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

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 

Articles

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?

Dengue virus, measles, TBI and TB disease: Are they being overlooked because of the pandemic?

When an adolescent presents to a pediatric primary care office and provides a history of recurring, sudden onset vomiting episodes that are separated by symptom-free intervals, have you placed cannabinoid hyperemesis syndrome (CHS) on the list of differential diagnoses along with cyclic vomiting syndrome (CVS)? Although pediatric providers are aware of the diagnosis of CVS and the rather rare presentation, many current textbooks do not include a discussion of CHS or list it as a possible diagnosis when discussing cyclic vomiting.

 Thus, CHS may not be listed as a potential differential diagnosis for CVS, even though cannabis use has increased. Eighteen states along with Washington DC and Guam have legalized marijuana for medicinal use in children and teenagers and for recreational use for those aged older than 21 years. Drs. Klembczyk, Calihan and Alinsky article, “

Diagnosis and treatment of cannabinoid hyperemesis syndrome

”provides a comprehensive analysis of CHS including the acute management and pharmacotherapy.

 In addition, they describe insights for pediatric primary care providers for the care of adolescents who use cannabis and/or are diagnosed with cannabis use disorder (CUD).

Difference in presentations for CVS and CHS

Children and adolescents presenting with CVS present with a history of recurring, sudden onset vomiting attacks but are separated by symptom free intervals of weeks to months, and often, by history, not related to cannabis use.

 In contrast, adolescents presenting with CHS experience 3 clinical phases beginning with a prodromal phase of morning nausea and a history of cannabis use.

 Another major difference between CVS and CHS is that those presenting with CHS present to the emergency room. Although children and adolescents may present with a first episode of CVS to the ED, often they present to primary care and once other diagnoses are ruled out, for the first episode a diagnosis of viral syndrome may be made. For the diagnosis of CVS, the pattern of sudden vomiting accompanied by free intervals that leads to the diagnosis. Providers who routinely ask about drug use will find that for CVS, the adolescents do not routinely report frequent drug use while those presenting with CHS have a history of drug use. 

Evidence-based primary preventive practices to reduce cannabis use

The CRAFFT tool is a well validated screening tool for use with adolescents from 12- to 21-years-old and is recommended by the American Academy of Pediatrics (AAP) for routine use in pediatric clinical practices.

 The CRAFFT tool is self-administered and covers a variety of topics including the use of alcohol, marijuana, and drugs, both legal and illegal, used by teens to experience a ‘high feeling.’ Adolescent responses on the CRAFFT tool provide opportunities for providers to implement primary preventive management services at that moment in time, when specific risky behaviors are identified. Drs. Klembczyk, Calihan and Alinsky also discuss the use of the evidence-based AAP recommendations for Screening, Brief Intervention, and Referral to Therapy (SBIRT) tool in clinical practice. Providers are trained to safely and effectively use the SBIRT tool in clinical practice. With the increased availability of marijuana in 18 states, pediatric providers should develop specific office-based policies for the use and interpretation of the CRAFFT and SBIRT tools and specific interventions to protect the adolescents in their practices.

Pediatric providers who use shared decision-making strategies with parents of pre-teens should be encouraged to discuss with their children their house rules about drug and alcohol use. Providers, especially in states where marijuana is legal, should discuss with parents how to protect their preteens and adolescents from accessing marijuana if they use it in their home. The providers approach to adolescent care that is open and attentive during history taking is a critical component for establishing a trusting relationship, especially when asking sensitive questions about drug and alcohol use. Adolescent responses to these questions provides numerous opportunities for providers to talk about effective the adolescent can avoid drug and alcohol exposure and/or help the adolescent determine effective ways to change these behaviors when identified.

1. Garzon Maaks DL, Starr NB, Brady MA, Gaylord NM, Driessnack M, Duderstadt, CG. (2020).

2. Berkowitz, CD. (ED.). American Academy of Pediatrics, 

Berkowitz’s pediatrics: a primary care approach

3. Klembczyk K, Calihan, J, Alinsky RH. Diagnosis and treatment of cannabinoid hyperemesis syndrome. 

4. Boston Children’s Hospital. (2018). 

It may not be included in the differential diagnosis and can seem like it's cyclic vomiting syndrome, but a cannabinoid hyperemesis syndrome diagnosis can be found through diligent history and compassionate care.

Will primary prevention strategies reduce the incidence of cannabinoid hyperemesis syndrome?

Children’s Mental Health Crisis…We can’t ignore it anymore. 

Have we, as pediatric nurse practitioners (PNPs) and family nurse practitioners (FNPs) who care for children and their families, been ignoring mental/behavioral health problems? PNPs and FNPs can make a difference in the mental and behavioral health as we begin to navigate our way through 

I highly recommend that every PNP and FNP read the special report on mental health and the 4 articles on behavioral health for the pediatric and adolescent populations and ask these critical questions: 1.) What must I know to diagnoses and treat children and adolescents presenting with mental/behavioral health problems? 2.) What can my practice do to identify, diagnose, and treat children and adolescents who are presenting with mental/behavioral health problems?

Screenings shine the light on mental and behavioral health problems

PNPs routinely screen for mental and behavioral health problems from an early age using a variety of age-appropriate evidence-based screening tools. In addition, PNPs screen parents and caregivers for adverse childhood events (ACEs)

 which help identify parents and/or caregivers who were exposed to ACEs during their childhood that may affect their parenting style.

“Screening adolescent for psychosocial concerns

Dr. Michael Jellinek and co-author Talia Benheim discuss implementation of evidence-based screening tools for adolescents with an emphasis on identifying depression by using a tool that includes a measure for possible depression. During these stressful times, it is important to not only use the recommended tools routinely in clinical practice but to also analyze the results in relation to the responses to history questions. PNPs and FNPs may have known parents, children, and adolescent well before the start of the pandemic and previously documented a well-adjusted family, but today must recognize that all of the pandemic adversities may have totally altered family dynamics as well as the mental and behavioral health of children and adolescents.

Another overwhelming concern is the article authored by Dr. Candice Jones, 

“Helping children grieve the loss of a caregiver due to COVID-19

 A significant number of children have lost a parent or caregiver over the past 2 years due to COVID-19. The question PNPs and FNPs must ask themselves is: “Am I prepared to talk with a child or adolescent about their loss and have a meaningful conversation about their personal feelings while providing guidance that will be helpful to the child or adolescent?” These are difficult conversations and require thoughtful preparation that is not the usual norm for pediatric practices. PNPs and FNPs can also access school-based resources for the child and adolescent by referring to school-based social workers or psychologists that are experienced with working with children who have experienced the loss of a parent. Dr. Jones provides recommendations for improving communication and recognition of grief and ways to help children and adolescents develop positive coping skills.

“How pediatrician can help mitigate the mental health crisis

 by Dr Janine A. Rethy and Dr. Elizabeth M. Chawla asks what pediatricians can do to advocate for change? The authors present several valuable suggestions in which pediatricians ‘care for the whole patient.’ Likewise, PNPs and FNPs need to ask the same question as well as analyze their practices to determine if, at present, they are meeting the totality of both physical and mental/behavioral health needs of children and adolescents or if change is needed to achieve a goal of meeting these needs. PNPs and FNPs who have provided care to children in primary care practices and to children and adolescents who present with mental and behavioral health needs can take a certification examination to be recognized as a Pediatric [primary care] Mental Health Specialist (PMHS).

 This recognition provides opportunities for PNPs and FNPs to offer an integrated approach to primary care in which a child/adolescent can receive their primary care and also schedule an appointment to talk with a PNP or FNP who holds the PMHS credential about their personal mental or behavioral health problems. This is also an opportunity to make referrals for children and adolescents who need additional services to help resolve their problems.

It is more than time for PNPs and FNPs to join the advocacy movement to improve the mental and behavioral health of children and adolescents who have been adversely affected by the COVID-19 pandemic. The pandemic has upended their world, including but not limited to their routines, the comfort and security of their homes, their friendships, their socialization, their feelings and emotions, their participation in recreational and competitive sports, and their abilities to interact in ways that support normal growth and development. Take time to consider the impact of the pandemic on our children and adolescents. Establish practice goals to help pediatric patients and their families emerge from the pandemic with mental and behavioral health tools to go forward strong, confident, and as leaders making a positive impact in the ‘new norm.’

1. Stop Abuse Campaign Corp. What does your ACE score mean? Adverse Childhood Experience. (2022). Retrieved March 21, 2022 

https://stopabusecampaign.org/take-your-ace-test/what-does-your-ace-score-mean/

2. National Center for Injury Prevention and Control, Division of Violence Prevention. Adverse Childhood Experiences (ACEs). Reviewed April, 2, 2021. Accessed March 21, 2022 from 

https://www.cdc.gov/violenceprevention/aces/

3. Steps to PMHS Certification. Pediatric Primary Care Mental Health Specialist exam information. Accessed March 21, 2022 from 

https://www.pncb.org/pmhs-certification-steps

As we begin to navigate our way through year 3 of the COVID-19 pandemic, it's time to question whether mental and behavioral concerns have been ignored.

Consider the impact of the COVID-19 pandemic on the mental and behavior health of every kid and teen

I vividly recall the extreme sadness that I felt along with everyone in the United States the day reporters broke the news on December 14, 2012, that 20 children and 6 adults, teachers and school personnel, were shot and killed at Sandy Hook Elementary School in Newtown, Connecticut. The gunman, Adam Lanza, aged 20 years, shot 154 rounds of ammunition in less than 5 minutes using a M16 assault 0.22-calibre rifle, and 2 AR-15 semiautomatic pistols.

 His mother had purchased these weapons for him. I also recall the emotional speech that President Obama gave on December 16, 2012, at an interfaith vigil to honor the victims of this horrific tragedy. The Sandy Hook Elementary School shooting is just 1 of 304 fatal school shootings with more than 292,0002 students experiencing gun violence since the Columbine school shooting in Colorado on April 20, 1999.

Miranda Hester reports on firearm related injuries, “

,” and Dr. Steven Selbst wrote a commentary on the report. Data from an investigation on US firearm fatalities among children and young adults revealed an increase in firearm mortality risks was related to increased concentrations of poverty. The Dr. Selbst commentary presented data on the increased number of children younger than 20 years of age living in Chicago, Illinois, and Philadelphia, Pennsylvania, who have had firearm related deaths. Measures to reduce the number of children living in poverty and exposed to gun violence have been proposed by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners. Poverty and gun violence are 2 overwhelming problems that must be addressed at local, state, and national levels to achieve significant changes to overcome the adversity of living in poverty and to stop gun violence. New ways of thinking, listening, and behaving must occur to assure meaningful change occurs through processes of design and implementation that abolish poverty as a way of life and to stop gun violence.

It seems that every incident of gun violence has the root cause of undiagnosed or poorly managed mental health problems. Are there history questions in your electronic health record (EMR) that address the social determinants of health (SDOH)? Do you use specific screening tools to capture the parameters of the SDOH and refer for needed assistance? Do you assess the mental health status of every child/adolescent using a valid screening tool? Do you routinely refer children for treatment of mental health problems? Do you ask parents and teenagers specifically about guns? For example: 1). Do you have guns in your home? 2). If yes, are the guns securely locked in a case? 3). Does your child have access to guns in your home or with friends? 4). Do you talk to your children about gun violence? 5). Has you child/adolescent gone hunting? 6). Has your child/adolescent been taught to respect guns? 7). Has your adolescent brought a weapon to school? 

If we do not ask, we will never know if we could have prevented a tragedy!

 to access work completed with US Department of Health Resources and Services Administration grant funding for a preceptor development grant, Module 9 entitled: 

Are you prepared to React in the Event of Workplace Violence: An interview with a police expert

. The police expert was the Captain in charge after the shootings at Sandy Hook Elementary School.

1. Ray M. Sandy hook elementary school shooting. Updated February 16, 2022. Accessed February 21, 2022.

 https://www.britannica.com/event/Sandy-Hook-Elementary-School-shooting

2. Cox J, Rich S, Chin A, Muyskens J, Ulmanu M. More than 292,000 students have experience gun violence at school since Columbine. Updated January 24, 2022. Accessed February 21, 2022.

 https://www.washingtonpost.com/graphics/2018/local/school-shootings-database/

3. Vigderman A, Turner G. A timeline of school shootings since Columbine. Updated August 9, 2021. Accessed February 21, 2022.

https://www.security.org/blog/a-timeline-of-school-shootings-since-columbine/

Gun violence is an issue with many causes and will require solutions that address mental health and poverty.

Gun violence in schools and on the streets

Dermatology cases are always fascinating. The clues are visual and more easily investigated than many other nonspecific case presentations. The investigation to find most likely causes for dermatologic cases challenges providers to critically analyze the case, possible underlying co-conditions, and the best treatment options. Case outcomes that lead to resolution and return to normal integumentary functions are often rewarding for the child/adolescent and the provider. However, some dermatologic outcomes may be overwhelming for the child/adolescent and the provider. The Dermcase article, “

,”written by Sarah York, RN and Dr. Bernard A. Cohen is one that can be categorized as overwhelming. Why? Because the outcome of the case was diagnosed as infant child abuse.

Pediatric health care is all about primary prevention, thus, the title for this commentary, asks an important question of providers: 

Have you reached out to your parents and teenagers during this pandemic?

Over the past 22 months, as everyone has been deeply embedded in the COVID-19 crisis and life is anything but usual, have you, the provider, reached out to parents via emails or social media platforms? Have you encouraged the parents of your pediatric and adolescent patients who have not been in for routine care to schedule an office visit? 

So many parents have not made routine office visits for the children or adolescents. Many children/adolescents are behind in immunizations, routine health care screenings, and physical exams and need to reconnect with their pediatric practice providers. It is critically important to recognize the impact of COVID-19 on child/adolescent emotions and the resultant anxiety and stress that have been placed on families. Many children have lost their parents, grandparents, and other close family members as well as family friends during the pandemic. Parental and child/adolescent stress and anxiety increases the risk of child abuse. Primary prevention including detailed history taking and recognition of anxiety or stress as well as other behavioral problems coupled with treatment planning may prevent escalation to child abuse. Pediatric providers engaging in telehealth visits and/or in-person visits play a critical role in early recognition and prevention of child abuse.

What is your child abuse IQ? Can you answer these questions as addressed in the article?

Considering a possible diagnosis of child abuse, what is the relationship between skin manifestations and the history provided by the parents or caregiver?

What factors, besides stress and anxiety, are identified in the article as increasing the risk of child abuse?

Viewing the photo of the right side of the child’s back, what are your differential diagnosis? [Answer the question before reading the article]

What does the law mandate a provider to do when the diagnosis is suspicion of child abuse?

The answers to each of the above questions can be found in the article. Great if you answered all of them correctly!

Let’s proactively encourage parents to make primary care appointments for their children and adolescents. Take the time to perform a detailed history and physical exam. Be alert for signs of child abuse.

And on a final note, yesterday marked the 800,00 reported deaths in the United States from COVID-19. We mourn the loss of life and the continued illness and potential for more lives lost from what is now a 

.Along with immunizations for all age-eligible individuals, COVID-19 is also controlled by adherence to evidence-based public health measures. It is time for every health care provider to tirelessly advocate for immunizations and continuance of public health measures. I fear, that if we are not strong advocates, the numbers

It may have been months since you've seen some patients as a result of COVID-19. Reaching out to patients and their families can be important to determining if there are red flags.