A healthy 14-year old boy was evaluated for an intensely pruritic shin rash (Figure) that developed 2 weeks prior and had been treated with oral antibiotics for 10 days. On examination, the rash appeared more severe, with discrete, confluent, crusted, red papules and plaques on the shins, with relative sparing of the knees and ankles, progressing to the trunk and parts of the face and ears. He was upset because the rash interfered with his ability to play soccer.

Additional history taken from the patient’s father revealed that the boy was a goalkeeper on his school soccer team. The father explained that the inner lining of the boy’s protective shin guards was frayed. Owing to the initial location of the eruptions and lack of improvement on antibiotics, a diagnosis of allergic contact dermatitis due to a component of the shin guards was suspected. The dissemination of the rash was caused by autoeczematization. Patch testing to standard allergens and components of the patient’s soccer shin guards was planned.

Diagnosis: Shin guard allergic contact dermatitis to acetophenone azine now with generalized autoeczematization

Contact dermatitis is a common inflammatory skin condition characterized by erythematous, scaly, crusted, pruritic, and/or painful skin lesions after contact with a foreign substance. The condition can be irritant or allergic. Irritant contact dermatitis is caused by nonimmune-modulated chemical damage to the skin. Allergic contact dermatitis is a delayed hypersensitivity reaction (type 4) to contact antigens, and skin changes occur with reexposure.

Autoeczematization, or id reaction, is a disseminated eczematous reaction that occurs when the antigen is released after exposure to a stimulus at a primary site, with the reaction spreading to distant sites.

When determining the diagnosis, irritant contact dermatitis due to friction and sweat generally comes to mind first. However, the reaction is typical of allergic contact dermatitis, and this patient’s history favors the contact allergen acetophenone azine, a relatively new allergen, from his shin guards. The differential also includes atopic dermatitis, fungal infection, and psoriasis. The differences in the presentation of irritant and allergic contact dermatitis are summarized in the Table.

When must one suspect acetophenone azine contact dermatitis? The distribution of the primary rash and history of fraying shin guards should make this a high priority. Patch testing with a piece of the shin guard and the specific allergen, if available, should be considered and is recommended when avoiding the suspected allergen fails to bring improvement.

Avoidance of the allergen is the mainstay of prevention of recurrent allergic contact dermatitis. In this case, using shin guards and shoes made of other materials and/or placing barriers between the skin and the shin guards can help treat the patient and confirm the diagnosis. Acetophenone azine is presently unavailable as a commercial patch-test preparation.

Cool compresses and calamine lotion can soothe the acute symptoms. Localized lesions are often successfully treated with mid- or high-potency topical steroids, such as triamcinolone 0.1% or clobetasol 0.05% applied twice a day for 2 to 3 weeks.

If allergic contact dermatitis involves an extensive area of skin, the symptoms are extremely severe, or there is autoeczematization, systemic steroid therapy is often required and generally offers relief within 12 to 24 hours. If the allergen is removed and no effective therapy is instituted, it can take 2 to 3 weeks for the reaction to resolve, so an initial course of at least 5 to 7 days of prednisone, 0.5 to 1 mg/kg daily, is recommended. The dose may be tapered over the next 7 to 10 days.

With severe dermatitis, oral prednisone should be tapered over 2 to 3 weeks with emollients and cool compresses with high-potency topical steroids applied to the worst areas. Emollients, moisturizers, or barrier creams are secondary treatment to help avoid continued exposure.

A case report published in 2016 recognized the occurrence of severe, dramatic shin contact dermatitis in a young football player that progressed to generalized dermatitis.

 On further investigation and patch testing, acetophenone azine was found to be the culprit. High-performance liquid chromatography (HPLC) identified the chemical substance at concentrations of approximately 20 μg/g of shin pad samples. Patch tests gave strongly positive reactions to pieces of shin pads and to acetophenone azine down to dilutions of 0.001% in acetone.

It was later recognized the potent new allergen caused rash even on exposure to footwear containing ethylene vinyl acetate (EVA).

 Acetophenone azine is not a component that is directly added to EVA during the manufacture of shin guards, shoe insoles, flip-flops, and other athletic gear and footwear. Though the exact chemical reactions that lead to its formation are unknown, it is presumed that it is due to cross-reactions with other materials added during EVA synthesis.

 Acetophenone azine may arise from the degradation of dicumyl peroxide and hydrazine in the foaming agent azodicarbonamide.

On patch testing with materials including rubber, plastic, and shavings from the inner foam lining the shin guards, the only positive reaction was to the foam shavings that contained EVA. This material was sent to a laboratory, where HPLC revealed the allergen to be acetophenone azine.

The antibiotic was continued for 4 more days, and oral prednisone at 1 mg/kg/day was added. He improved dramatically over the next 48 to 72 hours, at which point the antibiotics were discontinued. The prednisone was tapered over the next 10 days.

1. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. 

2. Bertoli MJ, Schwartz RA, Janniger CK. Autoeczematization: a strange id reaction of the skin. 

 2021;108(3):163-166. doi:10.12788/cutis.0342

3. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. In: Usatine RP, Smith MA, Mayeaux EJ, Chumley H Jr, Tysinger J, eds. 

4. American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology. Contact dermatitis: a practice parameter

2006;97(3 suppl 2):S1-S38. Published correction appears in 

5. Raison-Peyron N, Bergendorff O, Bourrain JL, Bruze M. Acetophenone azine: a new allergen responsible for severe contact dermatitis from shin pads. 

 2016;75(2):106-110. doi:10.1111/cod.12579

6. Raison-Peyron N, Bergendorff O, Du-Thanh A, Bourrain JL, Bruze M. Two new cases of severe allergic contact dermatitis caused by acetophenone azine. 

 2017;76(6):380-381. doi:10.1111/cod.12777

7. De Fré C, Bergendorff O, Raison-Peyron N, et al. Acetophenone azine: a new shoe allergen causing severe foot dermatitis. 

 2017;77(6):416-417. doi:10.1111/cod.12843

8. Darrigade AS, Raison-Peyron N, Courouge-Dorcier D, et al. The chemical acetophenone azine: an important cause of shin and foot dermatitis in children. 

9. Acetophenone azine: The 2021 American Contact Dermatitis Society Allergen of the Year. 

 2021;107(5):238-240.doi:10.12788/cutis.0252

Articles

A healthy 14-year old boy was evaluated for an intensely pruritic shin rash that developed 2 weeks prior and had been treated with oral antibiotics for 10 days. 

A case of shin guard dermatitis?

A retrospective study found that young women (postmenarchal) with a renal anomaly (RA) also were at risk of having a Müllerian anomaly (MA). The study group included 326 patients with an RA in whom a pelvic examination revealed a coexisting MA in 125 (38.3%). Of those who underwent the pelvic exam because of pain, about one-third were found to have an MA. The average age for RA diagnosis was 6.4 years and for MA diagnosis 16.4 years. Of the patients with obstructive MAs, 93.8% underwent urgent surgery, with the others started on hormonal suppression.

Patients with what investigators termed “solitary kidney” (true renal agenesis and involuted early multicystic dysplastic kidney [MCDK]) were most likely also to have an MA. In these patients, MA prevalence was 67% and included a 30% risk of an obstructive anomaly. Solitary kidney was the most common RA diagnosis in the study group, seen in 37.6%, but persistent MCDK also posed a 20% to 23% risk of an MA.

These findings support routine screening for an MA in patients with an RA, especially those with a congenital solitary kidney, the authors noted.


There has been controversy over the years about kidney disease and associated conditions (should we image the kidneys in children with isolated preauricular pits?), but this looks to have a more solid evidence base. For technical reasons, screening is best done shortly after menarche. Note that hydronephrosis is not one of the renal disorders that predisposes to MAs.

Fei YF, Smith YR, Wan J, Dendrinos M, Winfrey OK, Quint EH. Should we screen for Müllerian anomalies following diagnosis of a congenital renal anomaly? 

. 2022;S1477-5131(22)001164-4. doi:10.1016/j.jpurol.2022.04.017

A retrospective study found that postmenarchal women with a renal anomaly were also at risk of having a Müllerian anomaly. 

A renal anomaly? Look for a Müllerian anomaly as well 

Treatment of the various types of spinal muscular atrophy (SMA) with approved therapies results in an array of improvements, according to a review of 22 studies that assessed mid- and long-term (at least 12 months) outcomes in patients with SMA. Three therapies are approved for SMA: nusinersen, onasemnogene abeparvovec, and risdiplam, used alone or in combination, depending on the patient’s SMA type and other factors.

The analysis showed that nusinersen improved motor functions in patients with SMA type 1, while in SMA type 2 to type 4 disease this treatment was associated with patient stabilization or small improvements, though investigators also observed some deterioration. Onasemnogene abeparvovec improved motor functions (such as the ability to sit for at least 30 seconds or stand without support) in patients with SMA type 1, as did combination therapies in these patients. Procedure-related adverse events, generally caused by the lumbar puncture, were reported, though drug-related such events were rare. The authors noted, however, that the studies they reviewed either did not address pulmonary outcomes or reported on them “poorly.”


SMA is a disease we will start diagnosing earlier due to newborn metabolic screening. We now have options for this heretofore untreatable condition. The treatments look beneficial in at least the short term and it is hoped that better data will confirm their value long term, but for now I will cautiously classify them as “promising.”


Erdos J, Wild C. Mid- and long-term (at least 12 months) follow-up of patients with spinal muscular atrophy (SMA) treated with nusinersen, onasemnogene abeparvovec, risdiplam or combination therapies: a systematic review of real-world study data. 

 2022;39:1-10. doi:10.1016/j.ejpn.2022.04.006

Treatment of the various types of spinal muscular atrophy with approved therapies resulted in an array of improvements, according to a review of 22 studies.

Treatments alter the natural progression of SMA

JK is an 8-year-old boy who is struggling in school. Now in second grade, JK started kindergarten during the COVID-19 pandemic. JK attended first grade virtually, which was difficult. The transition to in-person learning has helped, but JK is still behind in reading. JK’s parent wonders: Is it hyperactivity/attention-deficit disorder (ADHD)? Would medication help? Should he repeat a grade? Or just hope that third grade goes better?

The dilemma faced by JK, his family, and his pediatrician is an increasingly common one made only more complicated by the COVID-19 pandemic. In part, the effects of COVID-19, with its disruptions to the educational system and to the lives of children and their families, amplify the drumbeat that educators have been making for some time: Let’s provide children with the help they need when they need it. Enter the Multi-Tier System of Supports, or MTSS.

Educational supports: an introduction to MTSS

In many ways, MTSS embodies the foundational tenets of pediatrics: prevention, early identification, and timely access to intervention. The MTSS approach aims to identify children who may need additional academic or behavioral supports, provides a certain level of support to all children, and tailors additional supports and intervention at an intensity that matches the child’s need(s). For the purposes of this article, the focus will be primarily on the academic aspects of MTSS, and specifically those that affect children with reading difficulties. The academic aspects of MTSS are sometimes referred to as response to intervention, or RTI, a term that reflects the importance of monitoring process. The behavioral aspects of MTSS, often referred to as positive behavioral interventions and supports, or PBIS, won’t be covered in depth in this article. (For more information on the behavioral aspects of MTSS, see 

https://mtss4success.org/resource/integrating-SEL-within-MTSS

MTSS provides 3 levels of intervention: tier 1 (universal) interventions that are available to all children; tier 2 interventions that are intensive, individualized supports, and often provided in a small group setting; and tier 3 interventions that are more intensive and individualized and may include referral for consideration of special education services.

 Foundational aspects of the model include:

universal screening to identify children who are having difficulties;

tailoring intervention to meet student need; and

systematically monitoring student progress.

Through universal screening, schools can identify children who would benefit from additional help and intervene without having to enter the process for consideration of special education services, which can be lengthy. MTSS also avoids inadvertent labeling of children experiencing learning difficulties due to other factors (eg, economic hardship, absenteeism, cultural factors, etc) as having a disability. Federal regulations provide states and local school districts with a substantial amount of flexibility when implementing MTSS to ensure that programming and intervention can be tailored to the needs of their communities.

 Critics of the model point out the need for timeliness in the monitoring phase to avoid students spending too long in a lower-level intervention.

Historically, school systems and psychologists have often identified a child as having a specific learning disability (SLD) when a significant discrepancy between the child’s intellectual ability (measured by intelligence testing, or IQ) and academic achievement (measured by achievement testing) was present. Often called the “discrepancy model,” this model had its flaws. In many cases, psychological testing did not occur until third or fourth grade and after the child had struggled for a few grades. Critics suggested that this model waited for the child to fail before providing help. In addition, the model may not be statistically valid for children with different types of cognitive profiles.

Starting in 2004, the Individuals with Disabilities Education Act (IDEA) specified that states could no longer require schools to use the discrepancy model when identifying children in need of special education services. It provided schools with the flexibility to use RTI as well as other alternative research-based process in determining the need for special education services. As specified by IDEA, a student should be considered for SLD determination when they are failing to meet age or grade-level state expectations despite the presence of appropriate instruction and in absence of other causes.

 for full description of SLD determination. SLD in reading is also referred to as dyslexia.

In 2015, the Every Student Succeeds Act (ESSA), which replaced the No Child Left Behind Act of 2001, provided more flexibility to states and school districts while providing protections to economically disadvantaged students, students with disabilities, and English language learners.

 This type of flexibility is designed to allow states and schools to better tailor intervention to the unique needs of their communities

, which will be especially important as schools tackle the effects COVID-19.

Regardless of how dyslexia is defined or identified, the core features remain the same. Children with dyslexia struggle with phonemic awareness and processing. That is, they have difficulties recognizing how letter symbols translate into specific sounds that form the building blocks of words and sentences. This can result in difficulties with reading and decoding words, with spelling, and with reading comprehension. These difficulties are typically out of proportion with the child’s overall cognitive level. Children with a history of language delay may also be at increased risk for dyslexia.

How COVID-19 has affected learning to read

Research to determine how COVID-19 has affected learning is ongoing. Early studies suggest that academic progress declined by the end of the 2020-21 school year compared with previous years by 8 to 12 percentile points in math and 3 to 6 percentile points in reading.

 These effects are not universal: Students in earlier grades,

 students in economically disadvantaged schools, and students of color (eg, Black, LatinX, and American Indian and Alaska Native)

 In part, these disparities likely represent the significant challenges schools and communities faced in scaling up high-quality instruction during disruptions caused by COVID-19. Interestingly, implementation of remote learning does not completely explain differences in the degree of learning loss experienced by certain students and schools,

 which also suggests the importance of other sociodemographic factors.

Given these changes in performance, schools will need to determine how children with SLD are identified going forward. It seems likely that a larger number of children will qualify for MTSS services, but additional questions remain. For example, should lower age/grade norms be used for reference? And if so, what should those norms be, given disparities described above? Flexibilities built into ESSA and IDEA should ideally allow for these types of considerations.

The role of the pediatrician in promoting literacy skills

Encouraging families to read with young children and provide exposure to language and book promotes foundational reading skills. Pediatricians can check in with their patients and families about early literacy skills at health supervision visits, or when concerns about development or learning arise. Dyslexia also runs in families, so taking a good family history is important. See 

 for possible signs of dyslexia that pediatricians can use as a part of the surveillance process.

Intervention for dyslexia often occurs in the school setting, and pediatricians can play a role in advocacy. Tutoring outside school may be an option for some families, but relying on tutoring alone can further exacerbate inequities related to socioeconomic factors. Given the flexibility states and school systems have in implementing IDEA and ESSA, pediatricians can work with local school districts to understand their current processes. Pediatricians can also encourage parents and caregivers to work with their children to practice reading skills and, most importantly, to help make reading fun. See 

 for ways to promote reading skills at home. Practice and repetition are important for children with reading difficulties, but understandably these children may resist practicing something that is inherently difficult. Children with dyslexia are at increased risk for co-occurring emotional/behavioral conditions, including anxiety, depression, and ADHD. In general, individuals with reading difficulties are at risk for poorer health and vocational outcomes, so early identification and intervention are especially important.

Getting back to our case, JK’s pediatrician can obtain a bit more history about the nature of his reading difficulties and provide advice to his family to contact the school about his progress. JK may already be receiving MTSS support or it may be time for his family to request an evaluation for SLD. Being able to help JK’s family navigate this process is time well spent.


Rebecca Baum is a developmental behavioral pediatrician and clinical professor of pediatrics at the University of North Carolina School of Medicine in Chapel Hill, and a member of the 

RTI-based SLD identification toolkit. RTI Action Network. Accessed June 2, 2022. 

http://www.rtinetwork.org/getstarted/sld-identification-toolkit/ld-identification-toolkit-introduction

National Center for Learning Disabilities: RTI Action Network position statement on RTI. RTI Action Network. Accessed June 3, 2021. 

http://www.rtinetwork.org/about-us/position-statement

Adlofa SM, Hogan TP. Understanding dyslexia in the context of developmental language disorders. 

 2018;49(4):762-773. doi:10.1044/2018_LSHSS-DYSLC-18-0049

US Department of Education. Individuals with Disabilities Education Act: Determination of eligibility. § 300-306. Accessed June 5, 2021. 

https://sites.ed.gov/idea/regs/b/d/300.306

US Department of Education. ESSA flexibilities. October 2018. Accessed June 06, 2022. 

https://www2.ed.gov/policy/elsec/leg/essa/essa-flexibilities-document-for-publication.pdf

Why the Every Student Succeeds Act (ESSA) matters. National Education Association. July 14, 2020. Accessed June 9, 2022. https://www.nea.org/professional-excellence/student-engagement/tools-tips/why-every-student-succeeds-act-essa-matters#:~:text=Today%20the%20Every%20Student%20Succeeds,education%2C%20regardless%20of%20ZIP%20code.

Lewis K, Kuhfeld M, Ruzek E, McEachin A. Learning during COVID-19: reading and math achievement in the 2020-21 school year. Center for School and Student Progress. July 2021. Accessed June 5, 2022.

https://www.nwea.org/content/uploads/2021/07/Learning-during-COVID-19-Reading-and-math-achievement-in-the-2020-2021-school-year.research-brief-1.pdf

Donnelly R, Patrinos HA. Learning loss during COVID-19: an early systematic review. 

2021;1-9. doi: 10.1007/s11125-021-09582-6

Domina T, Hashim A, Kearney C, Pham L, Smith C. COVID-19 and the system resilience of public education: a view from North Carolina. Urban Institute. April 2022. Accessed June 7, 2022. 

https://www.urban.org/sites/default/files/2022-04/COVID-19%20and%20the%20System%20Resilience%20of%20Public%20Education%20A%20View%20from%20North%20Carolina.pdf

Dyslexia basics. LD Online. 2012. Accessed May 31, 2022. 

https://www.ldonline.org/ld-topics/reading-dyslexia/dyslexia-basics

Sanfilippo J, Ness M, Petscher Y, Rappaport L, Zuckerman B, Gaab N. Reintroducing dyslexia: early identification and implications for pediatric practice. 

 2020;146(1):e20193046. doi:10.1542/peds.2019-3046

Johnson, DJ. Helping young children with learning disabilities at home. LD Online. Accessed May 28, 2022. 

https://www.ldonline.org/ld-topics/working-families/helping-young-children-learning-disabilities-home

The pandemic has disrupted academic progress and children with learning disabilities in particular have been impacted. Here is what pediatricians should know to help support literacy and recognize dyslexia.

Learning disabilities and COVID-19: Where are we now?

The short answer to this question appears to be no based on an investigation of associations between patterns of growth in infant weight and adult-onset coronary heart disease (CHD).

Using data from national health registers, investigators in Denmark followed 3645 people who were born between 1959 and 1961 for whom they had weight information at birth, at aged 2 weeks, and at aged 1, 2, 3, 4, 6, and 12 months. They then generated 5 sex-specific weight trajectories of infant weight development: very low-moderate increase (11.5% of the study population), low-marked increase (13.9%), low-stable increase (32.4%), average-stable increase (29.8%), and high-moderate increase (12.4%).

Investigators also examined parental socioeconomic and marital status, maternal prepregnancy body mass index (PP-BMI), maternal smoking, parity, birth weight, and gender. Infants in the very low-moderately increasing trajectory group were more often boys, had mothers who had more babies, and had a lower gestational age than those in other trajectory groups. Also, the mothers of the infants in the very low-moderately increasing weight group were more likely to be married, had a lower PP-BMI, and smoked more during pregnancy than the other mothers.

During follow-up, at a median of 31.4 years, 279 people (159 men and 120 women) received a diagnosis of CHD. Individuals with a very low-moderately increasing trajectory developed CHD more often than those with an average-stable increasing trajectory. Though this association persisted after adjustment for maternal factors, it decreased after additional adjustment for preterm birth and parity. Further, the association completely disappeared after adjustment for birth weight. Investigators therefore determined that though very low-moderate increasing weight during infancy was associated with more likelihood of adult CHD, this association was driven by differences in birth weight, not infant weight gain. These findings, they noted, highlight the importance of prenatal exposures.


This is a large and very long-term study. I find it difficult enough to win the weight battle with children in elementary school and up. It’s good to know that I do not seem to have to work on this in plump babies but can let them grow naturally.

 
Blond K, Jensen BW, Petersen J, Baker J, Bjerregaard LG. Trajectories of infant weight gain from birth to 12 months and adult-onset coronary heart disease. 

 2022;S0022-3476(22)00305-5. doi:10.1016/j.jpeds.2022.03.055

Based on an investigation of associations between patterns of growth in infant weight and adult-onset coronary heart disease, the answer seems to be no. 

Do infant weight gain patterns affect adult risk of coronary heart disease?

Approximately 60% of children go through selective-eating phases at some point in their childhood—most often during the preschool years.1 The fact that most children go through this phase doesn’t make it any less worrisome for parents though.

Pediatricians can help parents through this phase by offering resources, support, and education.

The first step in addressing this problem is to educate parents on the normal phases of childhood eating. The prevalence of picky eating during the preschool years—primarily between the ages of 2 and 5—has led experts to believe that being choosy about foods is a normal developmental behavior for many children. Increased selectiveness about food choices occurs around the same time as other independence-seeking behaviors and usually fades as children move into the elementary school years.

In most cases, these children do well nutritionally despite being picky about foods. One study found that most children—73.8%—who were considered picky eaters fell into normal weight ranges, whereas approximately 13% were considered underweight and 13% were considered overweight.

Picky eating behaviors usually diminish on their own as children age into the elementary years; however, the older children become while continuing these behaviors, the more worrisome the behaviors become. Research indicates that picky eating that extends into later childhood is often associated with later diagnoses including the following

Before a diagnosis is made or treatment begins for picky eating, researchers note that most parents go on their own journey of acceptance, adopting various positive-food parenting strategies to help their picky eater branch out to try to other foods.

 These can include involving children in food shopping, selection, and preparation or encouraging food play.

Helen Coulthard, PhD, a developmental psychologist specializing in food behaviors at De Montfort University in Leicester, United Kingdom, said sensory play with both food and nonfood items can be a helpful tool when it comes to sensory processing issues. It can also be used to check for more severe food-restriction problems because some children will find food items so anxiety triggering and disgusting during play that it serves as a red flag for more severe problems.

“Those are children with extreme food aversions, where they only eat 1 or 2 types of food,” Coulthard said. “But usually any type of sensory play seems to work well because they get in contact with different substances without the pressure to eat.”

Children who eat a very limited selection of foods are generally the ones who trigger the most concern, but it’s surprising how kids can eat a meager selection and amount of food and still get proper nutrition, she added. Humans have evolved to eat the amounts we do, she explained, but the actual types and amounts of food children need to grow may surprise some parents.

“Sometimes it looks like they are refusing a lot, but they are still eating enough to be healthy and grow,” Coulthard explained, adding that she encourages families to allow children to serve themselves at mealtimes when possible. “If a child is eating very few foods, you can do blood testing and things to check their nutrition, but often they end up choosing foods that give them just enough of what they need.”

When this isn’t the case, Coulthard suggested that parents be encouraged to wait out their child’s eating habits and offer supplements or vitamins as needed.
“It’s a really difficult issue because often worry just makes the problem worse,” she said. “Some of the problems associated with a very restrictive diet are when people are older, so it’s almost like you have to play the long game. And part of that is to take the pressure off and accept.”

Some studies have even documented the circular negative effect that parental pressure can have on picky eating habits. For this reason, it’s important that pediatricians assess parental feeding practices and experience perceptions as well as the behaviors of the picky eater.

“Children are acutely aware of their parents’ goals, emotions, and practices at mealtimes,” concluded one study on feeding dynamics. “In light of these parental expectations, children develop their own strategies for navigating food refusal, negotiating with parents, and overcoming dislikes. This study highlights the need to listen to children and work with them to develop meaningful, relevant, and effective eating interventions.”

This study and more illustrate the need for education—and often reassurance—for parents dealing with picky eaters.

Pediatricians may also want to share the following tips for parents tackling picky eating outside a medical or psychological diagnosis

Start having “no pressure” meals without urging “one more bite” or using guilt or threats to encourage eating.

Allow children to eat when they are ready or offer an option to return to eat at the next mealtime.

Offer meals and snacks at timed intervals, with “open” and “closed” hours for the kitchen to establish a schedule so that the child knows what to expect and when. This can help ensure the child comes to the table hungry.

Set the menu for a nutritionally balanced meal. Don’t cater to the child’s likes and dislikes, but do offer options and be straightforward about them and expectations (ie, no dessert without a nutritious meal).

Make mealtimes fun with child-friendly dishes or utensils.

Repeat foods that are refused at first. It can take 15 times of trying things before a child agrees to try or like a new food.

Teach children about nutrition and what food does inside their bodies.

Don’t place blame (on parents or children) for picky eating, and seek extra help if needed.

1. Cunliffe L, Coulthard H, Williamson IR. 

The lived experience of parenting a child with sensory sensitivity and picky eating.

2. Angraini DI, Arisandi R, Rosa E, Zuraida R. The relations between “picky eating” behavior and nutritional status of pre-school children. 

3. Schwarzlose RF, Hennefield L, Hoyniak CP, Luby JL, Gilbert KE. 

Picky eating in childhood: associations with obsessive-compulsive symptoms.

 2022; jsac006. doi:10.1093/jpepsy/jsac006

4. Wolstenholme H, Kelly C, Heary C. ‘Fussy eating’ and feeding dynamics: School children’s perceptions, experiences, and strategies. 

. June 2022;173(1):106000. doi: 10.1016/j.appet.2022.106000

5. Feeding a picky eater: the dos and don’ts. Children’s Hospital of Philadelphia. October 31, 2019. Accessed June 6, 2022. 

https://www.chop.edu/news/dos-and-donts-feeding-picky-eaters

Solve picky eating: 11 tips for parents of picky eaters.

 Kids Eat in Color. Updated August 2021. Accessed June 6, 2022. 

Address concerns that a child is not eating a balanced diet through education, reassurance.

How to help parents of picky eaters

According to Erin O’Connor Prange, MSN, CRNP, of Children’s Hospital of Philadelphia in Pennsylvania, drugs for attention-deficit/hyperactivity disorder (ADHD) have been in the market for more than 45 years, beginning with methylphenidate (Ritalin), which was approved in 1955. 

[Editor’s note: Although not included in the 

Diagnostic and Statistical Manual of Mental Disorders

 until 1968, methylphenidate was originally prescribed for fatigue and depression

 According to a 2016 study, roughly 6 million children in the United States have ADHD, noted Prange. Boys receive a diagnosis twice as frequently as girls, but overall, 77% of these children were receiving treatment, with roughly 32% of them having both behavioral and medication treatment.

What is a snapshot look at a child with ADHD? Prange, who was speaking at the 43rd National Conference on Pediatric Health Care in Dallas, Texas,

 in March 2022, explained that the main component of this developmental learning disorder is poor executive functioning in tasks. These include planning, time management, attention, organization, self-control, and others. Additionally, during the months that children were learning remotely due to the COVID-19 pandemic, impaired communication, eye strain, distractions, and anxiety were also reported, largely as a result of the struggle with virtual and hybrid learning.

Nonmedication treatment for ADHD includes cognitive behavioral therapy, extra time on test taking, creating lists (eg, what to put in the school backpack), and bouncy bands and wiggle seats for desks. The newest (those that have become available over the past 5 years) and most commonly prescribed drugs for the disorder include the nonstimulant viloxazine (Qelbree); for stimulants, there is now a variety of methylphenidates (Cotempla, Adhansia, Aptensio, Jornay) and amphetamines (Dyanavel, Adzenys, and Mydayis).

Before starting a patient on stimulants, the American Academy of Pediatrics recommends a thorough cardiovascular assessment, including patient and family health histories; evaluation of all medications being used; and a physical exam focused on cardiovascular disease risk factors. Prange also reviewed the adverse effects for stimulant medications, which include, but are not limited to, decreased appetite, trouble sleeping, headache, weight loss, and mood swings. She also encouraged audience members to seek out a copy of the ADHD medication guide, available at addwarehouse.com, which provides books, assessment products, and training programs for ADHD and related conditions.

Prange EO. ADHD treatment explosion: new meds are here! Presented at: 43rd National Conference on Pediatric Health Care; March 23, 2022; Dallas, Texas.

Epstein JN, Loren REA. Changes in the definition of DSM-5: subtle but important. 2013;35(5):455-458. doi:10.2217/npy.13.59

Symptoms, evaluation, and treatment of ADHD.

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 evokes images of early adolescence and for most children, that is when they transition to this next stage of growth. However, some children who are going through central precocious puberty (CPP) will enter puberty earlier than their peers, in some cases much earlier. In a webinar from the 

 series, 2 experts discussed a variety of subjects on CPP, including findings from a recent study that examined treatment initiation and duration with height, the need to individualize treatment decisions for girls with CPP, and 2 case reports.

 Karen O. Klein, MD, a pediatric endocrinologist at Rady Children’s Hospital-San Diego in California and an associate clinical professor of pediatrics at the University of California San Diego School of Medicine, led the discussion with Kent L. Reifschneider, MD, a pediatric endocrinologist at Children’s Hospital of The King’s Daughters in Norfolk, Virginia.

CPP occurs when the hypothalamic-pituitary-gonadal axis is activated early on, which leads to an increase in gonadal steroid hormone secretion. The ages of affected children are less than 8 years for girls and less than 9 years for boys. Children affected by CPP develop secondary characteristics early on; have at least 1 Tanner stage progression per year; and have less than 2 standard deviations in bone age (BA) beyond chronological age (CA). If untreated, CPP can lead to early fusing of growth plates, a reduction in adult stature, atypical pubertal physical development, and premature menarche. Gonadotropin-releasing hormone agonists are the standard-of-care treatment.

Klein discussed her recent study coauthored with Marcela Vargas Trujillo, MD; Sanja Dragnic, MD; and Petra Aldridge, MS. The authors performed the investigation to supply data for an area in which data were scarce: the benefit to height outcomes when treatment with leuprolide was initiated after CA of 7 years and continued after CA of 10 years or BA of 12 years. The study was carried out in 48 treatment-naïve girls who were treated with monthly leuprolide, administered intramuscularly every 28 days at doses based on weight. The investigators only included girls so that the results would have statistical power. The patients had visits at weeks 4, 8, 12, 24, 36, and 48 and then every 6 months until leuprolide was discontinued. They then had annual visits until age 21 years. The average treatment duration was 3.9 plus/minus 2.0 years (range, 1.1-9.8). The average CA at the end of treatment was 11.5 plus/minus 0.97 years (range, 9.8-14.1) whereas the average BA was 12.7 plus/minus 0.94 years (range, 11.5-16.4). Throughout the treatment period, the ratio of BA to CA consistently decreased. Fifteen girls achieved a BA that was less than 1 year above the CA. Longer duration of treatment was associated with increased predicted adult height for nearly all the girls, 45 of 48. Those who saw no improvement were either near midparental height when they started the treatment or showed poor growth velocity. A wide range was found in final heights: 162.54 plus/minus 7.35 cm (range, 146.47-176.11) that was similar to the predicted adult height in treatment (162.39 ± 8.38 cm). Midparental height was not available for all the girls, but of the 29 for whom it was available, 17 either met or surpassed it.

Reifschneider joined Klein to discuss nuances in the treatment of CPP. He noted, “With CPP, I think of the limitations of the disease state, which includes the impact of estrogen on growth velocity and BA and how much that should factor into clinical decisions as well as the variability in interpreting BA.”

Klein added, “When examining a patient, a clinician should balance the need for more data with the fact that early commencement of treatment can lead to better height outcomes.” She also noted that estimating predicted adult height is also mostly based on average-sized children who are having average growth patterns. Another consideration for starting treatment is the predicted adult height of the patient and the height of the child’s parents. For example, if the predicted height for a child is 155 cm and the mother is 157.5 cm, treatment may not be considered necessary by the patient’s family.

Klein added that although treatment will pause the tempo of puberty, once treatment ends, the tempo will resume its speed. However, this does not mean that a pubertal growth spurt will occur, and, in fact, data indicate that this typically doesn’t occur. 

The first case Reifschneider and Klein examined concerned a girl, with the following details:

Tanner stage 3 breast development, starting at age 7 years

With the girl’s BA and current height, her predicted final height is roughly 147 cm and her midparental height, 168 cm. The BA maturation was noted as significant by Reifschneider and the patient would meet his criteria for treatment. However, Klein emphasized the patient’s age, noting that she had been trained to only treat children when pubertal onset occurred before age 8 years. Countering that assertion, Reifschneider said, “One has to keep in mind the individual and that a lab [finding] or CA is just a piece of the puzzle. In this case, the fact that the girl started developing breast tissue when she was aged 7 years is important, in addition to growth velocity that is greater than prepubertal [velocity] as well as bones that are considerably advanced.”

When discussing treatment with families, a conversation about outcomes can be important. Many girls with CPP can be among the tallest girls in their class but their BA is often much advanced, and when their non-CPP peers reach puberty, many affected girls will be left behind in terms of height. If he were treating this patient, Reifschneider said, he would ideally initiate treatment and then see her every 4 to 6 months to determine how the treatment has changed the tempo of her puberty. Once the tempo became prepubertal, he would transition to twice yearly maintenance screenings.

The second case was of a girl with CPP who had undergone treatment, with the following details:

Leuprolide acetate treatment initiated at age 6 years

1 incidence of vaginal bleeding following treatment initiation

Tanner stage 3 breast development at age 6 years

The patient’s breast development has stabilized at Tanner stage 3. Her BA is 12 years and her height is currently predicted to reach 60 cm. She is now asking whether it’s time to stop treatment.

Reifschneider emphasized that this was a very successful case and the patient had responded very well to therapy. “When considering the ceasing of treatment, there are a couple of things that need to be thought through, like the limitation of predicted adult heights and not knowing the tempo that will occur when she ceases treatment. Although she is currently predicted to reach 5 feet, there is a likelihood that she would not achieve that height if she ended treatment.” Klein added that a BA of 12 years has often been considered the end point for treatment because of questions about whether continued growth could be achieved, but her study findings showed that 5 to 10 additional cm can be achieved with continued treatment. Reifschneider confirmed that prior to publication of the study’s results, he would have considered ending treatment at BA 12, although he noted that this patient was an outlier who likely would continue to benefit from treatment.

1. Klein KO, Reifschneider K. Between the lines: central precocious puberty. Virtual webinar. Recorded March 4, 2022.

Two experts discuss a variety of subjects on central precocious puberty, including recent study findings that examined treatment initiation and duration with height, the need to individualize treatment decisions for girls with CPP, and 2 case reports. 

July 2022