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

Insights for prescribing COVID-19 vaccines for the pediatric populations

 focuses on COVID-19 vaccines for pediatric populations and includes articles on mRNA technology, vaccine development, the latest news about COVID-19 vaccines, and responding to parental concerns and decisions to have their infants, children and adolescents receive the COVID-19 vaccines. An article by Tina Tan, MD, “What is the latest news in COVID-19 vaccines?” provides the current statistics for COVID-19 vaccination uptake in infants and children. These statistics are very concerning: only 7% of infants 6 months through 4 years have received 1 dose of the vaccine and in the 5 to 11-year-old population, only 30% have completed the 2-dose series. Pediatric nurse practitioners (PNPs) and all pediatric focused providers must not only be knowledgeable about each of the topics on COVID-19 vaccines presented in this October 2022 issue but also design evidenced-based practice strategies to improve vaccination rates in their pediatric practices.

If asked, ‘what is mRNA technology and how were the COVID-19 vaccines developed so quickly?’ can you as a PNP present information “

” by William J. Muller, MD, PhD, that clearly articulates the technology providing a knowledge base for parents upon which an informed decision can be made? Furthermore, can you succinctly articulate the established FDA protocols highlighted by Barbara J. Kuter, PhD, MPH, in her article, “Vaccine development,” that are designed to assure safety in the development of the vaccines, clinical trials and the ongoing surveillance? These articles provide information that can be synthesized by providers and presented to parents in less than two minutes to relieve them of anxiety and assure them of the value of the COVID-19 vaccines.

The statistics for the number of children between the ages of 6-months and 12 years who have received the COVID-19 vaccines inform us about the high level of vaccine hesitancy and refusal. In the article, 

Responding to increasing parental vaccine hesitancy

, Dr. Peck provides an overview of vaccine hesitancy and ways providers can speak with parents about vaccines for their children to reduce the hesitancy and enable parents to make an informed decision. Additionally, Assistant Editor Celeste Krewson’s article, “Experts discuss COVID-19 vaccine in pediatric patients,” highlights Drs. Muller and Offit scientific viewpoints on COVID-19 in children and the vaccines. They discuss the impact of the COVID-19 illness in the pediatric population identifying data that showed thus far, 45,000 children under 5 years required hospitalization and 1 in 4 of these children required admission to intensive care units. Drs. Muller and Offit also provide insights for talking with parents about COVID-19 vaccines including the safety and efficacy of the vaccines.

‘We have to learn to live with SARS-CoV-2’ is a statement that I had hoped, and I feel certain that all health care providers throughout the United States and around the world had hoped would not become a reality. The World Health Organization (WHO) declared the SARS-CoV-2 pandemic 2 years and 7 months ago. The devasting effects of this disease in the first year the outbreak overwhelmed hospital systems throughout the U.S. and the world. Listening to daily reports of the catastrophic way in which the disease attacked people and took so many lives was chilling. No one was untouched: we all had family members, friends, work colleagues, neighbors, and we lived in or near communities that suffered a high disease burden. So many people lost their lives. Thus, it is perplexing to try to rationalize the underpinnings of the beliefs of individuals and populations who are vaccine refusers. Vaccine refusers have adversely impacted vaccine uptake, some via spreading misinformation about the disease and vaccines on social media. Vaccine refusers remain adamant about refusal not only for themselves but also for their children. As of October 22, 2022, there have been over 1 million deaths from COVID-19 in the United States and over 99,000,000 COVID-19 cases in the United States.

 As a pediatric researcher, the importance of conducting research on the beliefs of vaccine refusers is critical to understanding ways to improve vaccine uptake. Both pediatric and adult clinicians and researchers have a lot of work to do to change the outcome from, ‘we have to learn to live with SARS-CoV-2’ to ‘we have conquered COVID-19 disease’ through vaccine uptake and respect for the health and well-being of all those with whom we come in contact.

1. Worldometer. United States Coronavirus statistics. October 24, 2022. October 24, 2022. https://www.worldometers.info/coronavirus/country/us/

Articles

Donna Hallas, CPNP, FAAN, FAANP, PMHS, PPCNP-BC, PhD, discusses the top news from the October issue of Contemporary Pediatrics®.

Everything you need to know about COVID-19 vaccines

Dr. Schuman provides insights for pediatric practices to transition to the ‘New Norm’

Thank you, Dr. Andrew Schuman, for 2 informative articles in the September issue of 

that provide valuable insights for pediatric practices to thrive within the "new norm" in an era emerging from post-COVID-19 practice strategies to include combinations of in-person and virtual visits using sophisticated technological advances. While COVID-19 has been extraordinarily disruptive to the day-to-day acquisition of health care for our pediatric patients and their families, the emergence of new technologies to inform diagnostic reasoning is a welcome change. Schuman’s articles, 

 Portals for screening patients for mental health and behaviors: update 2022

are a must-read for pediatric nurse practitioners (PNPs) and all health care providers.

Preventing diagnostic errors for plagiocephaly and brachycephaly

 clearly explains the new app to accurately identify plagiocephaly and brachycephaly. The back-to-sleep recommendations, while so beneficial in the reduction of sudden infant death syndrome (SIDS), has a side effect of an increased incidence of infants with a diagnosis of plagiocephaly. Prior to the COVID-19 pandemic, PNPs would assess the head circumference and the degree of asymmetry of the facial bones and facial features during in-person visits and, if needed, refer infants for a comprehensive evaluation for plagiocephaly. Schuman provides detailed information about the SoftSpot app that is available for use in both in-person office visits and telehealth visits. Of significance to clinical practice to reduce the incidence of the “600,000 babies with plagiocephaly or brachycephaly who go undiagnosed and untreated” (Schuman, page 31) for these conditions. For practitioners who strive to reduce medical diagnostic errors, (and missing 600,000 babies is most certainly a significant number of diagnostic errors), this SoftSpot app has the potential to not only improve practice performance but even more important to reduce harm to infants with these diagnoses.

Screening tools for in-person and telehealth visits

chuman’s second article in the September issue, 

Portals for screening patients for mental health and behaviors: update 2022

 also provides important information for practitioners who are now seeing so many more preschool children, school-age children, and adolescents who are experiencing stress, anxiety, and depression that are a direct result of growing up within the confines and conflicts directly related to the uncertainty of COVID-19 pandemic. This article is a 

as it provides valuable information and identifies some free resources for screening tools for the most commonly presenting mental health and behavioral health disorders practitioners encounter in clinical practice.

Can you answer these questions correctly? Match the list of tools to the names of the tools listed below:

Which of these tools, listed below, is a comprehensive web-based system for screening children for behavioral and developmental problems?

Which of these tools provides a free service for the assessment of ADHD?

Which of these tools screens for suicide ideation, violent behavior, psychosis, depression, conduct disorders, and other problems by having adults and adolescents respond to 58 questions and 48 questions for children, is completed in 10 minutes with results available in 15 minutes?

Which of these tools is used as a fast-tracking autism diagnosis for autism?

Did you answer the questions correctly? The answers to these questions can be found in Dr. Schuman’s article, 

Portals for screening patients for mental health and behaviors: update 2022.

Will your practice performance improve by incorporating these technological advancements in your daily pediatric practices? Conduct a Quality Improvement (QI) project to determine the effectiveness of the implementation of these tools in your practice and the benefit to the patients and families you provide healthcare services every day.

Throughout human history, technology has shaped every aspect of how we live and has allowed us to live longer, healthier lives. Read how technological advances in pediatrics are transitioning the specialty into a new normal. 

How tech is transitioning pediatrics to a ‘new norm’

Helping first-year college students manage expectations and stress

addresses ways pediatricians can communicate with college students who may be having an array of emotions as entering college and campus life becomes a reality. Dr. Aron discusses ways to ask non-threatening questions of the adolescent/young adult about feelings of anxiety, depression, and alcohol use, especially binge drinking and ways to provide appropriate anticipatory guidance including brief interventions for alcohol avoidance behaviors and mindfulness strategies for stress and anxiety, eg, meditation, progressive muscle relaxation.

Pediatric and family nurse practitioners (PNPs, FNPs) who have practices based on a medical home model are familiar with the emotional needs of the adolescent population and endeavor to build trusting relationships with adolescents during each annual health maintenance encounter. Practices that schedule one-half hour annual appointments with the PNP or FNP best serve the needs of adolescents as more time can be devoted to the emotional assessments and appropriate interventions. In addition, practices that have an “adolescent nurse-champion” meet with the adolescent at the end of each annual appointment to review adolescent age-specific anticipatory guidance and potential harms of high-risk behaviors further help to build trusting relationships. Thus, these adolescent friendly practices are an ideal setting to have a conversation with adolescents who are preparing to attend college for the first time and those returning to college with less pandemic restrictions.

Dr. Aron supports discussing drinking behaviors with the adolescent. We are all acutely aware of the problems of fraternity initiations in which excessive drinking has led to the death of a college student. Although these behaviors are prohibited on college campuses, providing insight into potential problems and a brief role-playing session with the adolescent is an important component of anticipatory guidance. As providers, we know that the desire to ‘belong’ should not be overshadowed by potential risky behaviors. This is an opportunity to convey this message to the adolescent with insights into avoidance of potential problems.

The high school experience is completely different from the college experience. College students are expected to be engaged in their own learning, to plan their study time, to meet assignment deadlines, to pass comprehensive high-stake midterm and final exams. Often, these new demands are stressors for adolescents who have had successful high school experiences. Adolescents may miss their home with parents or guardians available to recognize problems and intervene. Although colleges offer student health center services and wellness centers to meet emotional needs, adolescents must seek out these services. Adolescents who have not struggled previously may find themselves facing a dilemma: Do I have a problem? Can I handle it myself? Should I find help? Am I in too deep? The anticipatory guidance here focuses on prevention of harmful behaviors such as suicidal ideation and the awareness of available hot lines. The discussion may begin with a brief scenario in which the adolescent is asked to evaluate an exemplar of a college student who observes a roommate or study friend having overwhelming feelings of doubt, frustration, anxiety, or sadness. The conclusion is to immediately seek help. This is an opportune time to explore with the adolescent the college website for services available at the specific college the adolescent will attend.

OTC, prescribed drugs, and the college student

Another important discussion to include in anticipatory guidance for college age students are over-the-counter (OTC) drugs and prescribed medications. Ask any adolescent: What do you think about OTC drugs? Most often the immediate answer will be “They are safe or they wouldn’t sell them.” This thinking now applies to marijuana including softgels, gummies, other edibles, and topicals as well as cannabidiol oils. It also applies to prescribed medications. Adolescents may ask to take a prescribed drug that a friend has for attention-deficit/hyperactive disorder to stay awake all night to write a paper or cram for an exam. Awareness of these pitfalls through a brief case scenario may provide the adolescent with “emotional protective gear” to avoid unintentional and intentional drug use and misuse. 

College students returning with less COVID-19 restrictions

Many college students will be returning to colleges as juniors, and for the first time since entering college, experience less COVID-19 restrictions. The annual office visit is an ideal time to talk about “life with less COVID-19 restrictions” and the importance of avoiding high-risk behaviors that spread CPVID-19 disease. This may be a time when returning students feel liberated with more freedom than they experienced over the past 2 years and will need guidance to focus on their personal health, academics, in combination with enjoying the college experience. Additional discussions with returning college students should focus on the same information as presented to first time college students but the scenarios will be different. The focus may be on such questions as: What experiences have you encountered that have caused you stress, anxiety, feeling sad or bad about yourself? Routine screening for anxiety, depression as well as the CRAFFT tool and other screening tools are very helpful in helping returning college students gain the most from their campus life experiences, as interventions can be in place before they leave for college.

With many adolescents on the way to school, it's important to ensure your practice is taking the opportunity to talk with them and give them the tools they need be successful.

Adolescents are ready for college: Is your practice?

The summer months traditionally allow school-age children opportunities to play outdoors with friends, vacation with family members at home or away from home, attend camps, and equally as important, visit their health care providers for the annual back-to-school physical examinations and health care updates. Over the past 2 summers, COVID-19 has influenced child health care visits with a focus in the 2020 – 2021 return to school physicals on adhering to school health safety measures to prevent COVID-19 infections and in 2021-2022 talking with parents to encourage acceptance of the COVID-19 vaccines for their children. Although we remain embedded in the COVID-19 pandemic and children may experience school disruptions in the 2022-2023 academic year related to the newest Omicron BA.4 and BA.5 variants which have become the predominant lineage in the United States,

 all pediatric providers including pediatric and family nurse practitioners need to include history questions for each child on attainment of learning milestones during the previous academic year. Responses to these history questions will guide discussions with parents to prevent missed opportunities for them to advocate for their child to receive educational services with the goal of remaining on track for academic progression.

Learning disabilities and COVID-19: Where are we now?

highlights the importance of helping parents of children with learning disabilities, including, dyslexia, to obtain the educational services needed for their child to progress academically. Dr. Baum discusses the Multi-Tier System of Supports for educational achievement in children with learning disorders and the importance of universal screening, tailoring interventions to the specific child needs, and the value of systematically monitoring student progress.

Obtaining a history from the school-age child

Children have experienced a variety of educational set-backs; emotional, behavioral, mental health; death of parents and/or relatives to COVID-19 disease; and relationship issues due to the pandemic. Although many history questions for school-age children are answered by their parent or guardian, school-age children, when asked directly, provide insights into school experiences that they may not have shared with an adult. If the young child is comfortable talking alone, these questions may guide history taking with the child and can be used even if the parent or guardian is present.

1.) Tell me about your usual day at school.

4.) Is there something that you study at school, like math, reading, or science that you like a lot or one that you have problems with?

In addition, the parents can provide history about reports from the school and report cards. Responses to question asked of the parent, when the child is present, should focus on what the child does well and what the child can improve, rather than any negative focus on poor performance. Likewise, we should review the Individual Educational Program reports from the school for children with disabilities. Sometimes a modification in medication management for children with behavioral disorders is helpful if the report shows an unexpected change in behaviors or performance.

Helping parents advocate for their children

Some parents will need guidance on how to advocate for their child within the school system. Based on their educational level, parents may also need guidance on how to help their child at home. Dr. Baum summarizes recommendations to promote reading skills at home (See Table 3 in her article). For parents whose first language is not English, suggest parents obtain audiobooks from the library for the children. Both the parent and child can listen together to the audiobook. In the summer months, parents can investigate whether their library offers weekly ‘story-telling’ hours for children. Parents living in underserved communities may need additional help in locating library and/or educational services for their children during the summer months. The pediatric office can investigate available summer time resources, especially for children living in underserved communities, and ask staff to provide the information to the parents as part of anticipatory guidance. The pediatric office may also want to investigate how the school systems within their catchment area are implementing ‘

‘ and how that may help the child who has learning delays that have emerged in the pandemic.

COVID-19 has disrupted the educational processes for many children. It will take time and effort from each educational school system and the community to correct the gaps in knowledge experienced by children over the past 2.5 years. Community leaders can play a major role in helping children and adolescents by considering ways to offer additional educational assistance especially to children in underserved communities.

Although our focus is on the health and well-being of the child during the annual physical examinations, a major component of child health is the ability to learn on a continuum that meets educational developmental milestones. We must consider possible stressful situations the children may will encounter in the 2022 - 2023 academic year. We must be mindful of how the social determinants of health interfere with educational achievement. Many pediatric offices provide brief educational videos or digital media presentations in the waiting area. Pediatric providers should consider creating brief videos using community members, eg, a lawyer, business leader, educator, police officer, office personnel including the physician, nurse, nurse practitioner, to highlight their careers, who can in a 2-minute video or digital presentation talk value in education for their careers. All pediatric health care providers play a role in helping children grow and develop into healthy adults: a child’s education is key to becoming a healthy, productive adult.

1. Centers for Disease Control and Prevention. COVID-19 COVID Data Tracker Weekly Review. July 5, 2022. Accessed July 18, 2022. Retrieved from 

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/

The annual back-to-school physical examination offers an opportunity to ensure that children haven't missed important learning goals, particularly due to the pandemic.

Helping children achieve learning milestones in pediatric practice encounters

Colleen Powers, MD; Hannah Badon, MD; and Thy Huynh, MD, describe 3 commonly seen dermatological conditions, (eg, atopic dermatitis, acne, vitiligo) with a focus on recognizing the dermatological differences in a diverse population

 The authors review the condition, epidemiology, role of genetics, clinical presentation, and treatment considerations for the three conditions. I believe the article is important to read for all pediatric health care providers. Additionally, I believe it is equally important for pediatric and family nurse practitioners (PNPs, FNPs) caring for children and adolescents with dermatological conditions to be comfortable talking about the conditions with children, adolescents and their parents.

Ways children and adolescents have presented with dermatologic conditions

I am often very concerned at how much a child or adolescent has endured both physically and emotionally prior to presenting to primary care with a treatable dermatological condition. I have cared for children whose parents, not knowing the diagnosis was treatable (atopic dermatitis) wrapped their arms and legs with bandages to prevent the constant scratching. I have cared for adolescents who were not socializing with others as they were fearful of what their friends thought about the ‘marks on their face,’ not realizing that the condition was acne and treatable. I have cared for children and adolescents who were depressed over the comments other children have made about noticeable changes in skin color on their face, arms and/or legs due to the diagnosis of vitiligo. The importance of speaking with the child, adolescent and parent using words that they understand about the diagnosis and treatment planning cannot be overemphasized. Equally as important is assessing the self-image/self-esteem and emotional status of the children and adolescents, at that moment in time, to help them begin the process of meaningful change about their personal feelings regarding their self-image, their emotional growth and interactions with peers.

Self-image/self-esteem in children and adolescents presenting with dermatological conditions

In clinical practice and education, I use the words ‘dermatological conditions’ and not dermatological disorders or diseases when speaking with children, adolescents and their parents. The idea to a child or adolescent that they have a ‘skin disease’ can be very traumatic affecting not only their self-image/self-esteem and overall mental health but also their desire to go to school to ‘be seen’ and interact with peers. A comparison study of self-esteem and dermatological quality of life in adolescents with a diagnosis of atopic dermatitis as compared with adolescents without a skin condition showed that those with atopic dermatitis displayed lower levels of self-esteem than healthy controls.The authors recommended psychological support for adolescents with atopic dermatitis.

 contain four questions with Likert scale responses that can be used to asses self-esteem and quality of life in primary care settings. The responses reported by the child or adolescent provide insights into their self-esteem status which may be managed by a PNP or FNP or may support a referral to a psychologist or mental health provider to enable the child or adolescent building self-esteem while managing a chronic condition. If a practitioner does not want to use a questionnaire, one or more questions relating to self-image or self-esteem may be helpful to evaluate how the child or adolescent feels and to establish a treatment plan: “How do you feel about your skin condition?” “Is your skin condition affecting your friendships or activities that you do with friends?” “What activities do you do with friends?”

For the child who presented with all extremities wrapped in bandages, the child needed immediate management of the skin infection directly related to atopic dermatitis and a referral to dermatology. Care management was achieved by frequent visits to dermatology as well as in the primary care setting. As the child’s condition improved, the parent and child were taught how to assess and feel for the most minor atopic eruptions to immediately manage the condition before it became out of control. Children, adolescents and parents need to understand that Atopic Dermatitis is a chronic condition that requires daily attention to details to prevent the onset of the itch-scratch-itch cycle.

Managing adolescents with ACNE also requires attention to details. Educating the adolescent and parent on skin care and appropriate use of prescribed medications and ways to minimizeinitial medication side effects is essential. Appropriate anticipatory guidance also supports the adolescents’ self-image. If treatment of ACNE does not respond as expected, a dermatology referral is needed.

Children and adolescents with vitiligo are often emotionally challenged by the condition. Their peers often do not understand the condition. They may not be selected to participate in social or play activities at school. It is critical to assess the emotional status of children with a diagnosis of vitiligo and refer for treatment and to follow the children closely in the primary care home. Drs. Powers, Badon and Huynh discuss the use of cosmetics which should be recommended for children who vitiligo not only on the face but also in all visible body areas such as arms and legs. I have found that expert cosmeticians play a critical role in helping improve the self-image/self-esteem of children and adolescents who have a diagnosis of vitiligo.

Dermatological conditions that alter the appearance of the skin making skin conditions visible to others, often adversely affect the self-image/self-esteem of children and adolescents. PNPs and FNPs need to assess the feelings of those presenting with skin conditions and help the child, adolescent and parents put into action strategies that will improve their self-image. PNPs and FNPs must use the best available evidence for prescribing medications to treat the specific condition, as recommended in the article by Powers, Badon, and Huynh and encourage appropriate follow-up care. Telehealth visits can be used for follow-up care and to further assess the emotional health of the child or adolescent. Referral to a school psychologist or social worker may be an option for further care at school to improve the emotional health and self-image/self-esteem of the children and adolescents with dermatological conditions.

1. Erturan, I. Aktepe, E. Balci, DD. Yildirim, M. Sonmez, Y. Ceyhan, AM. Evaluation of self-esteem and dermatological quality of life in adolescents with atopic dermatitis. 

Archives of the Turkish dermatology & venerology/Turkderm, 

(2013).47(1): 39-44. (6p). Accessed June 18, 2022. DOI: 

2. Ravens-Sienerer, U. Bullinger, M. Assessing health related quality of life in chronically ill children with the German KINDL: first psychometric and content-analytical results. 

, (1998a), 4, 7. Assessed June 18, 2022. Retrieved from 

https://www.kindl.org/english/questionnaires/

3. Ravens-Seiberer, U. & Bullinger, M. News from the KINDL-Questionnaire – A new version for adolescents. 

, 7, 653. Assessed June 18, 2022. Retrieved from 

It is important for pediatric and family nurse practitioners caring for patients with dermatological conditions to be comfortable talking about the conditions with children, adolescents, and their parents.

Dermatological conditions and the relationship to self-image

The COVID-19 pandemic has taught health care providers a lot: how quickly a virus can spread globally, how unprepared we were to respond to a pandemic, and how rapidly science and technology could evolve to make a safe and effective vaccine, as well as that many people are vaccine hesitant or re- fusers and that individuals and groups resisting public health safety measures (eg, masking, social distancing) could prolong a pandemic with repetitive surges. Most importantly, we have learned that it is critical to be more than a step ahead of future infectious diseases by analyzing and responding to emerging data both in the United States and globally. This article reviews infectious diseases that may have taken a back seat in the news since March 2020 and how they affect the daily lives of children and adolescents all around the world.

The Dengue virus (DENV) is a major public health problem in the tropics and subtropics and is endemic in the US territories of Puerto Rico, the US Virgin Islands, and American Samoa.

 As Americans begin to travel and the United States welcomes global visitors, pediatric providers must consider who may be exposed to 1 of the 4 known DENVs and the presenting symptoms (Table

). An individual can be infected with the 4 serotypes over time. Long- term immunity is achieved for an individual who contracted a homologous DENV, but this protection does not last more than 3 months if an individual is infected with a different serotype. Evidence has shown that a person who sustains a second infection is more likely to develop severe dengue compared with those experiencing the first or a third or fourth illness.

 DENV is most often transmitted to a human through the bite of an infected mosquito (

 The incubation period is 3 to 14 days before symptom onset. Infected individuals can transmit DENV to mosquitoes 1 to 2 days before symptoms develop and during the 7-day viral illness.

During the Ebola outbreak, it was critical when taking a patient’s history to ask anyone presenting with fever about recent travel. To diagnose a DENV illness, providers must continue the practice of asking about recent travel globally and within the endemic areas in the US territories. Dengvaxia, a Dengue vaccine, is now approved by the US Food and Drug Administration and is listed on the 2022 US immunization schedule for individuals aged 9 to 16 years. However, the vaccine can be administered only if prevaccination laboratory testing reveals confirmed evidence of a previous DENV infection.

 It is contraindicated to administer the Dengvaxia vaccine to children who are seronegative because that action would place them at high risk of hospitalization and severe dengue illness.

In 2019, there were 1282 confirmed cases of measles in 31 states.

 There were 2 primary reasons for US outbreaks: In 2019, the number of people who contracted measles abroad increased; then, upon their return to the United States, these individuals spread the virus in communities that had low measles vaccination rates.

 In 2020 and 2021, the number of reported measles cases in the United States dropped significantly to 13 and 49, respectively; thus far, in 2022, 3 cases have been reported.

Two factors may account for the 2020 and 2021 decreases. These data may represent the effect of the COVID-19 pandemic on measles transmission in the United States—fewer families traveled overseas as the pan- demic surged throughout this country. Also, many elementary and secondary schools were closed in 2020; when they reopened in 2021, masks and social distancing were in place. Thus, these factors may have significantly reduced children and unvaccinated families from contracting and spreading the measles virus.

These data provide evidence that pediatric providers should reach out to parents whose children need the measles-mumps-rubella (MMR) vaccine, citing 2 influential factors: (

1) Many states have removed school mask mandates, putting unvaccinated children at risk of contracting measles.

 Parents should be reminded that measles spreads through direct contact with an infected person or airborne transmission (via coughing or sneezing) up to 4 days before rash onset and for 4 days after the rash erupts.

(2) Timely measles vaccination will protect children who may be traveling to parts of the world where measles is endemic.

The World Health Organization (WHO) reported that measles remains a problem in developing countries, especially in parts of Africa and Asia. The WHO also reported that in 2018, more than 140,000 people—mostly children less than 5 years old—died from measles, with more than 95% of these deaths occurring in countries that have low-income populations and weak health care systems.

 The MMR vaccine saves lives. All health care providers should proactively encourage parents to vaccinate their children.

A diagnosis of pediatric tuberculosis (TB), for either latent TB (referred to as tuberculosis infection [TBI]

) or TB disease (active TB), is made for patients aged less than 15 years who have either a positive tuberculin skin test or a positive interferon- gamma release assay.

 Both tests have a high positive predictive value when used for children who have had a direct contact exposure to an adult with TB disease.

 Infants and young children are at increased risk of developing life-threatening forms of the disease, including TB meningitis and disseminated TB, compared with older children and adults.

 The greatest numbers of TB cases occur in children under 5 years old, with 38% of pediatric cases occurring

 within this age range. In addition, in 2020, 28% of the 10- to 14-year- old population had a diagnosis of pediatric TB.

 Data from TB cases in children aged less than 18 years living in the United States from 2010 to 2017 revealed that 32% of children with TB disease were born in other countries.

, spread the organism via airborne transmission by coughing, speaking, or singing. However, children with pediatric TB do not spread the organism as readily as adults, because pediatric TB is less infectious than the adult form.

 Children may present with a cough, weakness, weight loss, fever, change in playtime behaviors, and/or night sweats.

Children younger than 4 years are at the highest risk of progressing from TBI to TB disease, with data showing a risk of 40% to 50% for infants less than 1 year old and 25% for 1- to 2-year-olds.

 However, children with a diagnosis of TBI who receive drug therapy and whose parents adhere to the regimen have a 90% reduced risk of developing TB disease.

 Adolescents older than 12 years have a risk of progression to adult-type TB disease. Children and adolescents who are immunocompromised also have a high risk of disease progression.

In 2021, the clinical practice guidance for treatment of latent TB and TB disease was revised.

 Children older than 2 years may be treated with once-weekly isoniazid-rifapentine for 12 weeks. Additional regimens include 4 months of rifapentine or 9 months of daily isoniazid.

 Parents often prefer shorter courses, resulting in more children completing a full course.

For TB disease, children can be treated with several anti-TB medications for 4, 6, or 9 months, based on the selection of the drug therapy believed to be most effective for the child and for parental administration. Providers need to be aware that the Centers for Disease Control and Prevention does not recommend the 4-month rifapentine-moxifloxacin TB regimen for children younger than 12 years.

 Best practices for pediatric providers include consulting a TB expert prior to beginning the treatment course, based on the available data showing that young children have a high risk of developing life-threatening TB disease.

Pediatric health care providers are on the frontlines for identifying infectious diseases and, to prevent poor outcomes, must react quickly to diagnose and treat cases in children and adolescents. The COVID-19 pandemic public health measures— masking, social distancing, and limited social contact among children and adolescents—have reduced the prevalence of other infectious diseases. As public health policies begin to change and global travel resumes, pediatric providers must remain astutely aware of the potentially devasting effects of emerging infectious diseases and newer ones that may affect US and global pediatric populations.

1. Kimberline DW, Barnett ED, Lynfield R, Sawyer MH. Dengue. In: Kimberline DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021:301-304.

2. Paz-Bailey G, Adams L, Wong JM, et al. Dengue vaccine: recommendations of the Advisory Committee on Immunization Practices, United States, 2021. 

. 2021;70(6):1-16. doi:10.15585/mmwr.rr7006a1

3. Child and adolescent immunization schedule. Centers for Disease Control and Prevention. Updated February 17, 2022. Accessed March 25, 2022. 

https://www.cdc.gov/vaccines/schedules/hcp/imz/child- adolescent.html#note-dengue

4. Measles cases and outbreaks. Centers for Disease Control and Prevention. Updated April 6, 2022. Accessed March 26, 2022. 

https://www.cdc.gov/ measles/cases-outbreaks.html

5. Measles: key facts. World Health Organization. December 5, 2019. Accessed March 26, 2022. 

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

6. Measles. World Health Organization. Accessed March 26, 2022. 

https://www.who.int/health-topics/ measles#tab=tab_1

7. TB and children. Centers for Disease Control and Prevention. October 19, 2021. Accessed March 26, 2022. 

https://www.cdc.gov/tb/topic/populations/

8. Nolt D, Starke JR. Tuberculosis infection in children and adolescents: testing and treatment. 

. 2021;148(6):e20211054663. doi:10.1542/ peds.2021-054663

9. Cowger TL, Wortham JM, Burton DC. Epidemiology of tuberculosis among children and adolescents in the USA, 2007-17: an analysis of national surveillance data. 

. 2019;4(10):e506-e516. doi:10.1016/S2468-2667(19)30134-3

What infections besides COVID-19 should be on pediatric health care providers’ radar?