Kristy Luciano, MS, PA-C

 for pediatric health care providers as they care for patients in the age of COVID-19. Spring and summer of 2020 has been challenging on many different levels, requiring health care providers to demonstrate flexibility in almost all aspects of practice. This issue looks at the impact of the pandemic on pediatricians from multiple angles and provides some very practical advice. In the article

 “COVID-19: A battle plan for pediatricians

 ,” Dr. Schuman discusses some of the obstacles health care providers have faced this year and provides some trail markers as we look for a way forward.

As concerned families stayed home this spring in an effort to protect their family and communities, important well child care visits were missed. In a recent report, the Centers for Disease Control and Prevention stated that routine ordering of pediatric vaccines was significantly decreased due to the COVID-19 pandemic. The report showed that from mid-March to mid-April, doctors in the Vaccines for Children program ordered approximately 2.5 million less doses of all routine vaccines and 250,000 fewer doses of measles containing vaccines compared to the same period in 2019.

 It is vital that pediatricians take steps to increase access to care as they do their best to ensure patient safety. This will involve reworking some office procedures that have been in place for generations. In his article, Dr. Schuman provides some specific suggestions as forward-thinking providers attempt to adapt to the current climate in health care.

Strategies to increase patient safety include having patients wait in the parking lot rather than a waiting room, and offering separate well and sick visit appointments at different times of the day. Pediatricians need to communicate the importance of continuing to access health care, including well visits and vaccinations, to their patients. Part of this process should be clearly communicating the safety measures put in place to protect families as they receive health care.

In addition to in-person visits for vaccinations, telehealth visits should be maximized, and billed appropriately. Many pediatricians have not used telehealth in their practice prior to 2020. In this article, various telehealth platforms are discussed, including costs and details pertinent to pediatric practices. An additional layer to evaluating patients virtually is the decision on when to prescribe an antibiotic. Not surprisingly, antibiotics are often not necessary; however, Dr. Schuman discusses some potential guidelines on when it might be appropriate to prescribe antibiotics during a telehealth visit.

In addition, to maximizing safety and health care visits, either in-person or virtually, the author points out the importance of stocking up on personal protective equipment in anticipation of the continued presence of COVID-19 throughout the fall and winter.

This era requires flexibility, openness to new information although rigorously evaluating the available data at the same time, and the ability to communicate effectively with patients and their families via new modalities. As we scramble to keep up, this issue of 

1. Santoli J, Lindley M, DeSilva M et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration — United States, 2020. 

. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2

Articles

COVID-19 has rapidly changed many aspects of life and nowhere is this more apparent than in medical offices. 

Taking on a strategy to tackle COVID-19

Terrill Bravender, MD, MPH, and Lee Smith Bravender, MEd, discuss the 

. This concept emphasizes the importance of undirected, free play in a natural environment. The benefits of this kind of play are significant. It increases activity, may decrease conflict among children playing, and allows kids to use their imagination and create their own world with its own rules. The article gives a lot of suggestions for clinicians and parents on how to facilitate outdoor play, mostly by creating spaces that encourage outdoor creativity. In addition, the authors provide nature play anticipatory guidance by age based on suggestions from 

In ordinary times, there are a lot of barriers to encouraging nature play. Clinicians who see children are incredibly busy, and the number of important topics to discuss at well child visits seems unlimited. The implementation for parents is also complicated. I am a working parent of 3 young children aged 5, 6, and 7 years. Our days are filled with school, Boy Scouts, soccer practice and games, softball, speech therapy, and more. All these things are good things; however, they are also very structured. This article was a good reminder to me as both a clinician and a parent that I need to allow time in our schedule for creative, unstructured play. For me, this means saying no to some good things, opening the back door, and sending the children out to be creative with minimal guidance.

Of course, these are not ordinary times. As I write this, the United States is dealing with the COVID-19 pandemic. The state where I live has closed all K-12 schools and I am working from home and guiding my kids as they continue their education with electronic learning. Every morning their teachers email me detailed reading, math, gym, and art assignments. My 7-year-old son’s gym teacher sends a list of activities for him to do: 10 pushups, 10 jumping jacks, 5 burpees, and so on. I appreciate the ideas and emphasis on physical activity. I also wonder if we are missing the point a little. This article has reminded me to utilize the green space around my house; make water, mud, sticks, and leaves available; and let my children get to work. Prepping our garden space, cleaning up our sticks, raking our remaining leaves are all projects my children can participate in and use as a starting place for more creative play.

Finally, I would be remiss if I didn’t point out that not all children have free access to green space or a door they can open into a big backyard. One way that clinicians can advocate for children is to support or start initiatives that create green spaces in cities and schools that need them.

As we wait for daily life to return to some sense of normal, take the time this spring to incorporate nature play at home and look for ways to encourage your patients and their families to do the same. 

Kristy Luciano is a Physician Assistant who graduated from Midwestern University-Downers Grove Physician Assistant Program in 1999.  She is an Assistant Professor and Director of Didactic Education at Midwestern University and serves as a Member at Large on the Board of Directors for the Society for Physician Assistants in Pediatrics.

As we wait for daily life to return to some sense of normal, take the time this spring to incorporate nature play at home and look for ways to encourage your patients and their families to do the same.

Go outside and play!

current influenza immunization data from the Centers for Disease Control and Prevention (CDC)

.  Researchers looked at the 2016-2017 and 2017-2018 influenza seasons using inpatient data from 7 pediatric hospitals. Severe respiratory outcomes of immunized pediatric patients diagnosed with influenza were studied. Not surprisingly, the data demonstrated that immunization protects against hospitalization. Specifically, over the 2 influenza seasons, immunization decreased the risk of pediatric hospitalizations from influenza-related respiratory complications by 50%. 

In my experience as a pediatric Physician Assistant, discussing vaccination against influenza can go a few different ways. One group of families faithfully vaccinate their children every year. This is the easy group. These patient interactions do not require lengthy discussions about the risks versus benefits of vaccination and there is no tension in the room (at least among the adults, the patient might be a little tense!) Even better, families that fall into this category may initiate an appointment for a nurse-only flu clinic. They actively believe that vaccination is in the best interest of their family and community, and will find a way to get the vaccine.

The next group of families do not believe in vaccinating against the influenza, and often decline immunizations for other vaccine-preventable illnesses as well. Although most of us do our best to discuss the benefits of the vaccine and the risks of influenza to the patient and other members of the community, we understand that this is only 1 conversation in a long discussion. The goals of this discussion may include communicating a clear recommendation, strengthening the relationship with the family by respectfully listening and answering questions if they arise, and being available to facilitate vaccination if the family paradigm changes.

The third group is somewhat unique to the influenza vaccination discussion. These families may immunize against other conditions, but are not concerned about the influenza immunization. I have heard many stories from parents on how their children had influenza last year and ran a fever and coughed for a few days, but otherwise were fine. Other families may have immunized their children against influenza in previous seasons, yet their children acquired the illness anyways. In their minds, this nullifies the need for vaccination in subsequent years. 

These families may benefit the most from targeted, evidence-based patient education supported by the influenza immunization and hospitalization data that is highlighted in this issue. The truth is, although influenza may be a minor viral inconvenience for some patients, in others it leads to serious complications that can include hospitalization and even death. Parents need to be reminded of the facts, including that while their children may still get sick from influenza even though they received the vaccination, the chances of serious respiratory complications and hospitalization are significantly reduced. 

Discussing vaccination against influenza can go a few different ways. For parents who are either unconcerned with the influenza immunization or who had children who received it in previous seasons but still got influenza, a targeted, evidence-based patient education supported by the influenza immunization and hospitalization data could turn the tide.

Focus flu shot vaccine discussions on parents who waffle

Food allergies are a hot topic on the playground, at schools, and in pediatric offices. Parents of children with eczema or atopic dermatitis (AD) often have a lot of questions regarding the connection between eczema, exposure to common food allergens, and the development of or exacerbation of AD.  Pediatricians must advise families on when to start solid foods; if infants should be exposed to eggs, peanuts, or other common allergens; if labs should be ordered; and when they should be evaluated by a pediatric allergist.

Food allergy: A trigger for atopic dermatitis?

 an article by Lisette Hilton. This article discusses many of the complex questions that clinicians must answer when evaluating pediatric patients with AD.

In the article, Dr. Pooja Varshney, clinical assistant professor of pediatrics at Dell Medical School at the University of Texas at Austin and a pediatric allergist states that food allergy is rarely the primary cause of AD. It is well known that food allergies, AD, and allergic rhinitis are related. This relationship is often explained by the term “atopic march”, indicating that some children start out with AD and subsequently develop allergic rhinitis and asthma. This article discussed another way to potentially think of this relationship. Rather than a direct march, these conditions may travel together, and are influenced by genetic and environmental factors.

While food allergies may not cause AD, in some patients they may exacerbate the condition. The author, citing a recent guideline from the National Institute of Allergy and Infectious Disease, provides some helpful guidance for clinicians who evaluate children with AD. First, pediatricians should know that almost 40% of children with moderate-to-severe AD have immunoglobulin E- (IgE-) mediated food allergy. A thorough history in these patients should include questions regarding IgE-mediated allergy symptoms. If present, recommend strict avoidance, refer to an allergist, and consider prescribing an EpiPen.

Children with severe AD should be tested for an allergy before introducing peanuts. These patients should be evaluated by a board certified allergist trained in food allergy. Allergists can conduct skin prick testing, food challenges, provide advice on the safety of early introduction of peanut allergy in high-risk children who are not allergic, and provide follow-up to pediatric patients who have the potential to outgrow their allergies.

Many pediatricians may be tempted to order food IgE panels in patients with AD. Parents may prefer this option as it is often simpler for families to address issues within the primary care setting rather than establish a new relationship with a specialist. However, ordering food IgE panels may cause more confusion than clarity as they can result in misdiagnosis. For instance, what do you say to the patient with AD who tests “positive” for egg allergy but eats eggs without allergy symptoms? The article reminds us that the diagnosis of allergy is most reliable when guided by a solid history and physical exam. In addition, the elimination of foods unnecessarily may increase the risk of developing an anaphylactic food allergy. This is especially important to remember in children with AD who are at higher risk for developing food allergies. When possible, evaluation by an allergist is in the patient’s best interest rather than eliminating a food he or she may not be allergic to.

It can be difficult to make evidence-based management recommendations to families of infants with mild- to moderate-AD whose parents are concerned about food allergies. In the past, these parents may have been told to try an elimination diet, either in the mother’s or child’s diet depending on the age of the patient. Elimination diets were seen as a low-risk way to determine if eliminating common food allergens would improve the patient’s AD and perhaps help indicate a potential food allergen. The article in 

 reminds us that there is not much evidence to support management of AD with an elimination diet.  In fact, it may increase the patient’s risk of developing an anaphylactic food allergy.

The article also cites an American Academy of Pediatrics guideline regarding nutritional interventions for the prevention of AD. The guideline does not recommend changing the mother’s diet or support the use of hydrolyzed formulas to prevent the development of allergies.

Food allergies represent a constantly evolving field. This article helps clinicians stay up-to-date and navigate the daily decisions that will help protect their patients from food allergies and maximize control of AD.

Food allergies are a hot topic on the playground, at schools, and in pediatric offices. Parents of children with eczema or atopic dermatitis (AD) often have a lot of questions regarding the connection between eczema, exposure to common food allergens, and the development of or exacerbation of AD. There are many of the complex questions that clinicians must answer when evaluating pediatric patients with AD.

Author | Kristy Luciano, MS, PA-C

Articles

Taking on a strategy to tackle COVID-19

Go outside and play!

Focus flu shot vaccine discussions on parents who waffle

How treating food allergies and AD has changed