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

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

Articles

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.

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

The entire November issue of Contemporary Pediatrics is devoted to vaccines with the editorial board as lead authors for each vaccine article. All aspects of vaccinations are addressed providing opportunities for pediatric nurse practitioners (PNPs) and all pediatric providers to have candid discussions with colleagues, patients, and families about the value of vaccinations for all adolescents and young adults as well as adults who make health care decisions for children and adolescents aged younger than 18 years.

Vaccine controversy and the plight of controlling the COVID-19 pandemic

The pandemic has entangled evidenced-based public health measures designed to protect the population with strong political viewpoints and vaccine refusal that are perpetuating the pandemic. The evidence clearly shows that the unvaccinated are most at-risk for severe disease and death, with the majority of hospitalized individuals with COVID-19 symptoms identified as unvaccinated. If one hypothesized, human beings disheveled by an astoundingly powerful ever-evolving organism at pandemic proportions, controversial feelings related to vaccines and public health measures would be replaced by adherence to public health principles and a call for mass vaccination would prevail; based on today’s national data, the hypothesis would not be supported. Thus, despite scientific advances that enabled the development and production of safe and effective COVID-19 vaccines for individuals from aged 5 years and older, the pandemic remains victorious in the United States, primarily due to vaccine resistance and the social media spread for misinformation.

Vaccine articles: What lessons best inform current practices?

In this digital age of information overload, a Contemporary Pediatrics November issue with a focus on vaccines provides easy access to the most current information in one place for the busy pediatric provider. Topics include information on the history of vaccines, how to talk with vaccine hesitant individuals and families, immunization information systems, vaccine development, vaccines recommended but not required, the future of vaccinology, and the Centers for Disease Control and Prevention immunization schedules.

PNP students are often asked to highlight the most important principles or concepts learned when reading scientific information. Using this approach, I selected some important concepts from each article and highlighted the concepts in italics in each paragraph. Dr. Barakat’s article, “The History of Vaccination,” we learned that severe outbreaks of smallpox in the 1700s helped the public accept vaccinations. We also learned that once the smallpox vaccine was developed, vaccination uptake spread rapidly in England, but the United States was slower to implement vaccination recommendations. 

This historical information is similar to the current COVID-19 pandemic: even though the United States has led COVID-19 vaccine development, currently 62 million people in the United States, who are vaccine eligible, have not been vaccinated

. Likewise, vaccine hesitancy has affected vaccine uptake by adults for themselves and now for their children. Dr. Jones interviewed Drs. Colton-Poole and Clay on the topic of vaccine hesitancy. They provide suggestions for establishing trusting relationships with parents and children to combat vaccine hesitancy and improve levels of acceptance. 

Vaccine hesitant and refusing individuals continue to negatively impact the progress towards conquering the COVID-19 pandemic. Efforts to combat vaccine hesitancy must persist at local, state, and national levels for the United States to reduce disease and death from COVID-19. We currently have over 700,000 deaths in the United States alone. If the unvaccinated persist in their refusals, the death toll will continue to rise…the tragic thought of reaching 1,000,000 deaths is mind boggling, and so unnecessary, as COVID-19 is now a vaccine-preventable disease.

Drs. Libby and Schuman describe the current immunization information system in their articles, “Immunization information systems: Beyond the basics.” They describe ways to improve data entry into the immunization information systems (IISs) by bar coding vaccines received into the electroni health records (EHRs) which will then interact with IISs rather than have personnel enter data both into the EHR and the IIS, as they currently do not interact with one another.

 Drs. Libby and Schuman further suggest COVID-19 reporting vaccine requirements to enter data into a database that monitors vaccine uptake and sends out reminders may be “the silver lining for connecting all vaccine registries into a national database, accessible from anywhere.”

Dr. Tan’s article, “Vaccines in development: What we can look forward to in preventing infectious diseases,” Drs. Schuman and Libby’s article, “The Future of Vaccinology,” and my article, “Vaccines recommended but not required: Evidence that supports a strong recommendation to parents,” provides exciting new insights into current available vaccines and vaccines of the future as well as current recommendations for vaccines that are available but not mandated for attendance at school. The future is bright with more than a dozen vaccines in development and new ways to administer the vaccines other than by injection.

The COVID-19 pandemic has reinforced resistance to vaccine uptake. Thus, all providers must collectively consider how to address latest scientific developments that have the potential to alter the course of viral and bacterial infectious diseases that lead to a much healthier future. The messaging must counter the intensely influential social media on vaccines that persuades adults and leads to parental refusal of vaccines as we have seen throughout this COVID-19 pandemic. The time to design and implement rigorous research studies to combat vaccine refusal is now.


The November issue covered a variety of topics on vaccination, which can help clinicians have candid conversations with colleagues, patients, and families.

All about vaccines: Updates for pediatric nurse practitioners 

Several vaccines are recommended for infants, children, and adolescents on the Centers for Disease Control and Prevention (CDC) schedules,

 but are not required for entrance into school or other activities, such as sports and social organizations. However, there are compelling reasons for all providers who care for pediatric populations to be knowledgeable about these vaccines and make recommendations to parents to accept 1 or more of these vaccines. Provider recommendations should be based on the best available evidence on the CDC vaccine websites,

 the corresponding Advisory Committee on Immunization Practices (ACIP) websites,

This article presents 5 vaccines that are recommended but not required for various ages of the pediatric populations.

HPV is a common sexually transmitted infection (STI)

 that is often acquired soon after the first sexual encounter,

 in particular by individuals who do not practice safe sex recommendations eg, use of condoms and other barrier precautions.

 Although most HPV infections are transient and asymptomatic, there are high-risk forms of mucosal types of HPVs that infect adolescents and young adults and are transmitted through intimate skin-to-skin contact, eg, sexual intercourse or close genital contact. Repeated and/or persistent high-risk mucosal forms of HPV increase the risk for adolescents and young adults to develop precancerous lesions as well as oropharyngeal, cervical, and anogenital cancers in the young adult years, or even decades later.

 Six types of invasive cancers are caused by HPV infections. They include cancers of the cervix, vagina, vulva, penis, anus, and oropharynx, inclusive of the back of the throat, base of the tongue, and tonsils.

 Cervical cancer is the most common HPV-attributable cancer in females, and oropharyngeal cancer is highest among males.

Overall, HPV vaccine can prevent over 90% of cancers caused by HPV.

Although there were 3 prophylactic HPV vaccines licensed in the United States, only 1 vaccine, the 9-valent HPV vaccine (9vHPV, Gardasil 9, Merck), is currently available for use. The 9vHPV vaccine (types 6, 11, 16, 18, 31, 33, 45, 52, and 58), identified as Gardasil 9, was licensed by the FDA in 2014.3 Studies have shown that 97% of healthy vaccine recipients develop antibodies to the 9 serotypes in the HPV vaccine.

 The HPV vaccine is a prophylactic vaccine,

 thus the effectiveness of the vaccine is for those individuals who are free of infection at time of vaccine administration.

 It has been shown that individuals who are infected with 1 or more HPV serotypes prior to or at the time of HPV vaccine administration do not develop protection against progression of HPV disease for that particular serotype or viral strain.

The 9vHPV vaccine was initially licensed for use in children beginning at 9 years of age to young adults aged 26 years. It is now also licensed for some adults aged 27 to 45 years.

 The American Academy of Pediatrics (AAP) recommends starting the 9vHPV vaccine between ages 9 and 12 years whereas ACIP recommends beginning the vaccine between 11 and 12 years of age.

Dose, timing, and precautions for the HPV vaccine

For children and adolescents aged 9 to 15 years old, the recommended HPV schedule is for the 2-dose series. The second dose should be scheduled 6 to 12 months after the first dose. The minimal interval for the second dose is 5 months.

 Children with a history of sexual abuse or assault should begin the 9vHPV vaccine series at age 9 as they are considered at increased risk for high-risk sexual behaviors and/or future victimization.

All adolescents who are aged 15 years or older receive the 3-dose vHPV vaccine series. The second dose should be administered 1 to 2 months after the first dose. The third dose should be administered 6 months after the first dose with a minimal interval of 5 months, and 12 weeks after the second dose.

Influenza (flu) is a contagious respiratory illness that circulates throughout the year. However, influenza predominantly circulates at endemic and epidemic levels in the United States from October to March, and may persist until May in some areas of the country.

Infants, toddlers, children, and adolescents with chronic illnesses, are at high risk for complications and death related to influenza. However, even healthy children who contract influenza may experience the burden of influenza complications and death.

Each year, human influenza types A and B viruses are the usual cause of seasonal epidemics of influenza disease in the United States. There are currently 2 subtypes of influenza A viruses that routinely circulate in people: A(H1N1) andA(H3N2).

 Influenza type B are classified as 2 lineages: B/Yamagata and B/Victoria.

 Type B influenza does circulate in the United States and worldwide each year. Presenting symptoms for all types of influenza may include sudden onset fever, nonproductive cough, chills, myalgia, headache, and malaise. These initial symptoms are often followed by complaints of sore throat, nasal congestion, rhinitis, and cough.

 Infants may also present with sepsis-like illnesses, including complications of otitis media, croup, pertussis like-illnesses, bronchiolitis, or pneumonia.

Influenza vaccination rates increased in the 2020-2021 influenza season and additional attention to basic health safety measures, such as wearing masks, handwashing, and no sharing of eating and drinking materials, may have impacted the reduction in influenza disease burden during this influenza season.

All children and adolescents should receive an annual influenza vaccine. The earliest an infant can receive the influenza vaccine is at age 6 months.

 However, infants whose mothers receive the influenza vaccine during the prenatal period benefit from transplacental transfer of antibodies against influenza, protecting them during the first 6 months of life.

For any infant aged 6 months and older, or child up to 9 years of age who have not received the influenza vaccine in the past, needs to receive 2 doses of the influenza vaccine, spaced 4 weeks apart, to produce an adequate immune response. For infants and children who have received 2 doses of the influenza vaccine during the previous influenza season, the infants and children only need 1 dose of the vaccine annually, preferably before the start of the influenza season.

Dose, timing, and precautions for the influenza vaccine

Infants and children younger than 2 years must receive the inactivated influenza vaccine (IIV) and children aged older than 2 years, without asthma restrictions, may receive either the IIV or LAIV. The advantage of the LAIV is that it is administered as a nasal spray, thus “it is not a shot” for those toddlers and preschoolers who so dislike “the shots.” All nasal spray influenza vaccines for the 2020-2021 influenza season were quadrivalent, therefore the 4 influenza viruses that were covered included influenza A(H1N1) virus, influenza A(H3N2) virus, and 2 influenza Type B viruses.

Quadrivalent injectable influenza vaccines are available for infants, children, and adolescents. All providers must consult the manufacturer prescribing information or the CDC to determine the age-appropriate dose to prevent potential dose administration errors. For example, the Afluria Quadrivalent (Seqirus) for infants aged 6 to 35 months is 0.25 mL IM, whereas the Fluarix Quadrivalent, (GlaxoSmithKline) dose is 0.5 mL IM for infants aged 6 months and older.

All providers should ask questions about egg allergies and previous experiences after receiving the influenza vaccine.

 Practitioners should provide the flu VIS sheet for the influenza vaccine, noting that the flu VIS is no longer updated every year.

 For example, the August 15, 2019 flu VIS was given to all recipients of the 2020-2021 influenza vaccine.

Parents may hear about hepatitis A virus outbreaks in their communities when a food handler at a food establishment, or a day care worker, or a school employee, who unknowingly has hepatitis A, spreads the virus to a group of individuals who have had person-to-person contact with the infected individual. Unvaccinated infants and children in day care and preschool programs are at high risk of contracting hepatitis A virus if they come in contact with an infected day care worker. The long incubation period for hepatitis A virus of 15 to 50 days contributes to an individual unknowingly spreading the disease prior to onset of any symptoms.

 Transmission of hepatitis A occurs person to person by fecal contamination from the infected person followed by oral ingestion by a nonvaccinated, hepatitis A-susceptible individual.

 Adolescents may also contract hepatitis A during sexual con- tact with an infected person.

 In addition, reports of outbreaks of hepatitis A occur after individuals eat raw fruits and vegetables without thoroughly washing the fruits or vegetables, or after eating raw, contaminated seafood, such as oysters and mussels.

Parental acceptance of the hepatitis A vaccine protects their infants and children from acquiring hepatitis A virus if they are exposed to an infected individual or a carrier.

Hepatitis A is an acute, self-limiting illness.

 Hepatitis A does not result in a chronic infection.

 Symptoms may include fever, malaise, jaundice, anorexia, and nausea. These symptoms may last for 2 months, and even as long as 6 months.

 Public health measures are recommended by the state’s Department of Health when outbreaks occur including, postexposure prophylaxis.

Two single-antigen hepatitis A vaccines are available in the United States, Havrix and Vaqta. Pediatric and adult formulations for both Havrix and Vaqta are available. The hepatitis A vaccines are highly immunogenic.

 Data showed that 95% of healthy infants, children, adolescents, and adults have protective antibody concentrations 1 month after the initial dose, and the protection increases to 99% 1 month after receiving the second dose.

Infants should receive the first dose of the hepatitis A vaccine at the 12-month visit, and the second dose 6 months later, at the 18-month visit. Children and adolescents who did not receive the hepatitis A dose at the 12-month infant visit can begin the Hepatitis A 2-dose series at any age.

Adolescents aged 18 years and older who have not received the hepatitis A or hepatitis B vaccine may receive a combination vaccine, called Twinrix, in a 3-dose series. All doses of the hepatitis A vaccine are administered as intramuscular injections.

Dose, timing, and precautions for the hepatitis A vaccine

Pediatric formulations for the hepatitis A vaccines, Havrix and Vaqta, are for 12-month-old infants to 18-year-old adolescents. Providers and those who administer vaccines to the pediatric population, who also have the adult formulation in their refrigerator for patients aged 19 years and older, must be knowledgeable of the fact that the pediatric formulations are administered at a dose of 0.5 mL, whereas the adult formulations are administered at a dose of 1.0 mL.

The minimal interval between the first and second doses of the hepatitis A vaccines is 6 months. Second doses may be administered 6 to 12 months after the first dose of Havrix, and 6 to 18 months after the first dose of Vaqta.

 For infants who have routine health care visits at both 12 months and 18 months, it is best to administer the first hepatitis A vaccine at the 12-month visit and the second dose at the 18-month visit, as recommended by the AAP periodicity table.

, a gram-negative diplococcus organism, presents as an invasive meningococcal serogroup B infection, often with an abrupt onset of fever, chills, malaise, limb pain, and a macular or maculopapular rash that is followed by a petechial or purpuric rash within hours.

 Invasive MenB disease has a case fatality rate of 15%, with higher rates for the late adolescent population.

Undergraduate freshman college students aged 18 to 20 years, who are living in college dormitories for the first time, are identified as at risk for contracting serogroup B meningococcal disease. In addition, college students who actively participate in fraternity or sorority activities are also considered to be at increased risk for contracting MenB disease, although investigations for the fraternity or sorority settings have only occurred during campus outbreaks

Some adolescent and young adults have an asymptomatic colonization of serogroup B in their throats. This colonization becomes the reservoir for spreading the organism.

The decision to administer the MenB vaccine to a healthy adolescent is presented as “shared clinical decision making” among the parent and adolescent, with the health care provider discussing evidence-based information with them as they make an informed decision for accepting or rejecting the vaccine.

The MenB vaccine is recommended for all children with specific chronic diseases, such as anatomic or functional asplenia, including children with a diagnosis of sickle cell disease, as well as persistent complement component deficiency and complement inhibitor. These children are most often managed in specialty practices, thus their specialty providers may administer the MenB vaccine, or ask that the primary care provider administer the vaccine.

There are 2 MenB vaccines for adolescents and young adults aged 16 to 23 years. The preferred time to administer 1 of the 2 available vaccines is between the ages of 16 and 18 years. The MenB vaccine may be administered to children with specific chronic diseases at the minimum age of 10 years.

Dose, timing, and precautions for the MenB vaccine

There are 2 MenB vaccines: MenB-4C (Bexsero), a 2-dose series administered at least 1 month apart, and MenB-FHbp (Trumenba), a 2-dose series administered at least 6 months apart; if dose 2 is administered earlier than 6 months after the first dose, a third dose must be administered at least 4 months after dose 2.

 MenB-4C and MenB-FHbp are not interchange- able; whichever vaccine is administered for the first dose, MenB-4C or MenB-FHbp should be administered for all subsequent doses, including a booster dose, if needed.

Editor's note: This article went to press before the COVID-19 Pfizer/BioNTech vaccine was authorized for use in children aged 5 to 11 years.

Over the past 16 months, health care providers have been immersed in caring for patients with COVID-19. Although children and adolescents have experienced a lesser disease burden, some children who were infected with COVID-19 have experienced significant health consequences, including new onset cardiac diseases.

The COVID-19 vaccine for those aged 12 to 15 years has provided the gateway for children to return to school for educational, social, emotional, and behavioral developmental growth.

Dose, timing, and precautions for the COVID-19 vaccine

The BNT162b2 (Pfizer-BioNTech) was administered in the clinical trial with 12- to 15-year-old participants as a 2-dose regimen of 30 μg, 21 days apart. This is the same dosage previously studied in the initial population of 16 years of age to 85 years of age.

Symptoms most reported as AEs in the 12- to 15-year-old age group were headache and fatigue. Parents should inform the provider of any known allergies or reactions to medications, immunizations, or foods. Adolescents who receive this vaccine must adhere to the same precautions as adults. Any adolescent who has a reaction post vaccination should report their reactions on the V-safe website for the COVID-19 vaccine.

Immunization programs have been one of the most successful public health initiatives of the 20th century. Pediatricians and PNPs play a major role in helping parents and teenagers understand the value of accepting immunizations per the CDC schedule

 to assure the sustained health and well- being of our pediatric, adolescent, and young adult populations.

1. Centers for Disease Control and Prevention. Immunization schedules: table 1. Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2021.Accessed June 10, 2021. 

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

2. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices.Accessed June 10, 2021. 

https://www.cdc.gov/vaccines/acip/index.html

3. Kimberlin DW, Barnett ED, Lynfield R, et al. 

Red Book 2021-2024: Report of the Committee on Infectious Diseases.

 (32nd Ed). American Academy of Pediatrics; 2021.

4. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases: the

https://www.cdc.gov/vaccines/pubs/pinkbook/index.html

5. Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human papillomavirus vaccination for adults: updated recommendations of the advisory committee on immunization practices. 

. 2019;68(32):698-702. doi:10.15585/mmwr.mm6832a3

6.Centers for Disease Control and Prevention. Division of adolescent and school health. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB prevention: Youth Risk Behavior Survey Data Summary & Trends Report 2007-2021.Accessed June 12, 2021 

https://www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_summary_and_trends.htm

7. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2016

https://www.cdc.gov/std/stats16/CDC_2016_STDS_Report-for508WebSep21_2017_1644.pdf

8. Centers for Disease Control and Prevention. HPV cancers. Accessed June 10, 2021. 

https://www.cdc.gov/hpv/parents/cancer.html

9. Centers for Disease Control and Prevention. How many cancers are linked with HPV each year? Accessed June 10, 2021. 

https://www.cdc.gov/cancer/hpv/statistics/cases.htm

10. Centers for Disease Control and Prevention. Vaccines for Children Program. Accessed June 10, 2021. 

https://www.cdc.gov/vaccines/programs/vfc/index.html

11. Centers for Disease Control and Prevention. Vaccine Information Statements.Accessed June 10, 2021. 

https://www.cdc.gov/vaccines/hcp/vis/index.html

12. Centers for Disease Control and Prevention. About flu.Accessed June 1, 2021. 

13. Centers for Disease Control and Prevention. 2019-2020 preliminary in-season burden estimates.Accessed June 10, 2021. 

https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm

14. Lutz R. How deadly was the 2019-2020 flu season

https://www.contagionlive.com/view/how-deadly-was-the-2019-2020-flu-season

15. Centers for Disease Control and Prevention. Types of influenza viruses.Accessed June 12, 2021. 

https://www.cdc.gov/flu/about/viruses/types.htm

16. Centers for Disease Control and Prevention. 2020-2021 Advisory Committee on Immunization Practices summary.Accessed June 10, 2021. 

https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm#composition

17. Centers for Disease Control and Prevention. Live attenuated influenza vaccine (LIAV)/nasal spray vaccine.Accessed June 10, 2021. 

https://www.cdc.gov/flu/prevent/nasalspray.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fflu%2Fabout%2Fqa%2Fnasalspray.htm

18. New York State Department of Health. Glossary. Accessed June 11, 2021. 

https://www.health.ny.gov/prevention/immunization/glossary.htm

19. Centers for Disease Control and Prevention. Viral hepatitis questions and answers for health professionals. Accessed June 10, 2021. 

https://www.cdc.gov/hepatitis/hav/havfaq.htm#A2

20. American Academy of Pediatrics. Engaging Patients and Families Periodicity Schedule. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Ed.Published 2017. American Academy of Pediatrics. Accessed June 12, 2021. 

https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

21. Mbaeyi SA, Bozio CH, Duffy J, et al. Meningococcal vaccination: recommendations of the Advisory Committee on Immunization Practices, United States, 2020. MMWR Recomm Rep. 2020;69(9):1-41. doi:10.15585/mmwr.rr6909a1

22. Meningitis B Action Project. Meningitis B cases and mandates tracker.Accessed June 13, 2021. 

https://meningitisbactionproject.org/menbtracker

23. Centers for Disease Control and Prevention. Multisystem inflammatory syndrome (MIS). Accessed September 14, 2021. 

24. Frenck RW Jr, Klein NP, Kitchin N, et al. Safety, immunogenicity, and efficacy of the BNT162b2 COVID-19 vaccine in adolescents

. 2021;385(3):239-250. doi:10.1056/NEJMMoa2107456

25. Centers for Disease Control and Prevention. V-safe. Accessed June 13, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html

26. Food and Drug Administration. FDA approves first COVID-19 vaccine. Accessed September 16, 2021. 

https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines#news

27. Centers for Disease Control and Prevention. Pfizer-BioNTech COVID-19 vaccine overview and safety. Accessed September 16, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html

28. Lovelace B Jr. Moderna asks FDA to clear COVID-19 vaccine for adolescents 12 to 17. 

https://www.cnbc.com/2021/06/10/covid-vaccine-moderna-asks-fda-to-ok-inoculations-for-kids-12-to-17.html

29. Centers for Disease Control and Prevention. Ten great public health achievements–United States, 2001-2010. 

Not every vaccine is required, some are just strongly recommended. Here's what to know about 5 recommended vaccines.

Vaccines recommended but not required: Evidence that supports a strong recommendation to parents

“She needs the pink medicine. I know it will work.” These are often the first words we hear even before gathering the history and performing the exam, from the parent of a child presenting with a cough, fever, somewhat irritable, and not sleeping at night (parents are not sleeping either!). Thus, the immediate demand for the ‘pink medicine.’ Dr. Jane M. Carnazzo’s article, “

How to correctly diagnose and treat community-acquired pneumonia

”describes the presentation of subtle differences between viral and bacterial pneumonia that causes stress among providers as the decision to treat for bacterial versus viral is a major concern. We have all been educated about the judicious use of antibiotics and antibiotic stewardship to prevent bacterial resistance and adverse side effects when antibiotics are prescribed for viral presentations. Thus, the parent who comes to the practice with the intent of receiving the ‘pink medicine’ presents a communication challenge to providers.

 In 2014, the Commissioner for Public Health in Connecticut sent a ‘Antibiotic Stewardship: Call to Action’ letter to all providers in Connecticut. The Commissioner asked providers to speak frankly with patients (parents) about the need for antibiotics; refer to evidence-based, clinical practice guidelines before prescribing; and talk to colleagues and pharmacists about the judicious use of antibiotics.

 The Centers for Disease Control and Prevention (CDC) presents a map of the numbers of antibiotics prescribed by each state. The national outpatient antibiotic prescriptions rate was 185 prescriptions of penicillins (amoxicillin) per 1000 population in 2018. In addition, the total outpatient antibiotic prescriptions dispensed in 2018 was 60.6 million.

 These data provide compelling evidence that pediatric and adult providers need to use critical thinking diagnostic skills when making the diagnosis of community-acquired pneumonia (CAP), viral versus bacterial, as Dr. Carnazzo recommends.

The Pediatric Infectious Disease Society and the Infectious Disease Society of America published the clinical practice guideline (CPG) for CAP in infant and children in 2011.

Although it is time to update these guidelines, they remain the standard of care for treating CAP in infants older than 3 months of age, as well as children and adolescents. For infants and children who do not present with respiratory distress, these guidelines inform the assessment and diagnosis for children with CAP. First, testing for viral pathogens should be performed in outpatient settings. During the upcoming fall and winter months in 2021-2022, testing for COVID-19, influenza, respiratory syncytial virus (RSV), and other viral pathogens is appropriate, to make the correct diagnosis of a viral pathogen, or viral versus bacterial pneumonia. A complete blood count, erythrocyte sedimentation rate, or C-reactive protein testing are not needed per the guideline, unless clinical judgement is such that these laboratory results would be beneficial to establishing the diagnosis, consistent with Dr. Carnazzo’s recommendations. Also, consistent with Dr. Carnazzo’s article, chest X-rays are not recommended unless, clinical judgement for a particular child outweighs the CPG recommendation for management. 

It is recommended to obtain a pulse oximetry reading for each infant, child, and adolescent who presents with a potential diagnosis of CAP.

 The readings may be helpful in determining whether the child can be managed at home or must be referred to the hospital.

If CAP is suspected to be bacterial in origin, then amoxicillin remains as first line therapy for previously healthy, immunized infants and young children. The CPG also provides guidance on which antibiotics to use for specific age children presenting with bacterial CAP.

 Following this guidance is important as part of antibiotic stewardship, as pediatric providers make every effort to practice safe medicine, but also to reduce the incidence of antibiotic resistance and adverse side effects when antibiotics did not need to be prescribed.

The fall-winter season is also the time to message or call all of your patients to provide the influenza vaccine to eligible infants, children, and adolescents in your practice to reduce the incidence of the disease. In addition, it is also time, to fully support the COVID-19 vaccine for all children aged older than 12 years. If, in the next few weeks, the US Food and Drug Administration completes the data analysis for children between 5 and 11 years of age, and makes the recommendation for administrating the COVID-19 vaccine, providers should also support it and make arrangements for administration of the vaccine to this population. 

One additional protection children have against COVID-19, influenza, RSV, and CAP is mask wearing. For young children, wearing masks has become routine. For older children, parental and provider support goes a long way in following this strong recommendation. Let’s reap the benefits of the wearing masks as a protective strategy and have an uneventful, more normal 2021-2022 fall and winter season. We can all benefit from normalcy – and while we are at it – let’s acknowledge the strength of the parents, grandparents, and all caregivers who raising children during this pandemic! They deserve our praise and our support.

1. Centers for Disease Control and Prevention. Antibiotic prescribing and use. Reviewed July 15, 2021. Accessed October 11, 2021. 

https://www.cdc.gov/antibiotic-use/index.html

2. Mullen, J. Office of the Commissioner: Antibiotic stewardship: A call to action. Published April 9, 2014.. Accessed October 11, 2021. 

https://www.cdc.gov/antibiotic-use/community/~local/modules/programs-measurement/Call-to-Action-Letter-CT-508.pdf

3. Centers for Disease Control and Prevention. Antibiotic resistance & patient safety portal - penicillins. Accessed October 11, 2021. 

4. Bradley J, Byington C, Shah S, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. 

. 2011;53(7):e25-e76. doi:10.1093/cid/cir531

Between the subtle differences between viral and bacterial pneumonia and the demands or beliefs of certain parents can make an accurate diagnosis of community-acquired pneumonia (CAP) more difficult.

Is it COVID-19 or CAP? A look at diagnostic decisions and treatments for 2021-2022

“Pediatric obesity and the impact of COVID-19”

provides insights in causes of obesity through an extensive review of the epidemiology, genetic considerations, assessment, screenings, co-morbidities, and available treatments for pediatric/adolescent patients with a diagnosis of obesity. The article is presented at a critical time when children are returning to school, many of whom have been homeschooled for 18 months. These children and adolescents may not have experienced their usual play, sports, exercise routines, and eating patterns and may have gained more than the normal amount of weight for age and height. Since many K-12 schools only require a physical examination at specific grade levels, not all children will have seen their primary care providers prior to returning to school this Fall 2021. Thus, school nurses and nurse practitioners (NPs) in school-based health centers (SBHCs) will play an important role in assessing the child’s health status related to obesity, potential for co-morbidities, and implementing appropriate management strategies.

Role of school nurses and NPs in obesity assessment in school-age children

Each year, school nurses conduct multiple screenings for school age-children including measurements for height, weight, calculating body mass indexes (BMIs), blood pressure readings, vision, hearing, and scoliosis. This year it will be especially important for school nurses and NPs in SBHCs to compare the results of these screening to past measurements. Children who have gained more than the anticipated amount of weight should be further evaluated for potential comorbidities, by reviewing their personal medical and family medical history. School nurses and NPs should also perform a dietary history and make suggestions for changes that may help obese children begin lifestyle behavioral changes to improve health care outcomes.

School nurses can refer the children to their primary care providers for further evaluation based on personal and family medical history. NPs can begin an action plan with children and adolescents using techniques of shared decision making to improve dietary selections. Both school nurses and NPs can engage families in the conversations about healthy eating to develop a goal for the child and even the family to improve food selection choices. School nurses and NPs may also offer weight management programs at school to engage children/adolescents in taking charge of their eating behaviors and physical activities that promote healthy behaviors.

Screening for prediabetes and diabetes and appropriate actions

Screening for prediabetes and diabetes in overweight and obese school age children and adolescents with a strong family history of diabetes encompasses both primary and secondary prevention strategies for prediabetes, diabetes, and related comorbidities. Comparison of the results of prior blood work to the most recent blood work helps to identify trends in the body’s ability to manage glucose levels, that shows evidence of trending up towards levels indicative of prediabetes. Early identification of these trends along with the support and identification of resources to incorporate nutritional, behavioral, and physical activity interventions to reduce overweight and obesity behaviors is step 1 in helping the child/adolescent and family manage overweight or obesity. A Table is included in Dr. Magee’s article that presents the prediabetes and diabetes blood work and confirming laboratory testing with a 2-hour blood glucose tolerance testing.

Overweight and obesity and feelings about oneself and mental health

A quick review of the literature using CINHAL and search terms ‘adolescent obesity and mental health’ revealed 190 research studies and using ‘obesity and mental health and children and adolescents’ revealed 178 articles investigating the relationships between overweight and obesity in the pediatric/adolescent population. Adolescents focus on their personal body image and the ways others perceive them. Asking children and adolescents about how they feel about themselves is an important component of each annual health care visit. Approximately 1 in 3 preadolescents (11- 13-years old) and 1 in 4 adolescents experience a mental health issue.

Of importance to mental health in the pediatric/adolescent populations is a study that investigated the association of weight status to mental health in Massachusetts children aged 10 to17 years.

 Study outcomes revealed that overweight/obese children, especially girls, were more likely than children of normal weight to have parent-reported negative emotions.The researchers concluded that this evidence suggests an association between weight status and mental health. In addition, the authors reported that lower levels of physical activity were associated with negative mental health outcomes.

In a more recent study, researchers conducted a 2-year long longitudinal study to examine physical and mental health trajectories of change in youth with a diagnosis of severe obesity.

The study was conducted at a tertiary Canadian pediatric care center. Study participants ranged in age from 3 to 17 years. Study retention rate was 82.9%. Study outcomes included analysis of anxiety and depression in the children. Results revealed that improvement in mental health, quality of life, and cardiometabolic health of children and adolescents of all ages over the 2-year study period.

It is clear that pediatric providers need to assess infants, children, and adolescents for overweight and obesity and provide resources for strategies to reduce the incidence and prevalence of overweight and obesity in the populations that we serve. In addition, school nurses and NPs who interact on a regular basis in school settings should take an active role in primary and secondary prevention strategies to not only reduce the incidence of overweight and obesity but also to avoid anxiety and depression that is often seen in children who are overweight or obese. Implementation of evidence-based strategies in school settings to reduce the incidence of adolescents who enter adulthood with an elevated BMI and potential for multiple comorbidities is an important role for school nurses and NPs.

1. Hoying J, Melnyk B. COPE: A pilot study with urban-dwelling minority sixth-grade youth to improve physical activity and mental health outcomes. 

School nurses and nurse practitioners play an important role in assessing the child’s health status related to obesity, potential for co-morbidities, and implementing appropriate management strategies.