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

They’re our best friends and the stars of viral videos, but dogs, cats, and other furry animals can also be the cause of allergies that make children miserable. Dander, saliva, feces, and urine are all potential sources of allergens.

A reaction to a pet allergen typically occurs 15 to 30 minutes after initial exposure in children who are particularly sensitive, but those with mild allergies may not have a reaction for a day or 2. If dander collects on furniture or clothing, an allergic reaction may occur, even if the pet is no longer in the home. Anaphylaxis is not common with pet allergies. Common symptoms of pet allergies include:

In addition to using over-the-counter decongestants and antihistamines to relieve symptoms, families can reduce allergy symptoms by:

Having the pet groomed regularly, which can reduce dander

Washing hands and changing clothes after interacting with the pet

Vacuuming floors and furniture on a regular basis to remove pet dander

Preventing the pet’s access to rooms like bedrooms

Allergies can be confirmed by a clinician or allergist through either skin prick testing or testing for immunoglobulin E. For children with more severe allergies, allergy shots may be a way to ameliorate the allergies.

Articles

They may be our best friends and internet superstars, but pet allergies are a fact of life for many children.

Animal allergies 101

Jennifer Orahood is a RN IV clinical expert in the neonatal intensive care unit at the University of Arkansas for Medical Sciences in Little Rock and is co-chair of the NICU Unit Council. She also serves as a medical advisor for WaterWipes.

According to the World Health Organization (WHO), over 15 million babies are born preterm—before 37  weeks’ gestation—every year worldwide. Preterm birth complications are the leading causes of death for children aged younger than 5 years. In 2019, 47% of all deaths under the age of 5 occurred in the newborn time period of the first 28 days of life. One-third of those deaths occurred on the day of birth, and three-fourths were the first week of life.

One of the WHO’s many recommendations to improve survival and health outcomes in small and preterm infants is kangaroo care.

 Starting kangaroo care early and performing it often has proven to be a safe, low-cost, and effective intervention for preterm and low-birth weight infants.

 Also called kangaroo mother care and skin-to-skin contact, this is when the mother and baby have continuous skin-to-skin contact. These infants need interventions for hypothermia, better glucose levels, better regulation of blood pressure, and reducing stress hormone levels.

During kangaroo care, a mother or father holds their baby’s chest to their chest, skin to skin, for a minimum of 1 hour per day. For a healthy term infant, this begins immediately after birth. For an infant who is preterm or low birth weight or had complications at birth, kangaroo care begins once the infant is stable. Although the minimum time frame is 1 hour per day, the recommended time for kangaroo care is 2 to 4 hours per day.

 For an infant in the neonatal intensive care unit (NICU), health care workers including respiratory therapists and nurses can help with the placement of the infant on the mother’s chest. Infants who are intubated and have intravenous catheters can still be eligible for kangaroo care.

Kangaroo care initiated early and done often provides many benefits to mothers and infants. Mothers who practice kangaroo care report enhanced attachment and bonding, more confidence in caring for their infant, increased milk production, and more success at breastfeeding. Research from Vittner et al shows that kangaroo care is associated with an increase in oxytocin levels, which leads to decreased stress.

 Mothers who practice kangaroo care report breastfeeding their infants for a longer period of time each day at 1 month and at 6 months after discharge from the hospital.

 Additionally, fathers who participate in kangaroo care report enhanced bonding to their infant and more confidence in providing care and in providing for their infant.

 Importantly, both fathers and mothers experience decreased levels of anxiety during kangaroo care, and infants have decreased stress response regardless of which parent is holding them.

Infants in the NICU need kangaroo care as much as healthy newborns. Research shows that infants in the NICU who participate in kangaroo care have a reduced mortality rate, a better sleep-wake cycle, fewer incidents of infections, and increase in weight gain.

 Infants who are in the NICU and are stable tolerate kangaroo care well by keeping vital signs the same or having improved vital signs.

 Mothers, fathers, and caregivers of both term and preterm infants are encouraged to participate in kangaroo care to provide infants with the benefits of skin-to-skin contact.

1. World Health Organization. Preterm birth: key facts. Accessed August 3, 2021. 

https://www.who.int/news-room/fact-sheets/detail/preterm-birth

2. WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Committee. Accessed August 3, 2021. https://apps.who.int/iris/handle/10665/259269

3. Chan G, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers. 

2016;94(2):130–141J. doi:10.2471/BLT.15.157818

4. Gardner SL, Carter BS, Enzman-Hines M, Niermeyer S. 

Merenstein & Gardner's Handbook of Neonatal Intensive Care, 9th Edition

5. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. 

2016;11(11):CD003519. doi:10.1002/14651858.CD003519.pub4

6. Vittner D, McGrath J, Robinson J et al. Increase in oxytocin from skin-to-skin contact enhances development of parent-infant relationship. 

2018;20(1):54-62. doi:10.1177/1099800417735633

7. Preterm and low brith weight. World Health Organization. Accessed August 4, 2021. 

https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/newborn-health/preterm-and-low-birth-weight/

Kangaroo care is a cheap, effective intervention to improve outcomes in preterm and low-birth weight infants.

Kangaroo care in the neonatal intensive care unit 

AAP issues recommendations for 2021-2022 flu season

The American Academy of Pediatrics (AAP) has issued its recommendations for the upcoming influenza season, including guidance on administering the vaccine to patients with COVID-19.

Pediatric obesity and the impact of COVID-19

As we begin to emerge from the national lockdown due to the COVID-19 pandemic, many pediatricians may find that the already widespread problem of youth-onset obesity is worse than ever.

Artificial intelligence enters pediatric practice

Artificial intelligence (AI) is used to make everyday life easier. Here's how AI systems can help elevate your medical game.

AAP reports sharp increase in pediatric COVID-19 cases

The latest report from the American Academy of Pediatrics (AAP) and the Children's Hospital Association indicates that case of COVID-19 in children are continuing to sharply climb.

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

In case you missed it: September 6 to 10

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.

According to the American Academy for Pediatrics (AAP), there are over 5 million children diagnosed with acute otitis media (AOM) each year in this country.

 This results in 30 million visits for medical care and is responsible for over 10 million antibiotic prescriptions yearly.

 The increasing incidence of antibiotic resistance among the organisms responsible for AOM is a cause for concern. Although pneumococcal vaccine has reduced the incidence of AOM, by 1 year of age 23% of children have experienced one or more episodes of AOM and 3.6% have had 3 or more episodes.

 By 3 years of age, 60% of children have had one or more episodes of AOM and 24% have had 3 or more episodes.

 Otitis media with effusion (OME), or fluid behind the tympanic membrane without infection, often precedes or follows AOM. Although it does not require antibiotic treatment, persistent or recurrent OME can have significant impact on a child’s hearing and the structure of the middle ear space. The AAP recommendations, last updated in 2013, describe several criteria for diagnosing AOM and distinguishing this condition from OME.

 This article will describe how pediatricians can use various devices to assist in the diagnosis and monitoring of AOM as well as OME.

The AAP issued extensive AOM guidelines in 2004 recommending that pediatricians make efforts to more accurately diagnose AOM and distinguish AOM from OME. They also developed criteria for treating children with antibiotics or monitoring symptoms when withholding antibiotics.

 Subsequent surveys of AAP members demonstrated that the 2004 guidelines did not change clinical practice, and so the AAP revised their AOM guidelines in 2013.

 The 2013 guidelines recommend that (1) the diagnosis of AOM should be made in a child with bulging of the tympanic membrane or otorrhea when otitis externa is excluded and (2) clinicians should diagnose AOM in children who present with mild bulging of the tympanic membrane and recent (less than 48 hours) onset of ear pain or intense erythema of the tympanic membrane. Most importantly, the guidelines state that, “The diagnosis is excluded if middle ear effusion is not present based on pneumatic otoscopy or tympanometry.”

Despite evidence-based recommendations from the AAP, few pediatricians utilize pneumatic otoscopy and or tympanometry to diagnose otitis media. We should learn to utilize current technologies to exclude the diagnosis, or at least try to diagnose the condition with more certainty. There are many children with recurrent episodes of AOM who have hearing loss who become candidates for placement of tympanostomy tubes. Moreover, although previous recommendations suggested withholding antibiotics, the most recent guidelines are more liberal regarding when antibiotics should be used (see Table).

During their career, a pediatrician looks at thousands of ear canals and tympanic membranes, so presumably we’d would be pretty good at detecting bulging of the tympanic membrane and erythema. Truth be told, the diagnosis is often difficult. Early in the course of otitis media, there may be minimal bulging or slight erythema of the tympanic membrane. Additionally, a crying child will often have injection of the tympanic membrane which may be incorrectly interpreted as erythema.

Fortunately, we now have several new devices that help visualize the tympanic membrane and ear canal. It is likely you are currently using a Welch Allyn MacroView Otoscope to peer into your patients’ ears. This device provides a wider view and more illumination than its predecessor. Now Hillrom, who produces this otoscope, has improved upon the MacroView with the introduction of the MacroView Plus Otoscope.

 The MacroView Plus Otoscope provides up to 3 times the field of view than traditional otoscopes, and when it is used in conjunction with their new (and backward compatible) LumiView clear single use speculum, illumination is up to 8 times brighter than it is with their black speculum. They even have a new, slimmer, Lithium Ion Plus USB handle, which can be charged via a USB-C port, that retains a charge longer and is more ergonomic than previous models. In addition, the MacroView Plus can be attached to an Android phone or iPhone with their SmartBracket accessory. The SmartBracket places the camera lens of the phone over the viewing port of the otoscope. Using an application on the attached smartphone, one can capture (and enhance) the image of the tympanic membrane and transfer the image to a computer to include in the medical record or show to the parent and patient.

I have long been a fan of the Wispr Digital Otoscope

 from WiscMed. The device is a digital video otoscope head that fits most traditional otoscope handles. It enables one to take a picture or video of the ear canal and tympanic membrane and display the image on a screen. One can transfer images via USB drive to a computer for inclusion in the medical record. Parents and patients are always impressed with the Wispr images, and it now includes a “pediatric” mode that displays cartoon characters that can be used to engage patients and help with cooperation.

Not only is it important to visualize the ear canal and tympanic membrane when a child presents with fever and ear pain, but it is also important in many circumstances to establish whether a child’s hearing is normal or not. Pediatricians can determine whether a child with recurrent or persistent otitis has a hearing loss with otoacoustic emissions (OAE) screeners that can rapidly determine if a child has a hearing loss and can quantify the hearing loss with pure tone audiometry. Given that OAE screeners generate a “pass or refer” result, pediatricians should consider performing a pure tone audiogram to determine the hearing threshold for the child. Be aware that 20% of children aged 3 to 5 years will not be able to be screened by pure tone audiometry, and those unable to be screened should be evaluated by an audiologist. Hearing screeners such as the Bio-logic AuDX Pro and AuDX Pro Flex

 from Natus Medical are modular devices that facilitate screening in the primary care office. The Bio-logic AuDX Pro can be configured to display a cartoon to distract a child during the brief OAE screen. Additionally, it can be used to perform pure tone audiometry on children who refer on OAE screen or for those suspected as having auditory neuropathy. The Bio-logic AuDX Pro Flex provides all the capabilities of the AuDX Pro as well as providing tympanometry capability. In the latter situation, 1 device provides all the hearing screening capability a practice requires.

As pediatricians do not uniformly perform pneumatic otoscopy, they can also perform tympanometry to determine whether fluid is present behind the tympanic membrane. Many OAE screeners include tympanometry as an add-on feature. Tympanometry requires a good seal between the probe tip and the ear canal and is difficult to perform in an uncooperative or crying child.

Many years ago, one of my favorite devices was the EarCheck Pro Middle Ear Monitor. The device directs sound at the tympanic membrane and records its reflection, determining a value called the spectral gradient angle (SGA). In seconds, without a seal, the device displays the SGA, which could indicate a middle ear effusion. The device was very popular in the 1990s, and there was also a home version so parents could monitor their children for effusions. Unfortunately, Becton Dickinson acquired the device, but never promoted it, and eventually production was halted. The device is going to reemerge either this year or early next year, as an acoustic otoscope

 from Check My EAR LLC. It will be able to assist pediatricians in assuring that an effusion is present in mere seconds, which is much faster than tympanometry.

Another device that can be helpful in diagnosing and monitoring AOM and OME is the OtoSight Middle Ear Scope

 from PhotoniCare. The device provides a true color video otoscopy of the ear canal and eardrum. Additionally, it determines the presence or absence of fluid in the middle ear; characterizes the type of fluid; and visualizes the fluid’s density, even in the presence of significant wax. The device is an optical coherence tomography otoscope that analyzes reflected light from the middle ear space to determine whether an infusion is present. Studies have shown that the device is very accurate in diagnosing OME.

 It is available via a monthly subscription.

Another interesting device for diagnosing middle ear fluid is OtoNexus Medical Technologies’ Advanced Ultrasound Otoscope, which is reported to be unique in its ability to distinguish OME from AOM. The company has developed an inexpensive advanced otoscope that uses ultrasound technology to determine infection type with a high degree of accuracy. According to the company, this will enable clinicians to determine whether antibiotics are needed for treatment. The OtoNexus Ultrasound Otoscope

 is easy to use—pediatricians merely push a button when performing an otoscopic exam. The device displays a score that corresponds to both fluid presence and fluid type. FDA approval of the device is pending completion of clinical trials, and it is expected to be released sometime next year.

The COVID-19 pandemic has created an opportunity for the engineers at Remmie Health

 to develop and begin distribution of an inexpensive ($150) otoscope that can be used to capture images of the tympanic membranes and throat of an ill child or adult. The device is now available on Amazon and is designed to be nonthreatening to children. It complements ear or forehead thermometers that are likely used routinely by parents to screen children for fever. The Remmie Otoscope transmits images to a mobile application, allowing them to be sent to a child’s physician for review. As more and more physicians adopt telehealth, I anticipate that the Remmie Otoscope will prove useful for the otitis-prone child, as physicians can now diagnose otitis media or pharyngitis remotely. It can also be used to detect impacted cerumen and otitis external and to visualize foreign bodies in the ear canal.

To provide optimal care for our patients, it is important to diagnose AOM accurately and distinguish it from OME. These technologies can help visualize the tympanic membrane; determine whether fluid is present in the middle ear space; and, most importantly, determine if the fluid is affecting a child’s hearing. By making these efforts, we can prescribe antibiotics more appropriately.

1. Kaur R, Morris M, Pichichero ME. Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. 

 2017;140(3):e20170181. doi:10.1542/peds.2017-0181

2. American Academy of Pediatrics; American Academy of Family Physicians. The diagnosis and management of acute otitis media. 

2004;113(5):1451-1465. doi:10.1542/peds.113.5.1451

3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. 

 2013;131(3):e964-999.doi:10.1542/peds.2012-3488

4. MacroView Plus Otoscope. Accessed July 29, 2021. 

https://www.hillrom.com/en/products/macroview-plus-otoscope/

5. Wispr Digital Otoscope. Accessed July 29, 2021. 

6. Biologic AuDx Pro Flex. Accessed July 29, 2021. 

https://hearing-balance.natus.com/en-us/products-services/bio-logic-audx-pro-flex

7. Acoustic Otoscope. Accessed July 29, 2021. 

8. OtoSight Middle Ear Scope. Accessed July 29, 2021. 

9. Preciado D, Nolan RM, Joshi R, et al. Otitis media middle ear effusion identification and characterization using an optical coherence tomography otoscope. 

 2020;162(3):367-374. doi:10.1177/0194599819900762

10. OtoNexus Medical Technologies. Accessed July 29, 2021. 

The best devices for helping the 5 million children diagnosed with acute otitis media each year.

Tools for taming otitis media

Appendicitis is the most common surgical emergency in pediatrics. When significant delays occur in diagnosis, the risk of worse outcomes, particularly a perforated appendix, (which is linked to morbidities such as abdominal abscess, small bowel obstruction, sepsis, bowel resection, longer hospital stays, and higher cost) is increased. What 

 in diagnosis and how preventable are they?

The investigators used patients who were treated at 5 pediatric emergency departments for a diagnosis of appendicitis and were aged younger than 21 years. The Pediatric Appendicitis Risk Calculator was used to measure the individual features of appendicitis and determine pretest likelihood of appendicitis. Control patients had a single visit to the emergency department that led to an appendicitis diagnosis. Case patients had 2 emergency department visits before diagnosis and a case review showed that the patient very likely had appendicitis during the first visit. The preventability of delay was described as unlikely, possible, and likely.

There were 748 children included in the study and 471 had a delayed appendicitis diagnosis. Those who had a delay in diagnosis were found to be less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), as well as being more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). Pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed versus timely diagnosis. In the subcohort of delayed diagnoses, 109 cases were likely preventable and 247 were found to be possible preventable. Cases of delayed diagnoses were found to have higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3), longer hospital length of stay stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days), and undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4).

The investigators concluded that cases of delayed diagnosis of appendicitis often involved children who presented with milder symptoms, and the delays frequently led to worse outcomes. Additionally, many of the cases were at least possibly prevented and the fact that many of the case patients did not receive indicated imaging indicates that a push to improve rates of indicated imaging would prevent delayed diagnosis for some children.

1.Michelson K, Reeves S, Grubenhoff J, et al. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. 

. 2021;4(8):e2122248. doi:10.1001/jamanetworkopen.2021.22248

Not all cases of appendicitis are the same. What leads to delays in diagnosing it and are those delays preventable?

Delays in appendicitis diagnosis: Causes and outcomes   

The European Commission has granted an expanded approval to ravulizumab-cwvz (Ultomiris) to include children with a body weight of at least 10 kg, as well as adolescents, with paroxysmal nocturnal hemoglobinuria (PNH).1

The approval is based on interim findings from a phase 3 trial (NCT03406507), in which the long-acting C5 complement inhibitor demonstrated efficacy and safety in the pediatric and adolescent patient population (n = 12) with PNH. Specifically, results showed that ravulizumab achieves complete C5 complement inhibition through 26 weeks in children and adolescents up to 18 years old.

In July 2021, the European Medicines Agency’s Committee for Medicinal Products for Human Use recommended the expanded indication for ravulizumab based on these data. In June 2021, the 

FDA granted an expanded approval for ravulizumab

 in the pediatric and adolescent patient population with PNH.

“PNH is a devastating disease, and [ravulizumab] provides an advancement for pediatric patients in the EU with an established safety and efficacy profile,” said Austin Kulasekararaj, MD, of King’s College Hospital, in London, United Kingdom. “By requiring fewer infusions each year than [eculizumab], [ravulizumab] may reduce the need for these young patients to miss school to receive treatment.”

PNH is a rare and severe blood disorder in which destruction of red blood cells causes thrombosis and leads to organ damage and potentially premature death. Ravulizumab initially received approval in the European Union in 2019 for the treatment of adult patients with PNH.

The interim findings from the multicenter, single-arm, open-label, phase 3 trial were presented during the 2021 European Hematology Association Congress.2 The study enrolled patients with complement inhibitor–naïve and eculizumab (Soliris)-experienced pediatric patients younger than 18 years old with PNH, across 9 sites in 6 countries.

The complement inhibitor–naïve patients were treated with a weight-based loading dose of ravulizumab on day 1, followed by a weight-based maintenance dose on day 15, then once every 8 weeks. For patients who switched from eculizumab, ravulizumab was given on day 1, 2 weeks following the last eculizumab dose.

Primary end points of the trial were ravulizumab maximum and trough serum concentration (Cmax, Ctrough), accumulation ratio, and change in free C5 concentration. Secondary outcome measures were percentage change in lactate dehydrogenase (LDH) from baseline, transfusion avoidance (TA), breakthrough hemolysis (BTH) and hemoglobin stabilization (Hgb-S).

Treatment-emergent adverse events (TEAE) and serious adverse events (SAE) were also evaluated.

In the interim analysis (n = 12), 4 patients were complement inhibitor–naïve, and 10 (83.3%) patients were at least 12 years old; the median age at the first ravulizumab infusion was 15.0 years (range, 9-17).

Data showed that the steady-state therapeutic serum concentrations were immediately achieved after the first dose of ravulizumab and were maintained throughout the primary evaluation period; there was no evidence of accumulation (mean [SD] Cmax and Ctrough accumulation ratios of 1.1 [0.1] and 1.1 [0.2], respectively).

Additionally, complete terminal complement inhibition was reached by the end of first ravulizumab infusion (defined as mean serum free C5 concentration < 0.5 μg/mL) and was sustained through day 183 in all patients.

The mean percentage change in LDH was –42.1% (59.0) in the patients who were complement inhibitor naïve; in the eculizumab-experienced patients, this remained stable at +4.65% (44.7). Ten patients (83.3%) achieved TA, 8 (66.7%) achieved Hgb-S, and 0 experienced BTH.

Regarding safety, 10 patients experienced TEAEs, the most frequent of which were abdominal pain and nasopharyngitis. However, no meningococcal infections occurred, nor any deaths or discontinuations due to these events. At least 1 SAE occurred in 3 patients, none of which were related to treatment.

“This approval of Ultomiris reflects our ongoing commitment to delivering new treatments that can make a meaningful difference in patients’ lives,” said Marc Dunoyer, chief executive officer, Alexion. “Ultomiris has become the standard of care for the treatment of adults with PNH and we will make it available to this younger patient population as soon as possible.”

Ravulizumab is administered every 4 or 8 weeks, depending on body weight, following a loading dose.

For more on the American Cancer Society, click here.

Ultomiris approved in the EU for children and adolescents with paroxysmal nocturnal haemoglobinuria. News release. AstraZeneca. September 3, 2021. Accessed September 3, 2021. https://bit.ly/3n0NHpe

Kulagin A, Chonat S, Maschan A, et al. Pharmacokinetics, pharmacodynamics, efficacy and safety of ravulizumab in children and adolescents with paroxysmal nocturnal hemoglobinuria: interim analysis of a phase 3, open-label study. Presented at: 2021 European Hematology Association Congress; June 9-17, 2021; virtual. Abstract EP590.

The European Commission has granted an expanded approval to ravulizumab-cwvz to include children with a body weight of at least 10 kg, as well as adolescents, with paroxysmal nocturnal hemoglobinuria.

Approval in Paroxysmal Nocturnal Hemoglobinuria With Pediatric Indication

Bernard A Cohen, MD, is the section editor for Dermcase and professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

You are called to the emergency department to evaluate a healthy 9-day-old girl with erosions near her eyes, nose, and skin creases on the arm. She also has a positive Nikolsky sign (Figures A, B). The newborn is crying and uncomfortable, but is still feeding well. Upon examination, she is red from head to toe and has widespread erosions and crusting. The patient is afebrile with clear mucous membranes. 

Diagnosis: Staphylococcal scaled skin syndrome (SSSS)

Differential diagnosisfor diffuse erythema

Given these clinical skin findings, initial differential diagnoses include Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and bullous impetigo. A history of drug intake or viral infection typically precedes SJS/TEN.

 Additionally, SJS/TEN involves the mucous membranes of the conjunctiva, mouth, trachea, esophagus, anus, and genitalia.

 Bullous impetigo is characterized by small superficial blistering lesions with expanding crusts that are localized to the areas of skin infection.

Pemphigus foliaceus (PF) is rare in children but presents with similar superficial blisters as seen in staphylococcal scalded skin syndrome (SSSS). The adhesion molecule desmoglein-1 in the superficial epidermis is the target of both the autoantibodies in PF and SSSS toxins.

 PF can be confirmed with an immunochemical study to detect the presence of skin autoantibodies.

A hot water burn is another differential to be considered given the reddening, blistering, and sloughing of the skin.

SSSS is a reportedly rare, but likely more common than described, exfoliative disease of the skin mediated by epidermolytic toxins A and B produced by 

 The disease predominantly occurs in neonates of 3 to 15 days of age, children aged younger than 5 years, and adults with various comorbidities.

 Children are at greater risk due to their immature renal system and lack of immunity.

 In young children, the lack of prior exposure to SSSS-produced toxins triggers the development of anti- bodies to the causative agents, which protects against recurrence of SSSS in healthy patients. However, on first exposure, the toxins bind to and disrupt the adhesion molecule desmoglein-1 that is present in keratinized skin, but not in the mucous membranes. Be- tween 2010 and 2014, SSSS incidence increased 81% among infants younger than 1 year.

Key clinical features of SSSS include a brief prodromal phase where there may be fever and/or irritability, followed by diffuse erythema with superficial blistering and crusting that tends to be most prominent in areas of skin rubbing, such as the mucocutaneous junction and skin creases. Skin appears reddish and scalded after blisters rupture, and the Nikolsky sign (the easy separation of skin layers upon horizontal pressure to the skin) is present.

 Diagnosis of SSSS can be reached clinically and confirmed with bacterial culture. If in doubt, SSSS can be confirmed via skin biopsy, which shows superficial subgranular intraepidermal cleavage without necrosis.

Treatment of SSSS consists of antistaphylococcal antibiotics, temperature regulation, maintaining fluid and electrolyte balance, and skin care. SSSS-associated strains of 

 are usually methicillin-sensitive, so penicillinase-resistant beta-lactams, or cephalosporins, are favored for empiric management of SSSS.

 Vancomycin can be considered if a patient fails to improve following several days of treatment and methicillin-resistant strains of 

Clindamycin, a ribosomal inhibitor, is often recommended as a first-line agent to decrease SSSS toxin production, but up to 50% or more of triggering organisms may be resistant to clindamycin, and toxin binding may already be maximized at the time of diagnosis.

Thick moisturizers are important to protect the skin and decrease pain.

 In particular, moisturizers for the lips, which usually become crusty and painful, are essential to help with continued feeding in infants as their oral cavity remains unaffected by SSSS.

There is not an identifiable primary infection in many children with SSSS, but colonization can be demonstrated by obtaining bacterial cultures from sites of colonization, such as the medial canthi, nasopharynx, moist umbilical cord, and diaper area.

The patient was diagnosed with SSSS and treated with parenteral ceftriaxone and clindamycin. Bacterial cultures from her nares grew MRSA and the clindamycin was discontinued. The rash improved dramatically over the subsequent 36 hours followed by diffuse desquamation. The patient was discharged from the ICU 2 days later, on oral cephalexin.

1. Meshram GG, Kaur N, Hura KS. Staphylococcal scalded skin syndrome: A pediatric dermatology case report. 

. 2018;6:2050313X17750890. doi:10.1177/2050313X17750890

2. Lepe K, Yarrarapu SNS, Zito PM. Pemphigus foliaceus

 StatPearls; 2021. Accessed August 5, 2021. 

https://www.ncbi.nlm.nih.gov/books/NBK499829/

3. Ross A, Shoff HW. Staphylococcal scalded skin syndrome

 StatPearls; 2020. Accessed August 5, 2021. 

https://www.ncbi.nlm.nih.gov/books/NBK448135/

4. Wang Z, Feig JL, Mannschreck DB, Cohen BA. Antibiotic sensitivity and clinical outcomes in staphylococcal scalded skin syndrome. 

. 2020;37(1):222-223. doi:10.1111/pde.14014

A healthy 9-day-old girl presents with erosions near her eyes, nose, and skin creases on the arm as well as a positive Nikolsky sign. What's the diagnosis?

Diffuse erythematous rash in a healthy, afebrile infant

Today, Pfizer-BioNTech, the first pharmaceutical company granted Emergency Use Authorization for a COVID-19 vaccine for those aged 16 years and older, announced that it will be submitting data to the US Food and Drug Administration (FDA) on their COVID-19 vaccine trials for children aged 5 to 11 years by early October. In subsequent weeks, it will be submitting data for children aged 6 months to 5 years old.

As a result, Anthony S. Fauci, MD, the Director of the National Institute of Allergy and Infectious Disease, says that the FDA could authorize shots for this next group of school-aged children (5 to 11 years) as soon as mid-October.

"I believe it will work out this way, that by the time we get to the mid-fall, October or so, that we will have the capability of giving vaccines [to these younger children]," he said earlier today.

As of this writing, less than 40% of children aged 12 to 17 years are fully vaccinated, with children making up nearly 30% of new COVID-19 cases last week alone.

1. Percent of people fully vaccinated and cases per 100,000 population, by age, United States. Centers for Disease Control and Prevention. Accessed September 14, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/09102021/images/intro_09102021.jpg?_=14890?noicon

Anthony S. Fauci, MD, Director of the National Institute of Allergy and Infectious Disease, reveals when he believes a COVID-19 vaccine for children aged less than 12 years will be available.

Dr. Anthony Fauci discusses timeline for COVID-19 vaccines for young children

Although it remains illegal on the federal level, medical marijuana, to date, is legal in 36 states with recreational use legal in 18. Many states where marijuana hasn’t been legalized have upcoming ballot measures over the next 2 years on the subject. With this rapid increase in legalization, pediatric organizations such as the American Academy of Pediatrics have worried that this might encourage children and teenagers to use the substance, which, for developing brains, can negatively impact areas in the prefrontal cortex. A 

 that used data from the Youth Risk Behavior Survey assessed whether those concerns have a factual basis.

The investigators used data from the Youth Risk Behavior Survey for the period 1993-2019. Data on pre- and post-recreational marijuana laws were available for 10 states. Seven states had more than 1 wave of post-recreational marijuana law data and were also able to provide data for before and after the start of dispensary sales.

The average age of the respondent was 15.9 years. The cohort skewed slightly more female (51.4%)as well as non-Hispanic White (57.6%). Based on the pooled data, the adoption of recreational marijuana laws was not linked to either frequent marijuana use (odds ratio [OR], 0.98; 95% CI, 0.90-1.07) or current marijuana use (OR, 1.00; 95% CI, 0.92-1.10). Furthermore, the adoption of medical marijuana laws was tied to a 6% decrease in the odds of current marijuana use (OR, 0.94; 95% CI, 0.89-0.98) and a 7% decrease in the odds of frequent use (OR, 0.93; 95% CI, 0.87-0.99), in fully adjusted models. The link between the first recreational dispensary and marijuana use was considered qualitatively similar. Two or more years after the adoption of recreational marijuana laws, a decrease in marijuana use was noted (OR, 0.85; 95% CI, 0.76, 0.95).

The investigators concluded that there appears to be little connection between either recreation or medical marijuana laws and increased marijuana use in children and adolescents, with the link between recreational laws and marijuana use essentially equaling zero. They did note that recreational marijuana laws are a fairly new occurrence and with more data, firmer conclusions can be drawn about whether a relationship exists between the legalization of recreational marijuana and adolescent marijuana use.

1. Anderson D, Rees D, Sabia J, Safford S. Association of marijuana legalization with marijuana use among US high school students, 1993-2019. 

. 2021;4(9):e2124638. doi:10.1001/jamanetworkopen.2021.24638

A major worry with marijuana legalization, whether medical or recreational, has been that it would increase adolescent use of the substance. Has this concern been proven true in states that have legalized?

Does legalization of marijuana lead to adolescent use?

There are many things that can have an effect on a children’s ability to learn. Uncorrected vision issues are one potential problem. A 

 run in a school system assessed whether a school-based screening plan led to improvements in academic achievement.

Investigators ran a cluster randomize clinical trial in the Baltimore City public school district during the school years from 2016 to 2019 for grades 3 through 7. Schools that chose to participate were randomized 1:1:1 to receive eye examinations and eyeglasses during 1 of 3 school years: 2016-2017, 2017-2018, and 2018-2019. Academic achievement was defined by the difference in the scores on the i-Ready or Partnership for Assessment of Readiness for College and Careers tests on reading and mathematics, with the 1 year impact of the intervention being the primary endpoint and 2 year impact, as the secondary endpoint.

There were 2304 students included in the study who had an average age of 9.4 years. Most of the students were either Black (1789) or Hispanic (388). Additionally, 406 students were a part of the special education program. Overall, there was a positive 1-year impact (effect size [ES], 0.09; 

 = .02) seen with the i-Ready reading test during school year 2016-2017. Furthermore, improvement was seen in female students (ES, 0.15; 

 < .001), those in special education (ES, 0.25; 

 < .001), and students who performed in the lowest quartile at baseline (ES, 0.28; 

 < .001) on i-Ready reading and among students in elementary grades on i-Ready mathematics (ES, 0.03; 

 < .001) during school year 2016-2017. However, the program did not appear to affect performance on Assessment of Readiness for College and Careers testing, nor was a sustained impact after 2 years noted.

Overall, children in grades 3 through 7 who were given vision screening and eyeglasses through a program at the school attained better reading scores. Additionally, academic achievement improved over the course of 1 year, but a sustained impact was not seen following 2 years.

1. Neitzel A, Wolf B, Guo X, et al. Effect of a randomized interventional school-based vision program on academic performance of students in grades 3 to 7. 

. September 9, 2021. Epub ahead of print. doi:10.1001/jamaophthalmol.2021.3544

Uncorrected vision problems can create learning difficulties in children. Here’s how a school-based vision program might help improve academic success.

Improving academic achievement with school-based vision programs

This article will compare several Clinical Laboratory Improvement Amendments (CLIA) 88-waived COVID-19 nucleic acid amplification tests (NAATs) and antigen-based assays that can provide a diagnosis of COVID-19 before a patient leaves your office. We will also discuss how best to interpret results in relation to symptom onset and history of COVID-19 exposure. Note that we will not discuss COVID-19 antibody tests in this review.

COVID-19 point-of-care assays in perspective

One needs to understand the transmission of SARS- CoV-2 infections, as well as the concept of “viral load” to put COVID-19 point-of-care-tests (POCTs) in perspective.

The incubation period for COVID-19 ranges from 2 to 14 days following exposure, with most cases showing symptoms approximately 5 days after exposure. Individuals are most contagious just prior to or just after symptom onset.

A look at the top COVID-19 nucleic-acid amplification tests and antigen-based assays.