Among patients of all ages, anorexia nervosa (AN) has the second-highest mortality rate of all mental health conditions, after substance abuse.

 Both suicide and the physical effects of nutritional deficit are implicated. Mortality rates for other eating disorders, including bulimia and binge eating disorder, though lower than for anorexia, are still considerably higher than average.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 

defines 4 categories of eating disorders: AN, bulimia nervosa (BN), binge eating disorder (BED), and avoidant/ restrictive food intake disorder, along with several noted as “other” or “atypical disorders.”

 summarizes the diagnostic criteria for these categories. Body weight is among the diagnostic criteria for AN only; these patients may be underweight, within normal range, or overweight.

Analyses of prevalence vary widely in their findings.

 One meta-analysis found lifetime prevalence of AN from 1.7% to 3.6% for female patients and 0.1% for male patients; lifetime prevalence of BN for female patients was about 2.1%.

 BED, with reported prevalence rates of approximately 2% to 4%, is almost as common among male as female patients.

 Among adolescents aged 13 to 18 years, one study found prevalence rates of 0.3% for AN, 0.9% for BN, and 1.6% for BED.

Long characterized as affecting primarily affluent White adolescent girls, eating disorders now affect people from lower socioeconomic groups, members of non-White ethnic groups, preteen children, and boys.

 LGBTQIA+ young people may be at particular risk.

During the early months of the COVID-19 pandemic, hospitalizations for eating disorders doubled,

 and patients reported significant increases in unhealthy behaviors.

Caregiver reports about a child’s weight or eating habits or clinical observation of unexpected weight changes are likely to alert the pediatrician to the possibility of an eating disorder. Routinely charting patients’ weight and height on a graph can help physicians immediately identify a possible problem.

Screening instruments for eating disorders are more practical for use in eating disorder centers than in most primary care settings. An alternative is a set of questions known as SCOFF

 Do you make yourself sick because you feel uncomfortably full?

 Do you worry you have lost control over how much you eat?

 Have you recently lost more than one stone (14 lb) in a 3-month period? (Stones is a British measurement.)

 Do you believe yourself to be fat when others say you are too thin?

 Would you say that food dominates your life?

Although the originators of SCOFF suggest that 2 or more yeses warrant further assessment, health care providers (HCPs) may want to follow up with even 1 affirmative answer.

Secrecy and denial characterize eating disorders. Patients should be questioned alone, away from their caregivers, to encourage honesty. Questions should be specific and pointed—not just “Do you exercise?” but “What kinds of exercise do you do? How many times per week? For how many minutes? How many [miles, reps, laps]?” Similarly, a detailed 24-hour diet history should be taken. Does the patient count calories, carbohydrates, fats, or other nutrients or ever eat in secret? Other categories of questions include the following

 “What is your ideal weight? How much of the day do you spend thinking about food or your body?”

 “Do you ever binge? On what foods and how often? Do you ever vomit? How often? Do you use laxatives, diuretics, diet pills, or caffeine? How often?”

 For girls: “When was your first and last period? Are you regular?” For boys and girls: “How is your sex drive?”

 “How is your mood? Do you feel anxious or depressed? Have you ever harmed yourself or thought about it? Have you had prior therapy?”

 “Have you ever used any drugs? Have you experienced any blackouts?”

 “Does anyone in the family have a history of an eating disorder, obesity, or dieting or a history of psychiatric illness?” In addition, the pediatrician should interview caregivers separately to get supplemental history information. Parents are much more likely than patients to be forthcoming with accurate information.

The difference between normal adolescent eating behaviors and disordered eating may be subtle. Many teenagers skip meals (especially breakfast), occasionally binge, or sometimes feel dissatisfied with their bodies. Frequent deprivation, bingeing, purging behaviors, secrecy around eating, or dissatisfaction around eating, are danger signs.

Depending on the patient’s initial answers, the HCP may screen for depression, anxiety, or other psychiatric conditions that are often comorbid with eating disorders.

Imbalance between the body’s needs and nutritional intake affects nearly all body systems. Table 2 highlights some physical effects of eating disorders. Heart health is a significant factor, so the physician may order an electrocardiogram (ECG). Bradycardia is the most common arrhythmia and finding in patients with AN.

 Clinicians may be inclined to attribute a low heart rate to an “athletic heart,” but bradycardia due to starvation is a potentially lethal condition.

Laboratory tests rule out diabetes, thyroid disease, anemia, and other physical causes and also document the extent of physical damage. Checking electrolytes is important. One of the most important tests is the phosphorus level. Medical complications can include depleted adenosine triphosphate, which affects cardiac function and can lead to sudden death.

Patients with AN, in particular, may be in immediate danger of severe complications. Presence of any one of the following symptoms indicates the need for immediate medical hospitalization for refeeding

Heart rate less than 50 beats per minute (bpm) while awake; less than 45 bpm while asleep

Orthostatic changes: decrease in blood pressure of more than 20 mm Hg systolic or 10 mm Hg diastolic; heart rate increase of more than 20 bpm

ECG abnormalities: Prolonged corrected QT interval or other arrhythmia

Today’s young people typically know what anorexia and bulimia are. When asked screening questions, the patient understands what the clinician is getting at but is likely to be in denial.

Education can start during the screening interview: “Here’s what concerns me when you tell me these things. You’re taking in less energy than your body is expending, and that’s affecting your physical health. Your blood pressure is low. I’m worried that you could pass out while you’re playing your sport or driving.” Sharing weight numbers or commenting on the patient’s thinness may backfire because the patient is likely to view alarming weight loss as a positive development.

In contrast, weight trends, particularly charted on a graph, can help the HCP communicate the seriousness of the problem to the caregivers. Clinicians should share conclusions from the history and the physical exam with patients and caregivers separately and then bring them together to talk about next steps. Both patients and caregivers need to understand, for example, that a broad array of tests is necessary because disordered eating affects a broad array of body systems.

If it is safe to send the patient home, the practitioner can enlist the caregivers to start addressing the eating disorder. Patients who are severely malnourished or underweight or have severe restricting or purging behaviors may need to stop exercise until they have developed a healthier relationship with food. Parents may need to take the lead on preparing meals and monitor consumption.

Eating disorders are mental health conditions. In addition to helping families with practical matters such as meal plans, the pediatrician must link the patient and family with mental health support. Treatment of eating disorders requires a care team consisting of, at minimum, 3 professionals:

The HCP arranges care and assesses medical status.

A dietitian works with the patient and family to determine goal weight and provide an individualized nutrition plan.

A mental health therapist guides family-based therapy, a first-line mental health treatment with established effectiveness.

 Cognitive behavioral therapy or dialectical behavioral therapy may also be used.

Psychotropic medications are indicated for comorbid mood disorders. The FDA has approved fluoxetine for treating BN.

 Otherwise, evidence on the use of medications to treat eating disorders is mixed and often based on studies in adults.

Treatment goals, beyond any medical stabilization requiring im- mediate hospitalization, are to

address dysfunctional thoughts, feelings, and beliefs;

address affect and behavioral regulation;

Medical concerns associated with the first stages of recovery include refeeding syndrome and hypermetabolism.

 Refeeding syndrome can occur when nutrients, especially carbohydrates, are reintroduced after starvation. The delivery of glucose leads to increased insulin and rapid uptake of glucose and electrolytes. Low serum concentrations cause fluid retention; nausea or diarrhea may result from adaptation of atrophied gut mucosa and impaired pancreatic function; carbon dioxide production and oxygen consumption increase. Health professionals should introduce nutrition slowly, monitor electrolytes closely and supplement when indicated, and monitor weight intake and outputs.

The mechanisms of hypermetabolism are less well understood, but an increase in metabolism during refeeding makes weight gain difficult. Patients may require at least 3000 to 4000 calories a day to meet minimum weight gain goals. The effect can last for months, but metabolism does eventually stabilize.

Outpatient treatment consisting of an hour a week of mental health therapy and regular pediatric visits is beneficial only for patients whose condition has been caught early—typically, before any weight change. Most patients need more support. Treatment options include the following:

Intensive outpatient program: 3 to 5 hours, 3 to 5 days per week

Partial hospitalization: 6 to 10 hours, 5 to 7 days per week

Residential treatment: 24-hour supervision

Pediatric practices should have a regularly updated list of treatment centers that includes treatment models, specializations, and patient populations. Most centers work with a few insurers, which rarely include public insurance programs. Insurers often cover less treatment time or in- tensity than is clinically indicated.

Families are often reluctant to send their child away for treatment. If residential treatment is indicated and a bed is available, HCPs can talk with the parents about the severity of the disease and how much more likely the child is to recover with 24-hour support.

Caregivers are the key to the success of any mode of treatment. The family’s trusted pediatric health care provider is in a unique position to enlist their support. HCPs can reassure caregivers that, although their child’s illness is serious, a team of professionals will partner with them to address the problem.

BIO
Jasmine Reese is director of the Adolescent and Young Adult Specialty Clinic at Johns Hopkins All Children’s Hospital in St Petersburg, Florida. As a member of the faculty of 

, she teaches pediatric primary care providers to diagnose and treat common mental health conditions

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Articles

Pediatric health care providers understand that eating disorders are not lifestyle choices but life-threatening mental health conditions.

Assessment and treatment of eating disorders in adolescents

A review of current—but limited— studies on the relationship between diet and acne uncovered evidence that some dietary factors may indeed influence acne development and treatment. The implicated factors include glycemic index, dairy content, dietary fats, and probiotics.

Results of several studies demonstrated that patients with acne who consume diets with a low glycemic load (GL) have fewer lesions than those on high-GL diets, as shown in a study of 31 young men with acne that compared a low-GL diet with a control diet. Other findings reveal that eating chocolate and confections daily is independently and highly associated with acne. In addition, results of 2 randomized controlled trials showed that, compared with a carbohydrate-dense control diet, a low-GL diet reduced the number of acne lesions.

A 3-year prospective study of more than 6000 girls found a link between acne and consumption of full-fat, low-fat, and skim milk but no association with non-milk dairy foods, chocolate, and pizza. Yet a similar study of more than 4000 boys found only a weak association between acne and skim milk, and no association with higher-fat milks. Other findings showed that consuming dairy of some sort is positively linked with acne.

Some results suggests that patients with acne may benefit from increased intake of omega-3 fatty acids or γ-linoleic acid. For example, a randomized controlled trial in 45 patients found that supplementation with these fatty acids significantly reduced the number of lesions compared with no supplementation.

Finally, in a small pilot trial in adult patients with acne, probiotics showed promise for reducing acne lesions, but more study is needed to support these early findings. It also appears that diet significantly affects the efficacy of acne treatment, with maximum absorption linked with a fasted state and no consumption of dairy.

This is an interesting review article, but my takeaway is “Who knows what to do?” Milk and chocolate are low-glycemic foods but may still increase acne. Perhaps trial and error in an individual patient is the way to go (and there certainly are good reasons besides acne prevention to limit chocolate and other sweets).

Baldwin H, Tan J. Effects of diet on acne and its response to treatment. Am J Clin Dermatol. 2021;22(1):55-65. doi:10.1007/ s40257-020-00542-y

For years, teenagers have been told to avoid certain foods to reduce acne. A review article examines the evidence. 

Does diet really play a role in acne?

Although many primary care providers (PCPs) enjoy the freedom of managing their own offices, the number of physician-owned practices is slowly declining. Results of a 2020 American Medical Association (AMA) survey of 3500 PCPs showed that 49.1% of those surveyed worked in physician-owned practices, down from 54% in a 2018 AMA survey.

Respondents gave the following chief reasons for abandoning private practice:

Many feared that, as medical practice grows more complicated, health care reform will drive more physicians out of practice.

Most doctors saw joining a hospital or health system organization as a way to safeguard salaries, at least for the near future.

More than half of doctors cited electronic health record (EHR) requirements as a main reason for leaving private practice.

Pediatricians become employed by institutions because they believe that by joining a large medical organization, they will be assured of consistent pay and patient visits. However, as employees, they also give up their autonomy. This means using the EHR chosen by the institution and following policies established by managers. Pediatricians may be able to express their opinions and influence decisions, but , unlike with private practice, change comes slowly, and policies are often reactive rather than proactive.

The following suggestions will help independent pediatric practices thrive in an era of uncertainty, pandemics, and health care reform. The good news: The need for PCPs is expected to increase over the next few years, and those who provide quality care will be in the best position to negotiate lucrative contracts with insurance companies.

First and foremost, a practice needs a good office manager to ensure that revenues are maximized and patients and staff are happy, as well as keep a sharp eye on changes in the community that will affect a practice. The manager is the go-to person for patient or staff issues and works with the managing physician to oversee the well-being of the practice. Their skill set includes coding, familiarity with EHRs, experience in negotiating insurance contracts and accounts payable, and management of human resources. The office manager will lead and conduct regular meetings with all staff and business meetings with providers.

Cash flow is the lifeblood of any practice. If insurance companies delay payments or the practice has a slow month or 2, a decline in cash flow may threaten viability. Using an effective billing service or employing experienced coders and billers can optimize cash flow. Electronic claims should be submitted within 7 days of service for a busy practice and posted within 2 or 3 days of receipt; patient bills should be generated within a week of posting. Paper claims can significantly prolong the collection process and should be avoided

Co-payments and monies owed the practice should be collected at the time of service. Offering discounts for cash or check payments might be appreciated by patients while avoiding credit card fees. Patient eligibility should always be verified via the insurance company’s website—this usually takes less than 2 minutes.

Many practices have parents or patients sign an agreement enabling the practice to charge a credit card for their portion of the bill once insurance company has processed the submitted claim.

Billing services can be outsourced, but the vendor will collect a percentage of payments or a charge per claim processed (or a hybrid), even if the bill is not paid. Many pediatricians prefer to keep billing and collections in-house so they can monitor cash flow and react to problems sooner rather than later.

Finally, a practice should consider rewarding the office manager with productivity bonuses for increasing practice revenue or averting disasters. Additionally, coders and billers should be paid well and perhaps given incentives for hitting collection benchmarks.

Pediatricians should never be reluctant to challenge denied claims for charges they feel are appropriate. Not infrequently, insurance companies fail to make payments for new services that a practice offers, such as photo screeners for visual screening. Attaching American Academy of Pediatrics (AAP) policy statements that support appeal letters can be helpful. The LISTSERV run by the AAP’s Section on Administration and Practice Management is a great resource for researching related issues.

Some pediatricians are not aware that they can charge for both a well visit and a sick visit when coders use modifiers correctly and provide notes to document services. This can be done when, during a well visit, a patient is discovered to have an ear infection, a sore throat, or pneumonia or a new significant problem (eg, blood in stool, palpitations) is discussed requiring further evaluation.

A substantial cash reserve can keep a practice running for months should collections or productivity decline. If having a large amount of cash on hand is not possible, an established line of credit can be used in times of need and paid off in times of plenty.

Pediatricians need to scrutinize work-flow to optimize daily patient throughput. This means simplifying the check-in process by shortening patient intake or registration questionnaires, mailing new-patient registration forms or using patient portals, and using secure email or online services to remind patients of appointments. Technological devices, especially photoscreeners and otoacoustic emissions automated hearing screeners, can improve office-based care and screening, as can as in-office diagnostic tools such as rapid strep and influenza tests and testing for lead, respiratory syncytial virus, and COVID-19.

Workflow practices should maximize quality time with patients so pediatricians can reinforce recommendations. Staff should take vital signs in examination rooms, as well as document the chief complaint and update the medication and problem list, so providers can focus on patient care rather than deal with electronic housekeeping. To increase office efficiency, all examination rooms should be equipped with computers running the EHR and printers so that health forms can be handed directly to the patient’s caregiver before exiting.

It is important for pediatricians to offer telehealth services to facilitate patient access. Consider using telehealth even for well visits.

Learning coding for pediatric services is crucial. (To read about the most recent coding updates for pediatric health care providers, visit 

.) Simply understanding the nuances of documenting to support the level of service provided will improve a pediatrician’s bottom line and ability to survive any insurance company audit. Physicians tend to undercode office visits. For example, 99214 visits are generally reimbursed $30 to $50 more than 99213 visits; 99214 visits require moderate medical decision-making and should be considered when seeing patients presenting with the following:

At least 1 chronic illness with mild exacerbation, progression, or adverse effects of treatment (eg, asthma exacerbation, attention-deficit/ hyperactivity disorder, not responding to medication)

2 or more stable chronic illnesses (eg, asthma, enuresis)

An undiagnosed new problem with uncertain prognosis (eg, blood in stool)

Acute illness with systemic symptoms (eg, pyelonephritis, pneumonitis, colitis)

Acute complicated injury (eg, head injury with brief loss of consciousness)

A condition that requires prescription drug management (eg, urinary tract infection, streptococcal pharyngitis)

Practices can take many measures to reduce expenses. EHRs are extremely expensive, so practices should not hesitate to compare systems and make cost-effective changes. Patient portals can dramatically reduce overhead by saving postage and time by automating many of the tedious processes that can occupy much of a medical staff’s time. Most portals facilitate bill payment via the portal itself.

The costs of high-price items (eg, photoscreeners, copier) can be reduced through leasing agreements, which allow keeping up with the latest and greatest technologies—devices often become obsolete after a few years. Scribes or voice-recognition dictation software can save time in documenting office notes.

A strict no-show policy will help reduce the number of missed appointments. Another consideration: charging patients after the first missed appointment and discharging those who are frequent abusers.

Additionally, employing the right staff to meet office needs keeps costs down. For example, nurses should not be hired to perform duties that medical assistants can easily do. With the appropriate number of staff, everyone is busy but not stressed and overworked. Group purchasing services such as Physicians’ Alliance of America and Physicians’ Buying Group offer members discounted rates on frequently bought items such as table paper, syringes, and needles.

Keeping tabs on key performance indicators helps ensure a practice is functioning optimally. The Physicians Computer Company (PCC) provided current data for this article (see Table) regarding pediatric practice benchmarks, derived from over 1000 pediatric providers using the PCC EHR and practice management/ billing suite. The table shows average performance benchmarks as well as those for the top 10% performers using the PCC system.

Practitioners should take a realistic look at their financial and practice metrics and ask themselves if they are seeing as many patients as they did 2 years ago. Is the practice growing or shrinking in terms of enrolled patients? Is overhead rising? Practices that are not thriving might consider merging with others in the area. Larger practices offer advantages in controlling costs, negotiating contracts with insurance companies, and centralizing billing and computer operations.

Although we cannot be certain what a medical practice will look like next year or in 10 years, pediatricians can take solace in the fact that they take care of a very special group of patients.

Kane CK. Policy research perspectives: recent changes in physician practice arrangements: private practice dropped to less than 50 percent of physicians in 2020. American Medical Association. 2021.Accessed March 7, 2022. 

https://www.ama-assn.org/system/files/2021-05/2020-prp-physician-practice-arrangements.pdf

2021 Survey of America’s physicians: COVID-19 impact edition: a year later. The Physicians Foundation. June 2021. Accessed March 8, 2022. 

https://physiciansfoundation.org/wp-content/uploads/2021/08/2021-Survey-Of-Americas-Physicians-Covid-19-Impact-Edition-A-Year-Later.pdf

Primary care providers enjoy caring for their patients, but a practice is also a business and must be profitable. Here’s what you should know.

The business of being a pediatrician

The COVID-19 pandemic has taught health care providers a lot: how quickly a virus can spread globally, how unprepared we were to respond to a pandemic, and how rapidly science and technology could evolve to make a safe and effective vaccine, as well as that many people are vaccine hesitant or re- fusers and that individuals and groups resisting public health safety measures (eg, masking, social distancing) could prolong a pandemic with repetitive surges. Most importantly, we have learned that it is critical to be more than a step ahead of future infectious diseases by analyzing and responding to emerging data both in the United States and globally. This article reviews infectious diseases that may have taken a back seat in the news since March 2020 and how they affect the daily lives of children and adolescents all around the world.

The Dengue virus (DENV) is a major public health problem in the tropics and subtropics and is endemic in the US territories of Puerto Rico, the US Virgin Islands, and American Samoa.

 As Americans begin to travel and the United States welcomes global visitors, pediatric providers must consider who may be exposed to 1 of the 4 known DENVs and the presenting symptoms (Table

). An individual can be infected with the 4 serotypes over time. Long- term immunity is achieved for an individual who contracted a homologous DENV, but this protection does not last more than 3 months if an individual is infected with a different serotype. Evidence has shown that a person who sustains a second infection is more likely to develop severe dengue compared with those experiencing the first or a third or fourth illness.

 DENV is most often transmitted to a human through the bite of an infected mosquito (

 The incubation period is 3 to 14 days before symptom onset. Infected individuals can transmit DENV to mosquitoes 1 to 2 days before symptoms develop and during the 7-day viral illness.

During the Ebola outbreak, it was critical when taking a patient’s history to ask anyone presenting with fever about recent travel. To diagnose a DENV illness, providers must continue the practice of asking about recent travel globally and within the endemic areas in the US territories. Dengvaxia, a Dengue vaccine, is now approved by the US Food and Drug Administration and is listed on the 2022 US immunization schedule for individuals aged 9 to 16 years. However, the vaccine can be administered only if prevaccination laboratory testing reveals confirmed evidence of a previous DENV infection.

 It is contraindicated to administer the Dengvaxia vaccine to children who are seronegative because that action would place them at high risk of hospitalization and severe dengue illness.

In 2019, there were 1282 confirmed cases of measles in 31 states.

 There were 2 primary reasons for US outbreaks: In 2019, the number of people who contracted measles abroad increased; then, upon their return to the United States, these individuals spread the virus in communities that had low measles vaccination rates.

 In 2020 and 2021, the number of reported measles cases in the United States dropped significantly to 13 and 49, respectively; thus far, in 2022, 3 cases have been reported.

Two factors may account for the 2020 and 2021 decreases. These data may represent the effect of the COVID-19 pandemic on measles transmission in the United States—fewer families traveled overseas as the pan- demic surged throughout this country. Also, many elementary and secondary schools were closed in 2020; when they reopened in 2021, masks and social distancing were in place. Thus, these factors may have significantly reduced children and unvaccinated families from contracting and spreading the measles virus.

These data provide evidence that pediatric providers should reach out to parents whose children need the measles-mumps-rubella (MMR) vaccine, citing 2 influential factors: (

1) Many states have removed school mask mandates, putting unvaccinated children at risk of contracting measles.

 Parents should be reminded that measles spreads through direct contact with an infected person or airborne transmission (via coughing or sneezing) up to 4 days before rash onset and for 4 days after the rash erupts.

(2) Timely measles vaccination will protect children who may be traveling to parts of the world where measles is endemic.

The World Health Organization (WHO) reported that measles remains a problem in developing countries, especially in parts of Africa and Asia. The WHO also reported that in 2018, more than 140,000 people—mostly children less than 5 years old—died from measles, with more than 95% of these deaths occurring in countries that have low-income populations and weak health care systems.

 The MMR vaccine saves lives. All health care providers should proactively encourage parents to vaccinate their children.

A diagnosis of pediatric tuberculosis (TB), for either latent TB (referred to as tuberculosis infection [TBI]

) or TB disease (active TB), is made for patients aged less than 15 years who have either a positive tuberculin skin test or a positive interferon- gamma release assay.

 Both tests have a high positive predictive value when used for children who have had a direct contact exposure to an adult with TB disease.

 Infants and young children are at increased risk of developing life-threatening forms of the disease, including TB meningitis and disseminated TB, compared with older children and adults.

 The greatest numbers of TB cases occur in children under 5 years old, with 38% of pediatric cases occurring

 within this age range. In addition, in 2020, 28% of the 10- to 14-year- old population had a diagnosis of pediatric TB.

 Data from TB cases in children aged less than 18 years living in the United States from 2010 to 2017 revealed that 32% of children with TB disease were born in other countries.

, spread the organism via airborne transmission by coughing, speaking, or singing. However, children with pediatric TB do not spread the organism as readily as adults, because pediatric TB is less infectious than the adult form.

 Children may present with a cough, weakness, weight loss, fever, change in playtime behaviors, and/or night sweats.

Children younger than 4 years are at the highest risk of progressing from TBI to TB disease, with data showing a risk of 40% to 50% for infants less than 1 year old and 25% for 1- to 2-year-olds.

 However, children with a diagnosis of TBI who receive drug therapy and whose parents adhere to the regimen have a 90% reduced risk of developing TB disease.

 Adolescents older than 12 years have a risk of progression to adult-type TB disease. Children and adolescents who are immunocompromised also have a high risk of disease progression.

In 2021, the clinical practice guidance for treatment of latent TB and TB disease was revised.

 Children older than 2 years may be treated with once-weekly isoniazid-rifapentine for 12 weeks. Additional regimens include 4 months of rifapentine or 9 months of daily isoniazid.

 Parents often prefer shorter courses, resulting in more children completing a full course.

For TB disease, children can be treated with several anti-TB medications for 4, 6, or 9 months, based on the selection of the drug therapy believed to be most effective for the child and for parental administration. Providers need to be aware that the Centers for Disease Control and Prevention does not recommend the 4-month rifapentine-moxifloxacin TB regimen for children younger than 12 years.

 Best practices for pediatric providers include consulting a TB expert prior to beginning the treatment course, based on the available data showing that young children have a high risk of developing life-threatening TB disease.

Pediatric health care providers are on the frontlines for identifying infectious diseases and, to prevent poor outcomes, must react quickly to diagnose and treat cases in children and adolescents. The COVID-19 pandemic public health measures— masking, social distancing, and limited social contact among children and adolescents—have reduced the prevalence of other infectious diseases. As public health policies begin to change and global travel resumes, pediatric providers must remain astutely aware of the potentially devasting effects of emerging infectious diseases and newer ones that may affect US and global pediatric populations.

1. Kimberline DW, Barnett ED, Lynfield R, Sawyer MH. Dengue. In: Kimberline DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021:301-304.

2. Paz-Bailey G, Adams L, Wong JM, et al. Dengue vaccine: recommendations of the Advisory Committee on Immunization Practices, United States, 2021. 

. 2021;70(6):1-16. doi:10.15585/mmwr.rr7006a1

3. Child and adolescent immunization schedule. Centers for Disease Control and Prevention. Updated February 17, 2022. Accessed March 25, 2022. 

https://www.cdc.gov/vaccines/schedules/hcp/imz/child- adolescent.html#note-dengue

4. Measles cases and outbreaks. Centers for Disease Control and Prevention. Updated April 6, 2022. Accessed March 26, 2022. 

https://www.cdc.gov/ measles/cases-outbreaks.html

5. Measles: key facts. World Health Organization. December 5, 2019. Accessed March 26, 2022. 

https:// www.who.int/news-room/fact-sheets/detail/ measles

6. Measles. World Health Organization. Accessed March 26, 2022. 

https://www.who.int/health-topics/ measles#tab=tab_1

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https://www.cdc.gov/tb/topic/populations/

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