Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN 

Drs Saporta-Keating and Nyquist’s article, 

 provides a detailed review of how scientists and health care providers have unraveled some of the complexities of the coronavirus disease 2019 (COVID-19) over the past 11 months. Much of what has been learned worldwide has been garnered from adult populations who were diagnosed with COVID-19. Seniors and vulnerable populations have suffered tremendously and have died in large numbers in the United States and worldwide. As we know, COVID-19 has adversely affected children who experienced multisystem inflammatory syndrome in children (MIS-C). International efforts to diagnose and treat MIS-C were presented as soon as the newly identified symptoms emerged, first in England, and then in New York City. I vividly recall listening to the first group of physicians from England and the United States discuss the presenting symptoms and the newly identified syndrome. As of this writing, some states that are surging with new adult cases are also reporting MIS-C cases in children. Some children diagnosed in April 2020 with MIS-C are currently experiencing the after effects of the MIS-C diagnosis and only time will tell how the overall health of these children may be affected.

There is hope as vaccines are administered

The US Food and Drug Administration’s (FDA) emergency authorization for 2 vaccines from Pfizer and Moderna represents hope and shines a light for all at the end of this dark tunnel. The remarkable safety and efficacy data for both of these vaccines and the potential for additional vaccine approvals, provides further support for hope. In addition, Pfizer and Moderna are planning clinical studies to investigate the safety and effectiveness of their vaccines in the pediatric population. All pediatric providers look forward to reading and reviewing the results of these studies. As we wait for these results, all pediatric providers can encourage parents and grandparents who are eligible to receive the vaccine to get vaccinated. Pediatric providers have a unique body of knowledge about vaccines, as we administer 23 vaccines to infants in the first 24 months of life, and then continue to administer vaccines into the adolescent and young adult years. We know and understand vaccine hesitancy and vaccine refusers. We are skilled communicators and can use this skill set to encourage all those eligible to take the vaccine.

The mental health and well-being of our pediatric and adolescent patients is and has been front and center throughout this pandemic. We cannot talk about COVID-19 without acknowledging the real and potential mental health trauma that children/adolescents and their parents are experiencing on a daily basis. Dr Man’s article, 

Pandemic pediatric tips for mental health

 provides 10 tips that pediatric health care providers may prioritize as part of routine primary care office visits. Are there other ways that pediatric providers can help with the mental health of the populations that they serve? Is it feasible to offer a bi-monthly Friday night Zoom ‘talkathon” for parents and/or their children? Parents and children trust their pediatricians and pediatric/family nurse practitioners and pediatric nurses. Sharing the responsibilities among office-based pediatric health care providers is one way to make such an option feasible. A 10-minute digital access presentation on a topic of interest to parents, eg, “My child feels anxious: What can I do?”; “My child feels lonely having classes only on Zoom: What can I do?”; “Coping skills 101: How do I help myself and my children apply effective coping skills in this pandemic?”; and/or other topics relating to children or parenting during this pandemic would most likely be very popular. The 10-minute presentation can be followed by a 5-minute pre-screened question and answer period. It may be that a virtual 15-minute meeting twice a month or weekly, for larger practices, may inspire communities to continue on a lighted path that leads us out of this pandemic with newly acquired coping skills that reduce the burden of COVID-19 induced behavioral and mental health issues.

Articles

With the good news of the 2 successful vaccines and a much greater understanding of COVID-19, it is time to consider what lies ahead for 2021.

COVID-19: Moving forward cautiously

Twenty years ago, the report “To Err is Human” was published by the Institute of Medicine (today called The National Academy of Sciences) and presented a call to action for national initiatives to create a safer health care delivery system.

 At that time, the authors reported that 98,000 people die in any given year from medical errors that occur in hospital settings. The article by Drs. Selbst and Krill, 

Medical errors in the pediatric emergency department: Don’t make these mistakes

 quickly reminds us of the devasting effects of medical errors. The authors present and analyze the outcomes of several pediatric/adolescent case studies that clearly highlight medical errors in the emergency departments. The outcomes of these cases revealed that 2 children died and 6 children suffered serious complications: all, most likely preventable. I highly recommend reading this article, examining the cases, and prior to reading the authors teaching points, critically analyze how you, as a pediatric nurse practitioner (PNP), would assess and treat each of the patients in these cases

Your personal analysis of these cases may further inspire you to be active participants in quality improvement (QI) initiatives in your place of employment.

Measures to assure a safer health care delivery system

Prior to the 2000 IOM report, the Institute for Healthcare Improvement was established in 1991 with the overall goal of “redesigning health care into a system without errors”.

 Today, nurse practitioners lead QI initiatives in hospitals and outpatient settings to improve health care outcomes; to recognize medical errors; and design programs, policies, or guidelines to prevent future errors. Quality improvement initiatives hold significant promise to continually improve health care outcomes and prevent medical errors.

The nurse practitioner malpractice data bank for the years 1990 to 2014 revealed that malpractice claims involving all NPs, were for diagnostic errors (41.6%) and treatment errors (30.79%).

 It would be interesting to analyze whether rigorous QI initiatives and resultant practice and behavioral changes in specific hospital or outpatient settings over the past 6 years, have reduced the percent of diagnostic and treatment errors made by NPs.

Faculty initiatives to reduce medical errors

As a Director of the Pediatrics NP program, one major outcome goal for PNP student education is prevention of medical errors, with a focus specifically on preventing diagnostic and treatment errors. Clearly, a diagnostic error most likely leads to a treatment error: incorrect diagnosis = incorrect treatment. As the authors, Drs. Selbst and Krill pointed out, ‘premature closure’ is a major problem that leads to medical errors. Diagnostic reasoning is a new skill set for NP students in every discipline. Prevention of premature closure should be a goal for every case study used within NP curriculum and for every case analyzed in clinical practice with their preceptors.

In Case 1, Drs. Selbst and Krill stated that the cardiologist phone consult recommended sending the adolescent home. The provider followed the recommendation, and 8 hours later the adolescent collapsed and died. There is an important lesson here for all health care providers to learn from this case. If you disagree with a diagnosis or recommendation, take additional actions to assure patient safety. The 15-year-old teenager in this case is not unlike many adolescents who present to primary care practices with similar complaints of chest pain, often diagnosed as musculoskeletal pain or costochondritis, and the adolescent is discharged. However, instilling the students with the importance of preventing premature closure is critical to prevention of the more subtle diagnostic errors which were present in Case 1. There was rather clear evidence, at the point of presentation in Case 1, that a further work-up was needed at the time of presentation.

A major goal of NP education is to enable NP students to step out of their role as a Registered Nurse into their new role of a PNP. In their educational programs, PNP students are asked not only to review the recommendations of consultants and other health care providers but to also advocate for a different recommendation if the PNPs analysis of the case differs from the consultants. This skill can be achieved through interprofessional role-playing scenarios to enable all NPs to be confident in their diagnosis and treatment plans based on the presenting case evidence.

Let’s continue to be vigilant in our practices to prevent medical errors, thus attaining what we all strive for: helping our pediatric/adolescent patients return to their normal thriving state of health and well-being.

1. Kohn L, Corrigan J, Donaldson M, Institute of Medicine. 

. Washington, DC: National Academy Press; 2000.

2. Institute for Healthcare Improvement. History. Ihi.org. Accessed December 14, 2020. 

http://www.ihi.org/about/pages/history.aspx

3. Sweeney C, LeMahieu A, Fryer G. Nurse practitioner malpractice data: Informing nursing education. 

. 2020;33(4):271-275. doi:10.1016/j.profnurs.2017.01.002

The trauma of medical errors

Parental eating behaviors, both their personal habits and the way parents choose to feed their infants, children, and influence the eating habits of their older school-age children and adolescents leads to either healthy infant, childhood, and adolescent eating behaviors or a life-long struggle with eating and weight management. The Centers for Disease Control and Prevention identifies obesity as a serious problem in the United States with a prevalence of 18.5% of children and adolescents, aged 2 to 19 years, meeting the body mass index (BMI) criteria for obesity.

A major component of pediatric practice is guiding parents’ understanding of best feeding practices for infants, children, and adolescents. Obtaining relevant history related to eating practices and providing guidance on the weight and BMI status of the child and adolescent are significant aspects of every well pediatric health care visit. For years, much of pediatric nurse practitioners’ (PNPs) and other practitioners’ guidance for feeding infants was ‘passed down from training’ rather than based on scientific studies that investigated best nutritional practices. In the article entitled, 

Helping parents – and their kids – eat better

 Zimlich reports on a research study that investigated parental influences on their child’s diet and ways parents can change the dietary habits of their children and adolescents. Results revealed that parents should be encouraged to model healthful eating behaviors and select foods for home meals that reduce total sugar content and the consumption of junk food in the diets of their children and adolescents.

Parental weight and the influence on child/adolescent weight

The study, reported by Ms. Zimlich, does not report on the nutritional status of the parents who participated in the study. Previous studies have shown that the children of parents who are overweight or obese have a higher prevalence of obesity than children of parents whose BMI is within the normal range for their age and height. A child with one obese parent has a 50% change of being obese and when both parents are obese, their children have an 80% change of obesity.

 These data support the nutritional study reported by Ms. Zimlich that parental eating practices are a direct influence on their children’s eating behaviors. Parental obesity is a complex problem that is out of the scope of practice of pediatric providers, even though there is a direct correlation between child and parental obesity. As noted by Dr. Thomson, a lead author on the report, obesity is an ‘uncomfortable conversation’ with parents. As PNPs we understand the sensitivity of a discussion on healthy eating and role modeling healthy nutritional habits when 1 or both parents are obese. These discussions have the potential to hinder the trusting relationships we work hard to build with parents. Often, we circle the problem by referring the parents to websites that support healthy eating practices, such as Choose My Plate.

 We also refer the parents to a nutritionist for counseling for better eating practices for their children.

Pediatric providers who support exclusive breastfeeding for the first 6 months of life set the groundwork for healthy eating. Likewise, providers who strive to engage parents in developing healthy eating behaviors when introducing foods to infants aged 6 months and to continue healthy behaviors throughout toddlerhood, review growth charts with parents during routine office visits, and provide evidence-based feeding practices for infants and toddlers may be more successful in achieving healthy weight gains. However, studies need to be designed and conducted to analyze the outcomes of these strategies. Additionally, studies on methods to influence changing parental behaviors and ways to communicate with parents that their poor eating practices negatively influence the overall health of their children and adolescents are also needed.

1. Center for Disease Control and Prevention. Childhood Obesity Facts | Overweight & Obesity | CDC. Cdc.gov. Update June 24, 2019. Accessed November 17, 2020. 

https://www.cdc.gov/obesity/data/childhood.html

2. UCSF Benioff Children's Hospital . Obesity | Conditions & Treatments. Ucsfbenioffchildrens.org. Published 2020. Accessed November 17, 2020. 

https://www.ucsfbenioffchildrens.org/conditions/obesity/#:~:text=A%20child%20with%20one%20obese,gain%20varies%20for%20different%20people

3. United States of Agriculture. MyPlate | ChooseMyPlate. Choosemyplate.gov. Published 2020. Accessed November 17, 2020. 

Encourage parents to model healthful eating behaviors and positive relationships with good eating habits.

The relationship of parental eating behaviors and their children and adolescents’ weight   

We, as a country, need to emerge from the COVID-19 pandemic with our mental health and well-being strong and prepared to rebuild our communities to confront the new, and as yet unknown new world. The uncertainties about long-term health outcomes for a diagnosis of COVID-19 for oneself, one’s children, other family members, and especially elderly relatives have resulted in high levels of stress, anxiety, and/or depression for the primary caregiver as well as many family members. Complicate these stressors with the care of a child or adolescent with a diagnosis of attention-deficit/hyperactive disorder (ADHD) and the stress, anxiety, and/or depression can be overwhelming for the primary caregiver.

 has two articles addressing mental health. 

 by Rachel Lynch, MD, FAAP, provide a comprehensive review of ADHD for primary care providers. Dr. Lynch identifies the need for school-based interventions as part of the treatment plan for children with ADHD. However, with a lack of face-to-face education for children and adolescents during the pandemic, there has been and remains a critical need for teachers and providers to increase their communication with patients, families, and school professionals to identify the effectiveness of the new home teaching strategies for children with ADHD.

Mental well-being and families: How COVID-19 has changed things

 complements the articles on ADHD. She reports on a study published in 

, that revealed 45% of parents experienced increased caregiver burden since the beginning of the pandemic.

Changes in education and resultant social isolation

As we know, children with ADHD usually receive services at school for hyperactivity, inattentiveness, and/or learning disabilities. The pandemic abruptly changed school instruction from in-class professional teacher-learner encounters to virtual classes. In some communities limited or no access to internet or technology to attend virtual classes caused an abrupt stoppage of most professional educational encounters. The majority of parents were not prepared to provide the high level of educational expertise and instruction children receive at school. From my experiences talking with parents who have children with ADHD, many parents are frustrated and stressed during the day-to-day child-parent encounters and feel that their children are not achieving their previously planned educational goals. Many parents are concerned about the long-term effect of social isolation even as children are returning to school. In-school activities and afterschool play dates are limited due to social distancing and concerns for community spread of COVID-19.

As pediatric and family nurse practitioners, we can follow the ADHD assessment, evaluation, and treatment guidelines by authors Drs. Gephart and Lynch. We can, as Dr. Lynch recommends, make connections now with children, adolescents, and families. In our practices, we can engage parents in informed and shared decision-making experiences to help their children and/or adolescents achieve their educational goals, and equally as important, to achieve their socialization goals. Parents as well as their children and adolescents will need to ‘think out of the box’ to find safe ways to achieve their socialization goals but the outcomes will be worth their efforts.

It is extremely important for every health care provider to focus on emerging from this pandemic by helping our patients, ourselves, and our communities to have our collective mental health intact, resilient, and ready for success in a new and yet, unknown evolving world. A world that will hold the promise of a future for the children, adolescents and families we care for deeply and for the communities in which we live, work, play, and thrive.

COVID-19 has created many stresses: mental, job-related, and health. For some caregivers, these stressors are complicated further with caring for a child with attention-deficit/hyperactive disorder (ADHD).

Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN

Articles

COVID-19: Moving forward cautiously

The trauma of medical errors

The relationship of parental eating behaviors and their children and adolescents’ weight

Hyperactivity, learning disabilities, and social isolation…COVID-19 and its effects on ADHD