Call for Papers from Dr. Tina Tan

Dr. Jellinek is Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston, and Chief Executive Officer, Community Network, Lahey Health System, Burlington, Massachusetts.

As the weather gets warmer and we are increasingly liberated from COVID-19 constraints, accident prevention should become a high priority. As pediatricians, we appropriately focus on physical measures like helmets for biking or skateboarding, seat belts when in cars, and self-locking fences and gates around pools. Less often do we consider psychosocial issues that could significantly affect the risk for injury from accidents.

For younger children, drowning (about 1000 deaths per year) and unintentional gunshots (about 3000 firearm-related injuries) are the most common accidents.

 Both types of events happen quickly. Pools should have proper fences and gates. Guns should have trigger locks with ammunition stored and locked in a separate site. In addition, pediatricians should ask about potential stressors that could distract parents. Are the parents supervising several young children at the same time? Is there an elderly or ill parent who needs constant attention in the home? Is there family conflict that has resulted in distractions? Is there substance abuse, especially alcohol, that has interfered with childcare? These questions can seem hard to ask, but if, for example, the pediatrician starts by inquiring about access to a pool and then notes the dangers of drowning, these questions will be seen as caring and not critical.

Given an adolescent’s less-developed sense of judgment and often heightened self-confidence, teenagers don’t often stop to ask, “should I take this risk?” Children and adolescents with short attention spans, impulsivity, and depression are at increased risk, because these conditions further impair judgment and result in less consideration about safety. Pediatricians can assess a teenager’s behavior and judgment, and then have a frank conversation about potential decisions that youth may have to make. What kind of dangerous behaviors have they seen among peers? How do they decide how much to drink at a party? How rigorous are they about drinking and being a passenger or driving themselves? Will their friends watch out for them? Do they have good judgment? If they tend toward depression, do they ever think about taking a risk and not really caring about the consequences? Of course, parents have the major role in accident prevention. Pediatricians can ask how parents see their children reacting to safety measures. Do they accept seat belts and helmets, and how do their children assess risks? Have parents reviewed various scenarios for when their children and teenagers are on their own, such as with friends in a park, at a pool, at a party? Have there been forthright conversations about being vulnerable when drunk and how parents will react to a call for help if that call avoids a dangerous situation? What kind of risks did the parents take as teenagers? What behaviors do they demonstrate with alcohol or when driving? What parents do as role models far outweighs what they say.

Summer is a good time to prioritize accident prevention. Send out some information electronically prior to a visit, have some materials in the waiting room, and pick a question or 2 to ask during visits with your patients as the weather gets warmer.

1. Brady United. Key statistics. Accessed May 1, 2021. https:

Articles

With the joy of summer and easing of some COVID-19 restrictions, children and families are eager to be outdoors and active. Sadly, accidents, many of which are preventable, are a leading cause of morbidity and mortality in children and teenagers.

Preventing summer accidents

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

The seasonal influenza vaccination is recommended for expectant mothers to reduce the amount of influenza in both the mothers and newborns. There’s been little confirmation on whether this season flu vaccine in pregnancy is linked to adverse childhood health outcomes. A

The investigators used a birth registry that was linked to health administrative data. It included all live births in Nova Scotia, Canada that occurred between October 1, 2020, and March 31, 2014. Follow-up through March 2016 was included. The outcomes looked for included nonspecific (eg, urgent or inpatient health care utilization), non–immune-related (eg, neoplasms, sensory impairment), and immune-related (eg, asthma, infections), found through emergency department and hospitalization databases.

From a pool of 28,255 children born in the province, 10,227 children were born to mothers who had been given a seasonal vaccination during pregnancy. Over the course of follow-up, which was an average of 3.6 years, the investigators found no significant link between maternal vaccination and neoplasms (incidence rate, 0.32 vs 0.26 per 1000 person-years; difference, 0.06 per 1000 person-years [95% CI, −0.16 to 0.28]; adjusted hazard ratio [HR], 1.26 [95% CI, 0.57 to 2.78]), sensory impairment (incidence rate, 0.80 vs 0.97 per 1000 person-years; difference, −0.17 per 1000 person-years [95% CI, −0.54 to 0.21]; adjusted HR, 0.82 [95% CI, 0.49 to 1.37]), and childhood asthma (incidence rate, 3.0 vs 2.5 per 1000 person-years; difference, 0.53 per 1000 person-years [95% CI, −0.15 to 1.21]; adjusted HR, 1.22 [95% CI, 0.94 to 1.59]). Additionally, there was no significant link seen between maternal influenza vaccination in pregnancy and urgent and inpatient health services utilization (incidence rate, 511.7 vs 477.8 per 1000 person-years; difference, 33.9 per 1000 person-years [95% CI, 24.9 to 42.9]; adjusted incidence rate ratios [IRR], 1.05 [95% CI, 0.99 to 1.16]) and infections in early childhood (incidence rate, 184.6 vs 179.1 per 1000 person-years; difference, 5.44 per 1000 person-years [95% CI, 0.01 to 10.9]; adjusted IRR, 1.07 [95% CI, 0.99 to 1.15]).

The investigators concluded that there were no significant links between a mother’s influenza vaccination during pregnancy and an increased risk of adverse health outcomes in the offspring. The findings ensure that clinicians can continue to recommend the influenza vaccine in pregnancy to provide safe protection for both mother and newborn.

1. Mehrabadi A, Dodds L, MacDonald N, et al. Association of maternal influenza vaccination during pregnancy with early childhood health outcomes. 

. 2021;325(22):2285. doi:10.1001/jama.2021.6778

Many pregnant women are given the season influenza vaccination to provide protection for both mother and child. A study examines whether this vaccination is linked to adverse health outcomes in childhood.

Do flu shots during pregnancy lead to adverse childhood health outcomes?

Illuminating the gender-expansive pathway

A new report provides insight into the path of gender-expansive behavior to gender dysphoria and gender-affirming hormonal treatment.

Malnutrition signs aren’t limited to the scale

There are several indicators of malnutrition—even for children with normal growth.

Examining the severity of bronchopulmonary dysplasia in very preterm infants

A report offers the first epidemiological data that applied new criteria for bronchopulmonary dysplasia.

The pediatric provider plays a role in supporting sexual minority and gender-diverse youth.

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

In case you missed it: June 7 to June 11

 an indication expansion in pediatrics for Epclusa® (sofosbuvir/velpatasvir), which is a treatment for chronic hepatitis C virus. The approval allows the medication from Gilead Sciences, Inc. to be used in children as young as 3 years of age, with no regard for hepatitis C virus genotype or liver disease severity. The approval was for 2 strength oral pellet formulations of Epclusa (sofosbuvir 200 mg/velpatasvir 50 mg and sofosbuvir 150 mg/velpatasvir 37.5 mg) for use in children who are not able to swallow tablets.

A Phase 2, open-label clinical trial was the basis for the approval. The trial include 41 children aged 3 years to less than 6 years who were treated with sofosbuvir/velpatasvir for 12 weeks. Following the treatment course, the medication had a sustained virologic response or cure rate of 83% among all patients; 88% in children with a hepatitis C virus genotype 1; 50% in children with hepatitis C virus genotype 2; and 100% in children with hepatitis C virus genotype 3 and hepatitis C virus genotype 4. Among the children who did not achieve cure, all discontinued the treatment 1 to 20 days following the start of treatment.

Safety was overall consistent with what was seen with adults. Vomiting was reported in 15% of the subjects and 10% of the children had product use issues. They were rated as mild.

1.Gilead Sciences, Inc. U.S. Food and Drug Administration approves new formulation of Epclusa®, expanding pediatric indication to treat children ages 3 and older with chronic hepatitis C. Published June 10, 2021. Accessed June 11, 2021.

 https://www.gilead.com/news-and-press/press-room/press-releases/2021/6/us-food-and-drug-administration-approves-new-formulation-of-epclusa-expanding-pediatric-indication-to-treat-children-ages-3-and-older-with-chronic

The US Food and Drug Administration (FDA) approved expanded pediatric indication for Epclusa® (sofosbuvir/velpatasvir) to treat chronic hepatitis C virus.

 FDA approves oral pellet formulation of Epclusa®

You are asked to evaluate asymptomatic toenail changes in a 13-year-old girl whose great toenails have become yellow, thickened, ridged, and crusted proximally on the left over the last 8 months. What’s the diagnosis?

Diagnosis: Congenital malalignment syndrome

Congenital malalignment syndrome or congenital malalignment of the great toes.

Congenital malalignment syndrome is a dystrophic nail disorder caused by the lateral rotation of the nail matrix. The malalignment results in altered growth of the nail plate that is not directed along the major axis of the distal phalanx.

 Clinical appearance presents as lateral deviation of the nail plate, nail plate thickening, nail discoloration (brown, black, green-brown, yellow), transverse grooves across the nail, and frequently only involving the great toes.

Complications of the disorder include acute/chronic paronychia, onychogryphosis (hypertrophy of nail), onycholysis (detachment of the nail from bed), onychomadesis (shedding of a large portion of the nail), onychocryptosis (ingrown nail), hyperkeratosis (increased scaling of the nail bed), brachyonychia (short nail), and discoloration of the nail plate.1-3 Variations in the condition include medial deviation, the involvement of other toes and fingers, and single toe involvement.

The disorder is generally present at the time of birth. However, in individuals with minimal deviation, clinical manifestations may not be apparent until a child is older or begins to experience repetitive microtraumas or mechanical stress to the toenail from tight shoes, activities, and sports.

The etiology and pathogenesis of congenital malalignment are debated in the literature. Etiology is thought to be due to autosomal dominant genetic factors, extrinsic factors including constriction of toes by amniotic bands, increased intrauterine pressure, vascular abnormalities during fetal life, or a combination of genetically determined malalignment plus superimposed cumulative effects of postnatal trauma.

 Pathological features are discussed as increased tension of the extensor tendon of the hallux and desynchronization in growth between the nail and the distal phalanx of the hallux, resulting in larger nail plates.

The Table shows that a differential diagnosis would include onychomycosis, connective tissue disorders, nail apparatus tumors, and dermatoses with nail involvement (psoriasis, lichen, and ectodermal dysplasia).

The treatment of congenital malalignment is based on the degree of deviation. Spontaneous improvement may occur in half of patients before age 10 years.

 Conservative treatment in an individual with minimal deviation involves managing complication and wearing proper-fitting, comfortable footwear.

 Severe deviations may call for surgery to align the nail matrix and nail plate, and positional correction or elongation of the extensor tendon of the hallux.

 Nail matrixectomy would be an option for those who would tolerate the cosmetic deficit.

There was no family history of any nail disorder in this family. The patient was not symptomatic, and subsequently, the patient and mother were educated on the diagnosis and treatment. It was recommended that she switch to wider, comfortable footwear and avoid high-heeled shoes. Complications such as fungal and bacterial infections can be treated as they arise.

A dermatology referral was offered for possible nail matrixectomy, or nail matrix and nail plate realignment. The patient was educated that spontaneous resolution sometimes happens but typically occurs in those younger than 10 years. She has had no subsequent follow-up visits for this specific issue.

Catalfo P, Musumeci ML, Lacarrubba F, Dinotta F, Micali G. Congenital malalignment of the great toenails: a review. 

Batalla A, Curto JR. Congenital malalignment of the great toenail. Report of two cases. 

Pollack K, Zlotoff B, Wilson B. Hyperkeratosis and discoloration of the toenails in an 8-year old. 

Ҫayirli M, Parlak N, Parlak A, Ӧzenҫ S. Congenital malalignment of the great toenails. 

. 2016;10(1):16101l1. doi:10.6003/jtad.16101I1

Decker A, Scher RK, Avarbock A. Acquired congenital malalignment of the great toenails. 

A 13-year-old girl presents with great toenails have become yellow, thickened, ridged, and crusted proximally on the left over the last 8 months. 

Congenital malalignment syndrome

Acute respiratory illness is a common reason for a child to visit the emergency department. Such illnesses also have a history of being treated with antibiotics, despite many of them being viral. An 

examined whether the use of rapid respiratory testing in children who present with acute respiratory illness at an emergency department could lead to a decrease in antibiotic use.

The investigators performed a randomized clinical trial in children aged 1 month to 18 years who presented to an emergency department with an influenza-like illness between December 2018 and November 2019. Each child had a nasopharyngeal swab for rapid respiratory pathogen testing and were then randomized 1:1 to the intervention or control group, which involved results from the testing not given, routine care. The results of the test were available 45 minutes later.

There were a total of 931 emergency department visits, 452 in the intervention group and 456 in the control group. A positive result came back for 795 for rapid respiratory pathogen tests. The most common pathogens identified were enterovirus/rhinovirus (n=295), influenza (n=180), respiratory syncytial virus (n=162), and adenovirus (n=115) (children may have had ≥1 pathogen). The median age of the children was 2.1 years. Many of the patients were boys (509 children), Hispanic (478 children), had government insurance (688 children), and had high-risk medical conditions (314 children). In intention-to-treat analyses, the children in the intervention group were more likely to be given antibiotics (relative risk [RR], 1.3; 95% CI, 1.0-1.7), and have a diagnosis that would have an indication for antibiotics (risk difference, 8.6; 95% CI, 3.2-13.8). In adjusted intention-to-treat analysis, children in the intervention group were more likely to have longer emergency department length of stay (RR, 1.6 95% CI, 1.5-1.7), have higher hospitalization rates (RR, 2.0; 95% CI, 1.5-2.7), and be given appropriate antiviral medication (RR, 2.5; 95% CI, 1.5-4.2), when compared to the control group.

The investigators concluded that the use of rapid respiratory pathogen testing in the emergency department when a child presents with influenza-like illness was noted linked to a decrease in antibiotic prescribing. Overall, the greatest effect found was appropriate antiviral use, which offers support for the potential of rapid molecular influenza testing.

1. Rao S, Lamb M, Moss A, et al. Effect of rapid respiratory virus testing on antibiotic prescribing among children presenting to the emergency department with acute respiratory illness. 

. 2021;4(6):e2111836. doi:10.1001/jamanetworkopen.2021.11836

In the case of acute respiratory illness, an investigation looks into whether rapid testing could reduce the antibiotic use.

Could rapid testing in the emergency department impact antibiotic use?

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

Malnutrition might seem like an easy problem to diagnose. Scales and growth projections can be used to discern whether a child is growing as expected. However, there are also subtle signs of malnutrition to watch for during a visit.

“Every pediatrician should be thinking along a food group line,” says Praveen Sundaraj Goday, MD, a pediatric gastroenterologist and director of nutrition at Children’s Wisconsin in Milwaukee. Goday also serves on the American Academy of Pediatrics’ Committee on Nutrition.

Even children who are obese or overweight can suffer from poor nutrition. Others eat no fruits or vegetables but still meet growth and weight goals for their age. Pediatricians should be asking questions about diet at well visits, specifically focusing on the food groups from which the child eats and whether any special diet is being followed.

There are ways to have a child on a good vegetarian diet, Goday notes, but the pediatrician should still be aware of these special diets or any restrictions. The child may appear well nourished but still require supplementation with pediatric multivitamins, he says.

For detecting signs of malnutrition outside of the scale or assessment questions, Goday says there is much one can tell from a child’s appearance. Signs of malnutrition could include the following:

“I think focusing on whether the child is eating consistently from all food groups is key,” Goday says. “If the child is, that’s a good sign. If not, the pediatrician should be questioning why.”

The American Academy of Pediatrics offers guidelines

 to help pediatricians counsel parents on appropriate micronutrient requirements, especially in the first few years of life when neurodevelopment is critical.

Although in some cases, malnutrition could be an adverse effect of food choices or availability, pediatricians also need to understand when other factors are contributing to malnutrition. In most cases, regular nausea or vomiting is a red flag in children with gastrointestinal (GI) disorders, Goday says. “It would be rare not to have those. These could signal a problem,” Goday says.

Daily or frequent vomiting is usually because of a GI mucosal problem in the stomach or esophagus, Goday says, adding that these are the most common GI problems related to malnutrition in children. When frequent diarrhea is the complaint, there are tests that can check for lactose intolerance and other conditions that might result in malabsorption of sugars. Pancreatic insufficiency is also a cause of malabsorption, Goday says.

Inflammatory issues like eosinophilic esophagitis and even mental health or behavioral conditions can also lead to malnutrition. Mental health and behavioral conditions are not necessarily caused by a nutritional issue but rather a behavioral issue that affects a child’s ability to get proper nutrition. Autism is commonly linked to issues involving poor nutrition. “These 2 go together, but the reason is that the autism is causing feeding problems and not the other way around,” Goday says.

He recommends that children who are extremely picky eaters be evaluated for underlying neurobehavioral conditions. They may even require referral to speech behavioral therapists or other specialists.

Although pediatricians should be vigilant when it comes to assessing diet quality and eating habits of their patients, problems with nausea, vomiting, or diarrhea are usually reason for referral to a specialist. Pediatricians must be aware of problems not explained clearly by behavior. These are often associated with allergies or asthma.

1. Schwarzenberg JS, Georgieff MK. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. 

2018;141(2):e20173716. doi:10.1542/peds.2017-3716

More than 90% of parents of teenagers with severe acne who participated in a recent survey sponsored by Sun Pharmaceuticals Industries in collaboration with the American Acne and Rosacea Society (AARS) said they were “very worried” about the harmful impact of the skin disease on their adolescent’s physical, mental, and social wellness.1 They also shared concerns about effects on their entire family, and lifelong physical scars.

The catalyst for the online survey, which was conducted October 29 through November 5, 2020, by Regina Corso Consulting from Sun Pharma, the AARS, and Hilary Baldwin, MD. “As dermatologists, we know [what our patients go through], but we never took a collective look into how that impacted their parents,” Baldwin told 

“Kids don’t live in a bubble, and their parents are dealing with them every single day and [going through it] right alongside them,” said Baldwin, medical director of the Acne Treatment and Research Center in Brooklyn, New York, and past president of the AARS. “So, with this survey we wanted to make sure to better understand how parents are feeling about the what their teenage children with severe acne are going through.”

Survey questions were informed by what Baldwin and colleagues hear in their practices, such as teens wanting to come home from school due to being bullied, not wanting to have their pictures taken, or quitting the sports they loved because the physical contact with other players would result in the nodules on their chest or their back popping and dripping blood onto their uniforms. Wrestlers and swimmers told Baldwin about dropping out of programs because of embarrassment when taking off their shirts. This sometimes led to college scholarships being deferred or lost.

“These are big picture changes,” she said. “Parents are suffering, some perhaps as much as their children, and it's time for people to recognize that.”

Although there were not many surprises for Baldwin among survey respondents (n = 250), she was interested to see that 55% of parents delaying visits to the dermatologist and starting more aggressive medication earlier. The message needs to get out that early effective therapy is paramount to a successful outcome, Baldwin said. One finding showed that 23% to 26% of parents allowed their adolescents with severe acne to use OTC medications exclusively and that 8% were not giving their adolescents any medication.

“Many people think OTC medications are good enough for severe acne. Once those products fail, parents are likely to turn to a dermatologist,” Baldwin said. “The biggest hurdle is not about seeking care, but about seeking appropriate care. Some parents fight the use of effective medications. They want natural products, but those products are just not going to cut the mustard with nodular or cystic acne.”

She advised working with parents to allow their teenagers to use medications they prefer for “a bit of time,” but advised patients and their families that these products may not achieve optimal outcomes. “Preplan every step,” she said. “Think about how those parents make decisions. Are they hands off? Helicopter parents? Did they drag their kids in kicking and screaming or did the teens instigate the office visit? Just keep in mind [that] you have to move fast. The longer it takes to get people on good aggressive therapy, the more likely they are to have physical and psychological scars.”

Adherence is another issue, “most often non-compliance is based on forgetfulness,” Baldwin noted, however, there sometimes is a control issue between parents wanting their child to take a medication and the child feeling pressured and, in turn, not adhering.

In some instances, nonadherence may stem from adverse effects of stronger medications. “We have many new toys that are an improvement over the choices that we had before,” Baldwin said. “New formulations for topical and oral medications as well as new active ingredients have resulted in improved tolerability.”

“At each visit, noncompliant behavior should be evaluated, but it is important for providers and parents not to be accusatory. The script needs to be about acknowledging that teens forget, they get tired, they don’t want to get up early, they don’t like the smell or taste of the medicine, or maybe they’re having adverse effects,” Baldwin said. “Then discuss ways to improve that.”

Based on first-hand experience with her own adolescents who had severe acne, Baldwin recommended associating taking the medication with a certain everyday activity. “My kids probably would not be at all happy if they heard me share this, but I taped the tube of medication to the refrigerator door handle,” she said. “The first thing my kids did when they came home from school was make a beeline for the refrigerator, and the rule was they didn’t open the refrigerator door until they applied their medicine. Put the medication between the salt and pepper shakers on the table or close to their toothbrush. Throw samples into their gym bags or jacket pockets—whatever improves their ability to remember to use it.”

To get adolescent patients and their parents on the same page, Baldwin recommended that ideally dermatologists allow 30 minutes to 1 hour for a new acne visit. “Talk about what acne is, why they have it, when it's going to get better or worse, what medications we have in general, what we're going to use for them, anticipated side effects and expectations for improvement,” she said.

She stressed the importance of matching the treatment plan to the patient’s preferences and lifestyle. “We need to learn a lot about our patients in that first visit, starting off with how much the acne bothers them. I ask on a scale of 1 to 10—1 being, ‘What acne?’ and 10 being, ‘Get this stuff off my face now’ just to find out what they’re going to be willing to do,” she said. “Somebody who's at 10 will do everything I ask them to do, I could throw 6 medications at them, and they'll use all 6, whereas somebody who's down at a 2 will not use anything.”

Other pertinent questions include whether the patient is a morning or an evening person, how frantic their mornings are, whether the gear they wear for sports has head straps, chin straps, or items that rub on their shoulders, what time they get home, and when they shower.

Although discussing the emotional and quality-of-life impact of this skin disease is vital, Baldwin advised postponing that discussion. “At the initial visit, the teenager doesn’t know me from Adam and doesn’t trust me. It’s not a time that he or she is likely to open up,” she said.

On the second or third visit, she suggested an open-ended statement such as, “This [severe acne] must make you very angry.” She cautioned against pushing adolescent patients to share their feelings if they are unwilling. “It’s often helpful to ask the parent to leave the room, especially with male teenaged patients,” she said. “Try to schedule a time, maybe via telehealth, to have a separate one-on-one with the parent to let them unload.”

Open-ended questions about how patients are dealing with acne or whether they’re being bullied can ease the conversation. “Dermatologists don’t have much time with each patient,” Baldwin said. “But we need to take the time to ask questions and listen to answers from teen patients with severe acne or their parents.”

Baldwin also advised having a trained therapist for referrals, “Sometimes the floodgates open, and I don’t have the time or expertise to close them,” she said. “Patients frequently decline to see a therapist because of their perceived stigma about ‘being crazy’. I explain to them that they’re going through an extremely hard time and the referral is just to give them someone to talk to.”

The survey found that 78% of parent respondents felt they were having deep conversations with their adolescents about the emotional aspect of acne. That wasn’t her experience, according to Baldwin.

“I have twin daughters, both of whom had acne, both of whom ultimately needed isotretinoin, and what I learned was that knowing when to speak and what to say was really difficult,” she said. “No matter what I said, it was the wrong thing and resulted in an argument. Often this occurred at breakfast, and they left for school on a bad note. I learned to say nothing—which was not easy. I learned to talk to them about their acne in a calm, quiet moment, perhaps on the weekend when nobody was mad at anyone.”

“Another lesson was to talk to them about their acne in a calm, quiet moment, perhaps on the weekend when nobody was mad at anyone,” Baldwin said. “It also helped to have little snippets of conversation, to just sort of drop a comment [such as], ‘Are you happy with your medications? Is there anything I can do to change them?’ I tried not to insert my experience as a teenager into the conversation as they didn’t appreciate me telling them how I handled acne at their age. I ended up telling them, ‘Talk to me if you want to or I’ll help you find someone else to talk to. You know I’m here and I’ll do whatever it takes.’ Then leave it alone.”

This article was originally published by Dermatology Times.

Baldwin is a paid consultant for Sun Pharma.

1. Parents are very worried about the effects of severe acne on their teenage children as reported in a new survey. Sun Pharmaceuticals in collaboration with the American Acne and Rosacea Society. News release. Sun Pharma. April 7, 2021. Accessed May 13, 2021. 

https://www.sunpharmaderm.com/pdf/Sun_Pharma_Acne_Survey_Press_Release.pdf

2. Parents: Your teen’s severe acne affects the whole family. Sun Pharma. Accessed May 11, 2021. 

https://www.sunpharmaderm.com/pdf/Sun_Pharma_Acne_Survey_Infographic.pdf

More than 90% of respondents to a recent survey expressed concern about acne’s effect on their adolescent’s mental health and social life.

Caregivers worry about impact of severe acne on teens

The dietary habits and patterns in childhood can have a lifelong impact on a person’s adiposity trajectory. An 

 looked at whether a diet that has ultraprocessed foods, which typically have additives as well as poor nutritional components, was tied to a worse adiposity trajectory.

The investigators performed a prospective birth cohort study that included children who had participated in the Avon Longitudinal Study of Parents and Children. The participants, who were 7 to 24 years of age at baseline, were followed up from September 1998 to October 2017. A 3-day food diary was used to note the baseline dietary intake data. A child’s consumption of ultraprocessed foods was calculated as a percent of contribution in total daily food intake and was then categorized in quintiles.

There were 9025 children who were followed up for a median of 10.2 years. At baseline, the average ultraprocessed food consumption was 23.2% (5.0%) in quintile 1, 34.7% (2.5%) in quintile 2, 43.4% (2.5%) in quintile 3, 52.7% (2.8%) in quintile 4, and 67.8% (8.1%) in quintile 5. The diets in quintile 1 mostly consisted of foods that were minimally processed such as water and tea (22.2%), milk and plain yogurt (20.2%), and fruit (6.0%), whereas the diets of children in quintile 5 included fruit-based beverages (22.2%), carbonated beverages (11.5%), ready-to-eat/heat foods (8.6%), and industrial-processed breads and buns (5.9%). Among the children in the highest quintiles, the trajectories of body mass index increased by an additional 0.06 (95% CI, 0.04-0.08) per year; fat mass index, by an additional 0.03 (95% CI, 0.01-0.05) per year; weight, by an additional 0.20 (95% CI, 0.11-0.28) kg per year; and waist circumference, by an additional 0.17 (95% CI, 0.11-0.22) cm per year, when compared to the lowest quintile people.

The investigators concluded that higher consumption of ultraprocessed foods appears to be liked to greater increase in adiposity. They believe that public health measures to promote minimally processed foods as well as discouraging ultraprocessed consumption should be created and clinicians should do the same in well-child visits.

1. Chang K, Khandpur N, Neri D, et al. Association between childhood consumption of ultraprocessed food and adiposity trajectories in the Avon longitudinal study of parents and children birth cohort. 

. June 14, 2021. Epub ahead of print. doi:10.1001/jamapediatrics.2021.1573

An investigation examines whether ultraprocessed foods are linked to worse adiposity trajectories than diets with less processed foods.

Impact of ultraprocessed foods on future adiposity

A 2-year-old girl presents to the emergency department (ED) with a 36-hour history of left shoulder redness and pain. She developed a fever 24 hours prior to presentation. She is restless, crying, and refusing to move her left shoulder. Mother reports that the patient was stung by a hornet on multiple areas of her left upper extremity when playing outside 10 days prior.

Mother notes that a day prior to presentation at the ED, the day care staff reported that patient seemed more irritable. Patient has a history of recurrent ear infections. The mother was concerned about another ear infection and had gone to the pediatrician, where patient received a diagnosis of otitis media and was prescribed cefdinir. There is no history of rash, weight loss, vomiting, diarrhea, or abdominal pain. Patient is up to date on immunizations.

She is alert and crying but easily consoled. Vital signs show a temperature of 37.8 °C (100 °F), heart rate of 146 beats/min, respiratory rate of 26 breaths/min, blood pressure at 98/67 mm Hg, and oxygen saturations 100% in room air. There is an area of erythema measuring about 1 by 3 cm over the left shoulder without swelling. She cries with pain at abduction, adduction, and rotation of the left shoulder. There is no swelling over the clavicular area and no tenderness on palpation. Elbow and wrist examination findings are normal. Her tympanic membranes are erythematous and show purulence. Her physical examination findings are normal.

In the ED, initial laboratory studies reveal a white blood cell (WBC) count of 20,980 with a neutrophil predominance, C-reactive protein (CRP) level of (12 mg /L), and erythrocyte sedimentation rate (ESR) of 28 mm/hr. Her chemistry panel results are normal. Left humerus and left shoulder radiograph results are normal. Results from ultrasonography of the left shoulder are negative for joint effusion. With persistence of left shoulder pain, elevated WBC with a neutrophil predominance, and mildly increased inflammatory markers, she is admitted to the hospital and further testing reveals the diagnosis.

The differential diagnosis for joint pain and fever includes infectious and noninfectious causes (Table 1). In the absence of trauma, considerations include cellulitis, septic arthritis (SA), osteomyelitis, and, less likely, transient synovitis.

The patient was started on clindamycin although radiographs were normal, which can be seen in early osteomyelitis. She received parenteral ketorolac for pain control. She continued to be febrile with a maximum recorded temperature of 39.4 °C (103 °F) while on admission and continued with pain and resistance to any movement of the left shoulder. An orthopedic surgeon was consulted, and magnetic resonance imaging (MRI) was obtained on the second day of admission because of persistent symptoms. MRI showed left shoulder joint effusion and mild synovitis with significant surrounding myositis (Figure). There was no evidence of osteomyelitis. Based on the imaging appearance alone, SA could not be excluded. Her blood culture did not grow any organism after 5 days.

SA is defined as infection of the joint space. In the United States, estimated incidence is approximately 3 to 4 per 100,000 children, with those aged younger than 5 years affected most frequently.

There is a higher prevalence in boys than girls

 and it can affect any major joint, with the hip and knee joints frequently involved.

SA can be caused by bacteria, viruses, mycobacteria, and fungi, with bacterial joint infections being the most common etiology.

 It is spread via hematogenous means, direct inoculation, or extension of a contiguous focus of infection. Hematogenous spread is said to account for most cases of bacterial arthritis.

 Approximately two-thirds of infections are caused by 

 followed by gram-negative bacilli and streptococci. 

, a gram-negative coccobacillus, has been identified in the younger age group (2 to 3 years). However, more recently, there has been an emergence of community-associated methicillin-resistant 

Patients classically present with acute onset of fever and joint pain. Swelling may or may not be present with limited range of motion of the affected joint. Other symptoms include malaise, poor appetite, and irritability, especially younger infants. A high index of suspicion for SA should be maintained in all children with acute onset of fever and joint pain suggested by limping or limited movement, even in the absence of other associated symptoms.

Laboratory findings in SA include elevated inflammatory markers (CRP, ESR) and elevated peripheral WBC.

 Elevated inflammatory markers have more negative than positive predictive value for SA.

 Blood cultures are positive in approximately 40% of cases. Additionally, joint/synovial fluid studies (WBC count, gram stain, and culture) are important in the diagnosis of SA, where synovial fluid WBC count of greater than 50,000 cells/­L with neutrophil predominance are usually seen.

 Culture of a bacterial pathogen from the synovial fluid confirms the diagnosis of SA. Kocher criteria (Table 2) can help differentiate between SA and transient synovitis in a case of nontraumatic painful hip in a child. Although first introduced in 1999, more recent studies have validated its continued usefulness in the evaluation of SA.

 Components of the Kocher criteria are: (1) walking or weight-bearing inability, (2) fever greater than 38.5 °C (101.3 °F), (3) ESR greater than 40 mm/hr, and (4) WBC greater than 12,000 cells/­L. A point is awarded for the presence of each criterion and is associated with a likelihood of child having SA. The likelihood of a child with no Kocher criteria having SA is 0.2%. This percentage increases with each additional point, up to 99% likelihood at 4 points.

Plain radiographs usually show negative findings in SA. Ultrasonography is helpful in detecting joint fluid, but the presence/absence of fluid is not specific for joint infection

 as was the case in this patient. Using MRI is extremely sensitive for the early detection of joint fluid

; however, it is not as readily available as ultrasonography. It is important to note that a diagnosis of probable SA can be made even if blood culture or synovial fluid culture do not isolate a bacterial pathogen or if other diagnoses are excluded and if the patient has characteristic clinical, laboratory, and radiographic features.

The mainstay of treatment for SA is joint drainage and antimicrobial therapy.

 Joint drainage can be accomplished through arthrotomy, arthroscopy, or needle aspiration. Antibiotics that cover for common pathogens should be instituted promptly.

 It is recommended that initial antibiotics be given parenterally when treating SA. The antibiotic of choice will usually depend on the severity of illness, local prevalence of CA-MRSA, the susceptibility of CA-MRSA isolates to clindamycin, and suspicion for other pathogens. Antibiotic options include cefazolin, clindamycin, nafcillin/oxacillin, and vancomycin with duration of treatment usually 2 to 3 weeks. Clinical improvement as well as improved inflammatory markers is typically expected within 3 to 5 days after instituting treatment.

Early diagnosis of SA and treatment are associated with improved outcome. Long-term complications of SA, especially with delayed treatment, include limited range of motion of the joint, limb-length discrepancy or angular deformities, especially if there is involvement of the growth plate, and avascular necrosis or pathologic fractures.

On receipt of MRI results, patient was taken to the operating room, where she had left shoulder aspiration, left shoulder open irrigation, and debridement. Cloudy fluid was identified at the glenohumeral joint and 2 milliliters of necessary purulent fluid was aspirated. The glenohumeral joint was then irrigated with normal saline. Joint aspirate was sent for cell count, gram stain, aerobic, anaerobic, and fungal cultures. Synovial fluid aspirate showed 79,500 cells/­L with neutrophil predominance at 96.7%. Gram stain showed moderate WBC but no organisms were seen and there was no growth on culture. She was continued on parenteral clindamycin. She was discharged on hospital day 5 with much improved range of motion of her left shoulder. She was transitioned to oral clindamycin and received a total of 3 weeks of antibiotic therapy. At her outpatient follow-up a week after discharge, she was using her left arm without any difficulty.

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5. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. 

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6. Tu J, Gowdie P, Cassar J, Craig S. Test characteristics of history, examination and investigations in the evaluation for septic arthritis in the child presenting with acute non-traumatic limp. A systematic review. 

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7. Levine MJ, McGuire KJ, McGowan KL, Flynn JM. Assessment of the test characteristics of
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9. Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML. Approach to septic arthritis. 

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11. Uzoigwe CE. Another look: is there a flaw to current hip septic arthritis diagnostic algorithms? 

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12. Nguyen JC, Lee KS, Thapa MM, Rosas HG. US evaluation of juvenile idiopathic arthritis and osteoarticular infection. 

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13. Manz N, Krieg AH, Heininger U, Ritz N. Evaluation of the current use of imaging modalities and pathogen detection in children with acute osteomyelitis and septic arthritis. 

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14. Saavedra-Lozano J, Falup-Pecurariu O, Faust SN, et al. Bone and joint infections. 

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17. Baghdadi T, Saberi S, Sobhani Eraghi A, Arabzadeh A, Mardookhpour S. Late sequelae of hip septic arthritis in children. 

A 2-year-old girl with a 36-hour history of left shoulder redness and pain. She developed a fever 24 hours prior to presentation. She was stung by a hornet on multiple areas of her left upper extremity 10 days earlier. What’s the diagnosis?

Shoulder pain following a hornet sting in a 2-year-old

Although adult COVID-19 cases have declined dramatically, with nationwide numbers hitting lows not seen since before the pandemic’s beginning in March 2020, the number of cases and hospitalizations for the disease in children continues to climb. This outbreak makes understanding what conditions are linked to severe illness more important than ever. A 

Investigators collected data from the Premier Healthcare Database Special COVID-19 Release, which had data from over 800 hospitals in the United States. They included patients aged 18 years and younger who had International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes of either U07.1 (COVID-19) or B97.29 (other coronavirus) at an emergency department or inpatient encounter from March 2020 to January 2021.

There were 43,655 patients aged 18 years and younger who had COVID-19; 12,491 of those patients had an underlying medical condition. Among the patients with an underlying medical condition, the most common diagnoses included were asthma (4416 [10.2%]), neurodevelopmental disorders (1690 [3.9%]), anxiety and fear-related disorders (1374 [3.2%]), depressive disorders (1209 [2.8%]), and obesity (1071 [2.5%]). The strongest risk factors for hospitalization were found with obesity (adjusted risk ratio [aRR], 3.07; 95% CI, 2.66-3.54) and type 1 diabetes (aRR, 4.60; 95% CI, 3.91-5.42). For severe illness, the strongest risk factors found were cardiac and circulatory congenital anomalies (aRR, 1.72; 95% CI, 1.48-1.99) as well as type 1 diabetes (aRR, 2.38; 95% CI, 2.06-2.76). In children aged younger than 2 years, prematurity was a noted risk factor for severe illness (aRR, 1.83; 95% CI, 1.47-2.29). Having a chronic or a complex chronic disease were also risk factors for severe illness , with aRRs of 1.95 (95% CI, 1.69-2.26) and 2.86 (95% CI, 2.47-3.32), respectively, and hospitalization, with aRRs of 2.91 (95% CI, 2.63-3.23) and 7.86 (95% CI, 6.91-8.95), respectively.

The investigators concluded that children with medical complexity as well as certain conditions such as obesity or cardiac and circulatory congenital anomalies had a higher risk of having severe COVID-19. For patients who have medically complex conditions or these underlying conditions, clinicians should consider cautious management and close observation when COVID-19 is suspected.

1. Kompaniyets L, Agathis N, Nelson J, et al. Underlying medical conditions associated with severe COVID-19 illness among children. 

. 2021;4(6):e2111182. doi:10.1001/jamanetworkopen.2021.11182

In adults, certain health conditions were linked to a greater risk of hospitalization and severe COVID-19 infection. A report examines whether this is true in the pediatric population.

Impact of underlying conditions on COVID-19 severity

A pediatrician and a mother share sobering lessons learned regarding water safety for children.

A look at what to expect from Contemporary Pediatrics this week.