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

One year ago, and more than 9 months into the COVID-19 pandemic, everyone was asking if and how children could return to school safely in the unprecedented COVID-19 pandemic.

 One year later, with the remarkable successes of the development and free distribution of 

 COVID-19 vaccines for adults and 1 vaccine approved via emergency use authorization for children aged as young as 12 years, one would think that the return to school would be so much easier. And yet, as we all know, communities, parents, and educators have raised numerous questions on return to school and are strongly divided on 3 major issues: 1) Vaccinating all school personnel (inclusive of educators and all employees within the school system); 2) Wearing masks in school and in school outdoor activities that impact transmission; 3) Complying with other mitigation behaviors that reduce transmission of COVID-19 and in particular, the delta variant. Lois Levine’s interview with Sara Bode, MD, 

“What will the coming school year look like?”

 features guidance that focuses on the issues related to providing a safe school environment, including social distancing of 3 feet when in the classroom and maintaining this distance during cafeteria-style meals, school sports that have close contact, such as soccer and football, and most importantly the need to vaccinate everyone eligible to receive the COVID-19 vaccine.

School nurses and nurse practitioners (NPs) who practice in school based health care centers (SBHCs) as well as pediatric nurses and NPs who practice in primary care settings also provide guidance on keeping children safe at school to parents, children, and adolescents. In fact, school nurses and NP in SBHCs are on the front lines of controlling the COVID-19 virus in school settings. In addition, they talk with parents who are fearful for their child’s safety and also with parents and educators who are resistant to 1 or all of the safety and health care recommendations such as mask wearing, social distancing, and acceptance of the COVID-19 vaccine. It is a tremendous strain on each of these providers, as our role and passion is caring for children and families with the overall goal of helping parents keep their children healthy and safe. How can we accomplish this goal if there is an overwhelming resistance to safety such as masks and vaccines during a pandemic that attacks those who are most vulnerable, which, as we know, are unvaccinated adults, individuals who are immunocompromised, and children aged younger than 12 years who are not eligible, to date, for the vaccine?

Pediatric nurses and NPs guidance for parents and educators

Supporting the American Academy of Pediatrics position on having children return to school safely, and Dr. Bode’s responses to parental questions is step 1 when considering what to say to parents. Our message should also include the words: COVID-19 is a vaccine-preventable disease and the vaccine is scientifically shown to prevent serious illness, hospitalization, and death.Parents who are vaccinated protect their children from direct household exposure. Although we need to listen to parental and educator concerns, our responses must be strong and firmly focused on our health care mission to protect children, speak with those who are vaccine resistant, and direct those with questions to correct information about the benefits of masks, social distancing, and vaccines.

Parents may need to consider potential outcomes of resistant behaviors. The trauma of watching a child who is critically ill, in a pediatric intensive care unit (PICU), is one no parent should want to experience, and may not have considered this as a possible outcome. COVID-19 does cause this trauma and children are in the PICU struggling to breathe in states with low vaccination rates and no public health measures. Parents often report experiencing lifelong trauma after losing a child to any disease or accident. All pediatric nurses and NPs also experience the trauma of these losses. Our message needs to be that these traumas can be prevented and/or minimized through basic safety measures, and we are all responsible for protecting the children in our care, communities, and throughout our country.

I believe that we are all hoping that the August 2022 edition of 

 has a return-to-school article that says we have conquered the COVID-19 beast and that our educational system has been course corrected and the future for our children is bright.

1. Hallas, D. Spratling, R. Cupelli, E. Safe return to school: A call to action

2. Koslap-Petraco, MB. Taub, A. Hallas, D. Safe return to school: Part 2. Published August 19, 2020. Accessed August 23, 2021. 

https://www.contemporarypediatrics.com/view/safe-return-to-school-part-2

3. Levine, L. What will the coming school year look like? 

Articles

Children are returning to school, amidst a pandemic that is surging and even more dangerous for the pediatric population. How can pediatric nurse practitioners keep children safe?

Returning to school, once again, during a surging COVID-19 pandemic 

“Helping parents cope with adolescent behavior

 provides a comprehensive review of emotional and behavioral changes that occur throughout the adolescent years. The article focuses the role of pediatricians helping parents and adolescents understand the vast array of emotions including promising behaviors as well as at-risk behaviors, eg, substance use, that can lead to troubling consequences for the adolescent and the parents. Jellinek describes the flux of emotions in cycles that occur on a pendulum with behaviors that demonstrate the promise of entering young adulthood with mature cognitive and emotional responses to a more toddler-like behavioral swing that frustrates parents, teachers, coaches, their friends, and perhaps, themselves. I highly recommend reading Jellinek’s article.

Thinking about adolescent emotional/behavioral swings during the COVID-19 pandemic

The normal day-to-day lives of adolescents have changed significantly over the past 18 months during the COVID-19 pandemic. Their routine behaviors, eg, meeting and interacting with friends, participating in sports, the anticipated experience by adolescents of ‘newfound’ freedoms, the excitement of entering high school, preparing to enter schools of higher education, and/or a first job have all been either put on hold or significantly altered during the pandemic.

Most adolescents have experienced at least some form of virtual education throughout the COVID-19 pandemic. For many, their first return to a classroom, either high school or college, will be this Fall 2021 semester. However, for high school students, return to school may be impacted by the current community spread of the Delta variant in areas of the country that have a high number of unvaccinated populations. How has virtual education impacted the totality of adolescent growth and development experiences? We do not have the answer to this question, as yet. Many pediatric providers schedule extra time for the annual adolescent visit. Today, this extended time for the visit is more critical than ever, to allow time to talk with the adolescent, identify real or potential emotional and/or behavioral health problems and make sustainable plans to assure the adolescent is on the path to healthy behaviors.

What about adolescents who lost a parent, sibling, relative, or friend to COVID-19?

On July, 20, 2021, the National Institute of Health published a news release based on a published research studyrevealing that 1.5 million children around the world lost a primary or secondary caregiver due to the COVID-19 pandemic.

 The United States was identified as 1 of 6 countries with the highest numbers of children who lost their parent or primary caregiver during the pandemic. As pediatricians and pediatric nurse practitioners, it is essential to consider the loss of a parent by an adolescent and the influences and possible consequences of this loss on the adolescent emotional and behavioral development. Has the adolescent even had time to grieve the loss of their parent or caregiver? Who is now supporting the adolescent? Has the adolescent received counseling for their loss? How is the adolescent coping with the loss? This is a critical time to administer and interpret validated screening tools, such as the Patient Health Questionnaires (PHQ-2

 or the Screen for Child Anxiety Related Disorders (SCARED) tool,

 during each of the office visits. These tools will help to identify the emotional and behavioral status of adolescents who have lost a parent, and to implement evidence-based treatment plans to help the adolescent cope and emerge mentally and physically healthy. In addition, as Dr. Jellinek discusses, it is also essential to screen for suicide ideation in adolescents and even more so, for adolescents who have lost a parent or primary caregiver during this pandemic. The mental health, emotional and behavioral health of our adolescents must addressed in each primary care encounter.

1. Hillis S, Unwin H, Chen Y et al. Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study. 

. July 20, 2021. Epub ahead of print. doi:10.1016/s0140-6736(21)01253-8

2. National Institute of Health. New Release: More than 1.5 million children lost a primary or secondary caregiver due to the COVID-19 pandemic

Published July 20, 2021. Accessed July 20, 2021.

 https://www.nih.gov/news-events/news-releases/more-15-million-children-lost-primary-or-secondary-caregiver-due-covid-19-pandemic

3. American Psychological Association. Patient Health Questionnaire (PHQ-9 & PHQ-2). Accessed July 22, 2021.

 https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health

4. The CRAFFT Questionnaire (version 2.0). Accessed July 22, 2021.

 https://njaap.org/wp-content/uploads/2018/03/COMBINED-CRAFFT-2.1-Self-Admin_Clinician-Interview_Risk-Assess-Guide.pdf

5. Generalized anxiety disorder GAD-7. Accessed July 22, 2021. 

http://www.medi-mouse.com/graphics/GAD7.pdf

6 .Screen for child anxiety related disorders (SCARED). Accessed July 21, 2021.

 https://projectteachny.org/wp-content/uploads/2017/09/SCARED_child.pdf

Adolescence is often a time when a teenager swings between maturity and childish behavior. This already fraught period has been exacerbated by the effects of the pandemic as well.

Understanding the perplexing adolescent years

Summer is here, and at last, there is hope that the summer of 2021 will provide individuals and families’ opportunities to return to a more normal lifestyle, as many states and regions in the United States have achieved a COVID-19 vaccination rate at or approaching herd immunity. As exciting as this news is, the June issue of 

brings us back to the reality of summer and reminds pediatric nurse practitioners (PNPs) of the possible perils of “summertime fun.” In the blink of an eye, a child can quickly go from being healthy and inquisitive to sustaining an injury, a life-threatening disease, or die in a water-related accident. There are 3 articles that focus on summer concerns: Drs. Hefter and Hamdy’s article entitled "

Common recreational water illnesses in children

;”and Dr. Porter and Ms. Hughes article, “

How one child’s tragedy is making us reconsider our approach to drowning prevention

.”These authors present substantial evidence for inclusion of information about summer safety as a routine part of anticipatory guidance for all parents, children, and adolescents. Many parents may not have appointments for their children in the pediatric office early in the summer months; thus, pediatric providers should consider messaging parents, either via email, text or via their office-based websites, anticipatory guidance that increases the awareness of parents about summer safety concerns. We cannot reverse some potential summertime tragedies, but we can strive to prevent them.

In their article, “Common recreational water illnesses in children,” Drs. Hefter and Hamdy present information and treatment for water illnesses that are responsible for a number of summertime office visits, including gastrointestinal, skin, otitis externa, and acute respiratory infections. Recognizing the offending organisms and prompt treatment is an essential role of the pediatric provider. Additionally, the authors present key tips that PNPs can use as part of parental anticipatory guidance for summer safety via avoidance of infections by using safe water practices. This article is a must read for all PNPs.

In the article, “Preventing summer accidents,” Dr. Jellinek presents a comprehensive list of history questions that PNPs can choose to ask parents and/or teens about summertime behaviors including those that address the emotional and psychosocial issues that impact the risk for summertime injuries. Dr. Jellinek recognizes the need to prioritize summer safety as part of routine care prior to and throughout the summer months. I recommend reviewing the history questions and make a note of those you would like to include when talking to parents and teenagers.

You feel and experience sadness as you read the article “How one child’s tragedy is making us reconsider our approach to drowning prevention”by Dr. Porter and Ms. Hughes. Details of the tragic drowning death of Ms. Hughes’ 3-year-old son are presented. “One moment, he was sitting on the couch watching TV. In the next, I was pulling his lifeless body from the bottom of a pool.” All efforts to save the life of this young child failed. PNPs have heard these stories, have been on the scene in the emergency department when a child/adolescent arrives, and have taken care of the near-drowning victims in the intensive care unit, and in long-term pediatric care facilities. Data revealed that 40% of drownings treated in the emergency departments require hospitalizations or transfer for further care.1 There are no words to comfort parents, siblings, and family members…just overwhelming sadness.

In the United States, drowning is the second leading cause of unintentional death in children aged 1 to 4 years.

 Dr. Porter and Ms. Hughes researched the type of swimming lessons available for infants and children aged 6 months to 4 years. Their search of the literature showed a lack of research evidence-supported types of swimming lessons that would protect young children and prevent death or near drownings. The characteristics of formal swim lesson programs for children aged 6 months to 4 years are primarily family centered with a focus on treading water and swimming, rather than on aquatic survival. Only 1 of the 3 types of programs presented identified the primary goal for infants and young children as aquatic survival. In an aquatic survival program, infants and young children are trained to float and to roll the body to find the surface and get air. The focus of the swim lessons was on survival and a respect for water.

Ms. Hughes discusses how much children like water and are attracted to water, and that many children wear flotation devices that make them falsely believe that water is safe. This false belief places infants and young children at increased risk of drowning. They do not have the intellectual comprehension to understand the danger.

Recently, I saw an advertisement for ‘coloring the water’ in at-home in-ground swimming pools. When I saw the advertisement for dark water in the swimming pool, I immediately realized the danger to everyone who would swim or be near that pool. I was most concerned about young children, thinking how would an infant or child be seen if he or she slipped under the water.

There are so many advances in technology, that the question should be raised: Can technology, yet to be developed, change the outcome of deaths due to unintentional drowning in infants and young children? I wonder if a sensor could be designed for swimming pools that activated an alarm if anyone weighing less than 50 pounds entered the swimming pool when there was no adult supervision. Dr. Porter and Ms. Hughes support research on water and pool safety. There are so many drownings to be prevented each year. Rigorous research studies on drowning prevention are so needed.

1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS). Accessed June 14, 2021. 

https://www.cdc.gov/injury/wisqars/index.html

Addressing the need to be proactive in promoting safety during the summer months.

Let’s proactively support summer water safety

Surveying the article topics in the May 2021 issue of 

, there is a small but promising sense of comfort that perhaps, as a nation, we are at last defeating the COVID-19 pandemic. For the first time in 15 months, there are no major articles on COVID-19. The news release by the US Food and Drug Administration on May 10, 2021 and the Centers for Disease Control and Prevention on May 13, 2021 of the emergency use authorization (EUA) for the Pfizer/BioNTech COVID-19 vaccine for adolescents aged 12 to 15 years provides further assurance for defeating the COVID-19 pandemic. All pediatric health care providers and many parents have been anxiously awaiting the EUA for the Pfizer/BioNTech vaccine. The data from the randomized control trial (RCT) for 12- to 15-year-old participants are so powerful: 100% efficacy for the children enrolled in the study. Now is the time for all pediatric providers to speak with their parents about getting their children immunized.

Asthma presentation in children and adolescents during the COVID-19 pandemic

At the beginning of the pandemic, children and adolescents who had a confirmed diagnosis of intermittent or persistent (mild, moderate, or severe) asthma, were feared to be at high-risk for contracting COVID-19 and poor outcomes. However, we now know that children and adolescents with a diagnosis of asthma have not presented with increased wheezing or asthma exacerbations during the COVID-19 pandemic. After reviewing data from children and adults who were infected with COVID-19 in China during the initial outbreak, a large epidemiological study did not include asthma as a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or an increased risk for severe COVID-19 disease or death.

 Additionally, the pathology of SARS-CoV-2 infection shows that the virus’s spike protein binds to the angiotensin converting enzymes (ACE) 2 receptors and children have lower ACE 2 receptors than adults, thus, children have limited infection and/or less severe infection.

Can we better control asthma in children/adolescents post pandemic?

, Ms. Zimlich describes the many medications for management of asthma that may be included in the upcoming update to the 2007 asthma guidelines. Thoughtful and evidence-based management for children and adolescents with asthma is critical to their health and well-being which includes their ability to be like other children, running and playing freely, and breathing without effort.

The COVID-19 pandemic has provided new insights on many aspects of primary care but especially for children and adolescents with a mild-to-moderate asthma diagnosis. Evidence of less disease burden for those with an asthma diagnosis during the pandemic raises 2 important questions: 1). Was the pathophysiological effects of the COVID-19 virus’s spike protein and the lesser binding ability (lower ACE 2 receptors) in children and adolescents the main reason for a reduction in asthma disease burden? and 2). Was the primary reason for decreased disease burden highly correlated to ‘stay at home orders,’ mask wearing, social distancing, and the cleanliness of the school and home environments – all primary prevention strategies?

If the answer to question 2 is yes, then the primary care management for those with asthma must be focused on primary prevention strategies as first line management. To determine the ‘next norm’ for management of asthma, it may be prudent to conduct practice quality improvement (QI) projects to determine the status of the child or adolescent’s pre-pandemic symptoms and management to his or her status during the pandemic to then improve the management for the ‘next norm.’ Pediatric nurse practitioners are uniquely prepared in primary care and many are prepared in QI initiatives to lead practice-based initiatives and problem solve to better manage the care of those with asthma through both pediatric and family-centered care management strategies. Parents and their children and adolescents should be active participants in the identification of triggers, management of the triggers prior and during the pandemic, changes in the control of their personal environment(s) pre and post pandemic, and perhaps behavioral therapies for stress reduction to clearly understand the ‘next norm’ for management of asthma without undue dependency on medications. In addition, we look forward to new asthma practice guidelines that consider the significance of pandemic outcomes for those with a diagnosis of asthma.

1. Lu X, et al. SARS-CoV-2 infection in children. 

2020;382(17):1663–1665. doi:10.1056/NEJMc2005073.

2021;1-6. doi: 10.1007/s00408-021-00419-9.

As the COVID-19 vaccine expands to include more of the pediatric population and restrictions continue to loosen, what's going to happen now?

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

Articles

Returning to school, once again, during a surging COVID-19 pandemic

Understanding the perplexing adolescent years

Let’s proactively support summer water safety

Beginning to emerge from the COVID-19 pandemic: What’s next?