A 29-year-old White woman presented to the labor and delivery unit due to preterm premature rupture of membranes (PPROM). Gestational age was 32 weeks and 2 days by first trimester ultrasound, which correlated with her last menstrual period. That ultrasound also confirmed dichorionic diamniotic twin pregnancy.

After delivery (Table 1), the infants were transferred to the neonatal intensive care unit (NICU) because of apnea and were started on caffeine. Sepsis rule-out with 48 hours of ampicillin and gentamicin was given until blood cultures were reported negative. Maternal Group B 

 (GBS) screen done on admission returned a negative result.

Twin A had a head ultrasound (HUS) on day of life (DOL) 1 due to macrocephaly. It revealed right grade 1 intraventricular hemorrhage (IVH). Twin B had a routine HUS on DOL 3, with normal results. Both Twins were treated with phototherapy for indirect hyperbilirubinemia of prematurity. They were transferred to the NICU-B, a step-down unit on DOL 3, and were progressing as expected.

Both babies were in the process of being discharged on DOL 23 when their mother noticed that Twin A was not breastfeeding well. On physical examination, he was pale, lethargic, and ill-appearing. His vital signs were significant for hypothermia of 35.7°C, tachycardia to 211 beats per minute (bpm), and low blood pressure of 40/15 mmHg. A lab work-up was done immediately. An intravenous (IV) access was secured for fluids and empirical antibiotics, with oxacillin and tobramycin given for 1 dose and then the patient was switched to vancomycin and cefepime.

Twin A was transferred to NICU-A, the highest acuity unit, where he continued to get worse. Blood and cerebral spinal fluid (CSF) cultures resulted positive for 

, GBS (Table 2). He was confirmed to have GBS meningitis and sepsis; antibiotics were appropriately switched to penicillin G with gentamicin for synergy. Septic shock and disseminated intravascular coagulation symptomatology ensued. He required ample pressure support and multiple transfusions of packed red blood cells (PRBCs), platelets, and fresh-frozen plasma, as well as a bicarbonate infusion to correct for acidosis. He then developed intractable seizures confirmed on electroencephalogram (EEG), requiring multiple antiseizure medications. Repeat HUS showed evolving right grade 1 IVH. Eventually, he required intubation and mechanical ventilation.

During this time, consultations were made with pediatric infectious disease, neurology, and palliative care teams. Given his prognosis, a family conference was held. His parents were adamant that they did not want their baby to suffer anymore. A decision was made not to increase care beyond current support. The parents were allowed to hold their son. He died on DOL 25, approximately 48 hours after his acute decompensation.

Twin B remained stable and continued to feed well. She was without any signs or symptoms of sepsis and was well-appearing. However, due to the sudden deterioration of her Twin, a complete blood count (CBC) and C-reactive protein (CRP) were performed and were within normal limits. Her newborn screening test was within normal limits, and she passed the hearing screen. She was discharged on DOL 23 as previously planned and appropriate anticipatory guidance was given to both parents.

Approximately 4 days after hospital discharge at DOL 29, the mother presented with Twin B to the emergency department (ED) after she seemed more tired than usual with approximately a 5 mL decrease in oral intake per feed and was making grunting noises. On arrival, her vital signs were temperature of 37.2°C, heart rate of 174 bpm, blood pressure of 88/51 mmHg, respiratory rate of 54 breaths per minute, and 100% oxygen saturation on room air. A work-up was performed, including CBC, blood, urine, and CSF cultures (Table 3). Intravenous ampicillin and gentamicin were given empirically, and she was admitted to the pediatric floor.

She was admitted from the ED for suspected GBS meningitis and sepsis, which was subsequently confirmed. Pediatric infectious disease was consulted and recommended treatment for 14 days with meningitic doses of ampicillin every 6 hours with 48 hours of gentamicin on-board for a synergistic effect. Her repeat HUS was normal and repeat blood culture after 48 hours of antibiotics and on day 7 of admission were negative. The CSF culture was not repeated based on her clinical status. She was well-appearing throughout her hospital course and was gaining weight at approximately 35 g per day and developing appropriately. Her initial inflammatory marker, CRP of 6.9 mg/dL, declined to 1.2 mg/dL by day 12 of antibiotics. She was discharged home after approximately 2 weeks, now DOL 44, with a follow-up appointment with the pediatrician in 48 hours and audiology.

Six days after hospital discharge, on DOL 50, she returned to the hospital for increased fussiness and irritability, which had started approximately 9 hours before arrival to the ED. Her parents said she was feeling warm, but her rectal temperature was 37.7°C at home. Her parents gave her simethicone, but the fussiness and irritability continued. They brought her for evaluation given the prior history of GBS meningitis and recent discharge.

In the ED, vital signs were significant: febrile to 38.5°C, tachycardia at 184 bpm; blood pressure 97/46 mmHg; and tachypnea rate 64 breaths per minute with 100% oxygen saturation on room air. She received two 20 cc/kg saline boluses and acetaminophen with improvement in vital signs. Lab work-up included CBC, comprehensive metabolic panel (CMP), urine, and blood culture. Lumbar puncture (LP) was attempted 4 times in the ED, but the team was unable to obtain CSF. Given the recent history of GBS bacteremia and meningitis, she received meningitic doses of ampicillin and ceftriaxone empirically and was transferred to the floor for further work-up and treatment. Once on the floor, CSF was obtained for culture and chemistry.

She had recurrent GBS meningitis and bacteremia (Table 4).

Pediatric infectious disease was once again consulted. Recommendations were given as follows:

Treatment with ampicillin and ceftriaxone for 21 days after cultures are negative

Susceptibility testing of GBS isolates to ampicillin

Rifampin treatment for 4 days after completion of therapy to eradicate potential mucosal colonization

She was given IV ceftriaxone for the duration of treatment via a peripherally inserted central catheter line. She was transfused with 10 cc/kg of PRBCs for increasing tachycardia without increasing inflammatory markers or clinical deterioration. This anemia was likely iatrogenic due to frequent blood sampling. After discussing the results with parents, they decided to start feeding her formula. She was also being seen by physical therapy, child life, and nutrition. She showed good response to therapy and continued to gain weight and develop adequately. She was discharged on DOL 75 with discharge medications, including rifampin, for 4 days to treat oral mucosal colonization from breast milk and daily multivitamin with iron. Follow-up appointments were made with her pediatrician, audiology, cardiology, neurology, and physical therapy.

GBS is a major cause of neonatal morbidity and mortality as it remains one of the leading causes of neonatal sepsis and meningitis.

 GBS is a gram-positive diplococcus, a common colonizer of the gastrointestinal and genital tracts in pregnant women, and this colonization is often asymptomatic in pregnancy.

The age of onset classifies GBS in neonates as follows

Early-onset GBS presents from birth through DOL 6 but generally presents within the first 24 hours after delivery.

Late-onset GBS usually occurs at 4 to 5 weeks of life and may present from DOL 7 to 3 months of life.

The most common pathogenesis of early-onset GBS infection is vertical transmission by ascending colonization from the maternal gastrointestinal and genitourinary flora. Then infection occurs with subsequent colonization and invasion of the fetal compartment or fetal aspiration of infected amniotic fluid.

 This transmission primarily occurs shortly before or during labor and delivery. Late-onset GBS infection may be acquired vertically as well, but horizontal transmission from colonized household contacts, hospital contacts, and breast milk is also a practical pathogenesis.

The incidence of early-onset GBS has declined in the United States, and this is predominantly because of maternal GBS screening and intrapartum antibiotic prophylaxis (IAP), which was done in this case. In contrast, the incidence of late-onset GBS disease has remained approximately unchanged over the past 30 years.

 This is not surprising as IAP is only effective during labor and delivery and does not necessarily eradicate GBS colonization.

 Thus, even after women are given IAP, they may continue to be GBS colonized postpartum.

Twin A had rapid clinical deterioration after meeting discharge criteria 48 hours prior to his death. He had profound septic shock and meningitis with intractable clinically observed seizures despite multiple medications. Although HUS was done immediately and repeated during his acute decompensation, an early MRI may have provided more details and possible pathology. In hindsight, perhaps the macrocephaly diagnosed prenatally on obstetric ultrasound played a more significant role in his disease susceptibility, prognosis, rapid progression, and eventual mortality.

Horizontal transmission from colonized contacts plays a significant role in the pathogenesis of late-onset GBS, whether from parents or hospital staff. In this case it remains a likely possibility, especially given that maternal GBS screen resulted negative, IAP was administered, and both Twins had prolonged hospitalization from birth to DOL 23 before clinical deterioration. It can even be hypothesized that maternal breast milk was the agent of horizontal transmission.

An important clinical question has been raised about treating Twins and other multiples. What should be done when invasive GBS infection occurs in 1 sibling but the other sibling/siblings remain (or appear to remain) asymptomatic?

When invasive GBS infection occurs in an infant, the other Twin or multiples should be observed carefully for signs of infection.

 Whether this observation should be in hospital and for what duration or with the parents after thorough anticipatory guidance and counseling is yet to be determined.

The unaffected sibling/siblings likely may be colonized with GBS, given shared contacts and medical history, but there is no evidence to support a full antibiotic course in the absence of confirmed GBS disease.

However, some experts take a conservative approach of empirical evaluation and antibiotic therapy even in the asymptomatic sibling/siblings when the index case has invasive GBS disease.

 This then leads to the discussion of adequate duration of treatment when there is no identified source of infection in the asymptomatic sibling/siblings.

Another important takeaway from this case is the importance of prompt CSF testing for sterility after antibiotic treatment, despite the patient’s clinical appearance.

DIFFERENTIAL DIAGNOSIS FOR LATE-ONSET SEPSIS IN PRETERM INFANTS

Escherichia coli, Klebsiella, Pseudomonas, Enterobacter, Citrobacter

Follow-up with Twin B at 15 months revealed that she was developmentally appropriate. Her vision and hearing were normal. EEG and brain MRI at age 1 year were normal. She qualified for early intervention based on her prematurity and significant course of meningitis and currently attends physical therapy and occupational therapy.

There are limitations to GBS screening and IAP, especially because the exact delivery time cannot be predicted, particularly in the premature population. Universal antenatal testing of pregnant women for GBS colonization is obtained at 36 to 37 6/7 weeks gestation and on presentation in all preterm pregnancies.

 If administered to pregnant women and all sexually active females, the GBS vaccine is a promising solution that could potentially prevent these infections, especially late-onset disease. Clinical trials are being done on multivalent glycoconjugate GBS vaccines.

 Vaccine prevention remains a better solution than disease management.

This case serves as a reminder of the critical importance of prompt evaluation and empirical treatment of neonates at risk of invasive bacterial infection. There is an increased relative risk of invasive GBS infection in the Twin or other multiples of an affected patient, and therefore clinical hypervigilance must be maintained.

In invasive GBS disease, especially GBS meningitis, response to therapy and potential complications must be monitored clinically through serial neurologic examinations, repeat CSF analysis, and neuroimaging. In this patient with recurrent GBS meningitis, there is a high risk of permanent neurological sequelae, which so far, the patient has seemingly avoided.

1. American Academy of Pediatrics. Group B streptococcal infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS eds. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st ed. American Academy of Pediatrics, 2018.

2. Puopolo K, Lynfield R, Cummings J, et al. Management of infants at risk for Group B streptococcal disease. 

. 2019;144(2),e20191881. doi: 10.1542/peds.2019-1881.

3. Eichenwald EC. Perinatally transmitted neonatal bacterial infections. 

. 1997;11(1):223-39. doi: 10.1016/s0891-5520(05)70350-0.

4. Puopolo, K. and Baker, C. Group B streptococcal infection in neonates and young infants. Updated October 12, 2021. Accessed December 6, 2021. 

https://www.uptodate.com/contents/group-b-streptococcal-infection-in-neonates-and-young-infants?search=group-b-streptococcal-infection-in-neonates-and-younginfants&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

5. UptoDate. Group B streptococcus. Accessed December 6, 2021. 

https://www.uptodate.com/contents/group-b-streptococcal-infection-in-neonates-and-young-infants/abstract/7,8

6. Morinis J, Shah J, Murthy P, Fulford M. Horizontal transmission of group B streptococcus in a neonatal intensive care unit. 

. 2011;16(6): e48-50. doi:10.1093/pch/16.6.e48

7. Lin, F-Y, Weisman L, Azimi P, et al. Assessment of intrapartum antibiotic prophylaxis for the prevention of early-onset group B Streptococcal disease. 

. 2011; 30(9): 759-63. doi:10.1097/INF.0b013e31821dc76f

8. Patras K, Nizet V. Group B streptococcal maternal colonization and neonatal disease: molecular mechanisms and preventative approaches. 

. 2018; 6(27). doi:10.3389/fped.2018.00027

9. American College of Obstetricians & Gynecologists. Prevent of group B streptococcal early-onset disease in newborns. Published January 3, 2020. Accessed December 6, 2021. 

https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns.pdf

10. Doran K, Benoit V, Gertz R, Beall B, Nizet V. Late-onset group B streptococcal infection in identical twins: insight to disease pathogenesis. 

. 2002;22(4): 326–330. doi: 10.1038/sj.jp.7210675

11. Morgan JA, Zafar N, Cooper DB. Group B streptococcus and pregnancy. In: StatPearls 

https://www.ncbi.nlm.nih.gov/books/NBK482443/

12. ClinicalTrials.gov. Group B streptococcus vaccine in healthy females - study results. Updated February 2, 2021. Accessed December 6, 2021. 

https://clinicaltrials.gov/ct2/show/results/NCT03807245

Articles

A 29-year-old White woman presented to the labor and delivery unit due to preterm premature rupture of membranes and delivered twins. The twins were transferred to the neonatal intensive care unit following delivery. 

A case of late-onset group B Streptococcus infection in fraternal twins

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. 

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

As the first day of college looms for many students attending for the first time, pediatricians may be confronted with patients experiencing a range of emotions from excitement to stress and uncertainty. Most first-year college students report facing emotional challenges, according to an online survey of 1502 college students conducted by the Harris Poll.

 Fifty percent of respondents said they felt stressed most or all of the time.

Although there is traditionally an emphasis on academic preparedness, emotional preparedness is the most likely factor in students being emotionally and academically successful in college.

 Being able to care for oneself, adapt to new environments, control negative emotions, and build positive relationships are factors that determine a student’s success. By providing anticipatory guidance to patients and their families, pediatricians can mitigate the uncertainty that lies before them. 

Even before social media, college was represented as a party-filled atmosphere in movies and television shows. Often described as the “best 4 years of one’s life,” expectations for fun, meaningful relationships, and an enriching academic experience are what most students think they will find awaiting them once they settle into their dorms. The ubiquity of smartphones and social media have now amplified the ideal image of college life. In fact, many college students feel that social media, television, and movies make college seem more fun than it really is, and 49% of the survey respondents said that college was not living up to their expectations.

When talking with new college students, pediatricians should start with open-ended questions about what patients expect when they get to college. Pediatricians can help manage expectations, noting that college students may find the experience different from how it appears in the media. For example, pediatricians can ask, “Which social media apps do you prefer?” or “What kind of things do you enjoy reading on social media?” and then based on responses, ask about the patient’s perceptions of the content. As a pediatric psychiatrist, I often ask patients what they look at on social media and whether they think it is a true representation or a mirage. Creating a reflective process helps them do so on their own when they are feeling the familiar fear of missing out, better known as FOMO. Helping patients understand that it is normal to feel a range of emotions in the first year will help to normalize the feelings when they inevitably arise. 

One in 5 college students meets criteria for alcohol use disorder.

 Another 50% binge drink during college, and 1 in 5 students report doing so frequently.

These are concerning statistics that lead to significantly negative consequences. It is important to note that many students do not participate in substance use or binge drinking. Research suggests that social networks are a strong influence in substance use among college students.

 Furthermore, the majority of college students overestimate heavy drinking use of their peers, and this overestimation can lead to more heavy drinking.

 College students drink according to the social norms they perceive. 

To buffer students from substance misuse, pediatricians can remind teenagers that many do not engage in alcohol misuse and ask the patients to discuss what types of friends they hope to make in college. In fact, reducing normative misperceptions around drinking has been the most effective brief intervention strategy to reduce heavy drinking.

 Knowing where to get support is an important component of addressing the emotional challenges often underlying substance use at college. 

Many mental health challenges and disorders emerge in students during their college years. Other students will enter college with a diagnosis and in need of ongoing psychiatric or psychological care. Creating a plan with families prior to arriving on campus is an essential task in supporting students’ mental health. 

Touring the college counseling center will help foster familiarity with mental health resources on campus. Similarly, pediatricians can start the conversation about where students can go to access additional mental health support. It is also important to engage parents and discuss signs of common mental health disorders such as anxiety, depression, and substance misuse. Once patients turn 18 years old, parents have less access to health care providers, but they can still be an important partner in getting their children the help they need. If an individual entering college is already in treatment, ensuring that the family has a plan to continue treatment is helpful. 

For patients who take medications, review with them a plan to get refills before they run out when they are on campus. Families should be informed that their clinicians will need a license in the state where the student lives in order to continue care. Otherwise, parents should find a new therapist or psychiatrist if the student will need ongoing care. The misuse of prescription drugs on college campuses is common, so discuss with patients the important of taking medications as directed and not sharing or selling to other students. 

Practice problem-solving before the semester starts 

When I talk to parents about managing behavior, I always recommend “striking while the iron is cold.” It is much harder to manage a crisis, or a big tantrum, at peak intensity. Practicing strategies and creating routines around stress management and problem-solving will produce dividends when young adults need to navigate life independently. Build on preexisting strengths. Pediatricians can ask questions such as, “How have you handled stress in the past?” or “Have there been times when you have felt overwhelmed? What helped?” Reinforcing good habits and mentioning new ones in a time of calm will build a foundation for overall well-being. 

Mindfulness strategies are easy to learn and beneficial for mental health. In a pilot study using mindfulness training among 109 freshmen, participation was associated with increased life satisfaction and decreased depression and anxiety.

 Introducing simple mindfulness techniques (meditation, progressive muscle relaxation) and practicing them together in the office can create healthy coping strategies. 

Living independently requires learning problem-solving skills. Helping families reflect on past transitions can help them cope with the upcoming change. In the years and months leading up to college, parents should allow for more space to let their teenagers experience independence. Reviewing what needs to be completed prior to leaving for college and how the teenager can help is great practice for solving problems once they leave home. 

The college years are a time of stress and mental health challenges.

 In the midst of an ongoing pandemic, the baseline of stress among adolescents is even higher and necessitates a response.

 Pediatricians can be a part of crucial conversations that will help set the stage for a successful college transition.

Emily Aron is a psychiatrist affiliated with MedStar Georgetown University Hospital in Washington, DC. She also is a member of the Editorial Advisory Board of Contemporary Pediatrics®.

1. Harris Poll. The first-year college experience: a look into students’ challenges and triumphs during their first term at college. October 8, 2015. Accessed June 28, 2022. https://www.settogo.org/wp-content/uploads/2017/01/First-Year-College-Experience-Data-Report-for-Media-Release-FINAL.pdf

2. Allen J, Robbins SB, Sawyer R. Can measuring psychosocial factors promote college success?. 2009;23(1):1-22. doi:

3. Slutske WS. Alcohol use disorders among US college students and their non-college-attending peers. 

. 2005;62(3):321-327. doi:10.1001/archpsyc.62.3.321

4. Krieger H, Young CM, Anthenien AM, Neighbors C. The epidemiology of binge drinking among college-age individuals in the United States. 

5. Mason MJ, Zaharakis N, Benotsch EG. Social networks, substance use, and mental health in college students. 

 2014;62(7):470-477. doi:10.1080/07448481.2014.923428

6. Cox MJ, DiBello AM, Meisel MK, et al. Do misperceptions of peer drinking influence personal drinking behavior? Results from a complete social network of first-year college students. 

. 2019;33(3):297-303. doi:10.1037/adb0000455

7. Reid AE, Carey KB. Interventions to reduce college student drinking: state of the evidence for mechanisms of behavior change. 

8. Dvořáková K, Kishida M, Li J, et al. Promoting healthy transition to college through mindfulness training with first-year college students: pilot randomized controlled trial. 

9. Bruffaerts R, Mortier P, Kiekens G, et al. Mental health problems in college freshmen: prevalence and academic functioning. 

. 2018;225:97-103. doi:10.1016/j.jad.2017.07.044

10. Wang X, Hegde S, Son C, Keller B, Smith A, Sasangohar F. Investigating mental health of US college students during the COVID-19 pandemic: cross-sectional survey study. 

. Published online September 17, 2020. doi:10.2196/22817

As the first day of college looms for many students attending for the first time, pediatricians may be confronted with patients experiencing a range of emotions from excitement to stress and uncertainty. 

Helping first-year college students manage expectations and stress

In the hospital nursery, a 4-week-old boy has creamy white patches on his lips, right and left buccal mucosa, palate, and tongue. He had been admitted to the nursery intensive care unit (NICU) 2 days ago. His mother brought him to the pediatric emergency department because he refused to feed and felt warm. Seven days previously, his mother received a diagnosis of COVID-19 infection. He had a sepsis work-up and was started on intravenous (IV) antibiotics.

Diagnosis: COVID-19–associated pseudomembranous candidiasis

He was born at term via normal vaginal delivery with no complications. His mother received a diagnosis of gestational diabetes in the second trimester and was started on insulin.

On initial examination in the emergency department, he was noted to be moderately built and nourished, slightly irritable, and refusing to feed. His body temperature was 37.3 °C, heart rate was 134 beats per minute, oxygen saturation was 98%, and respiratory rate was 52. A chest x-ray showed no abnormal findings. A reverse transcriptase–polymerase chain reaction assay was positive for SARS-CoV-2.

He was admitted to the NICU after the sepsis work-up and treated with IV fluids and antibiotics. During hospitalization, he developed white creamy patches over the right and left buccal mucosa, palate, and tongue that on scraping left an erythematous, somewhat eroded mucosal surface. He also had red patches with superficial pustules in the diaper area. Microscopic examination revealed pseudohyphae and spores, and a fungal culture grew 

. He was treated with IV fluconazole once daily for 2 days and then transitioned to oral fluconazole for a week with complete clearing of the patches and a negative oral fungal culture on follow-up. Bacterial cultures were negative, and he was discharged home at the end of the week.

Candida is a type of yeast, part of the fungus family that normally lives in and on our bodies.

It can be found on the skin and in the mouth, for example, and in the intestinal tract and genital area. Candidiasis infection of the mouth, also referred to as oral thrush, is common in infants and toddlers. Up to 37% of newborns may develop thrush during the first months of life. Most of the time, 

 does not cause any problems. However, when it overgrows, it can cause infections ranging from simple asymptomatic oral candidiasis to life-threatening septicemia. Thrush also can affect fingernails, eyes, skin folds of the neck and armpits, as well as diaper area (

 diaper dermatitis), including genital and perianal skin.

Male sex and birth asphyxia are predominant risk factors. It also has been observed that neonates developing candidiasis had received antibiotics such as amoxicillin or amoxicillin-clavulanic acid for a significantly longer duration. Newborns can get a Candida infection from their mothers. This can occur before delivery, but also during passage through the birth canal during delivery. Infants at the highest risk of bloodstream infections with Candida include premature or very low birthweight infants, children with long-term IV catheters, and children with weakened immune systems caused by HIV, cancers, or medicines. Children on inhaled steroids also have an increased incidence of oral candidiasis. Maternal risk factors also include diabetes mellitus and immunosuppressive states such as HIV. Risk factors for systemic candidiasis also include prolonged administration of total parenteral alimentation and IV fluids, and being on a ventilator.

Lichen planus is reticulated and erythematous rather than plaque-like. Twenty percent of oral lichenoid lesions will have superimposed candidiasis.

Geographic tongue usually affects lateral/dorsal, rather than midline posterior, tongue.

Oral hairy leukoplakia is an HIV-associated disease. It often has an associated secondary Candida infection and is most common on the lateral borders of the tongue, often (but not always) in a bilateral and symmetric distribution.

Aphthous ulcers are much more painful and episodic than candidiasis.

Chronic cheek chewing is usually painless, with a gelatinous, shaggy consistency.

Hypersensitivity reaction to denture base material is rare.

Diphtheria membrane can be mistaken for candidiasis, although in diphtheria there may be hemorrhagic crusts around the mouth and nares.

Hairy tongue is hyperkeratosis of the filiform papillae, not a yeast infection.

White sponge nevus is a very uncommon genodermatosis; there may be a family history.

Leukoplakia presents as thick, white patches on the inside surfaces of the mouth. It can be a sign of precancerous changes in the mouth or mouth cancer.

Uremic stomatitis is a rare disease affecting the oral mucosa and causing painful plaques and crusts. It is associated with acute or chronic advanced kidney failure.

Oral thrush in infants often disappears within 2 weeks, and parents or caregivers may be advised to monitor the infection without using medication. The length and type of the therapy will depend on several factors, such as the severity of the infection and any other health problems. In case of chronic infection or severe immunodeficiency, topical application of clotrimazole (1%) 3 to 4 times a day with the maintenance of good oral hygiene is effective. However, resistant cases may require oral fluconazole or itraconazole. Fluconazole is available in convenient oral formulations for infants and children of 10 mg/cc and 40 mg/cc. In certain cases, nystatin also may be used.

When a mother receives a diagnosis of gestational diabetes, she should be educated about candidiasis risk to her and to the baby. Women who have nipple discharge or pain during breastfeeding should notify their health care provider so they can be evaluated for yeast infection, which can be transmitted to the mouth of a nursing infant. When breastfeeding, women should use breast pads that do not have a plastic barrier. Long-lasting thrush is sometimes related to pacifiers or bottles that have not been properly cleaned.

Good oral hygiene is vital. If any chronic health issues are detected, they should be managed properly. If a patient is on inhaled corticosteroids, the inhaler should be cleaned properly and a spacer should be used. To reduce the risk of diaper candidiasis, change diapers often, especially if the patient has loose stools. Use a barrier cream as needed.

A 4-week-old boy presents with creamy white patches on his lips, right and left buccal mucosa, palate, and tongue.

White oral lesions in neonate with COVID-19

Back-to-school time brings a mixture of emotions for students and parents alike. For parents and caregivers, sending a child to school for the first time can feel overwhelming. It’s even more stressful when the child has a chronic condition such as asthma. As a mother of a teenager with asthma, I remember my concerns when my daughter first went to preschool. As pediatricians, however, we know the importance of school attendance for academic and social growth, and we can help families prepare for a fruitful school year. 

Parents and caregivers need to know the triggers in a school environment that may worsen a child’s baseline condition and how to respond if the child has an asthma exacerbation. Practitioners should review triggers with the family before the school year begins. When children first attend school, they may have frequent upper respiratory infections (URIs) if they were not previously exposed to these infections in daycare or from older siblings. In my practice, I explain that the immune system is naïve until the child has been exposed to the viral infections and can create antibodies to protect them from future exposure. Since URIs and viral infections are some of the most frequent causes of asthma exacerbations, take the time to provide this anticipatory guidance and then have a plan in place for when it occurs. 

Recommend that parents talk to the child’s teachers or school nurse about unnecessary exposure to possible asthma triggers such as dust, mold, animal dander, or cockroaches. For instance, a child with asthma may be allergic to pets, and some students in the classroom likely come from a family with a dog, cat, or other animals. Pet hair and dander can linger on a child’s clothes, backpack, etc, so it would be best for the child with asthma to not sit next to that child with a pet. Another child may have asthma or an allergy to mold that is important to note if the school has a leak in the classroom roof or in an air conditioning unit.

Ensuring that the student has an asthma action plan in place is vital. If the child is old enough to discuss this plan, remind them that they need to tell their teacher or school nurse if they are not feeling well. Reviewing signs and symptoms of an asthma exacerbation is important. It also is essential to review proper administration of rescue inhalers. I tell the child that if they are running around at recess or physical education and feel short of breath or start to cough after a short period of exercise, they should tell their teacher and then rest. Rescue inhalers should be immediately available, whether the child carries it with them or a teacher has it available in the classroom. The medication should be kept in an environment without large temperature changes, so an outdoor locker in a hot climate is not an ideal location. For a younger child who may not be able to express how they feel, it is important for the teacher to know ahead of time about their asthma diagnosis so that they can identify the start of an asthma exacerbation during school hours. The rescue inhalers should be readily available; the teacher can keep it in their desk or carry it for the student during physical education. Asking the teachers to notify the school nurse or parents when an exacerbation occurs also is essential to ensure proper and prompt treatment.

Study results have shown that school nurses have a positive impact on the management of asthma in children.

 Approximately 20% of schools in the United States don’t have a school nurse,

 but at schools where nurses are not available, teachers and school administrators should advocate for the students and become educated on common chronic illnesses. The Centers for Disease Control and Prevention published a report addressing asthma in schools that included information on asthma education, linking children to medical care in school, and improving school air quality.

 SAMPRO is a comprehensive program that provides educational materials regarding asthma.

 This school-based asthma management program was developed by key stakeholders to improve asthma care in school communities. It has 4 essential components: a circle of support to facilitate communication among child, family, clinicians, school nurses, and community; asthma management plans, including the Asthma Action Plan, which is available online

 ; an education plan for all school personnel; and a plan to assess the child’s environment and remediation of school-based asthma triggers. The ultimate goal is to ensure children stay healthy, and if they do have an exacerbation and go to a hospital setting that it will not lead to a readmission.

School programs to improve the health of children with asthma are an integral part of the medical care many children receive, and resources for schools help provide a better environment for students with asthma. Starting the school year off healthy and with a plan of action in case of an asthma exacerbation is vital to a child’s success. As pediatricians and pediatric subspecialists seeing patients in preparation for back to school, we should ensure all prescriptions for rescue and maintenance medications are updated and address any questions or concerns the families may have. Looking forward to another successful school year!

Vivian P. Hernandez-Trujillo is a board-certified allergist/immunologist in Miami, Florida, and a member of the Contemporary Pediatrics® Editorial Advisory Board.

1. Trivedi M, Patel J, Lessard D, et al. School nurse asthma program reduces healthcare utilization in children with persistent asthma. 

. 2018;55(10):1131-1137. doi:10.1080/02770903.2017.1396473 

2. Centers for Disease Control and Prevention. School Health Services and Practices Study. Accessed June 22, 2022. https://www.cdc.gov/healthyyouth/ data/shpps/pdf/2014factsheets/health_services_ shpps2014.pdf 

3. Centers for Disease Control and Prevention. Strategies for addressing asthma in schools. Accessed June 22, 2022. https://www.cdc.gov/ asthma/pdfs/strategies_for_addressing_asthma_ in_schools_508.pdf 

4. Lemanske RF Jr, Kakumanu S, Shanovich K, et al. Creation and implementation of SAMPRO: a school-based asthma management system. 

. 2016;138(3):711-723. doi:10.1016/j. jaci.2016.06.015 

5. Elsevier. Asthma and asthma action plan. Accessed June 22,2022. https://www.elsevier. com/_ _data/assets/pdf_file/0007/164662/ FormAsthmaandAsthmaActionPlanPediatric.pdf 

6. Krupp NL, Fiscus C, Webb R, et al. Multifaceted quality improvement initiative to decrease pediatric asthma readmissions. 

. 2017;54(9):911-918. doi:10.1080/02770903.2017.1281294

Help your patients have a safe and healthy academic year.

Keep asthma under control at school

Musculoskeletal injuries, especially those due to repetitive use, are common in child and adolescent athletes.

 The most recent Centers for Disease Control and Prevention data showed that there were more than 2.7 million annual emergency department visits for pediatric sports injuries from 2010 to 2016. These data suggest that many pediatricians have likely treated or seen a child acutely or in follow-up for a sports-related injury.

 Pediatric health care providers are most likely familiar with the mnemonic PRICE: protection, rest, ice, compression, and elevation. This does not mention medications. The most common medications used for sports-related injuries include nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and lidocaine patches. Fortunately, most of these medications are available OTC.

The 2 most widely used oral NSAIDs for musculoskeletal injury are ibuprofen and naproxen, with naproxen often recommended by sports medicine clinicians due to its longer half-life. They provide analgesic, anti-inflammatory, antipyretic, and antithrombotic effects by inhibiting cyclooxygenases and subsequent cessation of the creation of prostaglandins from arachidonic acid.

 Jin et al performed a meta-analysis examining acute analgesic usage in emergency departments for pediatric musculoskeletal injuries.4 They found that oral ibuprofen produced better analgesic effect 60 minutes after administration and equivalent effect at 30 minutes when compared with acetaminophen, acetaminophen with codeine, and morphine. Results of this study,

 as well as those of a seminal study published in 2007 in the journal Pediatrics,

 showed ibuprofen to be superior to acetaminophen for the treatment of acute musculoskeletal injuries. 

A variety of nonprescription treatments, supplements, and patches can alleviate pain for children and adolescents.

August 2022

A case of late-onset group B Streptococcus infection in fraternal twins

Tips for coping with allergies in the school environment

Helping first-year college students manage expectations and stress

White oral lesions in neonate with COVID-19

Keep asthma under control at school

Healing the young athlete with OTC medications

What does back to school look like this year?