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

By now you are no stranger to telehealth (TH) virtual visits and have likely decided on your TH service provider of choice. Once the COVID-19 pandemic is over, you will, no doubt, continue to provide TH services for patients. Let’s explore several common myths about TH services and see if they need busting!

This is reminiscent of the terminology applied to our digital medical records. At one point these were referred to as “Electronic Medical Records” (EMRs) rather than “Electronic Health care Records” (EHRs) in common use today. Strictly speaking, telemedicine refers to virtual visits between providers and patients. Telehealth includes telemedicine services, but also includes phones calls, reviewing photos and videos sent by patients, call centers, and remote monitoring of patients via mobile applications connected to glucometers, cardiac monitors, and others.

The more you spend on a TH service provider, the better services you can provide patients!

In the case of TH services, the old adage “you get what you pay for” is just not the case. More expensive TH portals include virtual waiting rooms, a section within the TH application to document visits, the ability for patients to pay for visits, screen sharing, and more. These duplicate many of the features included in your EHR and patient portal. In my view you want to communicate with patients quickly and easily from both the provider and patient perspective. That’s why I will recommend Doximity’s Dialer Video as one of best TH services available today. It is free of charge, supports group visits, and “it just works”.

Telehealth video visits provide health care savings for physicians, patients, and insurance companies

During the pandemic, most states have mandated that TH video visits be paid at parity with in-office visits, and many have even mandated that telephone TH visits be paid in this way as well. Telehealth saves parents money in traveling expenses, lost time from work, as well as a multitude of inconveniences (getting kids dressed, arranging a babysitter for the sibling not being seen in the office etc.). At the practice level, for virtual visits, patients do not need to be roomed, have vitals taken, and personal protection equipment isn’t needed, saving overhead expenses. Moreover, if you are proficient at TH video visits you can “see” more video visits per hour than you can in-office visits. Therefore, TH can increase practice productivity at a time when the pandemic has reduced revenue. Lastly, insurance companies will realize reduced payments, as fewer patients will need to be seen in emergency departments, and likely fewer diagnostic tests will be ordered via TH visits compared to in office visits.

You cannot do physical examinations via virtual visits!

As a consequence of the pandemic, parents have avoided bringing children to their routine well visits. This is quite understandable as venturing into the community is considered hazardous, and most parents (and pediatricians) recognize that medical offices are especially risky environments for catching illnesses. The American Academy of Pediatrics (AAP) has given their approval for virtual well visits - “For practices who have successfully implemented telehealth to provide appropriate elements of the well exam virtually, these telehealth visits should continue to be supported, followed by a timely in-person visit.” You can provide important age appropriate advice during these visits and have the parents obtain measurements (baby scales are inexpensive and can be ordered from online vendors for $20-$40). You can also do a cursory physical examination looking for rashes, orthopedic issues, examine the throat, and have the parents palpate the neck, abdomen, etc.

Once the pandemic is over, regulations regarding TH virtual visits will change.

Hopefully, in the not too distant future, the pandemic will be over! Realistically, it is likely to linger for months to come. Emergency mandates at the federal and state levels have facilitated the performance of TH virtual and telephone visits by medical professionals. Eventually we can expect that these mandates will be lifted, the status quo will be state policies that were in place 

 the COVID-19 pandemic crippled our health care system. Many states, such as my state of New Hampshire, have mandates in place to assure that insurance companies and Medicaid pay for TH virtual visits at parity with office visits. You can check the status of your state by visiting the Center for Connected Health Policy’s webpage at 

. Many forward-thinking insurance plans may continue to cover TH virtual visits, realizing it is to their advantage to do so. It would also be prudent to ask your AAP state chapter to petition your state legislature to consider changing state laws, if needed, to continue full payment for virtual TH visits.

By the way, as of this writing, several US senators are collaborating on a bill to make current guidelines for TH care permanent – so stay tuned!

That’s it. Hope your experience providing TH services to patients is a positive one. Please send your comments and questions to me at 

Articles

What's telehealth fact and what's telehealth fiction? Dr. Schuman explores common assumptions regarding telehealth.

Telehealth myths: True or not true?

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 response to the COVID-19 pandemic, pediatricians have rapidly adopted telehealth (TH) to provide remote health care services for patients. Although state and federal emergency mandates permit temporary use of non-telehealth video applications such as Zoom, Skype, Facetime, and others for the duration of the pandemic, eventually medical practices will be limited to TH service providers if they plan to continue to provide virtual office visits. The COVID-19 crisis has established TH as an integral part of pediatric practice, one that can facilitate patient care, bring patients back to the medical home, and increase practice revenue at a time when pediatricians are recovering from dramatic pandemic- related revenue losses. 

In order to satisfy Health Insurance Portability and Accountability Act requirements, a TH service encrypts video visit data to safeguard protected health information and protects data during transfer and storage. All TH service vendors must provide medical practices with a Business Associates Agreement (BAA), detailing how the vendor is responsible for preventing and remedying data breaches. Click 

The quality of virtual visits is affected by bandwidth limitations (ie, high-speed vs low-speed, internet vs cellular network connectivity), computer or smart device configuration issues, as well as a patient’s or a provider’s technical acumen. In my view, establishing a virtual visit should be as quick and easy as launching and receiving a FaceTime call! Telehealth services vary in cost, and some are application-based or browser-based or both. Some TH companies sell a comprehensive “clinic” TH platform, that includes scheduling by office staff, a virtual waiting room, acceptance of payments, file sharing, and the ability to document visits within the TH portal or application itself. Telehealth services with more capabilities are more expensive but many of the more sophisticated services are more time consuming (and often complicated) to use from the perspective of staff, provider and patient. This is why I encourage pediatricians to utilize TH services that are easiest to implement! Many pediatricians already use bloated Electronic Healthcare Record programs (EHR) that require too many clicks to schedule and document visits. One doesn’t necessarily need 2 systems with overlapping features.

I have selected 5 TH platforms (Table) among many dozens available, as premium products worth your consideration, and will briefly contrast and compare these to help guide your adoption decision.

By far my favorite TH application is the Dialer Video included in the free Doximity Smartphone Application. Doximity provides a BAA to all registered users, and each provider can assign up to 20 team members to facilitate visits. One sends a text message via the smartphone application to a patient’s mobile phone and launches the visit by clicking a button in the application. This launches a browser window on your smartphone. The patient clicks on a link embedded in the message and joins the visit. One provides a caller ID to display on the recipient’s phone, so patients/parents see your office number rather than your own smartphone phone number. The video visit quality is excellent, and it is an easy matter to communicate with the patient on your phone while reviewing the EHR record on your computer screen. Best of all, the application is 

 and requires very few “clicks” to initiate a video visit. Doximity has a desktop version that is now in beta.

My second choice is Doxy.me (no relation to Doximity), which provides a free low definition video service that may be adequate for many practices. A BAA is included in the free version. For $35 per provider per month you can upgrade to Doxy.me’s high definition video visit system. It operates via a browser-based portal on your computer, smartphone, or tablet. Patients are invited through a text link sent via email or text message. The user clicks on the link to enter a waiting queue. The provider can see all waiting patients and clicks on a button to initiate the virtual visit. If practices are interested, Doxy.me has a clinic version available for $50 per provider plus a $300 setup fee.

My third choice is Zoom for Healthcare. Zoom is application-based and can be used on smart devices as well as computers. Zoom is extremely easy to use, and one merely initiates a visit by sending a link via email or messaging. Zoom for Healthcare provides a BAA to users, integrates a “virtual waiting room,” and one can record virtual visits for review at a later time. The downside of Zoom for Healthcare is that it costs $200 per month (for 10 users), and unfortunately there is no pricing for fewer users. If you have a small office, this is still a reasonable price, and you can assign your nursing and front office staff as users so they can communicate with patients via video, which makes patient communication more effective.

Lastly, if despite my admonitions you’d like to implement a “clinic” based TH system, consider Vsee or SnapMD. Vsee offers a Messenger service, similar to Doxy.me, that includes a BAA for $49 per month per user (a free version does not include a BAA), but this is the same price as its clinic TH system. SnapMD has been endorsed by the American Academy of Pediatrics (AAP) and waives the setup fee as well as offers substantial discounts for AAP members. Both Vsee and SnapMD include the comprehensive features presented above.

Good luck with your adoption and implementation of your TH service. Please send your questions and comments to me at 

In the market for a telehealth service? Here's how 5 stack up.

What 5 telehealth services have to offer

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

A recent study reveals that autism rates are dropping among children living in wealthy white areas of California while rising in poor, minority areas, but the reason why isn’t exactly clear.

Journal of Autism and Developmental Disorders

, reviewed autism prevalence among children born in different areas of California between 1993 and 2000. Data for the study came from children in the California Department of Development Services system.

Although prevalence increased fairly equally among all the children in the study born between 1993 and 2000, the research noted that prevalence remained steady or declined in children from wealthy white areas in the years that followed. At the same time, autism prevalence continued to increase after 2000 and until the study concluded in 2013 among both white and Hispanic children in low income areas.

However, the downward trend in diagnoses among wealthier white children may not be what is appears. Rather than a natural decrease in cases, the study team suggests that perhaps the decline is more of a result of these families seeking private care for their children—therefore excluding them from the state tracking system—or making other changes that could reduce their autism risk.

“Autism was once considered a condition that occurs mainly among white children of high socioeconomic status, but my current study suggests that ethnic minorities and low income families are increasingly experiencing higher rates of autism spectrum disorder (ASD), particularly severe autism,” says Cynthia Nevison, PhD, lead author of the study and a researcher from the University of Colorado in Boulder. “The logical implication is that the etiology of ASD is primarily environmental and that ASD risk can be influenced by parental choices, behavior, and access to resources.”

Prevalence for autism nationwide is about 1 in 59, or roughly 2% of 8-year-olds in the most recent Autism and Developmental Disabilities Monitoring (ADDM) Network from 2006. In that survey, prevalence had increased from the two previous surveys in 2002 and 2004, when prevalence was 1 in 68. Another survey, the National Health Interview Survey (NHIS), estimated prevalence in 2016 at about 1 in 36 among children aged 3 to 17 years compared to a prevalence of 1 in 45 2 years prior. In comparison, estimates of prevalence in the early 1990s were 1 in 150, and 1 in 2500 in the early 1980s.

Although autism prevalence appears to have increased significantly over the decades, more recent reports have indicated that this trend may be slowing or reversing—particularly among certain socioeconomic and ethnic groups. A 

 from the Centers for Disease Control and Prevention seems to back this idea, attributing a 15% drop in ASD to a narrowing gap in prevalence between white children and children from minority groups.

Nevison and other researchers examined newer data that confirmed that autism rates were increasing faster among black and Hispanic populations when compared to white children. Historically, prevalence of autism in minority groups had been lower than among whites, but the more recent review found that the rates of autism among black children in particular had not only caught up to that of white children, but had surpassed it in most states.

To investigate further, Nevison and her colleagues examined this newest cohort, breaking down prevalence rates by race and ethnicity, as well as by county. The county-level analysis allowed for an evaluation of autism prevalence by race/ethnicity, as well as specific income groups.

Researchers found that statewide prevalence of autism in California was 1.5% by the 2013 birth year group, with the highest prevalence of 1.8% found in black children, followed by 1.7% in Asian children, 1.4% in white children, and 1.2% in Hispanic children. There was a continuous growth in prevalence throughout the cohort from 1993 to 2013, but a flattened curve was noted in all groups except for Hispanic, and most noticeably among white children. Flattening was short-lived in most of the ethnic groups, the report notes, and was shortest among black children.

In terms of wealth, the research team also noted at growth rates were similar from 1993 to 2000, but after 2000 autism prevalence decreased in the wealthiest California counties. Increases continued but were slower in middle income areas, and were consistent across the study years in low income counties.

The finding in this study that autism prevalence among black children matched and then exceeded that of white children challenges previous theories that increased prevalence is a function of autism awareness and access to care, according to the report. Black and Hispanic children have typically had lower access to care, but increased emphasis on services for low income children may have helped to close these gaps in care.

A number of theories have been proposed to explain the differences in autism prevalence in various socioeconomic areas including, genetics, environments, access to care, and therapy choices. There is also a link to risk factors that could have an impact based on socioeconomic factors including immune inflammation and oxidative stress, diet quality, chronic stress, and more.

“Rising ASD rates among minority children generally are interpreted to suggest that these children have been underdiagnosed in the past and are now catching up to wealthy, white children due to better pediatric screening and awareness. There is likely truth to that view, but it also involves questionable assumptions, such as that there is a natural or genetic level of ASD prevalence in the population, that white ASD rates have more or less stabilized at that level, and that minorities are now catching up thanks to improved screening and will stabilize at a similar level. Those assumptions aren’t supported by data showing that minority ASD rates are surpassing white rates in many states and counties, and that ASD rates among low income whites are continuing to increase.”

Nevison says an alternative explanation is that minority children didn’t experience ASD at the same level as wealthy white children in the past, and that prevalence is genuinely increasing in this population.

“The fact that my study used an age-resolved snapshot from 2019—in which older minority children in that snapshot had lower rates of diagnosed ASD in 2019 than younger children—supports this latter, alternative explanation,” Nevison. “However, pediatricians might consider whether ASD has been missed or underdiagnosed in their older patients, especially among minority children and teenagers.”

This means ASD would join a number of other conditions like diabetes, asthma, and obesity that are more prevalent among the poor as a result of toxin exposure, poor diets, and other factors that lead to chronic inflammation.

The authors lean toward the conclusion that wealthy, educated parents in predominantly white areas likely opted out of public services programs for their children and began making lifestyle and care choices that lowered their likelihood of an autism diagnosis. Nevison says some of the changes observed in those communities as ASD cases fell could be implemented in lower income areas, but it would take a concerted effort to identify the environmental factors that cause ASD.

“Historically about 95% of ASD research funding has gone toward genetics. Many research institutions are still largely following a paradigm that views ASD as a genetic rather than an environmental condition,” Nevison says. “Wealthy parents in California appear to have moved beyond that paradigm and succeeded in lowering their children’s ASD risk. Hopefully the research community can follow their lead and conduct studies to understand what these parents have been doing.”

have also suggested a breakdown of ASD trends along private versus public insurance lines. She says she hopes her study will motivate more research, and inspire clinicians to examine their own practices and those in their communities.

“This may simply reflect underlying socioeconomic factors, as mentioned above, but may also suggest that children on Medicaid and Children's Health Insurance Program are receiving a lower standard of care than privately insured children,” she says. “Pediatricians in clinical practice might consider whether they are treating lower income and minority children differently than wealthier white and Asian children and move to address those disparities.”

1. Nevison C, Parker W. California autism prevalence by county and race/ethnicity: declining trends among wealthy whites. 

. March 19, 2020. Epub ahead of print. doi:10.1007/s10803-020-04460-0

2. Christensen D, Baio J, Braun K, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years — Autism and Developmental disabilities Monitoring Network, 11 Sites, United States, 2012. 

. 2016:65(3):1-23. doi:10.15585/mmwr.ss6503a1

3. Pearl, M., Matias, S., Poon, V., & Windham, G. Trends in birth prevalence of autism spectrum disorder (ASD) in California from 1990 to 2010, by race-ethnicity and income. Poster presented at: 2019 International Society for Autism Research Annual Meeting; May, 2010; Montreal, Canada.

A recent study investigates what is causing ASD to drop in wealthy, white California.

Drop in autism by ethnicity, class may not be what it seems

A 7-month-old male with severe hemophilia A (less than 1% factor VIII [FVIII] activity) presented to his pediatrician with fussiness and inability to sleep for 3 days. He had received his influenza vaccine 3 days earlier. His mother attributed the fussiness to introducing lentils into his diet.

The infant was born to a 32-year-old primigravida mother via cesarean delivery after a normal pregnancy. Severe hemophilia A was diagnosed due to bleeding after a circumcision done at birth. There were no subsequent bleeding episodes and he was not on FVIII replacement therapy.

The infant’s review of systems was positive for atopic dermatitis, intermittent constipation, mild gastroesophageal reflux, and co-sleeping. His growth and development were normal. He was not on medications and his immunizations were up-to-date, including his influenza vaccine 3 days prior to this presentation. There was no history of fever, cough, cold, vomiting, diarrhea, or trauma. The child was treated initially with reflux precautions, dietary advice, and observation but the fussiness worsened. He continued to feed well and smiled when held but started crying when laid down. He slept only in his mother’s arms and awakened screaming at night.

The mother called the hematologist for worsening fussiness and was advised to take the patient to the emergency department (ED). The Hematology service was consulted in the ED. The patient’s vital signs and physical exam were normal. Abdominal imaging (X-ray and abdominal ultrasound [US]) showed no evidence of constipation or intussusception.

The patient saw the pediatrician for a follow-up visit. He was afebrile, fussy, and tired appearing with normal vital signs and a normal physical exam other than crying when laid on the examination table that stopped when he was picked up. Rapid tests for respiratory syncytial virus (RSV) and influenza were negative. He was evaluated at the Hemophilia Clinic the next day when he had a complete blood count (CBC) and a head computed tomography (CT), which were normal.

He followed up again with the pediatrician. His mother reported continuing fussiness, increased flatulence, and pasty stools with straining and crying. On examination, the patient appeared uncomfortable and curled up when laid down. A repeat abdominal X-ray was normal. He was put on an elemental formula and advised polyethylene glycol 1 teaspoon per day in water. The family was advised to return to the ED if the fussiness continued.

The patient returned to the pediatrician the next day for worsening fussiness with a preference to curl up and turn to his left. Hospital admission with hematologic consultation was requested due to the concern for a hematologic, possibly intra-abdominal cause of his fussiness. During the hospital stay, a second abdominal US, a CT scan of his abdomen and pelvis, urinalysis, and blood tests including CBC, lipase, amylase, comprehensive metabolic panel, and C-reactive protein (CRP) were normal.

The patient was noted to be intermittently fussy but had normal vital signs and continued to feed well. He was noted to arch his back during episodes of fussiness. He showed a preference to turn his head to the left. Neck exam showed no asymmetry or evidence of muscle bleed. He did not awaken to an abdominal exam when asleep. The occupational therapist recommended gentle neck exercises for his neck stiffness that was thought to be related to his preferred sleep position in the parents’ arms for several days. His arching was attributed to gastroesophageal reflux. After 2 days, he was discharged.

Fussiness in infants is a common pediatric outpatient complaint and has many causes that range from trivial to life threatening.

 Both hematologic and nonhematologic causes of fussiness were considered in the differential diagnosis for this infant with hemophilia (Table 1). At the onset of fussiness, the patient appeared well, and nonorganic causes were considered such as his recent influenza vaccination, recent introduction of a new food, co-sleeping with parents, frequent awakening at night, and the onset of teething. His exam was negative for thrush, corneal abrasion, or musculoskeletal trauma. Infections appeared unlikely due to the lack of fever, cold symptoms, ear pain, or rash. Because of his history of mild gastrointestinal reflux, intermittent constipation, and fussiness, he was treated with reflux precautions, polyethylene glycol, and a trial of elemental formula.

The patient was simultaneously evaluated for signs and symptoms of hemophilia (Table 2). He demonstrated no obvious bruising, tenderness, swelling, or deformity. Additionally, he had no hemarthroses. He did exhibit worrisome signs such as refusal to lay on his back, turning to 1 side, and curving forward. Hence the child was evaluated for intracranial and intra-abdominal hemorrhage, which were ruled out based on clinical exam, laboratory evaluation, and imaging studies.

During the follow-up with his pediatrician on the day after discharge from the hospital, the patient’s mother reported worsening fussiness with “his hands numb from pain.” On examination, he had torticollis with a head tilt to the left and a partial ptosis of his left eyelid. Tone and spontaneous movements of his trunk and upper extremities were decreased and he reached for a toy with his feet.

Unable to sit, he curved his spine forward when placed in a seated position. He was unable to lift himself up from the prone position. Grasp reflex was absent, and he appeared to have no sensation in his palms. The pediatrician advised the parent to return to the ED and called the hematologist about the new neurologic findings. The child was intubated in the ED and an imaging study confirmed the diagnosis.

The patient was diagnosed with spinal epidural hematoma (SEH) with cord compression presenting with Horner syndrome.

Magnetic resonance imaging (MRI) of the patient’s spine showed multiple epidural hematomas extending from C2 down to S1 with significant cord compression. This was especially pronounced from C6 to T4 where the spinal cord was severely compressed and displaced anteriorly and to the left. Multiple septations suggested that the hematomas could be subacute or chronic. (Figures 1 and 2 present preoperative T1- and T2-weighted sagittal and axial images of the spine.)

Factor VIII replacement was given immediately after the MRI and perioperatively per standard guidelines for hemophilia.

 He underwent multiple partial hemilaminectomies for decompression of epidural hematomas. His neurologic exam improved the next day with increased spontaneous movements of his upper extremities.

One week postoperatively, another spinal MRI showed significant improvement (Figure 3). The patient was found to have a low titer inhibitor (0.8 BU) during the admission that self-resolved on follow-up testing. Postoperatively, further bleeding complications were successfully prevented with recombinant FVIII product, 200 units/kg/dose given every 6 hours that was gradually spaced out. He was discharged after 3 weeks with residual right-sided hemiparesis and left-sided ptosis.

Three months later, a central line was placed to facilitate the administration of the recombinant FVIII product every other day. Six months later, he transitioned to an extended half-life (EHL) FVIII product (50 units/kg/day every 4 days). He received physical and occupational therapy with steady improvement and was enrolled in Early Intervention services for children.

Hemophilia, an X-linked bleeding disorder, is the most common hereditary bleeding disorder in the United States. Its incidence is estimated to be approximately 1 in 5000 live male births.

 Hemophilia A, the condition affecting this patient, results from deficiency in FVIII. Central nervous system bleeding in patients with hemophilia is a rare complication with an incidence between 2% and 8%.

 Fewer than 10% of these hemorrhages occur within the spinal canal.

This case highlights the importance of recognizing infancy as a high-risk age group for the occurrence of SEH. Infants may be predisposed to epidural bleeding as their cervical musculature begins to develop between ages 4 and 6 months.

 Increased cervical motion in the developing muscle body (due to acceleration and deceleration of the head mass in babies with poor head control) leads to cervical spine injury

Spontaneous SEH can be either venous or arterial in origin. In venous SEH, absence of valves in the venous plexus allows for venous backflow and sudden increases in pressure (from an infant’s crying, straining, coughing, or sneezing), inducing spontaneous rupture of these fragile vessels.

 In arterial SEH, it is hypothesized that the higher pressure of arterial bleeding could result in cord compression with a rapid onset in patients who previously performed strenuous activities without incident.

 Young infants with hemophilia also are at higher risk for hemorrhage because they typically do not begin prophylactic factor replacement until after age 1 year or following their first joint or muscle bleed once ambulatory.

Babies with SEH have nonspecific symptoms such as unexplained irritability, inconsolable crying, poor feeding, or refusal to bear weight

 The classic clinical triad without history of trauma, making it difficult to recognize.

 The classic clinical triad of SEH—radicular pain, severe localized spinal pain, and sensorimotor deficits—may initially be difficult to perceive in a nonverbal infant. However, a diligent physical exam demonstrating specific neurologic signs such as decreased neck range of motion, diminished arm reflexes, or decreased strength, tone, and sensation in the upper extremities

Review of literature revealed 2 previous cases describing torticollis as a presentation of SEH in hemophilia A.

 Similar to this case, a 10-month-old infant with a cervicothoracic epidural hematoma presented initially with irritability and a normal neurologic exam but developed torticollis approximately 48 hours later that progressed to diffuse hypotonia, flaccid upper extremity paralysis, and respiratory distress requiring emergent decompressive laminectomy.

 Another 10-month-old boy developed torticollis 48 hours after an incident of repeated neck overextension and went on to develop flaccid upper extremity paralysis.

 There are no previous cases of SEH in hemophilia presenting with Horner syndrome. However, a similar presentation was found in a 72-year-old woman receiving anticoagulant therapy for atrial fibrillation.

Early diagnosis and treatment of SEH in hemophilia patients is necessary to prevent progression of neurologic deficits leading to long-term sequelae. Magnetic resonance imaging is the diagnostic modality of choice for SEH. However, spinal ultrasonography is a reasonable screening tool should MRI not be readily available.

 Empirical factor replacement, even prior to imaging, is the initial therapy in cases of suspected central nervous system bleeding and is dosed to achieve factor levels of 100%. The role of surgical intervention is less clear. Prompt surgical decompression with or without laminectomy should be considered.

 However, surgery may be deferred in the presence of a stable neurologic exam with successful correction of the underlying coagulopathy.

Kiehna and colleagues reviewed 24 cases of spontaneous epidural hemorrhage in children with hemophilia and found that prompt conservative treatment with FVIII and correction of coagulopathies was critical in patient outcomes. Aggressive medical management without surgery provided for full neurologic recovery in hemodynamically and neurologically stable patients.

 Importantly, these authors and other proponents of conservative management (under the appropriate circumstances) recommend a multidisciplinary approach to the treatment of these patients with a team consisting of a pediatric hematologist, neurosurgeon, and pediatric intensivist.

A high index of suspicion for spinal hemorrhage and recognition of subtle neurologic signs of cord compression, which can be difficult in a nonverbal and nonambulatory child, are essential in order to obtain the correct imaging and make the diagnosis in a timely way.

Horner syndrome or oculosympathetic paresis is a classic neurologic syndrome whose signs include ptosis, miosis, and anhydrosis due to a lesion along the sympathetic pathway that supplies the head, eye, and neck. Children with new onset Horner syndrome must be evaluated for an underlying disorder and paraspinal masses must be considered as an etiology.

 The history of severe hemophilia with new onset torticollis, Horner syndrome, and upper extremity weakness suggested cord compression from cervical spinal hemorrhage in this patient.

The patient at age 6 years has no neurologic deficits and his general health is very good. His cognition and speech are excellent. He has had no further bleeding episodes. He recently transitioned from EHL FVIII product to a new prophylactic agent called emicizumab given subcutaneously once a week.

1. Arumugam J, Sivandam A, Vijayalakshmi A. The evaluation and management of an incessantly crying infant. 

. 2012;41(4):192-198. doi: 10.4038/sljch.v41i4.4985

2. Srivastava A, Brewer AK, Mauser-Bunschoten EP, et al; Treatment Guidelines Working Group on Behalf of the World Federation of Hemophilia. Guidelines for the management of hemophilia. 

3. Soucie JM, Evatt B, Jackson D. Occurrence of hemophilia in the United States. The Hemophilia Surveillance System Project Investigators. 

4. Eyster ME, Gill FM, Blatt PM, Hilgartner MW, Ballard JO, Kinney TR.Central nervous system bleeding in hemophiliacs. 

5. de Tezanos Pinto M, Fernandez J, Perez Bianco PR. Update of 156 episodes of central nervous system bleeding in hemophiliacs. 

6. Kiehna EN, Waldron PE, Jane JA. Conservative management of an acute spontaneous holocord epidural hemorrhage in a hemophiliac infant. 

7. Lee JS, Yu CY, Huang KC, Lin HW, Huang CC, Chen HH. Spontaneous spinal epidural hematoma in a 4-month-old infant. 

8. Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. 

9. Jackson FE. Spontaneous spinal epidural hematoma coincident with whooping cough. Case Report

10. Caldarelli M, Di Rocco C, La Marca F. Spontaneous spinal epidural hematoma in toddlers: description of two cases and review of the literature. 

11. Cuvelier GD, Davis JH, Purves EC, Wu JK. Torticollis as a sign of cervico-thoracic epidural haematoma in an infant with severe haemophilia A. 

12. Oymak Y, Muminoglu N, Ay Y, et al. Torticollis in a haemophilic infant with inhibitor: a case of spinal epidural haematoma. 

13. Morelli N, Mancuso M, Guidetti D. Spinal epidural hematoma onset with Horner syndrome. 

14. Brown T, Purves E, Sargent M, Wu J. Clinical application of spinal ultrasound in screening for spinal haematoma in haemophilia A infants. 

15. Rois PV, López MR, de Vergara BC, de la Lama Zaragoza A, García JG, Uxo JM. Spinal epidural hematoma in hemophilic children: controversies in management

 2009;25(8):987-991; discussion 993, 995.

16. Borkar SA, Prasad GL, Satyarthee GD, Mahapatra AK. Spontaneous spinal extradural hematoma in a child with hemophilia B, surgery or medical management—a dilemma? 

17. Barrea C, Vigouroux T, Karam J, Milet A, Vaessen S, Misson JP. Horner syndrome in children: a clinical condition with serious underlying disease. 

A 7-month-old male with severe hemophilia A (less than 1% factor VIII [FVIII] activity) presented to his pediatrician with fussiness and inability to sleep for 3 days. He had received his influenza vaccine 3 days earlier. What's the diagnosis?

Epidural bleeding in an infant with hemophilia

The US Food and Drug Administration has approved Fintepla (fenfluramine) from Zogenix, Inc., which is a Schedule IV controlled substance, for treating seizures associated with Dravet syndrome in children aged 2 and older.

 Seizures in children with Dravet Syndrome are often severe, even with medical treatment.

Two studies were used to show the efficacy of the drug on treating seizures. The studies included 202 participants aged 2 to 18 and both examined the change from baseline in the frequency of convulsive seizures. Participants treated with fenfluramine were found to have greater reductions in the frequency of seizures than the participants who were given a placebo. The reduction was frequently seen by 3 to 4 weeks of treatment and mostly consistent over a 14- to 15-week treatment cycle.

The drug will be required to have a boxed warning that says fenfluramine is linked to both valvular heart disease (VHD) and pulmonary arterial hypertension (PAH). Due to the risks, children who are prescribed the drug must have cardiac monitoring via echocardiograms performed before treatment, at a 6-month interval during the course of treatment, and once every 3 to 6 months after treatment. If VHD, PAH, or any other cardiac abnormality is seen, the risks and benefits of the drug must be considered. Due to the cardiac risks, the drug is only available under a risk evaluation and mitigation strategy (REMS). The plan requires both the health care professionals and the pharmacies dispensing the drug to be specially certified in the REMS. Patients must also be enrolled in it.

In addition to the risk of VHD and PAH, common adverse reactions found in the clinical study included drowsiness, constipation, decreased appetite, ataxia, gait disturbance, fatigue, diarrhea, increased blood pressure, drooling, fever, vomiting, status epilepticus, risk of falls, and upper respiratory tract infection.

The application was granted Priority Review. Fintepla was given an Orphan Drug designation.

1. US Food and Drug Administration. FDA approves new therapy for Dravet syndrome. US Food and Drug Administration. Published June 25, 2020. Accessed June 29, 2020.

 https://www.fda.gov/news-events/press-announcements/fda-approves-new-therapy-dravet-syndrome

The US Food and Drug Administration (FDA) approves Fintepla (fenfluramine) through Priority Review.

FDA approves Fintepla for treatment of Dravet Syndrome

 for pediatric health care providers as they care for patients in the age of COVID-19. Spring and summer of 2020 has been challenging on many different levels, requiring health care providers to demonstrate flexibility in almost all aspects of practice. This issue looks at the impact of the pandemic on pediatricians from multiple angles and provides some very practical advice. In the article

 “COVID-19: A battle plan for pediatricians

 ,” Dr. Schuman discusses some of the obstacles health care providers have faced this year and provides some trail markers as we look for a way forward.

As concerned families stayed home this spring in an effort to protect their family and communities, important well child care visits were missed. In a recent report, the Centers for Disease Control and Prevention stated that routine ordering of pediatric vaccines was significantly decreased due to the COVID-19 pandemic. The report showed that from mid-March to mid-April, doctors in the Vaccines for Children program ordered approximately 2.5 million less doses of all routine vaccines and 250,000 fewer doses of measles containing vaccines compared to the same period in 2019.

 It is vital that pediatricians take steps to increase access to care as they do their best to ensure patient safety. This will involve reworking some office procedures that have been in place for generations. In his article, Dr. Schuman provides some specific suggestions as forward-thinking providers attempt to adapt to the current climate in health care.

Strategies to increase patient safety include having patients wait in the parking lot rather than a waiting room, and offering separate well and sick visit appointments at different times of the day. Pediatricians need to communicate the importance of continuing to access health care, including well visits and vaccinations, to their patients. Part of this process should be clearly communicating the safety measures put in place to protect families as they receive health care.

In addition to in-person visits for vaccinations, telehealth visits should be maximized, and billed appropriately. Many pediatricians have not used telehealth in their practice prior to 2020. In this article, various telehealth platforms are discussed, including costs and details pertinent to pediatric practices. An additional layer to evaluating patients virtually is the decision on when to prescribe an antibiotic. Not surprisingly, antibiotics are often not necessary; however, Dr. Schuman discusses some potential guidelines on when it might be appropriate to prescribe antibiotics during a telehealth visit.

In addition, to maximizing safety and health care visits, either in-person or virtually, the author points out the importance of stocking up on personal protective equipment in anticipation of the continued presence of COVID-19 throughout the fall and winter.

This era requires flexibility, openness to new information although rigorously evaluating the available data at the same time, and the ability to communicate effectively with patients and their families via new modalities. As we scramble to keep up, this issue of 

1. Santoli J, Lindley M, DeSilva M et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration — United States, 2020. 

. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2

COVID-19 has rapidly changed many aspects of life and nowhere is this more apparent than in medical offices. 

Taking on a strategy to tackle COVID-19

The use of oral immunotherapy has been helpful in reducing the seriousness of peanut allergies, but it hasn’t been well evaluated in treating wheat anaphylaxis. A 

Investigators recruited participants who were aged 5 to 18 years and had a history of wheat anaphylaxis. They also had confirmed symptoms during an oral food challenge that included exposure to 53mg of wheat protein. Following admission to the hospital for a 5-day buildup phase, children in the immunotherapy group gradually increased their wheat consumption to 53 mg/day and continued to ingest the same amount every day when they were home. A year later, the participants were given a 53mg and 400mg oral food challenge following a 2 week cessation of immunotherapy. The control group was made up of patients who avoided wheat for the same period.

In the oral immunotherapy group, which contained 16 children, the median wheat‐ and ω‐5 gliadin‐specific immunoglobulin E (sIgE) levels were 293 and 7.5 kUA/L, respectively. No child dropped off the study. Following 1 year of oral immunotherapy treatment, 88% of the children were able to withstand 53 mg of wheat protein. Additionally, after a year, 69% of the patients passed the 53 mg oral food challenge and 25% passed the 400 mg oral food challenge in the oral immunotherapy group. In the control group, 9% were able to pass the 53 mg oral food challenge and 0% were able to pass the 400 mg oral food challenge. Within the oral immunotherapy group, wheat‐ and ω‐5 gliadin‐sIgE levels significantly decreased to 154 and 4.1 kUA/L, respectively at 1 year. There were 7 incidents of anaphylaxis and all improved promptly without adrenaline.

Researchers concluded that a low dose of oral immunotherapy can safely prompt immunologic change in children who have wheat anaphylaxis and could potentially allow a 400 mg dose of wheat protein.

1. Nagakura K, Yanagida N, Sato S, et al. Low‐dose‐oral immunotherapy for children with wheat‐induced anaphylaxis. 

. 2020;31(4):371-379. doi:10.1111/pai.13220

Immunotherapy has shown promise in treating peanut allergies. An investigation looks at whether similar results can be found when treating patients for wheat anaphylaxis.

Can immunotherapy help with wheat anaphylaxis?

With children being exposed to media via television, smartphones, and tablets, there’s also exposure to advertising. The industry has taken notice and spent $3.2 billion on nondigital advertising and $900 million for digital advertising in the United States in just 2018. The American Academy of Pediatrics has issued a

The statement discusses how children aged 7 years and younger have difficulty understanding when someone is trying to persuade them, but this doesn’t mean that children can resist advertising, as children aged as young as 2 years can identify characters and connect them with a product that the characters have endorsed.

The statement offered the following recommendations for parents:

1. Know what the child is accessing and downloading.

2. Monitor privacy settings on all digital devices.

3. Create a family media plan that mostly includes media content with as few ads as possible.

4. Educate the child on how to analyze ads, understand what personal information may be collected, and to be aware of persuasive content.

5. Talk about digital privacy tools used in the child’s school with administrators and teachers.

1. Knowing how children are being targeted and assist parents in understanding how targeting may work.

2. Ask families if they have media use concerns during well-visits.

3. Give families resources that can help them build digital literacy.

4. Encourage parents to consider themselves as digital role models for their children.

5. Advocate for regulations that limit advertising and data collection for children and teenagers.

1. Radesky J, Chassiakos Y, Ameenuddin N, Navsaria D. Digital advertising to children. 

. 2020: 145(6):e20201681. doi:10.1542/peds.2020-1681

The American Academy of Pediatrics (AAP) has issued a statement on keeping children safe from the potential harms of advertising.

AAP issues guidance on advertising to children

Look at any social media app, such as Instagram, and you’ll find plenty of pictures of infants curled up with the family cat or dog. Does this close bond between child and animal play a role in developing asthma or allergy? An 

Researchers enrolled children who were participating in the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) Nutrition Study. When the child was aged 5 years, researchers administered a validated version of the International Study of Asthma and Allergies in Childhood questionnaire to find information on asthma, allergic disease, and exposure to farm animals and indoor pets within the first year. Serum samples were used for allergen‐specific immunoglobulin E antibody analysis.

Among the 3781 participants, investigators found that having a dog in the house was inversely tied to the risk of asthma (hazard ratio 0.60; 95% confidence interval [CI], 0.38‐0.96), allergic rhinitis (odds ratio [OR] 0.72; 95% CI, 0.53‐0.97), and atopic sensitization (OR 0.77; 95% CI, 0.63‐0.96). Houses with cats had a decreased risk of atopic eczema (OR 0.68; 95% CI, 0.51‐0.92). Farm animals, either on their own or in conjunction with house pets, had no association with outcomes.

The investigators concluded that exposure to a dog or cat in the first year of life may provide some protection against both allergy and asthma. They stated that future research would be required to determine specific exposures and whether those exposures could be recommended to prevent allergies.

1. Ojwang V, Nwaru B, Takkinen H et al. Early exposure to cats, dogs and farm animals and the risk of childhood asthma and allergy. 

. 2020;31(3):265-272. doi:10.1111/pai.13186

For many children, a furry animal can be a best friend. An investigation looks at whether that bond can also protect against asthma and allergies.

Does early animal exposure reduce allergy and asthma risk?

Warm greetings! It is hard to believe that summer is almost upon us.

Over the last 4 months, the spreading COVID-19 pandemic has made us rethink how we practice medicine in order to continue to provide outstanding comprehensive care to all our patients. This is especially important for our patients aged younger than 2 years for whom it is critically important that they receive their recommended vaccines on time and for medically complex patients who require close follow-up for the management of their conditions.

The pandemic has challenged us to be creative in the ways we evaluate patients and provide reassurance to their parents. In this issue of 

COVID-19: A battle plan for pediatricians

—This article highlights some strategies that pediatric practitioners can incorporate into their practices to safely and effectively provide care to their patients.

CDC issues preliminary information on MIS-C

—Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 was first described in the United Kingdom in late April 2020 and has since been reported in Spain, Italy, France, and the United States. This is a serious condition with some symptoms that overlap those seen in Kawasaki disease and/or toxic shock syndrome. Preliminary data indicate that many individuals who develop this syndrome have either COVID-19 infection or a history of exposure and that MIS-C may be a postinfectious inflammatory process. This article presents the CDC case definition of MIS-C and the need to report MIS-C to local, state, or territorial health departments.

Updated consensus guidelines issued for unexplained pediatric death

—There is limited medical awareness of SUDC, which is the sudden and unexpected death of a child aged 12 months or older that remains unexplained after a thorough investigation including autopsy. This document provides comprehensive guidance for the pediatric practitioner on the investigation of the event and the important role that they play in serving as liaisons to help families maneuver through the processes that occur after the death.

Chronic care management: Increase the value of your practice

—Fifteen to 25% of children in the United States have one or more chronic health conditions that require some level of chronic care management. This is an important Practice Improvement article that provides the information to properly code for the management of children with multiple chronic conditions and ensure proper reimbursement.

As we continue to work through the COVID-19 pandemic, remember that:

“No matter how hard things may seem, don’t get down and don’t give up. The clouds will clear and there are brighter days ahead.” —Anonymous

Please stay safe and well. I welcome your suggestions, comments, and questions.

The great unknown caused by COVID-19 has led to many questions and few answers. The one certainty is that pediatrics will have to change in order to ensure proper care.


Pediatrics’ new paradigm for practice in the era of COVID-19

Children who have cow’s milk allergies may struggle with long-term growth moreso than their peers with other food allergies, according to a recent study.

 on the effect of milk allergies on overall childhood growth was published through a letter to the editor in the 

Journal of Allergy and Clinical Immunology

A retrospective study reveals that children with cow’s milk allergies—and the restrictive diets they must follow—may negatively impact their growth and development in comparison to their peers with other food allergies.