school year ranging from 139 students to 164 students. The baseline uncorrected visual acuity in better-seeing and worse-seeing eyes was the only factor assessed that had a link to compliance.

The researchers found that around 3 to 4 of the preschool students included in the study wore their glasses to school on a consistent basis during the first year of use. This consistency supports continual implementation of vision screening programs in preschool. Additionally, the findings highlight how school-based screening and eyeglass delivery can reduce the disparity that can occur in access to pediatric vision care.

1. Sabharwal S, Nakayoshi A, Lees C, Perez S, de Alba Campomanes A. Prevalence and factors associated with eyeglass wear compliance among preschoolers from low-income families in San Francisco, California. 

. February 18, 2021. doi:10.1001/jamaophthalmol.2020.7053

Do school-based vision screenings and eyeglass delivery programs increase eyeglass wearing in children? An investigation offers some answers.

School vision screening and eyeglass programs lead to eyeglass wearing compliance

Maternal heart health in pregnancy appears to impact child’s heart health

A report adds cardiovascular health in pregnancy as another determining factor of a child’s future health.

Texting LGB+ teen girls to promote pregnancy prevention behavior

Lesbian, gay, bisexual, or other sexual minority (LGB+) teenaged girls are more likely to get pregnant than their peers. Could a text message program help reduce this?

As technology and the role that clinicians have with running the practice have changed, so have the needs for practice management. Andrew J. Schuman, MD, FAAP, shares his guidance for practice management.

Posttraumatic stress after disaster doesn’t always lead to chronic symptoms

Natural disasters can cause extreme stress. An investigation examines the trajectories of posttraumatic stress following such disasters.

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

In case you missed it: February 15 to February 19

Reports early on in the coronavirus 2019 (COVID-19) disease seemed to indicate that both very young age and comorbidities could increase the risk of severe progression of the disease in children, but no research findings had confirmed this yet. An

 offers some crucial information on whether this is true.

Researchers performed a national prospective surveillance of children hospitalized with COVID-19 in 60 hospitals in France. A positive infection was defined as a positive real-time reverse transcriptase polymerase chain reaction on a nasopharyngeal swab. Severe disease evolution was defined as requiring either hemodynamic or ventilatory support and ventilatory support was defined as use of noninvasive ventilation, including high-flow oxygen via nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure or the use of invasive ventilation. Hypoxemia and thrombocytopenia were defined as an oxygen saturation of <95% and a platelet count of <150 g/L, respectively.

A total of 397 children who were hospitalized with COVID-19 were included in the study. The researchers noted several clinical patterns including paucisymptomatic children who were admitted for surveillance, lower respiratory tract infection, and or multisystem inflammatory syndrome in children. Children aged <90 days old comprised 145 of the studied cases, but only 4 of the children had severe disease. After excluding both children hospitalized for a diagnosis not related to COVID-19 (n = 62) or those with multisystem inflammatory syndrome in children (n = 29), 23 of the children had severe deaths and there were 6 deaths. The researchers found that factors independently linked to severity were age ≥ 10 years (odds ratio [OR] = 3.4, 95% CI: 1.1–10.3), hypoxemia (OR = 8.9, 95% CI: 2.6–29.7), C-reactive protein level ≥80 mg/L (OR = 6.6 95% CI: 1.4–27.5).

The researchers concluded that young age does not appear to be a risk factor for severe COVID-19. In fact, very young children were at the lowest risk of having severe disease evolution.

1. Ouldali N, Yang D, Madhi F et al. Factors associated with severe SARS-CoV-2 infection. 

. 2020:e2020023432. doi:10.1542/peds.2020-023432

A report offers much needed information on whether very young children are at greater risk of having a severe disease course of coronavirus 2019 (COVID-19).

Are primary prevention strategies altering the course of the perfect storm?

What's new on Contemporary Pediatrics: February 22 to February 26

School vision screening and eyeglass programs lead to eyeglass wearing compliance

In case you missed it: February 15 to February 19

Are infants at more risk of severe COVID-19?