Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

As this article went to press, nearly half of all Americans were fully vaccinated against COVID-19. The relief is obvious as the world rushes back to open after more than a year under pandemic precautions. Airline travel has quadrupled compared with this time last year, and families are now eagerly planning vacations, summer activities, and visits with family and friends.

Although many parents—and about half of all children between ages 12 and 18—have been vaccinated, there still isn’t an approved vaccine for younger children.

 Parents are torn between what they and their older, vaccinated children can do and what they can do safely with younger, unvaccinated children.

The Centers for Disease Control and Prevention (CDC) has released guidance for unvaccinated people of all ages, as well as specific information to help pediatricians counsel parents regarding safe activities for unvaccinated children and what types of precautions to follow.

The CDC’s guidance for pediatricians includes helpful keys with visual aids showing which precautions to use and when.

 Charts depicting masked and unmasked faces and color-coded in green, yellow, and red break down activity-specific advice about safety levels and what precautions for both vaccinated and unvaccinated people.

Safest activities for unvaccinated people with no mask required— outdoor activities with members of own household or small outdoor gatherings with vaccinated individuals

Safe activities for unvaccinated people wearing a mask—outdoor events with a mix of vaccinated and unvaccinated people

Less safe activities for unvaccinated people, even when wearing a mask— dining outdoors with people from multiple households, visiting a salon or barbershop, going to an uncrowded indoor event, attending small indoor gatherings with vaccinated and unvaccinated people from multiple households

Least safe activities for unvaccinated people even when masked—attending crowded outdoor events, full-capacity indoor worship services, going to a movie theater, eating indoors at a restaurant, participating in an indoor exercise class or sporting event

Meanwhile, the CDC indicates that all these activities are safe without a mask for vaccinated individuals.

Gary E. Kirkilas, DO, a Phoenix, Arizona, pediatrician and spokesperson for the American Academy of Pediatrics (AAP), said counseling parents on what is safe for unvaccinated children can be difficult. “There are a million variables of different activities by location,” he said.

“It kind of helps to think in those 4 terms because people think with outdoor activities, it is generally safe,” Kirkilas said, explaining that an indoor event with 1 family would be a safer choice than an outdoor event with many families. “Less contact with multiple households for a short time is usually the way to go.”

What the CDC guidance lacks is advice on individual risk factors, Kirkilas added. That’s where pediatricians come in. Pediatricians who know families, individual risk factors, and other nuances are well positioned to offer suggestions for COVID-19-safe activities.

Generally, Kirkilas asks the following questions to his patients and their families, and suggests these 2 bullet points:

Children and adults who are unvaccinated should wear a mask.

Everyone, even vaccinated children and adults, should wear masks on public transportation. This can pose a problem for parents who are eager to get back to “normal” but whose children may not understand why they need to take different precautions than their parents do.

Discussing COVID-19 precautions with children can be challenging, Kirkilas said, especially as more parents get vaccinated before their children are eligible. For younger children, he says, parents should set a good example: Wear a mask—even if vaccinated—to encourage younger children to do the same. Don’t over-explain COVID-19 precautions if children ask about adults who aren’t wearing masks. Simply explain that until they get a shot to protect them from getting sick, they need to continue wearing a mask to stay safe.

For older children, Kirkilas said, a conversation using plain language should suffice. Explain the importance of masks and why children might need to wear one even if their parents don’t. Pediatricians can also help talk with older kids about the issue. Kirkilas said pediatricians can help clear up vaccine misinformation that kids aged 12 to 15 years are especially susceptible to believing.

Official vaccine support and education campaigns from national medical groups has already begun. On June 23, the American Academy of Pediatrics, the US Department of Health and Human Services, the US Centers for Disease Control and Prevention, and many other medical organizations issued a statement in support of the COVID-19 vaccines for children, underscoring that "The vaccines are safe and effective...we strongly encourage everyone aged 12 years and older who is eligible to receive the vaccine under Emergency Use Authorization, as the benefits for vaccination far outweigh any harm." 

Kirkilas said that Pfizer is currently investigating the vaccine in children aged 5 to 11 and 2 to 5 years. Dose changes may be needed in these age groups, whereas the dose for children aged 12 to 15 years is the same as for adults. Emergency use authorizations for children younger than 12 years are expected between fall 2021 and the start of 2022, Kirkilas said.

The whole family should participate in the vaccination discussion, according to Kirkilas. “The mistake that’s made sometimes is when you just talk to the parent,” he said. “You really need to involve the child.” Legally, children under 18 must have consent from a parent, he said, but older children appreciate being involved in the conversation about why they are getting the vaccine and how it works.

Pediatricians also will need to communicate with parents who have chosen not to vaccinate. “As pediatricians, a lot of us are used to parents being for or against vaccines. All you can do is provide education about what it does and why it would be good,” he said, adding that he compares the COVID-19 vaccine to more traditional vaccines like the influenza shot. “I try to link things that are known to things that are unknown. And remember to be respectful when talking to teens and parents who have chosen not to vaccinate.”

TSA checkpoint travel numbers (current year(s) versus prior year/same weekday). Transportation Security Administration. Updated June 17, 2021. Accessed June 12, 2021. 

https://www.tsa.gov/coronavirus/passenger-throughput

COVID-19 vaccinations in the United States. Centers for Disease Control and Prevention. Updated June 17, 2021. Accessed June 12, 2021. 

https://covid.cdc.gov/covid-data-tracker/#vaccinations

Guidance for unvaccinated people: guidance for wearing masks. Centers for Disease Control and Prevention. Updated April 19, 2021. Accessed June 12, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html

Choosing safer activities. Centers for Disease Control and Prevention. Updated May 28, 2021. Accessed June 21, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/participate-in-activities.html

Articles

Parents and children are eager to get back to “normal” as the number of COVID-19 cases drops, so targeted education and individualized advice are important for families in an almost post–COVID-19 world. Pediatricians can provide guidance about what is and isn’t safe.

Keeping your child safe from COVID-19 this summer

Malnutrition might seem like an easy problem to diagnose. Scales and growth projections can be used to discern whether a child is growing as expected. However, there are also subtle signs of malnutrition to watch for during a visit.

“Every pediatrician should be thinking along a food group line,” says Praveen Sundaraj Goday, MD, a pediatric gastroenterologist and director of nutrition at Children’s Wisconsin in Milwaukee. Goday also serves on the American Academy of Pediatrics’ Committee on Nutrition.

Even children who are obese or overweight can suffer from poor nutrition. Others eat no fruits or vegetables but still meet growth and weight goals for their age. Pediatricians should be asking questions about diet at well visits, specifically focusing on the food groups from which the child eats and whether any special diet is being followed.

There are ways to have a child on a good vegetarian diet, Goday notes, but the pediatrician should still be aware of these special diets or any restrictions. The child may appear well nourished but still require supplementation with pediatric multivitamins, he says.

For detecting signs of malnutrition outside of the scale or assessment questions, Goday says there is much one can tell from a child’s appearance. Signs of malnutrition could include the following:

“I think focusing on whether the child is eating consistently from all food groups is key,” Goday says. “If the child is, that’s a good sign. If not, the pediatrician should be questioning why.”

The American Academy of Pediatrics offers guidelines

 to help pediatricians counsel parents on appropriate micronutrient requirements, especially in the first few years of life when neurodevelopment is critical.

Although in some cases, malnutrition could be an adverse effect of food choices or availability, pediatricians also need to understand when other factors are contributing to malnutrition. In most cases, regular nausea or vomiting is a red flag in children with gastrointestinal (GI) disorders, Goday says. “It would be rare not to have those. These could signal a problem,” Goday says.

Daily or frequent vomiting is usually because of a GI mucosal problem in the stomach or esophagus, Goday says, adding that these are the most common GI problems related to malnutrition in children. When frequent diarrhea is the complaint, there are tests that can check for lactose intolerance and other conditions that might result in malabsorption of sugars. Pancreatic insufficiency is also a cause of malabsorption, Goday says.

Inflammatory issues like eosinophilic esophagitis and even mental health or behavioral conditions can also lead to malnutrition. Mental health and behavioral conditions are not necessarily caused by a nutritional issue but rather a behavioral issue that affects a child’s ability to get proper nutrition. Autism is commonly linked to issues involving poor nutrition. “These 2 go together, but the reason is that the autism is causing feeding problems and not the other way around,” Goday says.

He recommends that children who are extremely picky eaters be evaluated for underlying neurobehavioral conditions. They may even require referral to speech behavioral therapists or other specialists.

Although pediatricians should be vigilant when it comes to assessing diet quality and eating habits of their patients, problems with nausea, vomiting, or diarrhea are usually reason for referral to a specialist. Pediatricians must be aware of problems not explained clearly by behavior. These are often associated with allergies or asthma.

1. Schwarzenberg JS, Georgieff MK. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. 

2018;141(2):e20173716. doi:10.1542/peds.2017-3716

There are several indicators of malnutrition—even for children with normal growth.

Malnutrition signs aren’t limited to the scale

Diagnosing attention-deficit/hyperactivity disorder (ADHD) in young children is difficult on its own, but treating it can be even more challenging. Stimulant medications are recommended as the first-line treatment for ADHD, but a number of preschool-aged children are given α2-adrenergic agonists despite limited evidence about efficacy. A recent study sought to investigate how well these medications work at controlling ADHD symptoms, and what side effects might be expected.

, aimed to investigate exactly how effective α2-adrenergic agonists could be compared to stimulants, and whether there were any negative effects from the medication.

 Researchers reviewed the records of nearly 500 preschool-aged children with ADHD. Most of them--322 children in all--were treated with stimulant medications, and 78% of them showed improvement in their ADHD symptoms. One-hundred and seventy-five children received α2-adrenergic agonists, with 66% reporting improvement.

Elizabeth Harstad, MD, MPH, of the Developmental Medicine Center at Boston Children's Hospital in Massachusetts, and lead author of the study, said the report highlights the role α2-adrenergic agonists may play in treating preschool-aged children with ADHD.

"We found that both stimulant and α2-adrenergic agonist medications reduce ADHD symptoms in the majority of children for whom they are initiated," Harstad said. "However, only daytime sleepiness was more common for those receiving α2-adrenergic agonists compared to stimulants, whereas several adverse effects were more common for those receiving stimulants."

Harstad added that although this study focused on pharmaceutical treatments for ADHD, behavioral therapy remains the most recommended treatment for young children.

Roughly 3% of preschool-aged children are affected by ADHD and about a quarter of them are prescribed α2-adrenergic agonists despite the recommendation to use stimulants first. This retrospective study reviewed records of children treated with α2-adrenergic agonists between 2013 and 2017, following up on the cohort as late as 2019.

Although stimulants like methylphenidate (Ritalin) significantly reduce ADHD symptoms, prior studies show that the adverse effects that can follow are an issue. More than 40% of children who were given these stimulants were irritable when taking methylphenidate, and 20% were tearful or depressed. On the other hand, the most common effect noted in children who received α2-adrenergic agonists instead of stimulants was daytime sleepiness, the study notes. Other adverse effects reported among the children who were prescribed stimulants that didn't occur in children who used α2-adrenergic agonists included moodiness and irritability, appetite loss, and trouble sleeping.

Effectiveness without the same burden of side effects is one of the reasons that the use of α2-adrenergic agonists is becoming more common--increasing by 13% between 2012 and 2017--despite limited information on efficacy and adverse effects on children in this age group. Among children who receive α2-adrenergic agonists for ADHD, most were prescribed guanfacine medications, followed by clonidine. The research team recommended additional studies on the use of these medications for ADHD treatment, but also noted that although α2-adrenergic agonists produced less significant improvement in ADHD symptoms, there were also fewer adverse effects reported. The study also addressed the question of how often α2-adrenergic agonists are being used in preschool children, revealing that these medications were actually the first medications used for 35% of the children in the study. They were the preferred choice in particular for children who were on the younger end of the preschool age group, or who had other disorders like sleeping problems or autism spectrum disorders in addition to ADHD.

"Our study suggests that α2-adrenergic agonists, like guanfacine and clonidine, may be beneficial in treating preschool-age children with ADHD," Harstad said, adding that these results should be confirmed with additional, randomized trials before strong clinical recommendations are made. "Our findings highlight the potential role that α2-adrenergic agonists may play in treating ADHD for some preschool-age children. These medications may play a helpful role in treatment, especially for those with certain co-existing conditions. They may work well and be better tolerated than stimulants."

Although behavioral therapy should also be the first-line treatment for young children with ADHD, Harstad said it can be helpful to have more options available to children for whom prescription medications are warranted.

Harlan R. Gephart, MD, FAAP, ADHD expert, former director of the Group Health ADHD Clinic, past-chair of the American Board of Pediatrics, and editorial advisory board member for 

 said because there is no definitive test for ADHD at any age--let alone the preschool years--both diagnosing and treating ADHD can be difficult. Because there can be alternative diagnoses or contributors to a child's ADHD behaviors, behavior therapy is the best first treatment, particularly utilizing structured parenting classes or individualized therapy. Only when behavioral therapy fails to improve ADHD symptoms should medications be trialed, Gephart said, adding that the US Food and Drug Administration hasn't actually approved either type of medication for preschool-aged children. These medications are only approved for use in children aged 6 and older, he said.

Stimulants have been recommended as the first-line, Gold Standard pharmaceutical option since 2006 when 

 showed how well methylphenidate could reduce ADHD symptoms, Gephart said. Unlike the 2006 study, this new research is not randomized or prospective, there were no standardized treatments studied, and there was room for error. More than 60% of the children in the current study received behavioral therapy before medication was used, which could have skewed results, he explained.

"Nonetheless, the results are interesting and not totally surprising," Gephart said. "Stimulant medication appeared somewhat more effective in lessening ADHD-type behaviors from 78% to 66%, which is consistent with findings in older adults, that stimulants are the most effective medication in reducing ADHD symptoms."

Gephart acknowledged higher frequencies of adverse effects with stimulant medications compared to α2-adrenergic agonists, but also agreed with the study authors that more research is needed before making more concrete recommendations.

"More data is needed, in the form of randomized controlled trial data, before we truly known which medication is optimal," Gephart said. "At present, pending that information, it seems prudent to continue what we presently do, which is to treat preschool children with stimulant medication but start with small doses, titrating slowly upward while monitoring carefully for unacceptable side effects, particularly weight gain and growth."

Harstad E, Shults J, Barbaresi W. α2-Adrenergic agonists or stimulants for preschool-age children with attention-deficit/hyperactivity disorder. 

Greenhill E, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. 

Journal of the American Academy of Child and Adolescent Psychiatry

. Nov. 2006. doi:10.1097/01.chi.0000235077.32661.61.

Stimulants are recommended as the first-line treatment for attention-deficit/hyperactivity disorder (ADHD). A study examines whether α2-adrenergic agonists could be effective as well.

Study examines alternatives for preschool ADHD medications

“The most used contraceptives among adolescents are condoms, withdrawal, and oral contraceptive pills. Although fewer teenagers use LARC methods, use of IUDs [intrauterine devices] and implants is increasing,” says Cara Clure, MD, a family planning fellow at the University of Colorado in Aurora. “LARC methods are safe, highly effective options for adolescents that have higher continuation and satisfaction rates compared with teenagers who use short-acting contraceptives.”

According to the American College of Obstetricians and Gynecologists (ACOG), about 19 of every 1000 teenaged girls became pregnant in 2017. Although this is a record for the United States—down from 117 per 1000 in 1990—teenager pregnancy rates in the United States are some of the highest among developed countries.

 Although abstinence and sexual education have contributed to the decrease in adolescent pregnancy rates, the Centers for Disease Control and Prevention (CDC) reveals that increases in the use of contraceptives among these age groups are perhaps the biggest contributor to the decline.

Furthermore, use of LARCs is gradually increasing. The CDC reports that, nationwide, LARC use among teenagers in 1 study increased from 0.4% in 2005 to 7.1% by 2013

 Although these trends are promising, the reliance of teenagers in 65% of encounters to rely on the withdrawal method for birth control shows need for more education.

ACOG recommends discussing contraception options with patients between ages 13 and 15 years, regardless of previous sexual activity, clearing up misunderstandings; providing an overview of the most effective methods; and offering information on emergency contraception. “Because teenagers are at high risk of sexually transmitted infections (STIs), dual-method use—using condoms in addition to a more effective contraceptive method—is ideal,” Clure says.

Education on condom use seems to have taken hold, with about 97% of teenagers reporting condom use during sexual encounters, according to the CDC.

 However, as a dual method, Clure says many adolescents choose oral contraceptive pills along with the use of technology like cell phone alarms or apps that can send re- minders and improve medication adherence. Clinicians can’t rely on technology alone to help adolescents figure out contraception, though.

“Teenagers should also be counseled about what to do if they miss a pill and about options for emergency contraception. Technology reminders can be helpful for those using the contraceptive patch, vaginal ring, or Depo-Provera [medroxyprogesterone acetate],” Clure says. LARCs, on the other hand, take a lot of guesswork out of the adherence equation. “Some adolescents may choose a LARC method because it does not require medication adherence.”

LARCs have become a favorite in this age group because of how effective these methods are, along with ease of use. Adherence is simpler than with oral contraceptives, so teenagers are more likely to be satisfied and continue with these forms of birth control. The safety and ease of LARCs make them an ideal choice to recommend to teenagers, ACOG reports.

These single-rod implants contain etonogestrel and are highly effective, with failure rates of less than 1%, according to the American Academy of Pediatrics (AAP). These implants are inserted into the inner part of the upper arm and can remain in place for up to 3 years. This option can be offered to pregnant teenagers or teenagers who have just given birth for immediate postpartum protection. No effects have been noted regarding breastfeeding, says AAP.

 Clinicians must warn patients about the need for a backup method of contraception for at least the first week after implantation, as well as the fact that implants may prevent pregnancy but do not prevent STIs.

Inserted into the uterus, these devices are also highly successful and can provide long-term contraception. There are 2 types of IUDs approved in the United States. These include a T-shaped device that releases levonorgestrel and a T- shaped implant that contains copper. The latter may also be used as an emergency contraceptive method up to 5 days after unprotected intercourse. Like progestin implants, these LARCs have a less than 1% failure rate, but concerns have been raised about infection and infertility risks with these devices.

Although infertility has largely been disproved, there are other drawbacks to IUD insertion, according to AAP.

 These include pain with insertion and expulsion, which AAP says can occur more often in younger women. However, like implants, IUDs can be used as emergency contraception, can be placed in pregnant and immediately postpartum women, and have higher continuation rates than oral contraceptives. IUDs can- not be used in patients with purulent cervicitis, gonorrhea, chlamydia, and active pelvic inflammatory disease or certain other pelvic infections.

These LARCs are not as long lasting as other methods but also do not re- quire removal to stop therapy. Long- acting progestin, also known as depot medroxyprogesterone (DMPA), is administered every 13 to 15 weeks as a single intramuscular or subcutaneous injection. Although backup contraception must be used for at least a week, and the injection cannot be used in pregnant women, this method is sometimes favored because it can usually be initiated on the same day as the decision is made to begin birth control.

A disadvantage to this method, outside of frequent injections, is more potential adverse effects (AEs) than from other LARCs.

Other options for contraceptives in teenagers include oral contraceptives, vaginal rings, contraceptive patches, and barrier methods like condoms, but adherence and proper use can be difficult for some younger patients—particularly those with special health care needs like developmental disability. Even if sexual activity is not the primary concern, contraceptives are sometimes used in these populations to help address other menstrual complications.

“Although there are few medical contraindications to contraceptives in healthy adolescents, a complete medical history, including a review of current medications, is important before contraceptive initiation. Adolescents with complex medical conditions may not be candidates for all contraceptive options,” Clure says. For example, estrogen-containing contraceptives or combined hormonal methods are contraindicated in adolescents with migraine with aura or a history of venous thromboembolism, she explains.

“If teenagers are not good candidates for estrogen-containing contraceptives, progestin-only options are preferred, including LARC methods,” Clure says. “Adolescents with intellectual or physical disabilities may benefit from contraceptive choices that reduce or suppress menstrual bleeding such as the levonorgestrel IUD, Depo-Provera, or combined hormonal methods like the pill and patch, because menstrual management may be difficult for these patients.”

Clure says all teenagers should be educated about possible AEs associated with different contraception methods. For example, combined hormonal methods such as pills, the patch, and the vaginal ring can cause irregular bleeding, breast tenderness, and nausea, especially with initiation. Irregular bleeding is common with the levonorgestrel IUD and contraceptive implant. Overall, the decision should rest solely with the patient after thorough education on all the options.

“The patient’s choice should be the guiding factor in prescribing one method of contraception over the other. When providing contraceptive counseling to adolescents, it is important to offer all contraceptive options that are appropriate for that patient, including LARC methods, and engage in shared decision-making with the adolescent,” Clure says. “Contraceptive counseling for teenagers should include anticipatory guidance about AEs, efficacy, and noncontraceptive benefits, such as improvement in dysmenorrhea and heavy menstrual bleeding, which may be a deciding factor for some patients. Adolescents should also be informed about how each method is initiated and discontinued.”

AEs, and the ease of use and adherence that LARCs offer, make them the first line of contraception for teenagers that AAP recommends.

 Pediatricians can receive training to offer LARCs to their patients but should also be prepared to make necessary referrals. Clure, however, cautions that there is no best method for everyone.

“Contraceptive counseling for adolescents should elicit and address concerns and misperceptions about contraception. Misinformation, particularly about the safety of LARC use in teenagers, can be a barrier, making it important to address the safety and benefits of LARC use in adolescents,” she adds. “No single contraceptive method is right for every teenager, and counseling should empower the teenager to make the decision that fits his/her needs and goals.”

1. Gerancher K; American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care. Counseling adolescents about contraception. American College of Obstetricians and Gynecologists. August 2017. Accessed May 15, 2021. 

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/counseling-adolescents-about-contraception

2. About teen pregnancy. Centers for Disease Control and Prevention. Updated March 1, 2019. Accessed April 24, 2021. https://www.cdc.gov/teenpregnancy/about/index.htm

3. Romero L, Pazol K, Warner L, et al; Centers for Disease Control and Prevention. Vital signs: trends in use of long-acting reversible contraception among teens aged 15-19 years seeking contraceptive services—United States, 2005-2013. 

4. Abma JC, Martinez GM. Sexual activity and contraceptive use among teenagers aged 15-19 in the United States, 2011-2015. 

. 2017;104. https://www.cdc.gov/nchs/data/nhsr/nhsr104.pdf

5. Committee on Adolescence. Contraception for adolescents. 

. 2014;134(4):e1244-e1256. doi:10.1542/peds.2014-2299

Contraception for teenagers may seem like a taboo topic, but it is an important part of wellness care for adolescent girls.

Rachael Zimlich, RN, BSN

Articles

Keeping your child safe from COVID-19 this summer

Malnutrition signs aren’t limited to the scale

Study examines alternatives for preschool ADHD medications

The latest on teenage contraceptive options