Lois Levine

This week, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry (AACAP), and the Children's Hospital Association have declared a national state of emergency in child and adolescent mental health. 

 spoke with Dr. Matthew Biel, assistant professor of clinical psychiatry and Director of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital, and AACAP member and expert about the current state of emergency and what pediatricians can do to help this national crisis.

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The AAP, AACAP, and CHA call on policymakers to act quickly to address the children's mental health crisis 

National emergency in children's health declared

“Adolescent depression has almost doubled since the pandemic, going from 13.3% to 25.2%” noted Christina Low Kapalu, PhD, pediatric psychologist at Children’s Mercury in Kansas City, Missouri at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. “We also know that older adolescents, females, and those with 2 or more races have the highest rates.” The situation is further exacerbated, Kapalu states, by the fact that “There has been reduced screenings in primary care for depression and anxiety and increases in presentation to the emergency department (ED) for mental health concerns,” continued Kapalu.

When looking at the core symptoms of depression: amotivation, fatigue, psychomotor slowing, change in appetite, hopelessness, and difficulty concentrating, it becomes clear, says Kapalu, that “lifestyle modifications can be incredibly helpful in addressing some of these symptoms.”

Additionally, emerging research in children and adolescents reveal that poor diet, physical isolation from peers, sedentary lifestyle, and poor sleep convey additional risk for mental health depression, which opens the door to using lifestyle medicine to address some of these symptoms. “Lifestyle medicine, she explains, “involves the application of environmental, behavioral, and psychological principles to enhance patient outcomes.” Specifically, these include sleep, physical activity, connecting with others, nutrition, mindfulness/relaxation, and reduced screen time, all which are used for the treatment of unipolar depression. And while these treatment have been used as guidelines in adult treatment for depression, the pediatric guidelines “have been less specific,” Kapalu points out, instead recommending active support and monitoring, psychoeducation and peer support. Ideal child and adolescent candidates for lifestyle medicine would be those with mild to moderate depression, who are motivated to change, have few comorbidities, and depression of shorter duration. “While studies have been done that show risk factors for suicidal ideation in teens include sleep dissatisfaction, stress, substance use, smoking, internet game addiction, interpersonal factors and binge-eating disorders, there have been fewer studies that looked at modifying these lifestyle habits to reduce suicidal risk,” observed Kapalu.

So, how to help these patients make change that sticks? It is important to note that when recommending lifestyle changes (such as physical activity or nutrition), your patient may not be ready to change. Here, she brings up a classic model of behavioral change by Picasa and DiClemente, which shows change as a process. They include precontemplation; contemplation; preparation; action; and maintenance. Additionally, these changes should be implemented through SMART goals: specific, measurable, attainable, realistic, and time-limited. Finally, Kapalu urgers practitioners to keep the “rules” of behavioral change: resist telling the patient what to do; understand their motivation; listen with empathy; and empower them.

1. Kapalu CL. Using a lifestyle approach to manage adolescent depression. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 10, 2021.

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At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Christina Low Kapalu, PhD, discusses evidence-based lifestyle interventions that should be part of an adolescent depression management and treatment plan.


Using a lifestyle approach to manage adolescent depression

“While the surge of teen vaping levels off, it still remained high as of early 2020,” said Maria Rahmandar, MD, FAAP, medical director of the Substance Use & Prevention program at Lurie Children’s Hospital in Chicago, Illinois, during her presentation at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. “We also still don’t know what has happened in the past year, and should find that out in a couple of months. What we do know is that teen mental health has suffered during the pandemic, and so we can only imagine what’s going on with youth e-cigarette use.” Rahmandar also noted that as children are now back to school, e-cigarette use will again become a huge problem in high schools, with students using on school grounds, in bathrooms, and even classrooms.

Rahmandar next discussed the types of e-cigarettes available, which include cig-a-likes, vape pens, mods, advanced personal vaporizers, e-cigars and pipes, and pod systems. As some of these e-cigarette users inhale into their lungs, bystanders can also inhale the aerosol when the person who is using the e-cigarette exhales. E-cigarettes contain varying amounts of nicotine as well as propylene glycol, vegetable glycerin, flavoring, and other compounds. Additionally, they can contain carcinogens, heavy metals, and ultrafine particles.

“The risks of e-cigarettes, as we know, can initiate use of combustible tobacco products, result in nicotine addiction, poisoning and burns,” said Rahmandar. “There are also both emerging and unknown long-term health risks.”

In helping teenagers to stop e-cigarette use, Rahmandar urged practitioners to ask these patients about tobacco use at every visit and make asking routine, consistent, and systematic, with questions such as “Do you use any tobacco products, like cigarettes, hookah, or chrewing tobacco? Have you used them in the past year?” Additionally, Tahmandar suggests, consider screening for other mental health concerns using the PHQ-A screening for depression or the GAD-7 screening for anxiety. Using other tools, such as the Hooked on Nicotine Checklist may show the teen that they are, in fact, addicted to nicotine. If you find your teenager is ready to quit, help them set a time, within 2 weeks, and avoid stressful periods like final exams. “Also,” says Tahmandar, “there are cessation support services like Smokefree Teen, and This is Quitting, as well as 1-800-QUIT-NOW, to help teens stop their e-cigarette habit.”

For patients not quite ready to quit, you can discuss the  relevance and risks of not quitting; roadblocks that may arise; and repetition: that it may take several attempts to succeed in quitting. Having e-cigarette resources handy in your office such as brochures, posters, and videos can also be helpful.

At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Maria Rahmandar, MD, FAAP, reviews issues surrounding teen e-cigarette use in schools, along with methods to help teens quit.









It takes a village: community interventions to address teen e-cigarette use

"Evidence is constantly changing and we expect new guidance and therapeutics in the coming months," began Ibukun Kalu, MD, assistant professor, and medical director of Pediatric Infection Prevention at  Duke University in Durham, North Carolina on her presentation of MIS-C at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. Kalu first took a look at the history and current definition of this disease, noting that “paediatric inflammatory multisystem syndrome” associated with COVID-19 was first described in the United Kingdom in April 2020. The increase in cases of this Kawasaki Disease (KD)-like syndrome started about 2 weeks after the rise in acute COVID-19 infections, Kalu noted. Subsequent cases described in the United State became known as MIS-C.

“The first lesson here,” Kalu said, “is that, with surging community rates of COVID-19, we expect subsequent surges of MIS-C cases.” Current data, Kalu explained, shows very high peaks from this past summer up through September, due to the Delta variants spreading amongst other changes in behavior and protocol practices. The CDC tracking graph also shows MIS-C cases starting to peak this past summer, going from some 20,000 cases in the United States in early July to roughly 130,000 in late August.

Kalu next addressed racial disparities of MIS-C, with both Hispanic and non-Hispanic Black children having higher rates of both COVID-19 and MIS-C. “Data from the CDC summarizing patients with MIS-C by ethnicity and age group shows children aged 6 to 11 years old who are Hispanic and non-Hispanic Black having the highest number of cases,” said Kalu. A study of 869 hospitals from March 2020 to October 2020 showed 39% of children hospitalized were Hispanic, as opposed to 25% who were non-Hispanic White. Additionally, children requiring hospitalizations for COVID-19 were more likely to have cardiac or congenital heart disease, prematurity, immunocompromising conditions, obesity and other comorbidities.

Kalu went on to summarize the common symptoms of COVID-19 in children, which include cough and fever, fatigue, headache, abdominal pain, diarrhea, nausea, and poor appetite.

“Current variants of concern,” said Kalu, is Alpha, first identified in the United Kingdom, which spreads much faster than other variants. The Delta variant clearly seems to have more severity in adults, commented Kalu, “Although the concern is that we will start seeing more kids hospitalized from this and also have more post COVID-19 symptoms.”

Kalu then pointed to the similarities between MIS-C and KD. The mean age of children developing MIS-C is 8.5 years; with KD, 3 years. There are, however, many similarities in symptoms, including fever, rash, conjunctivitis, with some level of lymphadenopathy occurring in both. “However,” notes Kalu, “there does seem to be more cardiac dysfunction and gastrointestinal symptoms when MIS-C is the diagnosis.” And, death associated with MIS-C is still higher than death associated with KD. Kalu went on to review symptoms leading to diagnostic certainty of MIS-C, which include fever for more than 3 consecutive days and 2 or more of clinical features, including rash, gastrointestinal (GI) issues (abdominal pain, vomiting, diarrhea), shock/hypotension, and neurologic (altered mental status, headache, weakness, etc.)

Kalu moved on to her next point, that GI symptoms with signs of cardiac inflammation should raise in the practitioner the suspicion of MIS-C. Treatments for MIS-C include immunoglobulins plus or minus steroids, and aspirin due to the cardiac inflammation. Quite often anticoagulations may also be used.

The good news, Kalu noted, is that “currently, long-term morbidities or complications after MIS-C are rare. While long-haul COVID-19 symptoms include fatigue, headache, attention disorder, hair loss, and dyspnea, a new study in the 

Journal of the American Medical Association

 showed, that, at a 1 year follow up, 76 patients who had MIS-C showed normalized lab tests and no deaths.

For practitioners, Kalu recommended telling patients and caregivers “there are increased risks of MIS-C after a COVID-19 infection in some patients,” to use awareness of the disproportionate impact of COVID-19 and MIS-C to inform decisions, and to commit to reviewing updated guidance on recommended therapeutics for COVID-19 and MIS-C that can be used safely for children.

Kalu I. Multisystem Inflammatory Syndrome in children: lessons learned, next steps. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 10, 2021.

At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Ibukun Kalu, MD, discussed what is known about the pathophysiology of multisystem inflammatory syndrome in children and implications for related diseases such as Kawasaki syndrome.

Multisystem inflammatory syndrome in children: lessons learned, next steps

“Sleep disorders may not be at the front of your mind when evaluating a child for the first time, with inattention, hyperactivity, or behavioral disturbances,” began Grace Wang, MD, FAAP, assistant professor of pediatrics, Penn State Health in Lancaster, Pennsylvania, at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. “I hope to convince you, by the end of this talk, that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have a consistently higher prevalence of sleep disorders as compared to the general pediatric population. There is evidence that shows that resolving the underlying sleep disorders can improve and in some cases, resolve, a patient’s ADHD diagnosis.”

“Sleep disorders are not listed in the differential diagnosis of ADHD in the 

,” Wang continued. This, Wang believes, is why practitioners evaluating children for ADHD might not have it on their radar to screen for sleep disorders.

Wang went on to describe several case studies, the first being a 6-year-old female with seasonal allergies and dysfunctional voiding patterns in the context of constipation; hyperactive and emotionally labile; threw frequent tantrums; has difficulty sustaining attention; and is starting to fall behind her peers at school. She had no past surgical history, no family history of ADHD, and family would rather not start her on a stimulant, asking if anything else can be done. She presented as an alert girl with normal vital signs, normal intellect, good eye contact and cooperative with interview. Vanderbilt parent/teacher rating scales are implemented and the child screens for ADHD, combined type. Psychometric testing reveals normal intellect with no learning disabilities. In recalling that sleep disorders can be seen in children with ADHD, the physician asks about snoring, and discovers the child does indeed snore, is a mouth breather, is restless throughout sleeping and occasionally sleepwalks. Furthermore, she is exhausted after school, falling asleep in the car on the drive home. This prompts a polysomnography, which shows she has sleep-related hyperventilation, and a mild/ borderline degree of obstructed sleep apnea syndrome (OSAS).

At this point, Wang interjects, “Studies have shown that 25% of children with ADHD have OSAS, and 33% have snoring. Additionally, 25% to 64% of patients with ADHD have some sort of sleep-disordered breathing.” The million-dollar question then becomes, Wang, admits, “can you expect improvement of ADHD symptoms after addressing sleep disorders? Literature shows that adenotonsillectomy in treating sleep disorders does improve ADHD symptoms and may even resolve the diagnosis,” proven in studies such as the Childhood Adenotonsillectomy Trial, which showed improved quality of life and behavior ratings by parents and teachers, says Wang. She points to a remarkable study of 5 to 13 year old children, where 28% were diagnosed with ADHD before an adenotonsillectomy. One year after the surgery, half of those children no longer met DSM criteria for ADHD. Similarly, ADHD scores were normalized in 69% of 40 children who had undergone the surgery 6 months prior.

Returning to the case study of the 6-year-old-child with a diagnosed sleep disorder, it was ultimately recommended that she get an adenotonsillectomy. Not only did her sleep improve after the surgery, but so did her attention span and behavioral issues.

Another patient discussed in this session was a 15-year-old male with Delayed Sleep-Wake Phase Disorder, a condition where children do not feel as sleepy as their peers at bedtime because of the delayed release of melatonin. Treatments for this condition include consistent weekday and weekend sleep schedules; avoiding blue light in the evening; and exposing the child to bright, natural light upon waking. If these do not resolve the disorder, sleep medicine and behavioral therapy are often suggested.

Wang also went into a discussion of restless leg syndrome (RLS) in patients with ADHD, which can be treated with iron supplements, leg massages, compression devices, and lower body exercises.

In concluding, Wang summarized, “keep that high index of suspicion for both sleep disorders and RLS in children with ADHD; as RLS runs in families, ask about RLS in the biological parents and siblings; and as iron deficiency is a risk with RLS, be sure to check on that as well. Also, she stated, since sleep deprivation and RLS can mimic symptoms of ADHD, have a high index of suspicion when examining and screening a patient for these conditions.



1. Wang G. My child won’t sit still! Is it ADHD, or an underlying sleep disorder? American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 9, 2021.

At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Grace Wang, MD, FAAP, discusses how treatment of underlying sleep disorders can improve ADHD symptomatology.


My child won't sit still! Is it ADHD, or an underlying sleep disorder?

On the second day of the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Dr. Hernandez-Trujillo, division director, Allergy and Immunology, and fellowship training program director, Allergy and Immunology at Nicklaus Children’s Hospital in Miami, Florida began her session on essential advice for preventing food allergies in children by explaining, “Food allergy affects approximately 8% of children, roughly 2 children per classroom in the United States. “With the pediatrician playing a key role in early nutrition, discussion with parents regarding solid food introduction is essential.”

New parents and families often ask about the need for dietary restriction during pregnancy, noted Hernandez-Trujillo, but there is in fact a lack of evidence supporting dietary restriction during both pregnancy and lactation. Having said that, Hernandez-Trujillo pointed out, “exclusive breastfeeding during the first 3 to 4 months of a child’s life does decrease incidence of eczema in the child’s first 2 years.” Breastfeeding beyond 3 to 4 months protects against wheezing in the first 2 years as well.

Other questions that parents often ask pediatricians is about formula choice and delayed introductions of food, says Hernandez-Trujillo. On these points, there is no convincing evidence for use of soy-based formula in allergy prevention, little evidence that hydrolyzed formula prevents atopic disease, and no evidence supporting delayed introduction of solid foods beyond 4 to 6 months in protection against atopic disease.

“The times are changing: the recommendations of avoidance of solids and ‘allergenic’ foods until 3 to 5 years old are no longer advised,’ says Hernandez-Trujillo, but breastfeeding for 4 to 6 months is recommended, with no introduction of solids until at least 4 months of age.” In noting the Learning Early About Peanut Allergy (LEAP) study, Hernandez-Trujillo said, “the take-home message of this study was that the early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk.”

Next, Hernandez-Trujillo pointed to the 2016 Enquiring About Tolerance (EAT) study, which was designed to investigate the best time to introduce 6 allergenic foods to the infant diet: cow’s milk, peanut, egg, sesame, fish, and wheat. The study proved that early introduction of this food group resulted in lower food allergy prevalence, was achievable and safe.

Hernandez-Trujillo went on to discuss the addendum guidelines for the prevention of peanut allergy in the United States, a report from the National Institute of Allergy and Infectious Disease. The summary guidelines state that infants with either egg allergy, severe eczema or both should be evaluated by testing to peanut prior to introduction; infants with mild to moderate eczema should be introduced to peanuts at 6 months; and infants with no eczema or egg allergy should be introduced at the preference of parents.

When it comes to peanut introduction, says Hernandez-Trujillo, “always keep in mind the form of food given to an infant or toddler, and remember the choking risk.” Additionally, “regular consumption early on is needed to ensure tolerance: encourage consumption of 2 teaspoons of peanut butter 3 times per week,” she said. There should be no food introduction if the child is sick, and finally, she adds, “Adults should spend at least 2 hours after feeding to monitor possible allergic reaction.” Good peanut products to try, she suggested, include peanut puffs, thinned smooth peanut butter, smooth peanut butter puree, and peanut flour or peanut powder. And “while allergic reactions are rare at the time of introduction,” she warns, “if there is a severe allergic reaction, child should avoid the food and be evaluated and tested, with no reintroduction until the testing is completed.” She also reminded health care professionals that “anaphylaxis can be difficult to diagnose in infants, since they are non-verbal, so adults need to be able to monitor and identify any potential allergic reaction.” Finally she noted, “be aware of panel testing. Broad food panels can result in unnecessary avoidance of foods. Furthermore, children who eat a food and are tolerating it should continue to consume that food, something to keep in mind because while panel testing may be easy, it really does lead to some unnecessary avoidance of food and can impact the overall nutrition of the child.”

Hernandez-Trujillo concluded the session with highlighting overall strategies for safe introductions of foods which included open communication with parents regarding the benefits of early introduction; offering in-office feedings for patients who may be at risk of reaction; review of signs and symptoms of allergic reactions; and steps to take if an allergic reaction occurs. She also reminded practitioners to discourage dietary restrictions during pregnancy or breastfeeding to prevent atopic disease and to remember, “if a child has developed food allergy, treatment requires identification of the allergen and dietary restriction.”

1. Hernandez-Trujillo V. Essential advice on preventing food allergies. 2021 AAP National Conference & Exhibition, virtual. Accessed October 9, 2021.

At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Vivian Hernandez-Trujillo, MD, FAAP, FAAAAI, FACAAI, division director, Allergy and Immunology, and fellowship training program director, Allergy and Immunology at Nicklaus Children’s Hospital in Miami, Florida presents a session on best practices for preventing food allergies in newborns and infants.