Lois Levine

I think probably one of the most important issues that came up [in 2022] was the mental health crisis that occurred in the pediatric population. The pandemic really had some major effects, especially on adolescents that had underlying anxiety or depression, and really pushed these kids to the edge, where there were many more of these kids that were trying to commit suicide, which I think is just really very sad. But I think because we now recognize that there's so many mental health issues that were brought to light, we really are able to identify these kids and help them.

Other trends that I think were really important in 2022 was the approval of the COVID-19 vaccine for use in infants and children down the six months of age. You know, for a long time, during the pandemic, there was this misinformation that was out there that people believe that either children did not get COVID. Or if they got COVID, they didn't get sick. And we know that's not true. So with the approval of the vaccine, down to six months of age, we are now able to protect so many more of these kids from getting COVID. And we really have to encourage providers to vaccinate their children with the COVID-19 vaccine.

The pandemic really did change the pattern with which the respiratory viruses circulate. We don't really understand why that occurred. But we do know that RSV influenza, even COVID, these surges are occurring much, much earlier than they normally would. And, you know, the RSV surge is very interesting, because there was a surge during the summer, even though it was smaller. And then in October, we started to see a major surge, which, as you said, has really completely strained the pediatric healthcare system. One thing about RSV is that it is a respiratory virus for which the care is really supportive. So the use of antibiotics and the use of albuterol as well as steroids are not really recommended, unless the child is truly having respiratory distress, and they need those drugs for other reasons. But the normal treatment of RSV does not include the use of those agents. The problem is, is that we're also having a surge of influenza COVID-19 is now also starting to increase. And there are a number of other respiratory viruses that are surging at the same time, such as Rhino, enterovirus, adenovirus, para influenza, so it is really made, you know, trying to distinguish which respiratory illness a child has much more difficult. And, you know, we can test for all of these, but you really, you know, because they're viruses, there really is no treatment for them. And the problem is, is that when some of these kids and infants present to say, in an emergency room that's not pediatrics, or to an urgent care or a Minute Clinic, many people, you know, take a look at them. And they think, Oh, my gosh, you know, are they going to develop a bacterial infection. And this has really led to the shortage of antibiotics, because many of these kids are being placed on antibiotics unnecessarily.

The other thing that has really led to kind of a shortage in the pediatric beds situation is that many community hospitals during the pandemic closed down their pediatric units completely, primarily because they felt that they would make more money serving the adult population and not the pediatric population. And this has really led to a bed shortage in many areas where, you know, the Community Hospital is the only hospital that is close by for these kids to be evaluated in. So the vaccine that will be licensed first is a maternal vaccine, meaning that it would be pregnant women, probably between 24 and 36 weeks gestation, that would be getting this vaccine. And what we know from the phase 3 clinical trials, the data that was released, is that this vaccine is very, very effective at preventing hospitalization and lower respiratory tract disease in infants of moms who had received the RSV vaccine during pregnancy with a vaccine efficacy of around 82% at preventing these children from being hospitalized from lower tract infection during the first three months of life, and even beyond that between three and six months. of life, we know that the vaccine efficacy in preventing RSV lower tract infection and hospitalization in these young infants is around 70%. So very, very good vaccine efficacy, and is one way of protecting normal healthy infants against being hospitalized and having severe RSV disease.

The most important thing that pediatric providers can do is to vaccinate their patients against those viruses for which we have vaccines, mainly influenza, and COVID-19. With all these different viruses circulating at the same time, it is going to be critical that, you know, you provide vaccines to your patients in order to provide them with some protection, because what we're seeing in the hospital now is infants and children who are not only infected with one of these viruses, but with multiple of these viruses. And this really makes their clinical course much more complicated.

So I think the direction that IDSA wants to move in is really to address some of the disparities that were brought forth by the pandemic. And this is disparities in all age groups, but especially in the pediatric age group, and in the pregnant women group. Because most trials of drugs and vaccines that are done, generally are done in adults to begin with. And there is now a push to see whether or not some of these trials can also be started in infants and children and pregnant women in an earlier time, so that these therapeutics are available for these individuals much sooner than they normally would be available for so the Infectious Disease Society of America has always served as a resource, not only for the infectious disease physicians, but also for public health and for all other practitioners. If you go on to the Infectious Disease Society of America website, there are resources there that the general practitioner can use in their practices to provide the best care possible for their patients.

So I think what's really going to be exciting are some of the vaccines that are teed up to hopefully be approved by the beginning of 2023. I mean, one is the maternal RSV vaccine, and other one is PCV 20 or Prevnar 20, which is an increased valency pneumococcal conjugate vaccine that will provide more protection against the strains that are currently causing invasive pneumococcal disease now, as well as otitis media and pneumonia. And the other exciting vaccine that is teed up and may be licensed by sometime in mid 2023 Is the pentavalent Meningococcal vaccine. So this is a vaccine that covers meningococcal serotypes A, B, C, y and w. And I think this will greatly simplify the way that meningococcal vaccines are given and will provide the needed protection for those teenagers and young adults that are at risk for the disease.

Videos

Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, editor-in-chief of Contemporary Pediatrics, talks about the most significant moments in children’s health in 2022; what the tridemic really means for pediatric health care providers; and what we have to look forward to in 2023 when it comes to new vaccines and medications.

Tina Tan, MD, discusses most important pediatric news of 2022 and what to look forward to in 2023

Alok Patel, MD, is a pediatric hospitalist and clinical assistant professor of Pediatrics at Stanford Medicine Children's Health in Palo Alto, California. Here he discusses a potentially serious new strain of group A streptococcus, its presentations, and what health care providers should do right now to manage this illness.

Dr. Patel, thank you so much for joining us today. Let's just get right into it. There's a new, apparently serious invasive strain of strep A that was first noticed by the CDC in Colorado last month. Since then more states are reporting it and it looks like it's getting pretty scary. What can you tell us about this new strain?



Simply put, group A strep is a very common bacteria: we see millions of infections related to group A strep every single year, parents have heard of things like strep throat, skin infections. This is all group A strep. What is concerning, what is dangerous, potentially life threatening is when the bacteria moves from a place it normally is like your throat into a place it shouldn't be, like the blood deep muscles and your lungs. This is the transition from group A strep to invasive group A strep. And for parents out there who are seeing these headlines and freaking out, I totally get it. I'm also a parent. And what people want to be on the lookout for are infections or sicknesses that look particularly bad and worse than a common cold. Because invasive group A strep, when this bacteria is in a child's bloodstream, when it's causing something like necrotizing fasciitis, fancy term for flesh eating bacteria, when it actually causes rheumatic fever, scarlet fever, kids are going to look really sick. I'm talking really high fevers, muscle aches that are keeping kids up at night, warm, tender rashes on their body tender joints. These symptoms, this constellation should warn a parent to go and call a doctor immediately and not delay. We are also telling parents right now there is absolutely treatment for invasive group A strep in the form of antibiotics. But the most important thing is to not have a delay in care.



That makes total sense. Is there any relationship to this and what we've been hearing so much in the press about the triple endemic RSV and COVID and influenza. How does this connect with what's been talked about in those illnesses?



Several infectious disease experts in public health theorize that the rise of invasive group A strep right now is possibly related to what we're seeing with respiratory viruses. Because when anyone has a severe infection from a respiratory virus, whether it is RSV, COVID-19, or influenza, this makes the host, us, more susceptible to bacterial infections. This is why when parents look at the bottle of Tylenol or ibuprofen, it says contact a doctor after a certain amount of days of fever. This is because we worry about viral infections like influenza, RSV, or all the other cold viruses transitioning to bacterial. So this is one thought right now is it the fact that so many people out there are getting sick. This is why we're seeing a rise in invasive group A strep, but it's too early to kind of pinpoint what exactly is causing it.



So on top of all this, there have been reported shortages of over the counter medicines. Is this something that both parents and pediatricians need to worry about? Will this be addressed soon, do you think?



I think the concomitant shortage of basic antibiotics medications like amoxicillin, especially the oral suspension of amoxicillin that we give to young patients with these headlines about invasive group A strep is concerning because any pediatrician out there knows that amoxicillin is a frontline antibiotic to treat infections that are commonly caused by group A strep. It's really important that we have these. To open conversations with families, we help them find the medications, wherever they live, whatever pharmacy they're using, because what we don't want to see is a delay in care, because a family is scrambling to find a med, or because all of a sudden it's 6 pm, and the pharmacy next to them is closed. So what myself and a lot of my colleagues have been doing in the hospital setting is just making sure that that script is filled, and the family can access it before they get back to wherever they're going before they're traveling, wherever it may be, because we want to prevent those delays in care: even a delay in something like strep throat could be potentially serious if it transitions over and becomes invasive group A strep, and we can prevent it all with antibiotics. Right? It's also important that we educate our families about the difference between bacterial infections and viral infections. We've all had those patients who are a little bit resistant towards antibiotics and say, can I just get better on my own, and we're able to have that conversation, if we suspect it's a viral etiology for an illness. But if it's bacterial, it's super important to tell our families, this antibiotic is absolutely necessary. You have to take it, you have to take it for the full duration and not delay.



Right. So finally, what are the key takeaways would you say for pediatric health care providers who thinks they might be seeing this in their patients? What are the top things you suggest they do?



No physician out there is going to be surprised at a group A strep infection, but I think it's important for all of us just to revisit some of the signs and symptoms of invasive group A strep. I work as a hospitalist. I see kids with infections literally on a regular basis. And I myself just revisited some of the literature about scarlet fever, post strep glomerulonephritis, toxic shock syndrome, necrotizing fasciitis, just to make sure it's on my radar. And it's important that we give parents, we give patients, everyone out there, good preventive information about signs and symptoms to look out for: what to do if their children all of a sudden have a tender joint, or a really high fever or just appear slightly more sick than a routine cold. And we educate families about not delaying seeking medical care. We're kind of in this duality right now about telling people to avoid the ER or urgent care unless it's an emergency because hospitals are overrun, but then also telling parents, hey, don't delay. So I think we can find that happy medium right there and just tell parents, if there's any doubt, just call a doctor or clinic jump on a telehealth visit, because that small intervention could mean the difference between inpatient care for a child who has invasive group A strep and an outpatient antibiotic and everyone can have a happy holiday and be healthy.




Alok Patel, MD, shares what pediatric health care providers should know about a concerning new strain of group A streptococcus.

Alok Patel, MD, discusses the new invasive strep A strain

For the first time since 2019, American Academy of Pediatrics (AAP) National Conference and Exhibition was held in person in Anaheim, California, from October 7 to 11, 2022. The agenda was chockful of a dazzling array of sessions, product theaters, workshops, and an exhibit hall on virtually every pediatric topic under the sun. Topics range, but are not limited to, sessions and lectures on LGBT health and wellness; oral health; obesity and nutrition; neurology; pediatric trainees; osteopathic pediatricians, and so much more. Some of the session highlights include:

Booster seats in a bag: A pandemic success

Presenters discussed how the research project Clinic in the Park offered booster seats to low-income families during the COVID-19 pandemic.

For project, researchers targeted low-income families, 85% of which identified as Hispanic or Latino. They set up neighborhood distribution hubs, where they distributed the booster seat in a bag, educational materials, and a liability waiver. Educational materials included a self-guided, online 15-minute HIPAA-compliant educational module in both English and Spanish. Content included information on age and size-appropriate protection devices and current California state laws. Participants also completed a 3-month follow-up survey online.

The 3-month follow-up electronic survey included 80% of respondents (100/125). Of those, 99% reported that children were using the booster seat, 98% stated that the seat belt fit better with a booster seat, and 100% agreed that children may need to ride in a booster seat until 10 to 12 years of age.

The researchers concluded that the virtual platform was a success—it was cost-saving, convenient, and efficient. It also eliminated access barriers and could be used as a model for bicycle helmets and water safety for parent education.

AAP reports on which children are at greatest risk for COVID-19

Children with preexisting conditions are at the greatest risk of severe COVID-19, while vaccinated children have decreased risk, according to research from AAP.

In the study presented at the AAP National Conference, pediatric patients were divided into 3 groups based on age to account for clinical differences, data set coding limitations, and vaccine eligibility.

Among pediatric patients, about 19% tested positive for COVID-19, with 4% being hospitalized, needing intensive care unit or ventilation, or dying. These severe outcomes were most often seen in cases of comorbidity. Also, children who were Black, Asian, and Hispanic were at the greatest risk of severe outcomes.

Vaccination was a major protector against COVID-19, with at least 1 vaccination to no known vaccination having an odds ratio of 0.55 for severe disease. Based on this data, populations in need of the COVID-19 vaccination and other preventative measures can be identified.

1. Carr L. Booster seats in a bag: A pandemic success. Contemporary Pediatrics. October 11, 2022. Accessed November 7, 2022. https://www.contemporarypediatrics.com/view/booster-seats-in-a-bag-a-pandemic-success

2. Krewson C. AAP reports on which children are at greatest risk for COVID-19. Contemporary Pediatrics. October 14, 2022. Accessed November 7, 2022. https://www.contemporarypediatrics.com/view/aap-reports-on-which-children-are-at-greatest-risk-for-covid-19

Articles

Learn about the most recent news discussed at the 2022 AAP National Conference and Exhibition.

The latest from the 2022 AAP National Conference and Exhibition

Contemporary Pediatrics® Editor-in-Chief Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, sits down to discuss the recent surge in pediatric RSV hospitalizations and the rising threat of the "triple epidemic" consisting of influenza, COVID-1, and RSV in children. 

Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, sits down to discuss the rising threat of a  "triple epidemic" consisting of influenza, COVID-19, and RSV in children.

RSV, influenza, and COVID-19: Gearing up for the threat of a 'triple epidemic'

“While I was in the hospital, when I was struggling the most, like when I was really struggling toeat, they would punish me. They would put me in time out, and then I was missing groups, which really didn’t help.” - patient, aged 18 years 

“Recovery is definitely not a linear process. A slip does not always mean a fall.” - patient, aged 19 years


“I have atypical anorexia – I was always told I wasn’t sick enough” – patient, aged 17 years

These are the powerful patient quotes that Ellen S. Rome, MD, MPH, FAAP, head of the Center for Adolescent Medicine and professor of Pediatrics at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University in Cleveland, Ohio opened with in her presentation on discussing helping families manage their children’s eating disorders at the 2022 AAP National Conference & Exhibition.

The first point that Rome noted is to remind families, “Your child is NOT their eating disorder. Name it and disinvite it to the table at mealtimes, in and out of the hospital.” Another important message: that body type is not indicative of healthy eating. Hearing things like, “you aren’t that thin,” can deter people from treatment, she said.

Rome then shared some pearls to discuss with families:
--Food is medicine
--It is absolutely not the parents’ fault that their child has this illness
--Separate the child from the illness in your mind: symptoms like emotional dysregulation is a result of the illness
--Patients with eating disorders are anxious, stressed, and scared. Caregivers, in return, need to stay compassionate, calm, and confident.
--Always remember, EDs are complicated illnesses, connected by genetics, environment, neurotransmitters, triggers, and serotonin levels. “Build your team as best you can,” says Rome, “and take advantage of virtual health opportunities to fill in the gaps. The treatment need not be ‘one size fits all.’”

Additionally, caregivers need to educate themselves as much as possible about current evidence-based practices for ED, and get a current copy of their health plan benefits from their employers.

Rome also shared a pearl she got from parents during the course of her practice: get a spiral notebook to jot notes from hospital, treatment information, etc.;  and offered some highly regarded resources (the FEAST website; 

 Sick Enough: A Guide to the Medical Complications of EDs

, by Jennifer Gaudiani, among others.

Rome discussed inpatient criteria, based on AAP, AED, and SAHM guidelines, which included watching for certain vital signs (severe bradycardia, orthostatic hypotension); acute food refusal; and suicide ideation. Rome also went through a vocabulary that caregivers should learn to understand the disease better (caloric restriction, which can cause GI, renal and endo disorders).

Very importantly, “make sure that caregivers know that all the physiological changes—heart, brain, gut, bones, fertility—are reversible with refeeding,” Rome emphasized. Rome shared with the audience a hospital case study, and details of process of a child admitted for an ED, as well as how to create quality, family-based treatment for adolescent anorexia nervosa.

For the pediatrician, however, it is important to:
--be a consultant to parents and family-based treatment clinician
-explain medical seriousness of disorder and provide comprehensive medical assessment
-avoid being directive
-empower parents in decision making
-support full weight restoration and full remission

“Parents need to stay informed every step of the way,” remarked Rome. She emphasized that there will be a wide range of emotions, including feeling scared, confused, and relieved, and noted that “while family therapy is not fun, it helps the kid understand what the parents are going through.” 

In addition, Rome offered recommendations for responses to behavioral symptoms in a child with ED, and ended her presentation with this quote from a 19 year-old patient, “The eating disorder lives in the gaps. It will find the gaps and split the kid from the parents and parents from the care team. So the more you can stand shoulder to shoulder, the better. The eating disorder lives in the last bite.”

Reference
Rome ES. Supporting parents of youth with eating disorders in and out of the hospital. 2022 AAP National Conference & Exhibition. October 8, 2022. Anaheim, California.




At the 2022 AAP National Conference & Exhibition, a practitioner shares her expertise on how to communicate with families to manage a child’s eating disorder (ED) and review practical strategies while increasing patient and family satisfaction.

Supporting parents of youth with eating disorders in and out of the hospital  

Pediatric health care providers are accustomed to seeing a variety of dermatological disorders in babies, often presenting as acne vulgaris, atopic dermatitis, and other skin conditions. Raegan Hunt, MD, PhD, FAAP, FAAD, division chief, pediatric dermatology vice chair of dermatology at Texas Children’s Hospital Baylor College of Medicine in Houston Texas, offered a comprehensive and educational session covering dermatological skin eruptions in newborns, with conditions ranging from common and self-resolving to rare and sometimes deadly. Her session, which included such nuances as “acne imposters” offered pearls, especially for the general pediatric practitioner who may not be as familiar with some of the more unusual infant skin conditions.

Her session started with this case: A healthy, 2-day old infant presented with irregular erythematous patches with yellow pustules on stomach area. The diagnosis? Erythema toxicum neonatorum, a benign, self-limited eruption. This skin disorder is in fact, a relatively common eruption in newborns, affecting 40% to 70% of babies, though not present at birth. The treatment is self-resolving.

Similarly, a full-term infant presented with pustules and hyperpigmented macules at birth, with a diagnosis of transient pustular melanosis, another normal and harmless skin condition affecting infants, which appear as hyperpigmented macules and is also self-resolving.

Other dermatological presentations in newborns are not quite that simple, however. “Congenital candidiasis,” noted Hunt, “acquired in utero or during delivery, presents as erythematous monomorphic papulovesicular eruptions within the first 12 hours of life. The papules progress to pustules then crust, and palms, soles, nails may be involved.” This rare disorder can range from diffuse skin eruption without any systemic symptoms to respiratory distress, hepatosplenomegaly, sepsis, and death, a particularly high risk for extremely low birth weight infants. Blood and urine cultures should be done, with the treatment being oral fluconazole, topical antifungal cream, and, if unstable, intravenous amphotericin B.

Hunt next discussed bullous impetigo, a localized infection that causes fluid-filled blisters on the trunk, arms, and legs of infants. This rare disorder is often a minor infection that is treated with anti-staphylococcal antibiotic.

Neonatal acne, a benign, transient, non-scarring condition presents in the first 3 weeks of life with erythematous papules and pustules on forehead, cheeks and scalp, sometimes caused by transient maternal hormones. For this disorder, watchful waiting is recommended and, if needed, topical azole cream is usually prescribed. Hunt warned audience members, though to be on the lookout for the “newborn acne imposter,” milia. Milia, a superficial occlusion of follicles, appear as tiny white bumps or clear blisters, is harmless, and goes away by itself. Another newborn acne imposter mentioned in this session was sebaceous hyperplasia, white or yellow papules on the nose of newborns where the sebaceous glands are enlarged. This too, is self-resolving.

Hunt’s presentation continued with a look at various other neonatal and infantile acne conditions, symptoms and treatments, as well as neonatal herpes, cutis marmorata, infantile seborrheic dermatitis, scabies, and other skin conditions.

Some best practice takeaways for pediatricians:
--Look for comedones in neonatal acne, a sign of true infantile acne, which can be scarring and needs treatment

--Consider Langerhans cell histiocytosis if infantile seborrheic dermatitis is not responding to treatment

--Recognize that nodules or acral pustules in babies are a frequent sign of scabies in infants. “If scabies is suspected or diagnosed,” said Hunt, “treat the entire household!”

Reference
Hunt R. Diagnosis and management of common skin rashes in the newborn. 2022 AAP National Conference & Exhibition. October 11, 2022. Anaheim, California.

At the 2022 AAP National Conference & Exhibition, a presenter delves into diagnosis and management of common and uncommon skin rashes in newborns.