Lucia had begun to take school seriously in 8th grade but now, in 9th grade, she has become disheartened and says the teachers do not explain things well virtually. She does not like to show her face on camera and has begun to stay in her room, refusing to even eat dinner with the family. She keeps asking them to leave her alone. Her parents are worried. She just wants to play video games and play music in her room, and she has stopped seeing her best friend. The freshman guidance counselor called the parents to say she has missed more than half of the school days in the last week. The parents had no idea because they both work through the day online and assumed Lucia was participating in school virtually. They don’t know what to do.

The impact of the COVID-19 pandemic has hit home, school, work, and social life unlike any other acute change in our lifetime. Resulting isolation, loss of routine, limited social contact, grief, hardship, and stress have increased difficulties and further challenged youth. The deficiencies in our health care provision of mental health care for children have been further highlighted in the press and academic journals. What can those of us on the front lines caring for children do?

Devising an approach for health care workers to address mental health concerns in brief office visits may feel overwhelming. The sections below offer practical pandemic relief to help manage mental health concerns brought by families. During office visits, you can discuss the pillars of well-being by including these 10 priorities.

 Since the pandemic hit, there have been a range of reasons for misery for everyone. Remind families that it is understandable that stress levels are high, and worrying is rampant. Parents and children face new stressors to navigate. Acknowledging this reality has potential benefit. Family environment, parenting practices, coping, and support influence psychological consequences on children.

Parental mental health significantly impacts children, so remind parents that their own self care is important for their own and their children’s well-being. Help parents acknowledge how much their children are missing from their usual lives. School no longer includes the favorites of lunchtime chatting and playful recess interaction. Children are not likely having much opportunity online to solidify new friendships or flirt with a new crush. Their favorite activities are likely limited or on pause. Encourage parents to set aside time to devote their full focus on their children. Emotional support from parents can be protective.

Speak privately to your patients themselves to hear concerns, validate their struggles, and share guidance for those whose home life is affected by substance use or other dysfunction. For the teenagers, their peers become top priority, yet their current environment is blanketed by a large dose of family. Family members that do not support a patient’s LGBTQIA identity, or hold opposing cultural beliefs or sociopolitical values may create tension in the home. Find out if your patients are facing rejection at home and ensure they are coping with that difficulty. Consequential stress from these conflicts and/or the presence of domestic physical, verbal, and/or emotional abuse may have a lasting impact that could be mitigated if identified.

Teach families the myriad ways the pandemic is increasing stress for many by reviewing how stress occurs in the following conditions:

When an event is UNPREDICTABLE as to when or how it may occur.

When competence is being THREATENED (challenged/threatened).

When lack of control forces SURRENDER of your autonomy.

Despite current times meeting all of the above criteria, there is reason for optimism. A study among 381 undergraduate students (age range: 17–24, mean: 20.16, SD = 1.46 years) suggested that active coping strategies predicted life satisfaction during the 2003 Beijing SARS epidemic, whereas the number of stressors and use of avoidant coping strategies predicted psychological symptoms.

Present this pandemic crisis as an opportunity to learn and support well-being.

 Because unpredictability contributes to stress, a schedule does much to regulate our daily lives and contribute to a sense of stability.

Recommend families maintain consistent routines for wake up, bathing, meals, exercise, designated screen time, unwind time, and sleep. Suggest schedules be discussed collaboratively with children emphasizing what is healthy and within reason. Instead of hours, speak in minutes

 about their available time after school of 180-360 minutes depending on grade and homework prior to bedtime. The reason? To children, 120 minutes of screen time sounds like a lot compared to 20 minutes for sitting with family for meals.

 Emphasize what you already know about the importance of sleep’s effect on physical health, appetite, mood, and coping ability. This may be the simplest but most powerful intervention you can suggest, as so many parents do not realize how significantly inadequate sleep affects a child’s functioning. Advise families on good sleep hygiene.

 Watching or scrolling through the media makes us even more anxious. An excess of news and visual images about a traumatic event can create symptoms of posttraumatic stress disorder and negative health effects that remain years later, according to research by University of California at Irvine’s Roxy Silver, PhD, and others.

 Turn off the background news. Monitor Internet safety. Encourage families to view the Netflix documentary, “The Social Dilemma,” because it provides a convincing argument to limit internet use.

 Sedentary scores have shot up during the pandemic. Our brains are programmed to move and when we don’t it’s not good for our mind or body. Children in school are recommended to get 60 minutes of exercise daily. Encourage parents to keep their children active. Websites online offer creative indoor options such as “indoor and at home exercises for kids” at 

 Suggest families identify a new skill/hobby/or activity to learn or do together. Learn sign language, paint a room, create questions to share with family at meals, create homemade gift surprises, play board games, learn to cook, teach the pets new tricks, make posters of passionate beliefs for windows, listen to audiobooks together, or start sharing a daily high and low.

 Research supports the link between altruistic behavior and increased health and well-being.

 Do something that makes someone’s day better. A surprise sticky note, help with cleaning up dinner, call a relative who is alone during the pandemic, bake cookies for neighbors, write a letter to a favorite teacher, volunteer online.

 Anyone interested can learn this skill with simple, brief, regular practice. Help your patients understand that their goal is not to empty their minds of thought but to become aware of their sensations, emotions, and thoughts so they can use that self-awareness for their own benefit. There is evidence supporting benefits on mood, cognition, and symptoms including pain and associated with depression and anxiety.

 There are many options for learning, and countless easy and practical ways to incorporate mindfulness into a daily routine.

 Social isolation and loneliness can contribute to worsening of mental health.

 It’s a human need. Urge families to prioritize social meet ups while keeping safety in mind. Meeting outdoors wearing masks and socially distancing can still allow kids to see each other at a park, for a walk, in the yard, on a deck or porch. Even a prearranged consistent Zoom connection for your child and a friend has value. A limited group of contacts by designating a pod within which to socialize could be considered. Reiterate Centers for Disease Control and Prevention guidelines, handwashing, and testing options to maintain safe activities.

 Encourage parents to initiate the daily practice of noticing 3 positive moments of the day and share them with family. Create opportunities to enjoy time together. Noticing and appreciating daily pleasures can help improve mood.

In every mental health diagnosis that by definition is causing impairment and/or significant suffering, whether mild, moderate, or severe, evidence supports inclusion of psychotherapy in the treatment plan. Especially in pediatrics, this may include parental guidance and intervention. When conditions are severe, a combination of psychotherapy and medications provides the best outcome across conditions. For anxiety and depression-related conditions that cause moderate impairment, consider adding Selective Serotonin Reuptake Inhibitors medication if needed to help them engage in therapy, if they have persistent issues despite evidence-based therapy, or they are unable or refuse currently to access therapy.

Finally: As caregivers, our role is to both support well-being and address common reactions during these historic threats. Additionally, we must remain vigilant and prepared to initiate treatment when challenges have progressed into significant impairment and suffering.

Coping advice and helpful links for range of potential challenges: 

https://psychiatry.ucsf.edu/copingresources/covid19

American Academy of Child and Adolescent Psychiatry Link

Broad list and links of resources for both Families and Clinicians

Clinician resources for mental health management in primary care

 (courses on caring for the mental health needs of youth for Pediatricians, PAs, NPs, Therapists, & Schools) 

Guidelines for Adolescent Depression in Primary Care (GLAD-PC).

This comprehensive and practical resource includes practice guidance for administrative steps and billing as well as clinician tools such as diagnostic guidelines, rating scales, and pt/family handouts.

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Primary-Care-Tools.aspx

A Guide to Psychopharmacology for Pediatricians

http://web.jhu.edu/pedmentalhealth/Psychopharmacolog%20use.html#Other_issue

Text crisis line: 741741 (only 6 digits); text STEVE for POC counselor

Trans Lifeline Peer Support US:1-877-565-8860

TrevorLifeline(LGBTQIA support) 1-866-488-7386

RAINN Sexual Assault Hotline: 1-800-656-4673

National Helpline for Substance Use 1-844-289-0879

Substance Abuse and Mental Health Services Administration National Helpline 1-800-662-HELP, or TTY 1-800-487-4889

American Academy of Child and Adolescent Psychiatry: 

1. Cobham V.E., McDermott B., Haslam D., Sanders M.R. The Role of Parents, Parenting and the Family Environment in Children's Post-Disaster Mental Health. In 

. 2016;18(6) doi: 10.1007/s11920-016-0691-4

2. Gudmundsdóttir D.G., Ásgeirsdóttir B.B., Huppert F.A., Sigfúsdóttir I.D., Valdimarsdóttir U.A., Hauksdóttir A. How Does the Economic Crisis Influence Adolescents’ Happiness? Population-Based Surveys in Iceland in 2000–2010. 

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https://humanstress.ca/stress/understand-your-stress/sources-of-stress

. Published August 22, 2017. Accessed October 1, 2020.

5. Guessoum SB, Lachal J, Radjack R, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323662/

. Published September 2020. Accessed October 1, 2020.

6. As suggested by Grizelda Anguiano, MD, FAAP on REACh PPP call. 

https://mindworkstx.com/staff/grizelda-anguiano-md-faap/

7. Healthy Sleep Habits: How Many Hours Does Your Child Need? HealthyChildren.org. 

https://www.healthychildren.org/English/healthy-living/sleep/Pages/Healthy-Sleep-Habits-How-Many-Hours-Does-Your-Child-Need.aspx

8. Roxane Cohen Silver EAH. Mental- and Physical-Health Effects of Acute Exposure to Media Images of the September 11, 2001, Attacks and the Iraq War - Roxane Cohen Silver, E. Alison Holman, Judith Pizarro Andersen, Michael Poulin, Daniel N. McIntosh, Virginia Gil-Rivas, 2013. 

https://journals.sagepub.com/doi/10.1177/0956797612460406

9. Irani A. Positive Altruism: Helping that Benefits Both the Recipient and Giver. ScholarlyCommons. 

https://repository.upenn.edu/mapp_capstone/152

. Published 2020. Accessed October 1, 2020. 

10. Simkin DR, Black NB. Meditation and mindfulness in clinical practice. 

. 2014;23(3):487-534. doi:10.1016/j.chc.2014.03.002 

https://www.sciencedirect.com/science/article/pii/S0022347616315487

11. N. Leigh-Hunt, D. Bagguley, K. Bash, V. Turner, S. Turnbull, N. Valtorta, W. Caan. An overview of systematic reviews on the public health consequences of social isolation and loneliness, 

12. The Neuroscience of Gratitude and How It Affects Anxiety & Grief. PositivePsychology.com. 

https://positivepsychology.com/neuroscience-of-gratitude/

. Published 2020. Accessed October 1, 2020.

Articles

The COVID-19 pandemic has had a severe negative toll on the mental health of many children. Here are some tips to help children achieve better psychological well-being.

Pandemic pediatric tips for mental health

It is hard to believe that 2021 has arrived. I am sure we all are happy to bid 2020 farewell and are looking forward to a much more “normal” year in 2021.

As the COVID-19 pandemic continues to surge across the country and stay at home orders, travel bans, and other restrictions remain in place, the Emergency Use Authorization of 2 COVID-19 vaccines brings a most welcomed glimmer of hope to obtaining some control over this pandemic. The start of large COVID-19 vaccine trials in children are planned for these next several months, with the hope of vaccine availability for children by the 4th quarter of 2021. This month’s issue has several “must read” articles:

, which provides a comprehensive review of different aspects of COVID-19 in the pediatric population.

The pandemic has fostered the exponential growth of social media outlets and the creation of many social media challenges, some of which present significant danger to a person’s health and well-being. The pediatric pharmacology article in this issue addresses the 

 that is trending on TikTok and discusses the dangers of and treatment for this challenge.

The pandemic has created nutritional challenges for persons of all ages. The nutrition article looks at the nutritional needs of children during the winter months and the importance of 

Best wishes for a peaceful, healthy, and happy New Year. As Oprah Winfrey states “Cheers to a New Year and another chance to get it right”. Please stay safe and well. And as always, I welcome your suggestions, comments, and questions.

Dr. Tina Q. Tan wonders how the event of 2020 will affect 2021.

New Year’s greetings!

It is now 2021, and our understanding of the novel coronavirus first reported in Wuhan, China in December 2019 has drastically expanded due largely to the extensive number of individuals who have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide, as well as those who have exhibited symptoms of disease from this virus (COVID-19). Currently, the increase in incidence throughout the country is significantly impacting our health care system capacity. Whereas children in general have been reported to experience less disease from infection with SARS-CoV-2, the nationwide surge in cases has led to an increase in pediatric hospitalizations, as well as cases of multisystem inflammatory syndrome in children (MIS-C). Despite a growing number of cases throughout the United States, we have greatly improved our understanding of infection control measures to curb transmission, have better access to personal protective equipment (PPE), and have improved testing availability to aid in mitigating transmission. We must now reduce community, household, and workplace transmission to relieve the strain that an ill and reduced workforce is having on the health care system.

What we know right now: SARS-CoV-2 infection in children

Due to variation in public health reporting, accurate numbers of SARS-CoV-2 infected pediatric patients are a challenge to obtain. However, available data show a consistent increase in pediatric patients that tested positive for SARS-CoV-2 over the past year, and particularly the past several months. As of November 19, 2020, the American Academy of Pediatrics/Children’s Hospital Association (AAP/CHA) Children and COVID-19: State Data Report

 reported 1,183,609 cumulative child cases, representing 11.8% of total cases reported and 1572.6 cases per 100,000 children. Fifty-seven percent of these cases were reported since September 2020.

Despite climbing numbers of pediatric SARS-CoV-2 infections, children continue to be proportionally less affected by infection than adults. Although children represent about 22% of the United States population, they represent only 1.8% of total hospitalizations related to SARS-CoV-2.

 The scope of asymptomatic infections in children is challenging to fully represent due to the retrospective nature of current reports, but estimates range between 5% and 35%.

 Children presenting to care with symptoms and subsequently diagnosed with SARS-CoV-2 infection most commonly have fever or cough.

 There is variation in representation of other complaints, including pharyngitis, rhinorrhea, congestion, headache, or gastrointestinal (GI) complaints. Children with some underlying medical conditions (obesity, asthma or chronic lung disease, and immunosuppression) are at greater risk for severe illness from SARS-CoV-2 infection.

 This does not, however, discount the potential for healthy children to develop severe disease or require hospitalization.

Although rates of severe illness due to SARS-CoV-2 are generally lower in children than adults, a hyperinflammatory syndrome associated with SARS-CoV-2 infection has been identified as MIS-C.

 As of December 9, 2020, 23 of these cases in the United States resulted in death.

 More than 75% of reported cases of MIS-C occurred in children of Hispanic/Latino or Black, non-Hispanic reported race/ethnicity and the average age was 8 years.

 The most common symptoms reported for children with MIS-C include GI complaints (abdominal pain, vomiting, diarrhea), rash, and conjunctival injection. Whereas some MIS-C patients may present with symptoms overlapping with Kawasaki disease or toxic shock syndrome, multiple case series of patients with MIS-C demonstrate clear differences between these patients, including age distribution, prominence of GI symptoms, the degree of multisystem organ involvement, and cardiogenic shock with myocardial dysfunction.

 Multiple studies are ongoing to better understand the pathophysiology of this inflammatory syndrome.

Infection prevention in community and health care settings

Understanding of SARS-CoV-2 transmission has increased exponentially throughout the pandemic. Basic concepts of infection prevention such as wearing face coverings/masks, hand hygiene, not working when ill, and social distancing have proved to be of the utmost importance for the health care setting and for the public, including our patients and their families. Although children who cannot remove their mask in case of an emergency or those with sensory sensitivities should not use face coverings, children aged as young as 2 years can learn to don them when out in public or at school. The epidemiologic curve in relation to social distancing and masking guidance over the past 10 months supports the use of these infection prevention methods. Additionally, household contact with an individual with SARS-CoV-2 is a risk factor for transmission, likely due to individuals exposing one another during the pre-symptomatic period and lack of use of face coverings within the household.

In-school learning is dependent upon the level of community transmission and ability to mitigate transmission of infections. School attendance is important not only for education, but also for food security, access to other services, and physical activity. If open, schools should enforce the basic principles described above: Masking and social distancing (depending on the age group), as well as extensive cleaning of the environment. Creation of cohorts of students and teachers (“pods”) within schools has helped alleviate the need to close an entire school in some circumstances. Testing, contact tracing, and school or class closure policies are contingent upon local transmission rates and other factors. Unlike other viruses such as influenza, younger children appear to be less affected by and less likely to spread SARS-CoV-2 than older children.

 Age-based schooling recommendations may therefore be an appropriate consideration, with greater emphasis on the ability of younger school-aged children to continue in-person learning even if this cannot be maintained in older age groups.

In the health care setting, use of negative pressure rooms, PPE, social distancing, environmental cleaning with focus on high touch surfaces, and hand hygiene decrease the likelihood of transmission of SARS-CoV-2 between patient and provider. Nosocomial transmission is likely more associated with lack of PPE particularly during prolonged exposure and/or performing aerosol-generating procedures (AGP) without the recommended PPE.

 Transmission dynamics of SARS-CoV-2 to date support transmission via direct or indirect contact with secretions, respiratory droplets, or fomites unless a procedure is being performed that may generate aerosol. Use of a face mask and eye protection has been shown to reduce risk of transmission.

 Face masks prevent large droplets from being breathed in, but also to prevent any viral secretions from going out. However, if an AGP is being performed, a respirator (eg, N95 respirator) should be employed to keep generated aerosols from being inhaled. The Infectious Diseases Society of America has published a table of AGPs to aid in decision making around PPE use.

 It is yet unclear whether SARS-CoV-2 can be spread through aerosol other than those generated by medical procedures, though the transmission dynamics of this virus does not match those of known airborne infections such as measles or varicella. Implementation of these infection control strategies can mitigate transmission of SARS-CoV-2 between health care personnel and patients if they are followed.

 Fatigue from using PPE and laxity with social distancing have more recently become real concerns and problems. Universal mask use and social distancing guidelines have been adopted within many health care settings, yet transmission among health care workers has become a new challenge when mask use is inconsistent. A recent Cochrane Review reported that a key facilitator to adherence to infection prevention guidelines among medical personnel was understanding the rationale behind the guide-lines.

 Education of team members is therefore likely the most important approach to take in the coming months as we face PPE fatigue and burnout in health care.

In addition to the continuing SARS-CoV-2 pandemic, we are now within the winter respiratory virus season. Though some reports from the Southern Hemisphere have shown a mild influenza season,

 it is difficult to predict what the United States can expect with influenza or any of the other winter respiratory viruses. Given the overlap of symptoms between SARS-CoV-2 and influenza infections, use of SARS-CoV-2 and influenza testing is crucial. Results will aid in identifying people who require isolation, inform contact tracing efforts, particularly for schools, and for those requiring hospitalization, inform treatment for either virus. Communities with more infection mitigation measures in place and adherence to those measures may have less influenza circulation than typically would be expected. Reinforcing the basics of infection prevention, promoting influenza vaccine for health care providers, patients, and families, in addition to maintaining high rates of routine immunizations will be important to alleviate hospital admission rates and reduce strain on hospital bed availability.

Strategies for treatment and immune modulation of the effects of SARS-CoV-2 continue to develop. An Emergency Use Authorization (EUA) was granted by the FDA for the use of hydroxychloroquine for treatment of COVID-19 and revoked in June 2020 due to insufficient data to show efficacy. In parallel, an EUA was granted for the use of remdesivir in May 2020. Recommendation for use is with or without dexamethasone in patients who are hospitalized and require supplemental oxygen

 (Table). In October 2020, remdesivir became the first drug approved by the FDA for treatment of COVID-19 in individuals aged ­12 years and ­40kg. Safety and efficacy in children aged <12 years has not yet been established, so use in this group remains under EUA. In November, bamlanivimab, a neutralizing monoclonal antibody targeting the spike protein of the SARS-CoV-2 virus was issued an EUA for use in non-hospitalized patients with mild-to-moderate SARS-CoV-2 infection who are at high risk for adverse effects from the infection (Table). In December, as this article was going to press, the Pfizer and BioNTech mRNA vaccine had just been granted EUA: Shortly thereafter, doctors and nurses throughout the country were televised receiving the first vaccines and plans have been made to distribute to additional health care workers. By the time this article is published, a second vaccine, developed by Moderna, might very well have been approved as well.

The Advisory Committee on Immunization Practices recommends a phased approach with initial vaccine being made available to the groups most at-risk for SARS-CoV-2 infection, including inpatient and outpatient health care personnel, first responders, and a variety of other health care personnel.

 Initial vaccine uptake will help maintain the health and availability of health care personnel to continue to provide both acute and preventative care to patients. Subsequent phases of vaccination will then be able to mitigate spread among the general community. The Pfizer-BioNTech vaccine is approved for persons aged 16 years and older, and the company has begun trialing vaccine administration for children ­12 years of age. Emphasis for now will therefore remain on uptake by adults and older children.

There have been many successes and many “educational moments” in our journey through the SARS-CoV-2 pandemic. The speed with which our large health care and public health systems, as well as our governments and communities, have had to mobilize and adapt to continually new information is tremendous. Early in the pandemic, focus was primarily on creating protocols and gaining better understanding of the virus and its dynamics. We have confirmed that public health and infection control measures can positively impact infection rates. Our concern in the health care setting has shifted from acquisition of SARS-CoV-2 from our patients to its acquisition from coworkers, community, or household members.

In the coming months, we will be challenged with continuing to care for the growing number of patients with SARS-CoV-2 and increasing rates of hospitalization, as well as managing distribution of new vaccines. We will still encounter school closures, be challenged with our patients’ and colleagues’ mental health, and continue to seek preventative care. However, looking back over the past 11 months, it is evident that we have made tremendous strides in understanding COVID-19, mitigating spread, treating the virus and its sequelae, and connecting scientists to advance our knowledge of this virus and how to combat it.

Children’s Hospital Association and American Academy of Pediatrics. Children and COVID-19: State data report – November 19, 2020. Accessed November 30, 2020. 

https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%2011.19.20%20FINAL.pdf

Zimmerman P, Curtis N. COVID-19 in children, pregnancy and neonates: A review of epidemiologic and clinical features. 

Assaker R, Colas AE, Julien-Marsollier F, et al. Presenting symptoms of COVID-19 in children: a meta-analysis of published studies. 

. 2020;125(3):e330-e332. doi:10.1016/j.bja.2020.05.026

Foster CE, Moulton EA, Munoz FM, et al. Coronavirus disease 2019 in children cared for at Texas Children’s Hospital: Initial clinical characteristics and outcomes. 

Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. 

. 2020;174(9):868-873. doi:10.1001/jamapediatrics.2020.1948

Kim L, Whitaker M, O’Halloran A, et al. Hospitalization rates and characteristics of children aged <18 years hospitalized with laboratory-confirmed COVID-19 – COVID-NET, 14 states, March 1-July 25, 2020. 

. 2020;69(32):1081-1088. doi: 10.15585/mmwr.mm6932e3

Verma S, Lumba R, Dapul HM, Gold-von Simson G, et al. Characteristics of hospitalized children with SARS-CoV-2 in the New York City metropolitan area. 

. 2020. Epub ahead of print. doi: 10.1542/hpeds.2020-001917.

CDC. Information for healthcare providers about multisystem inflammatory syndrome in children (MIS-C). Accessed November 30, 2020. 

CDC. Multisystem inflammatory syndrome in children: Cases in the US. Accessed November 30, 2020. 

https://www.cdc.gov/mis-c/cases/index.html

Kaushik A, Gupta S, Sood M, Sharma S, Verma S. A systematic review of multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection. 

 2020;39(11):e340-e346. doi: 10.1097/INF.0000000000002888

Bautista-Rodriguez C, Sanchez-de-Toledo J, Clark BC, et al. Multisystem inflammatory syndrome in children: an international survey. 

Guo CX, He L, Yin JY, et al. Epidemiological and clinical features of pediatric COVID-19. 

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Laws RL, Chancey RJ, Rabold EM, et al. Symptoms and transmission of SARS-CoV-2 among children – Utah and Wisconsin, March-May 2020. 

Grijalva CG, Rolfes MA, Zhu Y, et al. Transmission of SARS-COV-2 infections in households — Tennessee and Wisconsin, April–September 2020. 

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Leeb RT, Price S, Sliwa S, et al. COVID-19 trends among school-aged children – United States, March 1-September 19, 2020. 

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What we knew about COVID-19 when the pandemic began, what we know now.

State of the union on COVID-19

A newborn boy born via normal vaginal delivery at 38.6 weeks gestation to a 33-year-old G5P2022 mother presented at birth with an asymptomatic 8-mm red, papulonodule with central crusting on the right cheek (Figure 1). Pregnancy had been complicated by maternal type 2 diabetes mellitus and obesity. Delivery was uncomplicated and the patient was otherwise healthy.

Mother was otherwise healthy and the pregnancy was uneventful. Medications that were used during the pregnancy included prenatal vitamins, insulin, ranitidine, and diphenhydramine. All antenatal ultrasounds, serologies, and labs were unremarkable. Mother reported no relevant personal or family history, specifically no history of herpes simplex virus (HSV) infection, other viral infections, leukemia/lymphoma, or immunodeficiencies.

Initial physical examination revealed a well appearing infant. The Apgar scales were 9, 9, and 9 at 1, 5, and 10 minutes respectively. Patient weighed 3485 grams, an appropriate weight for his gestational age. Vital signs were within normal limits upon delivery.

Skin examination revealed an asymptomatic, round, red, non-blanching, 8-mm firm papulonodule on the right cheek. The lesion had an erythematous base with no drainage or crusting on initial exam. Central crusting later developed on the first day of life. The patient did not appear bothered by the lesion. Physical exam was otherwise unremarkable.

The patient received all routine neonatal labs. Hemoglobin and hematocrit levels were within normal limits. He required 2 oral glucose gels prior to glucose normalization. Metabolic screens were within normal limits. At 24 hours of life, C-reactive protein and a complete blood count were drawn and returned with no abnormalities.

Ultrasound of the lesion of the right cheek demonstrated a heterogeneous, hypoechoic lesion with no evidence of increased vascularity. Pediatric dermatology was consulted for further evaluation of the lesion and performed a biopsy that revealed Langerhans cells with surrounding inflammatory cells and eosinophils (Figures 2 and 3). A cutaneous proliferation of CD1a, CD68, and S100 positive cells was also confirmed via immunohistochemical staining (Figures 4 and 5). Fungal cultures, aerobe-anaerobe cultures, and an acid-fast bacilli culture were negative. These findings were typical of cutaneous Langerhans cell histiocytosis.

The initial differential diagnosis included several infectious and noninfectious etiologies that could account for such a skin lesion (Table). Infantile hemangiomas were high on the differential, as these are the most common skin neoplasms presenting in infancy.

 These are benign vascular tumors with a prevalence of 4%-10% worldwide.1 Ultrasound imaging may demonstrate an increase in internal vascularity. Ultrasound of our patient on day 1 of life indicated no prominent internal vascularity, making the diagnosis of infantile hemangioma less likely. Moreover, the presence of a nodule at birth and uniform blanching erythema with central crusting would not be typical of a classic infantile or congenital hemangioma.

Langerhans cell histiocytosis (LCH) was another diagnosis considered as it has a variable clinical presentation. Manifestations of this hematologic disorder can range from single cutaneous lesions to multiple cutaneous lesions, and to a multi-organ disease. Skin involvement is present in 33% of patients and appearance can vary from dry scaly lesions to crusted vesicles and red papules.

 Biopsy confirms characteristic histologic and immunohistochemistry findings.

Biopsy is also critical to exclude other diagnoses such as congenital juvenile xanthogranuloma. This is a form of non-Langerhans cell histiocytosis which can present as subcutaneous masses with overlying skin changes, papules, or nodules that are erythematous at presentation and become yellow in color over weeks to months.

 These lesions vary from a few mm in diameter to over 3cm, and most commonly involve the head, neck, or trunk.

Leukemia cutis describes skin manifestations that arise as a result of an underlying leukemia. These lesions can also have a variable presentation including red or violet papules, plaques, nodules or hemorrhagic lesions.

 These lesions commonly appear after a diagnosis of leukemia has already been made, but may also appear before there is any involvement of the peripheral blood or any systemic symptoms arise.

 Approximately two-thirds of patients presenting with neonatal acute myeloid leukemia also present with skin lesions, but lesions may be limited to the skin and resolve without treatment. However, these patients usually have other findings including hepatosplenomegaly or a high systemic tumor burden.

 Confirmation of this diagnosis is also completed via skin biopsy.

Other potential etiologies include congenital sarcomas, such as rhabdomyosarcoma. These soft-tissue neoplasms can present as red or violaceous nodules if they metastasize to involve the skin.

 Additionally, extramedullary hematopoiesis, or a “blueberry muffin rash”, can also present as similar papules and nodules that can be the result of an underlying infection (often TORCH infections), hemolysis, or malignancy.9

An infectious etiology also cannot be ruled out when a newborn presents with an abnormal skin lesion. Neonatal HSV needs to be considered due to the high morbidity and mortality rates associated with this infection.

 Patients with neonatal HSV usually present with clusters of vesicles localized to the skin, eyes or mouth. Failure to treat could lead to disseminated disease or spread to the central nervous system.

 Cutaneous lesions can also be the manifestation of infections caused by the other congenital TORCH infections, 

Infection could suggest that there is an underlying immunodeficiency such as HIV, malignancy, or a white blood cell disorder. Our patient did not present with any risk factors for these conditions and lab values were reassuring. Additionally, the patient was not exposed to any risk factors that would alter the function of the immune system at this age including maternal illness, prematurity, immunosuppressive medications or inadequate prenatal care.

Langerhans cell histiocytosis has an incidence of 2.6-8.9 cases per million amongst children aged younger than 15 years, and a median age of diagnosis of 3-4 years.

 This disorder is characterized by proliferation of CD1a, S100, CD68, and CD207 myeloid dendritic cells and has a highly variable clinical presentation.

 Any organ system can be affected, thus requiring a comprehensive evaluation of affected patients. Commonly affected sites include the bone, skin, central nervous system, pulmonary, hematopoietic, and hepatobiliary systems.

Among patients diagnosed with LCH, 33% present with skin findings.

 Skin lesions usually present as ulcerated, red papules, as was seen in our patient, but may also appear pustular, vesicular, or petechial in nature.

 In infancy skin manifestations may also resemble other skin disorders such as erythema toxicum neonatorum, eczema, or seborrheic dermatitis. As a result, it is important to accurately diagnose this condition to ensure appropriate treatment.

A rare variant of LCH named congenital self-healing reticulocytosis has also been identified. This condition was first described by Hashimoto and Pritzker and presents at birth or within the first few weeks of life.

 Patients may present with brown to violaceous papules located anywhere on the body. As with classic LCH, these lesions can be single or multiple. It is thought that the true incidence of this variant is underreported because most of these lesions resolve without treatment within the first 3-4 months of life.

Although children with lesions isolated to the skin usually have a good prognosis, patients with LCH who have isolated skin involvement also have an excellent prognosis, however, close observation is still required.

 In 40% of patients with similar isolated cutaneous findings progression to multi system disease or reactivation was observed.

Initial evaluation of patients with LCH requires determining whether there is single or multisystem involvement. Recommended testing includes a complete blood count with differential, complete metabolic panel including liver function tests, and coagulation studies. Imaging assessment should include a skeletal survey, ultrasound of the liver and spleen, and chest radiography.

 Treatment can then be tailored to the individual patient and extent of their disease.

Treatment for LCH is dependent on the site affected and the number of lesions. For patients presenting with isolated skin involvement, surgical resection can lead to cure. If lesions are multiple then topical corticosteroids are first line therapy, with second line agents including topical nitrogen mustard, oral thalidomide, and oral methotrexate.

 Additional studies need to be completed to further assess the efficacy of second line treatment options.

If skin involvement is diffuse or there are signs of multisystem disease, a systemic steroid with vinblastine for 6-12 months is first-line treatment. For patients with organ involvement (spleen, liver, bone marrow) 6-mercaptopurine may also be added to this treatment regimen.

 Prognosis for patients who fail these first-line treatment options is typically poor, and salvage therapy is indicated in these situations. This includes treatments such as hematopoietic stem cell transplant or a combination of cladribine and cytarabine.

Recent research has been investigating the use of therapies targeting BRAF-V600E mutations. Patients with this mutation are more likely to have higher risk LCH or have increased resistance to treatment.

 Vemurafenib, a BRAF inhibitor, has been shown to be efficacious, however further studies are required to determine appropriate dosing and duration of therapy.

Current recommendations for follow up for patients treated for isolated skin findings include evaluation of the lesion every 2 to 4 weeks. This includes monitoring for any signs of progression to multisystem involvement. Once the skin lesions have resolved, follow-up is recommended every 6 months for at least 5 years.

The cheek lesion was excised by pediatric dermatology and our patient was evaluated by the pediatric hematology-oncology service. Initial skeletal survey to assess for bone involvement showed a calvarial lesion suspicious for LCH. Follow up whole body positron emission tomography scan was completed and showed no findings of bone or other multisystem involvement. As a result, systemic therapy was not indicated as the cheek lesion was previously excised. It was determined that the patient likely had the congenital self-healing reticulocytosis variant of LCH. The patient continues to follow with serial skeletal surveys and labs, and remains in complete remission.

A newborn boy born via normal vaginal delivery at 38.6 weeks gestation to a 33-year-old G5P2022 mother presented at birth with an asymptomatic 8-mm red, papulonodule with central crusting on the right cheek. What's the diagnosis?

Vol 38 No 1

Pandemic pediatric tips for mental health

New Year’s greetings!

State of the union on COVID-19

Red papulonodule with central crusting on a neonate’s cheek

It’s winter: Are children getting enough Vitamin D?

A pediatrician’s role in dyslexia: Where theory meets practice

A case of terra firma—forme dermatosis

Dangers of the TikTok Benadryl challenge

Plagiocephaly may be an early indicator of developmental delay risk

Shorten time to antibiotics for oncology patients with suspected neutropenia

How well can a brief step test assess exercise tolerance?