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

Early in the COVID pandemic, surges of other seasonal respiratory viruses like influenza and respiratory syncytial virus (RSV) were far below normal levels, likely because of masking and other precautions that were in place to try and stifle the spread of SARS-CoV-2.

But in the third year of the pandemic, as the public has largely abandoned masking and other measures, public health experts warned of the threat of a “tripledemic” of COVID, flu, and RSV infections.

It’s still too early in the season to get a final tally on the toll of each of these viruses, but so far each has made a strong showing.

RSV cases got an early start, ticking up as early as May and peaking around fall, according to the Centers for Disease Control and Prevention (CDC).

COVID-19 infections were declining through most of 2022, but new the highly Omicron transmissible variant changed that. The version of Omicron that was circulating the United States in late 2022 and into early 2023—XBB.1.5—has proven to be highly contagious, but not necessarily leading to as many hospitalizations or severe illness as previous variants.

Influenza cases were still being reported at high numbers as of mid-January, but the CDC revealed that infections appeared to be trending down. Annually, there are between 9 million and 41 million cases of influenza reported in each flu season, according to the CDC.

 This year’s total so far is at about 24 million, the CDC reports.

 While this total places the year’s cumulative flu burden at an average level, it’s not uncommon for flu cases to continue into early spring.

The good news is that each of these viruses have seemingly taken turns reaching a peak, despite warnings that the U.S. was headed for a triple pandemic of flu, COVID, and RSV this winter. Although it may not seem like it for families who have battled one illness after another, the worst of the predicted “tripledemic” seems to have missed its predicted target.

Adam J. Ratner, MD, of Hassenfeld Children’s Hospital at NYU Langone and a member of the American Academy of Pediatrics’ committee on infectious diseases, says it seems like these viruses had the greatest impact on higher risk groups, including children with other comorbidities or those did not receive the available vaccinations.

“I think it’s been a really bad respiratory viral season all over the country, and different areas have seen different things,” Ratner says.

RSV and flu made up the bulk of infections—at least those that he saw requiring hospital admission—early in the season, Ratner says. Hospitalizations are on the decline, now, but there are still plenty of kids becoming sick enough with any of these viruses to need a hospital bed, he adds. New COVID variants caused a spike in cases over the holidays, he says, but for a variety of reasons, severe illness from COVID appears to be limited to high-risk individuals for the most part.

“Most people in the U.S. Have some immunologic experience, meaning they’ve had COVID, been vaccinated one or more times, or both,” Ratner says, adding that there are estimates that somewhere around 75% of children in the U.S. have now been infected with COVID at some point during the pandemic whether they knew it or not.

There have been some co-infections with more than one of these viruses at a time, too, Ratner says, but there isn’t really any data that shows co-infection is leading to more severe illness. On the other hand, Ratner says complications like bacterial pneumonia can happen after an initial infection with COVID, flu, or RSV.

Vaccinations, when available, remain the best defense, Ratner adds. COVID and flu vaccines are available, but effective RSV immunizations are still in trial phases. One maternal vaccine from Pfizer has shown promise, he adds, and there is good data on the efficacy of long-acting monoclonal antibodies.

Currently, oseltamivir remains the treatment of choice for influenza, Ratner says, and remdesivir can be used in children who need hospitalization from COVID-19 or require oxygen therapy. Nirmatrelvir/ritonavir, another COVID treatment option, is only approved for children aged 12 and up, Ratner says.

RSV is perhaps the most difficult to manage beyond supportive care. Monoclonal antibodies are more of a preventive tool than a treatment option, he says. This treatment is used in premature infants and young children with congenital lung diseases, and its given monthly for their first RSV season, Ratner says.

While the winter respiratory virus season is far from over, Ratner says hospitalizations do appear to be on the downswing, and the number of children requiring intensive treatments remains relatively low.

“Fortunately for kids, getting hospitalized and needing that level of support is much rarer for kids than adults,” Ratner says.

1. RSV Numerator Data for the U.S. Centers for Disease Control and Prevention. Accessed January 15, 2023. https://www.cdc.gov/surveillance/nrevss/images/trend_images/RSV14Num_Nat.htm. 

2. COVID-19: COVID data tracker weekly review. Centers for Disease Control and Prevention. Accessed January 16, 2023. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. 

3. Disease burden of flu. Centers for Disease Control and Prevention. Accessed January 17, 2023. https://www.cdc.gov/flu/about/burden/index.html. 

4. Weekly U.S. influenza surveillance report. Centers for Disease Control and Prevention. Accessed January 17, 2023. https://www.cdc.gov/flu/weekly/index.htm. 

Articles

Virus triple threat

An earlier than expected onslaught of respiratory syncytial virus (RSV) cases this fall strained healthcare resources across the country, increasing worries about the availability of hospital beds for the remainder of the winter cold and flu season.

By mid-winter though, when RSV cases usually hit their peak, experts say the virus’ run appeared to be on the decline.

“It was a really impressive early RSV season this year,” recounts Adam J. Ratner, MD, of Hassenfeld Children’s Hospital at NYU Langone.

Ratner says pediatric hospital beds were certainly in short supply throughout the fall—much earlier than usual—as RSV cases surged. The peak seems to have passed, at least in New York, he says.

While different areas of the country have seen RSV viral surges come and go in waves, nationally it seems that the virus made an early appearance almost everywhere in 2022.

Typically, RSV leads to between 58,000 and 80,000 hospitalizations in children aged 5 years and under each year in the U.S. Additionally, the virus is usually blamed for around 2 million outpatient visits and between 100 and 300 deaths in children aged under 5 years.

On average, the Centers for Disease Control and Prevention (CDC) reveals that there were around 43.4 RSV-associated hospitalizations per 100,000 people so far in the 2022-2023 season.

 Typically, the bulk of RSV-associated hospitalizations are in children aged under 1 year old, according to previous studies.

It’s too early to close the curtain on the RSV season, but weekly case totals reported by the CDC reveal a significant jump in early cases over previous years.

For example, the CDC tallied nearly 42,000 cases of RSV between October and November 2021. In contrast, there were more than 126,000 cases detected between October and November 2022. However, the data also shows that while RSV cases began rising earlier in the year, a decline in cases started by early December 2022—more than a month earlier than the previous year.

This earlier than normal peak spurred public health experts to offer new guidance on managing RSV, especially in high-risk infants.

In November 2022, the American Academy of Pediatrics (AAP) updated its recommendations on the use of the monoclonal antibody treatment palivizumab as a tool to prevent severe cases of RSV.

Citing a decrease in RSV infections during the COVID-19 pandemic followed by significant change in seasonal epidemiology, the AAP revealed that additional doses—more than the typical 5 consecutive doses—of palivizumab may be required to provide adequate protection. There is no evidence that additional doses, or doses of palivizumab given at increased frequency would lead to adverse effects, notes the AAP.

Research continues also into a number of immunization options that could help decrease the RSV burden in future seasons. Ratner says there are several promising late-stage clinical trials, and Pfizer announced in late 2022 that its bivalent RSV prefusion vaccine candidate, RSVpreF or PF-06928316, offered promising protection to infants when administered to expectant mothers in late pregnancy. According to data from the clinical trials, the vaccine was administered to mothers late in the second trimester or third trimester of pregnancy. The vaccine was found to be almost 82% effective in preventing severe respiratory infections from RSV in infants from birth to 3 months of age. Protection continued through the first 6 months of life, according to trial data, demonstrating about 70% efficacy.

Pfizer is currently seeking approval to make RSVpreF/PF-06928316 the first maternal vaccine to help prevent severe RSV-related illness in infants. Another formulation of the vaccine has also been developed for use in older adults who at high risk of severe RSV-related illness, according to Pfizer.

1. RSV research and surveillance. Centers for Disease Control and Prevention. Accessed January 15, 2023. https://www.cdc.gov/rsv/research/index.html. 

2. RSV-NET interactive dashboard. Centers for Disease Control and Prevention. Accessed January 15, 2023. https://www.cdc.gov/rsv/research/rsv-net/dashboard.html.

3. Zheng, Z, Warren, JL, Shapiro, ED, et al. Estimated incidence of respiratory hospitalizations attributable to RSV infections across age and socioeconomic groups. 

. 2022;14(6). doi:10.1186/s41479-022-00098-x

4. RSV numerator data for the US Centers for Disease Control and Prevention. Accessed January 15, 2023. https://www.cdc.gov/surveillance/nrevss/images/trend_images/RSV14Num_Nat.htm. 

5. Updated guidance: use of palivizumab prophylaxis to prevent hospitalization from severe respiratory syncytial virus infection during the 2022-2023 RSV season. American Academy of Pediatrics. Accessed January 10, 2023. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/interim-guidance-for-use-of-palivizumab-prophylaxis-to-prevent-hospitalization/. 

6. Pfizer announces positive top-line data of phase 3 global maternal immunization trial for its bivalent respiratory syncytial virus (RSV) vaccine candidate. Pfizer. Accessed January 10, 2023. https://www.pfizer.com/news/press-release/press-release-detail/pfizer-announces-positive-top-line-data-phase-3-global. 

New maternal vaccine options could offer extra protection in upcoming seasons.

RSV surges early in 2022, but appears to make early retreat

The sudden cardiac arrest of Buffalo Bills safety Damar Hamlin, 24, on January 2 shocked the public, but the condition believed to have triggered his collapse is one that is more common in young athletes than any other group.

Although there have been no official statements on the exact cause of Hamlin’s sudden cardiac arrest (SCA) after taking a hit in the January 2 football game, many are speculating that commotio cordis is to blame.

Commotio cordis is a condition that develops when blunt force to the chest wall leads to a disruption in the heart’s normal rhythm. The impact of the blow at a specific time in the cardiac cycle can disrupt the normal electrical signals in the heart and trigger arrhythmias like atrial or ventricular fibrillation.

While this phenomenon can really develop in anyone, it’s most common in young competitive athletes. About 95% of cases of commotio cordis happens in adolescent males, according to a report in Circulation, and the mean age at the time of SCA was 14.5 years.

Studies have found that an impact equivalent to around 40 mph of force that strikes directly perpendicular over the left chest wall can trigger commotio cordis.

The collapse of the athlete can happen instantaneously, but the effects of the blow can also appear as long as 24 hours after a hit. Immediate resuscitation efforts with cardiopulmonary resuscitation and defibrillation are key to managing this condition, improving survival rates following commotion cordis from about 15% in 2002 to more than 50% today. Increased awareness, and improved availability of automated external defibrillators in the community have been credited for these improved survival rates.

Although this condition often develops in young athletes with no previously known cardiac history, the American Academy of Pediatrics released guidance in 2021 to help pediatricians recognize patients who may be at risk of commotio cordis.

Multiple conditions can contribute to an increased risk of sudden cardiac arrest, and primary care providers and pediatricians should refer any young athletes with known risk factors to a pediatric cardiologist or electrophysiologist for further evaluation and management.

Some conditions that are believed to increase the risk of developing commotio cordis include:

Regular wellness exams may uncover some of these issues, but the American Heart Association recommends a 14-point history and physical screening for young athletes.

Assessments of personal and family history include:

· A history of chest pain, tightness, or discomfort during exertion

· Excessive shortness of breath, fatigue, or palpitations with exercise

· Prior restrictions for sports participation

· A family history or sudden or unexpected premature death

· Disability from heart disease in close relatives under 50 years of age

· A family history of hypertrophic or dilated cardiomyopathy, clinically significant arrhythmias, genetic cardiac conditions, long QT syndrome, Marfan syndrome, or other ion channelopathies

Physical assessments are also part of the screening and include examination of:

Patients whose screenings generate any concern should undergo additional evaluations, including an electrocardiogram, the guidance states.

1. Buffalo General releases latest update on Damar Hamlin. Buffalo Bills. January 10, 2023. Accessed on January 16, 2023. https://www.buffalobills.com/news/buffalo-general-releases-latest-update-on-damar-hamlin

2. Commotio cordis in athletes. The Sports Medicine Review. January 8, 2023. Accessed January 15, 2023. https://www.sportsmedreview.com/blog/commotio-cordis-athletes/

3. Understanding cardiac arrest and emergency response following Damar Hamlin’s collapse during Monday Night Football. American Heart Association. January 3, 2023. Accessed on January 10, 2023. https://newsroom.heart.org/news/understanding-cardiac-arrest-and-emergency-response-following-damar-hamlins-collapse-during-monday-night-football#:~:text=Commotio%20cordis%20is%20a%20rare,absence%20of%20apparent%20cardiac%20damage

4. Ota K, Bratincsak A. Atrial fibrillation induced by commotio cordis secondary to a blunt chest trauma in a teenage boy. 

2015;135(1):e199-e201. doi:10.1542/peds.2014-1972

5. Link MS, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task force 13: Commotio cordis. 

. 2015;132(22):e339-e342. doi:10.1161/CIR.0000000000000249

6. Erickson CC, et al. Sudden death in the young: Information for the primary care provider. 

 2021;148(1):e2021052044. doi:10.1542/peds.2021-052044

The sudden cardiac arrest of Buffalo Bills safety Damar Hamlin on January 2 shocked the public, but the condition believed to have triggered his collapse is one that is more common in young athletes than any other group.

Red flags in pediatric practice

Social contagion theory—or the effect of a peer’s actions on one’s own choices—has been attributed to all sorts of adolescent behaviors including participation in social media challenges, cigarette smoking, and academic involvement.

But a new study refutes any link between social contagion theory and transgender or gender diverse trends among teens, despite concerns that rates of teens identifying as transgender may be influenced by trending sexuality and gender identity shifts.

, used data from the 2017 and 2019 Youth Risk Behavior Survey. In this survey, data was collected across 26 states, calculating that ratios of adolescents who identify with a gender other than the one they were assigned at birth.

Anecdotally, some pediatric gender clinics have been reporting an increase in gender diversity among teens assigned female at birth (AFAB) more than those assigned male at birth (AMAB), according to the authors, so the analysis also compared these trends.

What the research team found was that despite any appearance of trends at a clinic level, national study data does not support the theory that social pressure or assigned gender at birth has any impact on adolescent feelings toward gender identity.

More recently, the authors note that some legislative debates have implied that teens who are AFAB are more vulnerable than AMAB to the social contagion effect of gender diversity. The researchers warn that this hypothesis—effectively invalidated by this study—carries a threat of fueling efforts to deny gender-affirming medical care or even criminalizing these services.

The research teams reports that a poll of nearly 100,000 teens for each study year found that the overall number of teens identifying as transgender decreased from 2.4% in 2017 to 1.4% in 2019. Ratios of AMAB versus AFAB identifying as transgender also didn’t match a social contagion theory or the insinuation that females are more vulnerable to transgender trends, with AMAB:AFAB ratios dropping from 1.5:1 in 2017 to 1.2:1 in 2019.

Another goal of the study was to address the notion that more teens are making decisions about their gender identity based on “social desirability.” In reality, the study reveals that transgender youths are significantly more likely to be bullied—both in person and through electronic means—than both heterosexual and sexual minority cisgender peers.

The findings of the study refute any suggestion that teens are identifying with other genders to improve their social status, illustrating instead the fact that transgender teens have even higher rates of bullying and victimization than non-transgender teens who are in the sexual minority. Researchers also highlight the fact that instead of showing transgender identification trends in AFAB teens increased, it was really AMAB transgender identification that decreased, creating an illusion that AFAB were more vulnerable to questioning their gender.

Turban JL, et al. Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States. 

. 2022;150(3):e2022056567. doi:10.1542/peds.2022-056567

Social contagion theory for trans teens challenged

Parents can control the home environment for their child with food allergies, but it is more difficult outside the house, especially at school. Pediatricians are often asked for guidance by parents on how to teach their kids about their food allergies, and how to manage those allergies when their children are on their own. 

There’s no single perfect piece of advice, but experts say that a multidisciplinary effort, proactive measures, and self-sufficiency on the part of the child are all important components of an allergy management plan. 

“Once a child goes to school and the parents cannot monitor them or control what the child eats, the concern is that they will have an accidental exposure to one of their allergens, particularly in young children who may pick up another child’s snack and eat it,” says Vivian P. Hernandez-Trujillo, MD, director of the Division of Allergy and Immunology at Nicklaus Children’s Hospital in Miami, Florida. 

An estimated 8% of school-aged children in the United States have potentially life-threatening food allergies,

 but study results show that many teachers and schools aren’t knowledgeable enough about conditions such asthma and allergy treatment to address them properly.

 Better team- and school-wide plans can help,

 especially considering that many children with food allergies report high levels of anxiety.

Most schools have policies to assist students with food allergies, but there is no national blueprint. Policies vary by school district, are loosely defined, and often are poorly implemented. Prevention policies are generally followed the closest at the lower grade levels, where it might be less practical to expect younger children to assume responsibility for monitoring their allergies. 

For some parents and school districts, the answer has been to remove children with allergies from certain sections of the classroom or lunchroom. 

“Families get very worried about how their kids are going to react,” said Jonathan Spergel, MD, PhD, chief of the allergy program and the Stuart E. Starr Chair of Pediatrics at Children’s Hospital of Philadelphia in Pennsylvania. “They want an allergy-free table, and the most common reaction is, ‘Nope, there’s no such thing as a milk-free table or a milk-free school.’” 

Peanut allergies have received a lot of attention, and some schools have created policies to separate children with peanut allergies, but Spergel disagrees with this school of thought. He notes that milk allergies are more common than peanut allergies and that separating children with allergies from their nonallergic peers may cause more harm. 

“We tell families that as long as they eat their own food they are fine,” Spergel said. This puts a large amount of responsibility on the child, but parents and pediatricians have to educate them about their allergy, how to manage it, and how to avoid their allergens. Just being at a table with children consuming the allergen, or even touching it, won’t cause a reaction. As long as children know to be careful not to ingest certain foods, there is no harm in them sitting with friends during meals. 

“We want kids to be as normal as possible and not be ostracized because of their food allergies,” Spergel said. “If you’re ostracized, you’re going to get bullied. If you’re sitting with friends, you’re less likely to be bullied.” 

Birthday parties or class holiday parties are usually the biggest worry, he said, because food is often a central part of these celebrations. Schools can take steps to limit common allergens or find ways to celebrate without food instead. For example, the student could bring a favorite book to share instead of a favorite treat. 

“This can help support education as well as [work] against food allergies and obesity,” Spergel said. 

Who should be notified of a child’s food allergy varies from school to school, Spergel said. A school nurse is a good place to start, followed by the principal. It also can be helpful for parents to discuss the allergy with their child’s direct teachers. All children with allergies should have an allergy management plan and an anaphylaxis plan, he said, and most schools require children with allergies to have emergency medications available at school. 

Each school has its own rules, but Spergel said the important thing for parents to remember is that their child probably is not the only child in the school—and perhaps not the only one in their classroom—with food allergies. In fact, on average there are 2 children with food allergies in every classroom, according to Spergel. 

information on the need for strict avoidance (allergy vs intolerance),

signs and symptoms of the child’s allergic reaction,

Parents should be encouraged to ask about existing policies, when and where children will eat, where emergency medications are kept, and who is able to administer them, Hernandez-Trujillo said. If parents run into trouble having an allergy and anaphylaxis plan created or enforced at school, Spergel said they can ask their allergist or pediatrician for help. A 504 document—a formal plan for children with disabilities—can be drafted to solidify steps the school must take to increase accountability, but Spergel said he usually doesn’t recommend such a drastic step. It’s totally acceptable, however, for clinicians to speak to school on behalf of the student and the parents. 

Parents should be encouraged to reach out to resources such as the Allergy & Asthma Network or Kids With Food Allergies to get an idea of what types of policies schools should have in place to address food allergies.

Rachael Zimlich is a freelance medical writer in Cleveland, Ohio. She has nothing to disclose.

1. Dupuis R, Kinsey EW, Spergel JM, et al. Food allergy management at school. 

. 2020;90(5):395-406. Accessed June 6, 2022. doi:10.1111/josh.12885

2. Urrutia-Pereira M, Mocellin LP, de Oliveria RB, Simon L, Lessa L, Solé D. Knowledge on asthma, food allergies, and anaphylaxis: assessment of elementary school teachers, parents/caregivers of asthmatic children, and university students in Uruguaiana, in the state of Rio Grande do Sul, Brazil. 

 2018;46(5):421-430. Accessed June 21, 2022. doi:10.1016/j.aller.2017.09.018

3. Vollmer RL, Girsch V, Foster JS. A qualitative investigation of parent and child perceptions of school food allergy policies in the United States. 

 2022;92(2):185-193. Accessed June 23, 2022. doi:10.1111/josh.13121

4. Kanter AB, Yasik AE, Zaccario ML, Saviano JC. Self-reported anxiety ratings in children with and without food allergies and teacher knowledge of food allergies.

 2022;92(6):541-549. Accessed June 23, 2022. doi:10.1111/josh.13181

Multidisciplinary, proactive plans, and student self-sufficiency are vital.


Tips for coping with allergies in the school environment

Cyberbullying has been a growing problem for years alongside the increased use of the Internet and social media by children and teenagers, but the COVID-19 pandemic may have given online bullying the biggest boost yet.

Children are spending about 20% more time online than before the pandemic, according to one report, and 71% of parents with children aged 11 and younger are worried about the amount of time their children are spending in front of screens.

Time isn’t the only problem, though. Roughly 21% of the children between the ages of 10 and 18 years who were polled admitted to having been victims of cyberbullying. More than half of these cases happened between January and July 2020 in correlation with worldwide COVID lockdown orders.

Name-calling is the most common form of cyberbullying, and although more than half of teenagers felt angry after being bullied; a third reported feeling hur; and 15% said they were scared. In most of these cases, children blocked or tried asking the bully to stop contacting them, but only 11% talked to their parents about the problem.

Although many schools have instituted programs to try and address all forms of bullying, the reach and impact of these programs is questionable.

One study found that educational interventions had a “very small to small” effect on both traditional and cyber bullying. These interventions were least effective when offered by teachers and appeared to have more effect when they came from tech-savvy content experts.

Pediatricians need to be aware of the impact that cyberbullying can have on their young patients and help parents identify behaviors that could signal a problem.

Any electronic or online bullying can be considered cyberbullying, with offenses ranging from harmful words to actions. This can include things like sending mean messages to sharing embarrassing photos. Even in the “real world,” cyberbullying can carry through in the form of spreading rumors about someone or leaving them out of activities, said Megan Moreno, MD, MSEd, MPH, FAAP, in guidance for the American Academy of Pediatrics.

Cyberbullying isn’t really a new thing, but it does differ from traditional bullying in several ways. For one, cyberbullying can follow children home and be difficult to get away from it. Secondly, the effects can be far more widespread, particularly with “viral” postings that are seen by large populations. The ability to perpetuate this kind of bullying anonymously can also be a draw for would-be bullies.

Although Moreno noted that bullying is sometimes seen as a childhood rite of passage, the increased reach of cyberbullying is further fueling the risk of depression, anxiety, sleep problems, and even substance abuse in the children and teenagers who are victims.

Girls are most often the victims of cyberbullying, according to one study, whereas boys are more involved in cyberbullying episodes. The study also noted that depression and anxiety are among the most common effects reported with cyberbullying in younger children.

Young children also may not be able to speak as directly about the problem, often describing cyberbullying with examples whereas older children and adolescents can provide more complex explanations.

Getting children and teenagers to talk about bullying is only one part of the problem. Clinicians and parents may underestimate the impact cyberbullying has and need to recognize the weight it carries in terms of suicidal thoughts.

Ran Barzilay, MD, PhD, a psychiatrist with the Youth Suicide Prevention, Intervention and Research Center at Children's Hospital of Philadelphia in Pennsylvania, said research shows that just one question from a pediatrician can be enough to raise a red flag about cyberbullying as a risk factor for suicidality. Being a target of cyberbullying on its own is enough to trigger suicidal thoughts, Barzilay added.

In one study, researchers found that nearly 8% of children and teenagers who reported being victims of cyberbullying also reported feeling suicidal thoughts as a result. However, targets of cyberbullying aren’t the only ones at risk. The report found that 69% of the teens that admitted to perpetuating online bullying had also been victims, and suicidality was at its highest level in this group.

 There is no real consensus on the best interventions for cyberbullying, but experts say helping parents identify the problem and encouraging them to establish a family media use plan are good ways to start.

1. Security.org Team. Cyberbullying: twenty crucial statistics for 2022. Updated March 29, 2022. Accessed August 2, 2022. 

https://www.security.org/resources/cyberbullying-facts-statistics/

2. Ng ED, Chua JYX, Shorey S. The effectiveness of educational interventions on traditional bullying and cyberbullying among adolescents: a systematic review and meta-analysis. 

. 2022;23(1):132-151. doi:10.1177/1524838020933867.

3. Moreno M. Cyberbullying: how to help prevent it. Healthchildren.org Published January 28, 2022. Accessed August 2, 2022.


https://www.healthychildren.org/English/family-life/Media/Pages/Cyberbullying.aspx

4. Evangelio C, Rodríguez-González P, Fernández-Río J, Gonzalez-Villora S. Cyberbullying in elementary and middle school students: a systematic review. 

. January 2022;176:104356. doi:10.1016/j.compedu.2021.104356.


5. Leduc K, Nagar PM, Caivano O, Talwar Vl. “The thing is, it follows you everywhere”: child and adolescent conceptions of cyberbullying. 

. May 2022;130:107180. doi:10.1016/j.chb.2022.107180

6. Arnon S, Brunstein Klomek A, Visoki E, et al. Association of cyberbullying experiences and perpetration with suicidality in early adolescence. 

 2022;5(6):e2218746. doi:10.1001/jamanetworkopen.2022.18746.

Bullying can be all-encompassing for children and teenagers, thanks to technology, and it can have a very negative impact on all involved.