Racism is a Social Determinant of Health

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Racism is a social determinant of health – Pediatricians, children and their parents need to be a part of the conversation

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

Nguyen-Thao Tran, DO, PGY2
Department of Pediatrics
Wyckoff Heights Medical Center

As Pediatricians, our longstanding responsibility is to advocate for children’s health. The current events within our communities surrounding racism forces us to evaluate its role and the effect it has on children. Protests and civil unrest against racism took to the streets across America the last few weeks in response to the inhumane murder of George Floyd. Mixed emotions of anger, pain, confusion, stress and fear as a result of racial injustice are flooding social media and news platforms. The issue of racism at its core warrants conversations between parents and their children, with support by us as Pediatricians now more than ever. As Dr. Thomas J. Nasca, M.D., MACP, CEO of the ACGME stated in his recent letter to the community, “we as physicians bear a special responsibility to respond. It is our collective duty to advocate for all our patients, and to care equally and equitably for all our patients.” The special responsibility he mentions is to also “take on the challenging work required to solve deep rooted societal problems as they manifest in medicine.” Racism is a prime example of such a societal problem.

In 2019, the American Academy of Pediatrics (AAP) published a Policy Statement, “The Impact of Racism on Child and Adolescent Health.” In the policy, the AAP addresses racism as a social determinant of health. Children experience what the policy refers to as the “outputs of structural racism through place (where they live), education (where they learn), economic means (what they have), and legal means (how their rights are executed).” 1 The consequence of the inequality of access and attainment in education, based on the disparity of the social environment they grow up in has been shown to negatively impact their health and development as well as set the parameters for how kids understand race.1 Therefore, it is so important that the conversation of racism with children not be ignored. As Dr. Joseph L. Wright, M.D., M.P.H., FAAP, a member of the AAP Board of Directors stated in an AAP news release “if we are to progress in this country, it is going to be because we help our children, adolescents and young adults learn not just that racism exists, but that it is something all of us can work together to dismantle. Racism is not inexorable.”2

It is never too early to talk to children about race or racism. Rather, failure to talk openly with children about racial inequity contributes to the development of racial biases. Infants as young as 3 months of age notice race-based differences and begin to express preference by race; by toddler years, they internalize racial bias and begin to apply stereotypes and express biases; and by the age of 12 years it has been shown that most children become set in their beliefs.3

The AAP provides guidance for parents on how to talk to their children in an age-appropriate manner as outlined below: 1, 4

  • Check in with their child regarding what they know, what they have seen and how they are feeling.1, 4
  • Monitor for any changes in their children’s behavior. Children may internalize their feelings, expressing fear or anger. Parents are encouraged to reach out to their Pediatrician and/or mental health provider for additional support. Parents should also be aware of their own emotions and reach out for help as well, in order to develop their own coping strategies to refer to during these moments of heightened emotions. 1, 4
  • Limit screen time and exposure to the news. It is important however to recognize that if questions arise, parents do not avoid discussing the topic of racism. Parents should be encouraged to point out racial bias and stereotypes in the media, movie and/or TV shows. 1, 4
  • Use resources such as books during this teachable moment in history to address and recognize that racism still plagues our country. Children’s books are a practical tool for initiating these conversations. Children not only need to know what individual and structural racism looks like; they need to know what they can do about it. 1, 4 The Reach Out and Read (ROR) program recently took the initiative and will be diversifying the book selection to help support the conversation about race, racism and resistance. Below are links to a ‘Medical Provider Crisis Guidelines6 and a ‘Virtual Learning Resources for Young Learners and their Families7 put together by the ROR of Greater New York.

Pediatricians can play a pivotal role in helping kids and families discuss the current events regarding racism and the protests taking place nationwide. We can help children and their families build empathy and embrace diversity by discussing racism and racial justice during pediatric visits. To do so, we also need to check our own biases, create a culturally safe medical home for our patients, and continue to actively advocate at the local as well as federal level the policies that will bring about advancing social justice and change.1,5 In this manner, our collective voice and action will help reduce the inequities in education, housing and access to health care for all children.

References:

  1. Trent M, Dooley DG, Douge J, AAP SECTION ON ADOLESCENT HEALTH, AAP COUNCIL ON COMMUNITY PEDIATRICS, AAP COMMITTEE ON ADOLESCENCE. The Impact of Racism on Child and Adolescent Health. Pediatrics. 2019; 144(2):e20191765.
  2. Jenco, M. (2020, June 1). Dismantle racism at every level: AAP president. Retrieved June 18, 2020, from https://www.aappublications.org/news/2020/06/01/racism060120
  3. Anderson, A., & Douge, J. (2019, July 29). Talking to Children About Racial Bias. Retrieved June 18, 2020, from https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/Talking-to-Children-About-Racial-Bias.aspx
  4. Heard-Garris, N., & Douge, J. (2020, June 1). Talking to Children about Racism: The Time is Now. Retrieved June 18, 2020, from https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/Talking-to-Children-about-Racism.aspx
  5. American Academy of Pediatrics Addresses Racism and Its Health Impact on Children and Teens. (2019, July 29). Retrieved June 18, 2020, from https://www.healthychildren.org/English/news/Pages/AAP-Addresses-Impact-of-Racism-on-Children-and-Teens.aspx
  6. Medical Provider Crisis Guidelines: https://drive.google.com/file/d/15wYVQHqlZjuNiWtEYtyGPs6DgpVfx7hV/view
  7. Virtual Learning Resources for Young Learners and their Families: https://docs.google.com/document/d/1893FrURp664uUFmHS0rO1R_f_f9K_4wObzMU9p78oTU/edit

See and Not Miss The MIS-C

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Leonard Krilov, MD, FAAP

Leonard Krilov, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

Dr. Leonard Krilov, MD, FAAP is Chairman of Pediatrics and Chief of the Division of Pediatric Infectious Disease at NYU Winthrop Hospital.  He is the Co-chair of the Infectious Disease Committee of the NYS AAP

See and Not Miss The MIS-C: What Pediatricians & Parents Need to Know About Multisystem Inflammatory Syndrome in Children Related to COVID-19

As of May 21st, there were 54,031 confirmed cases of COVID-19 in children in the United States. Children represent only 4.2% of all the confirmed cases nationally. It appears that children escaped the burden of severe lung disease associated with COVID-19. However SARS-CoV-2, posed a new challenge for the pediatricians in the form of a novel inflammatory syndrome.

On April 26th, pediatricians in the United Kingdom reported a severe inflammatory syndrome with Kawasaki like features in otherwise healthy children.1 These children tested positive for SARS-CoV-2 based on either reverse transcriptase polymerase chain reaction assay or /and serology. The initial UK case series described eight children presenting with persistent fevers, hypotension, and multi-organ involvement with evidence of inflammation. None of these children had respiratory symptoms.

Similarly, characterization on 35 children with cardiac failure in midst of COVID-19 was published from France and Switzerland.2 In Bergamo Province, a 30-fold increase in Kawasaki-like disease was observed in children. This followed a rapid recognition of analogous cases in New York. As of June 1st, there were over 200 cases with three pediatric deaths. New York State continues to collect data on children presenting with signs and symptoms suggestive of this inflammatory condition.

New York State has been on the forefront of developing guidelines on management. Our pediatric emergency departments quickly adapted screening procedures for children presenting with prolonged fevers (≥ 3 days). Instantaneously fever work ups for children included inflammatory and multi-organ system labs. Treatment regimens were promptly tried drawing an analogy to some components of Kawasaki disease. Most Centers are using intravenous immunoglobulins (IVIG) as the first-line agent, along with other immunosuppressive such as steroids and/or IL-1 blockers (Anakinra).

On May 14th, the Centers for Disease Control and Prevention (CDC) defined this new inflammatory syndrome temporally related to recent exposure of SARS-CoV-2 as the “Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19.

Centers for Disease Control has the following case definition:

Any child or young adult less than 21 years of age presented with:

Fevers

Laboratory evidence of inflammation

Severe illness requiring hospitalization

Multisystem organ involvement ( ≥ 2) such as cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurologic

AND

No alternate plausible diagnosis

AND

Evidence of recent or current SARS-CoV-2 by PCR, serology or antigen, or COVID-19  exposure 4 weeks prior to the onset of symptoms

 

This led to increased awareness by pediatricians as well as parents of MIS-C primarily from the news media. Despite development of plans for expeditious management strategies in the pediatric emergency room, there exists little guidance for pediatric offices in this regard. As the number of cases surge, a wide spectrum of MIS-C is acknowledged. In this blog, we provide a clinical pathway to triage children with fevers and concern of MIS-C presenting to the pediatrician’s office.

What is MIS-C? It is likely a post inflammatory response to recent infection by SARS-CoV-2. The clinical spectrum ranges from severe presentations such as shock-like presentation, macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH) syndrome to Kawasaki-like disease and milder variants manifesting as fevers and lab evidence of inflammation only. Abdominal pain is often a significant part of the presentation as well.

This is a general guidance and should be interpreted and applied with caution. It is expected to evolve as more information becomes available. Clinical judgment should supersede this clinical pathway.

 

Inflammation *Mild Severe Severe

Organ 

Involvement

No liver, kidney, heart involvement No liver, kidney, heart involvement Involvement of heart, liver or kidney
Next step
Follow up

 

Follow-up outpatient in

24 hours with repeat labs and refer to cardiology for Echo if still elevated

 

Send to emergency room for admission and follow-up labs and Echo

Sent to emergency room for further workup, admission and treatment consideration
*Mild CRP 10-40, Severe > 40  mg / L
Emergency Room Work up

 

     Clinical

Laboratory

 

SARS-CoV-2

  Inflammatory Organ involvement

□Shock-like presentation

□Kawasaki-like presentation

□ Fever only

 

 

□ ↑  WBC

□ ↑ CRP

□ ↑ Procalcitonin

□ ↑ Ferritin

□ ↑ ESR

□ ↑ D-dimer

□ ↑ Troponins

□ ↑ Transaminases

□ ↑ Creatinine

 □ PCR

 

□ Serology

 

□  Exposure

Obtain baseline echocardiogram, consider treatment with intravenous immunoglobulins +/- steroids + /- IL-1 blockers +/- IL -6 monoclonal

How to educate parents on MIS-C:

Parents should be encouraged to contact pediatrician if there is any concern about child’s health. While this inflammatory condition sounds frightening, the American Academy of Pediatrics reassures that this condition is rare. A blast email, phone texts, or phone calls to patient’s families in this regard will help with increased awareness as well as accessibility.

A script from American Academy of Pediatrics can be used, “MIS-C has been compared to another rare childhood condition, known as Kawasaki disease. Although it is different, if you notice any of the following symptoms please call your pediatrician:

  • Fevers lasting for more than 24 hours
  • Red eyes and/or a skin rash
  • Abdominal pain, diarrhea or vomiting
  • Child seems confused or overly sleepy
  • Trouble breathing

In addition, please let you pediatrician know if the child was tested positive for COVID-19 or exposed to this virus. Based on this information, the pediatrician will determine whether the child can be seen in the office, via telemedicine or you would need to go to the emergency department.”

As a pediatrician, please remember to report any such cases to the New York State Department of Health at (866) 692-3641.

References:


Mental Health Matters in the Month of May!

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

Christian McCartney-Melstad, DO, PGY1
Department of Pediatrics
Wyckoff Heights Medical Center

May is Mental Health Awareness Month and an excellent reminder to pediatricians to consider the mental health of their patients and their families at every visit.

This is even more important than usual, given the enormous disruptions caused at all levels of society by the COVID-19 pandemic.  Schools have been closed, children have been isolated with their families, and social activities have been cancelled or changed.  Families may be under enormous health, financial, and interpersonal stress.  Amidst all of these adjustments, mental health can become particularly vulnerable.

For young children, parents can adopt some simple steps to help children deal with these new fears and anxieties.

  • Talking with your child and ascertaining what they know about the coronavirus and COVID-19 can be a good place to start.
  • Answering their questions and reassuring them in an age-appropriate manner may ease their concerns.  Even if you don’t know the answers, voicing the child’s concerns may ease their anxiety.
  • Help your child understand that it is natural and normal to worry about these changes, and that everybody does.
  • Don’t try to protect or shield your child from news or current events.  The child may hear other, less-accurate information from their friends or online.
  • Be mindful that you model behavior for your child; if you exhibit anxiety or fear, they will perceive this.  Adults may need to be more thoughtful in how they express their emotions.
  • Teach your child that they are unlikely to become seriously ill, and that if they are sick, you will take good care of them.  Tell them what kind of support you have in case you get sick.
  • Help your child learn how to take proactive steps to protect themselves.  Practice handwashing, mask usage, and discuss the importance of social distancing.
  • Maintain as much normality in your lives as possible.  Try to keep some of your old, familiar routines.  This will help your child feel safe and stable.
  • Devote quality time to your child.  This can be challenging when everyone is at home together all day long, but it creates a space for gentle reassurance and an opportunity for them to voice their concerns informally.
  • Help your child think about actions they can take to feel safer.  Encourage them to pursue hobbies and relaxation.
  • Your child may want more close contact with you and feel more than usually anxious about separation.  Be prepared for more physical contact than usual.

School-aged children may have different concerns.  At this age, they may begin to take more comfort from facts. Parents can discuss some more of the science behind the disease with these children, and use informative graphs and figures to greater effect.  These kids can also be taught to distinguish truth from rumor, especially when considering anonymous or internet sources.  As with younger children, don’t try to disguise or conceal information: they’ll either get their information from you or from their friends.

Older children’s social needs are also more sophisticated.  Until it is possible to see their friends in person or return to school, consider setting up video calls or play dates.  Even short interactions can serve to maintain connections and decrease loneliness and social isolation.  Scheduling such calls in advance or making them part of the home school routine can help preserve a sense of predictability in the child’s life.

Teenagers’ needs are different than those of the younger or school-aged children, of course.  They may feel especially isolated as social distancing cuts them off from their friends.  The loss of milestone events like proms, graduations, and organized sports can be particularly difficult for them.

For teens, create a schedule that accommodates their online learning requirements.  Be flexible and allow “down time” and privacy.  Share the information that you receive from reputable sources and talk about how the can do their part to help slow the virus’s transmission by social distancing and practicing good hygiene.

Parents need to look after themselves, too!  Adults should take advantage of their social networks and healthcare resources to get the support that they need to best care for their kids.

Beyond these simple steps, we have identified several resources that pediatricians can use to help their patients and their families to understand the illness, the changes in their daily lives, and the importance of maintaining healthy habits in this time of uncertainty.

Organizations like ProjectTEACH provide many resources for pediatricians and their patients of all ages.

COVIBOOK” is a free PDF book downloadable in many languages that addresses young children’s emotions and explains the virus and its spread in simple language.

For older kids, “Coronavirus: A Book for Children” (also a free PDF) discusses the basic science behind the virus and its transmission, and specifically addresses the stress and difficulty of the social changes that children are dealing with, like staying home and not seeing their friends and family members.

There are abundant resources available online for parents, too.  The AAP’s own healthychildren.org website is an excellent place to start.  Other AAP resources, like the “Information for Families” webpage, add even more information. For comprehensive children’s mental health resources, parents can visit NYU Langone’s “COVID-19 Mental Health Resources for Families” website, the American Psychological Association’s page, or American Academy of Child and Adolescent Psychiatry’s resources.  Even mainstream publications like the USA Today have offered helpful advice.

Of course there are many, many other resources available online; many are of dubious quality.  With so many options, pediatricians can help their patients’ families by recommending high-quality, evidence-based information sources.

Resources:


New York The Epicenter of COVID-19: Challenges for Pediatricians

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

A calamity brought to the elderly, I’m scared for
A virus being polite to the children, I cared for
A virus inflicting fellow pediatricians, I teared for
Please halt the spread in my town, I pray for

 Six weeks ago New York reported its first case of coronavirus disease (COVID-19).  We now stand more than 150, 000 cases and 6,200 deaths as of April 9th,  2020.  New York has become the new epicenter of this pandemic.  It has affected every aspect of our lives.  Within days New York hospitals have been transformed into COVID units.  Bed capacity has been bumped up by 50 % as mandated by the New York State. Instead of cruise ships, a Navy hospital ship is docked at the Hudson River Bay.  Instead of exhibitions, Javits Center now holds 2500 beds.  The misery brought by COVID-19 has disproportionately inflicted our elderly especially those with underlying medical problems.

Pediatricians are facing radical changes as well.  Pediatricians are working side-by-side with adult colleagues in the hospital.  Pediatricians are providing virtual care using Telemedicine.  Pediatricians are at risk of getting infected while caring for the sick.  Several challenges to tackle at various fronts!

Let’s begin with the weekly morbidity and mortality report (MMWR) report on COVID-19 in Children.  Disease characterization in pediatrics was provided in this report published April 6th, 2020.  1 In summary:

  • Data from 149, 760 reported cases of laboratory confirmed COVID-19 was analyzed during February 12th – April 2nd, 2020.
  • Cases in children < 18 years were low at 2,572 (1.7 %).
  • New York State children comprised majority (56 %) of the cases in the US.
  • Mean age was 11 years (0-17), one third of the cases are in teenagers 15-17 years (32 %).
  • Majority of the pediatric patients were males (57 %).
  • In terms of symptoms, 73 % of children had the characteristic fever, cough and shortness of breath when compared to adults (93%).
  • Hospitalization information was available on 745 (29%) children. Among those 147 (estimated 5.7-20 %) were hospitalized and 15 admitted to the ICU (0.58-2 %).

These findings are similar to the data on children from China.  COVID-19 has been polite with the children.  Majority of the cases are mild with rare cases of severe disease in teenagers and infant particularly those with underlying medical conditions.

I would like to discuss:

  1. Management of childhood COVID-19 pneumonia
  2. Care for neonates exposed to COVID -19 infected mothers
  3. Infection Control in office in midst of COVID -19 outbreak
  • COVID-19 Management

As pediatricians we are familiar with management of viral infections.  The activity of high impact pediatric cold weather viruses, namely respiratory syncytial virus (RSV) and influenza (flu) is winding down.  RSV season is almost over, with only 1.2% of all the PCR tests during the first week of April. Influenza activity continues to decrease sharply and it is low, only 2.1% during the last week of March.  There is also low activity of late winter and fall viruses such as human metapneumovirus and parainfluenza virus.

This implies that a child presenting with viral symptoms during widespread community transmission of SARS-CoV-2 is most likely to have COVID-19 infection.  Thereby it is of utmost importance that pediatricians who continue to see sick children in the office MUST have full personal protective equipment.  If you cannot safely provide office care then AAP recommend Telehealth visits.

If a child has confirmed or suspected COVID-19 infection based on symptoms (URI, fever, cough, shortness of breath) pediatricians should assess if these patients can be cared at home.  Most of the young children and youth who are otherwise well appearing can stay home.  Respiratory guidance should be provided regarding fever control with acetaminophen and hydration.  If an infant or a child with underlying medical problems (high risk group) or a child is deemed to have moderate to severe diseases i.e. difficulty breathing, they should be sent to emergency room for evaluation.

Hospital Care.

Based on the available hospitalization status in the MMWR summary, 157 children were reported to be hospitalized with 15 admitted to an ICU. Infants less than 1 years of age had the highest percentage (15-62 %) of hospitalization among the pediatric COVID-19 cohort.  All pediatric patients admitted to the ICU had one or more underlying medical conditions.

Children’s hospitals around the nation have adopted clinical pathways and algorithms to assist pediatricians with standardized care.  These guidelines take into account, a) evidence based care recommendations (evolving), b) protection of health care providers with adequate PPE, and c) best possible PPE conservative measures.  I will mention here few significant components of care:

Identification and isolation: Upon entry to the emergency room, any child with fever and/or respiratory symptoms such as cough or difficulty breathing should get a surgical mask.  Triage nurse as well as the healthcare providers providing initial care need to have surgical mask (if N95 is not available), eye protection, gloves and gowns.  If the child has moderate to severe disease or it is anticipated that the child needs an aerosol generating procedure (nebulization, intubation, nasopharyngeal swabbing [can induce coughing]), an N95 mask or PAPR should must be used by the provider in a negative pressure room.

Initial evaluation of suspected cases: Most of the Children’s Hospital have in house polymerase chain reaction (PCR) available now with a turnaround time of 4-6 hours.  Testing can also be done through the New York State Laboratory.  One nasopharyngeal swab should be obtained in children and transported in a viral transport medium.  In addition to COVID-19 testing, as clinically indicated, one should consider screening laboratory assessment with a complete blood count, inflammatory markers to asses cytokine storm (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], pro-calcitonin, ferritin, D-dimers, troponins) and complete metabolic panel. In children with severe presentation or underlying medical problems, consider sending interleukin-6 levels.  If I child has signs or symptoms suggestive of lower respiratory tract infection, a chest x-ray should be performed.

 Decision to send home: If there is no evidence of lower respiratory tract infection and the child does not have hypoxia the child should be sent home.  Instructions should be provided on home isolation, common infection prevention methods at home and quarantine of the household members for 14 days and a follow up visit, preferably a Televisit should be arranged.

Treatment for hospitalized cases:

Mild disease: Children with mild disease without hypoxia should be provided supportive care if the reason for hospitalization is other than COVID-19 infection.  Preferably, these children should be managed at home with Telemedicine/phone follow-ups.

Moderate to severe disease: In children with evidence of lower respiratory tract infection and hypoxia supportive care with oxygen, noninvasive ventilation and invasive ventilation is the mainstay of treatment.

 There exists no robust evidence on treatment options for COVID-19 infection. In the absence of strong literature, in the midst of this outbreak, it is reasonable to use anecdotal reports and weak evidence until better treatment options are available.  With every single case of COVID-19 pneumonia, pediatricians should balance benefit versus risk of treatment.

  • Hydroxychloroquine and azithromycin combination for 5 days: Given in vitro activity of hydroxychloroquine against SARS COV-2 many medical centers including our institution is using hydroxychloroquine and azithromycin combination.  There is a clear lack of robust studies on this regimen at this time.
  • In children with evidence of cytokine storm, as suggested by worsening of lower respiratory tract lung disease coupled with rising inflammatory markers and elevated IL6 levels, an interleukin-6 monoclonal antibody such as tocilizumab should be considered.  Anakinra, an IL 1 blocker has been shown to be beneficial in patients with cytokine storm and is currently being used at some centers.
  • In children less than 18 years of age, with severe disease requiring mechanical ventilation, remdesivir can be obtained from Gilead: https://rdvcu.gilead.com/

Remdesivir is an adenosine analogue, which incorporates into RNA and causes premature termination.  It was shown to be effective in animal models against the previous SARS 1 and MRSA infections.  It can be obtained if you are a clinical site or may be obtained for compassionate use in children less than 18 years of age and pregnant woman.

  • Others: Fever control medication of choice is acetaminophen over ibuprofen until more data on safety of ibuprofen is available.
  • Use caution when using the following medications:
  • Corticosteroids should be avoided, as WHO cited no mortality benefit and delayed viral clearance in SARS-1 infection.  One should refrain its use solely for COVID-19 infection and consider if there are any other reasons such as asthma.
  • Generally we recommend against NSAIDs such as ibuprofen until more data on its safety is available in confirmed or suspected COVID-19 patients.

 

  • Care plan for neonates exposed to COVID-19 mothers

Another challenge faced by pediatricians is regarding care of neonates born to mothers with COVID-19 infection. Neonates are considered vulnerable due to an immature immune system.  As a pediatrician, we strive and advocate for early skin to skin contact and promote benefits of breast feeding.  The concern of infecting neonates has led to a cautious approach until more data is available.

At our institution (unpublished data), about 30% of pregnant woman are COVID positive including asymptomatic mothers. American Academy of Pediatrics has provided guidance regarding this regard. https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.

In summary:

  • When attending delivery, Airborne, Droplet and Contact Precautions should be utilized.
  • Neonates are to be temporarily separated until mother’s symptoms improve (no fevers without antipyretics for at least 72 hours and improving respiratory symptoms) or two negative tests 24 hours apart.
  • In addition, AAP suggests COVID-19 testing in neonates at 24 and 48 hours of life via a single swab, in the oropharynx and nasopharynx.
  • SARS-CoV-2 has not be detected in breast milk. Mother with symptomatic diseases can express breast milk to be fed by infected caregiver.  Asymptomatic mother can breastfeed with good hygiene practice.

As we continue to care for neonates, we will encounter different challenges. COVID-19 is affecting families, thus many worry these babies will get exposed when they return home. Guidance should be provided to keep COVID-19 positive mother/any sick household members and the baby separated in different rooms or have at least a distance of 6 feet. As long as mother has symptoms, she should wear a mask.

  • Infection Control in the Office.

During this outbreak, AAP recommends using Telehealth services to increase practice capacity.  At the same time, well visits for newborns and infant/toddlers/young children requiring immunization can be seen in the office, if able to arrange safely.  Well visits for older children and adolescent can be deferred to a later date.

A few tips for providing safe office care.

  • Have different office times for well visits and sick visits.
  • Have a separate space, if possible, for well visits and sick visits.
  • At entrance, children with a fever, or respiratory symptoms should be given a mask and escorted to a separate room.  All health care providers should wear full PPE. New York State Department of Health provides infection control guidelines for evaluation of patients in outpatient setting: https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-infection-control-outpatient.pdf

 

References:

  1. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. ePub: 6 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e4external icon.
  2. https://www.cdc.gov/surveillance/nrevss/images/rsvstate/RSV14NumCent5AVG_StateNY.htm
Management of COVID-19 pneumonia 
Supportive care, acetaminophen is the preferred antipyretic, avoid steroids unless another indication

Lack of robust evidence for the following:

o   Hydroxychloroquine and azithromycin combination for 5 days

o   If worsening respiratory status along with evidence of cytokine storm:

·       Monoclonal antibody against IL-6: tocilizumab

·       IL1- receptor antagonist: ankinra

o   Remdesivir, an antiviral available through Gilead for children < 18 years and pregnant woman https://rdvcu.gilead.com/


March 2020

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Dear NYS AAP – Chapter 2 Member,

As we all adjust to the changes in our lives brought about by COVID-19, I wanted to update you on what our Chapter, the National American Academy of Pediatrics, and the state and local government have been doing to assist patients and pediatricians during this time.  Like you, we are learning as we go and dealing with an ever-shifting array of regulations in both our personal and professional lives.  However, this is what has been done so far.
  • The New York State Department of Health has created a single website for all information related to COVID-19:  https://www.health.ny.gov/diseases/communicablecoronavirus/providers.htm The website includes medical information for healthcare providers.
  • For more pediatric-specific information, the National AAP has created a web resource for members: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/ and established an email address COVID-19@aap.org for questions related to pediatrics.
  • Dr. Lenny Krilov, Chairman of Pediatrics and New York University Winthrop Hospital at a Pediatric Infectious Disease specialist, recorded a short video about the importance of social distancing and handwashing which is available from multiple sources in Nassau County.
  • Both AAP Chapters 2 and 3 were consulted about the decision and timing of closing New York City Public Schools. Advocacy by senior NYS and Chapter leaders, particularly Drs. Lisa Handwerker (President, NYS AAP – Chapter 3) and Warren Seigel (Chair, NYS AAP District II), helped assure that the city implemented a plan to make school meals available to eligible students prior to closing until April 20th.
  • New York State released a downloadable PDF of a sign to assist triage of patients who enter a healthcare setting and may be exhibiting possible symptoms of COVID-19: https://health.ny.gov/publications/13076.pdf
  • Within hours of the announcement that schools in Nassau and Suffolk County would be closed for 2 weeks, Chapter 2 submitted a list of questions/concerns to the County Legislatures concerning the need to ensure healthcare workers receive priority for childcare and school services. As of this writing, that plan is currently being created.
  • The Chapter has reached out to the Departments of Health of Nassau and Suffolk Counties, and New York City, on behalf of its members in an attempt to secure Personal Protection Equipment (PPE), particularly gowns and N-95 masks – which many private pediatric offices do not stock and are unable to obtain.  All 3 departments have relayed that the shortage of PPE requires prioritizing ERs and hospitals, particularly intensive care units and therefore no other PPE is available.  In fact, conservation of PPE is actively occurring within hospitals due to concerns of a potential future shortage.  That said, all of these departments are aware of the critical role pediatricians will play in assessing the status of children, particularly those with primary caretakers in higher risk groups.
  • New York City recently announced that small businesses may be eligible for no-interest loans or grants if they can demonstrate significant financial losses from COVID-19.  The Chapter is working with officials in New York City to ensure that small pediatric practices which voluntarily reduced well-child visits during the pandemic as a means of reducing community spread are eligible. More information on these programs is available here:https://www1.nyc.gov/site/sbs/businesses/covid19-business-outreach.page
  • As Nassau and Suffolk Counties consider similar programs, the Chapter is working to ensure that small medical practices are also included.
It’s now been another week that we’ve been living and dealing with COVID-19 24 hours a day.  As always, we at the NYS AAP – Chapter 2 are inspired by the efforts of all our pediatric members to keep children safe during this pandemic.
As I reiterated a few weeks ago, I know you are getting deluged with emails, and that hospital regulations are changing (sometimes dramatically) daily.  Keeping up with all the information for yourself and your patients, adapting to new ways to delivering care, and just keeping our families together (and our kids from killing each other) is exhausting.  This is what your local AAP Chapter and the National AAP have been doing:
  • National AAP issued a “CALL TO ACTION” on behalf of pediatricians and other physicians to increase the availability/supply of Personal Protective Equipment (PPE).  The Chapter has partnered with Nassau County’s Office of Emergency Management to assist with distribution of Personal Protective Equipment.  The Chapter has already distributed ~300 masks and other PPE to pediatricians across Long Island.  Through our strong partnership with legislators across New York, the Chapter obtained a small amount of standard (non-N95) facemasks for outpatient, private pediatric practices.  The Chapter has stepped in to distribute about ~100 masks which general pediatricians can use to see children who require in-person visits in the office, thereby reducing the burden on emergency rooms.  Contact Jessica Geslani if you require a portion of this allotment.  Pediatricians that provide care in Nassau can complete the short online form available here: https://app.nassaucountyny.gov/OEM/supply-request/ to request equipment.  As we receive more, we will be distributing it accordingly.
  • The Chapter has also sent letters to all 11 of the Chapter’s federal representatives outlining the dire need for personal protective equipment, faster roll-out of point-of-care testing for COVID-19, a national stay-at-home order, and increased enforcement of current regulations.
  • At the onset of the COVID-19 pandemic, pediatricians in Chapter 2 realized that health plans covered under the Employee Retirement Income Security Act (ERISA) were NOT uniformly paying for telehealth visits, financially impacting pediatricians and reducing healthcare access during a time of public health crisis for up 5-8% of children in our Chapter.  Within TWO WEEKS, Chapter leaders brought this to the attention of Representative Tom Suozzi of New York 3rd Congressional District.  As a member of the powerful House Ways and Means Committee, he was closely involved in reviewing pending COVID legislation. Based on discussions with Chapter 2, Rep. Suozzi urged members of the House Education and Labor Committee to ensure that federal legislation REQUIRED these plans to cover telehealth services for both adults and children. The measure passed into law on March 27, 2020 as part of the “Coronavirus Aid, Relief, and Economic Security Act” or CARES Act. Chapter members should be proud of our role in detecting a loophole in federal policy and working expeditiously to close it in close partnership with our legislators.  Read the letter congratulating our Chapter on influencing national policy.
  • We are in contact with Tanuja Mohapatra of the New York State Department of Financial Services to ensure compliance of state-regulated health plans with telehealth.  If you are denied payment for a telehealth visit during the pandemic, please contact us.
  • Chapter 2 member and Pediatric Pulmonologist Dr. Melodi Pirzada from NYU Winthrop Hospital has answered questions from the public live on News 12 Long Island.
  • Dr. Eve Krief also participated in a “VIRTUAL TOWN HALL” on COVID-19 via Facebook LIVE.
  • Immediate Past President of New York Chapter 2, Dr. Steve Goldstein, made an appearance on MSNBC as one of several physicians calling for increased access to PPE.
  • Through our partnership with State Senator Jim Gaughran, our Chapter was THE STATE LEADER in ensuring that pediatric outpatient offices will qualify for Empire State Development and state Small Business Administration loans in New York. Until we brought this to the state’s attention, there was no consideration given to whether outpatient medical practices (themselves small businesses) would qualify.  Pediatric practices will be treated no differently than any other business and will be able to receive grants/loans based on their number of employees.
  • The Chapter partnered with local Girl Scout Troops and received donations of unsold Girls Scout Cookies which have been delivered to children’s hospitals within the Chapter.
  • We are considering starting a listserv, similar to the popular listserv on the National AAP’s Section on Practice Management, to help area pediatricians dealing with any COVID-19 issues.  If you are interested in having the Chapter pursue this, please contact me or Jessica Geslani at jgeslani@aap.org
  • Don’t forget to read our Pediatric Blog on COVID-19 by Dr. Asif Noor, available at: http://ny2aap.org/category/blog/
  • The NYS DOH’s COVID-19 Weekly Healthcare Provider Update Compilation provides healthcare providers in New York State with a consolidated update of guidance released by the New York State Department of Health (NYSDOH) related to the COVID-19 pandemic response.  Click Here for this week’s update.
  • Raise the Age NY put out a call for help in urging NY Governor Cuomo and NYC Mayor de Blasio to act quickly to reduce the risks to young people and families posed by the COVID-19 pandemic.  Learn more and spread the word by using their social media toolkit.
In the past few weeks, I’ve felt like the world is going crazy and tilting off its axis.  Then I think about the vital role we play in the lives of our patients and families as we show up each day to care for children, all of whom – either directly or indirectly – have been impacted by this virus.  It’s a quick way to rejuvenate yourself before the next encyclopedia of regulations/policies/procedures arrives in your inbox.
As always, if there is anything more the Chapter could be doing to help pediatricians in this demanding time, please do not hesitate to reach out to us.
Sincerely,
Shetal Shah, MD, FAAP
President, NYS AAP – Chapter 2

COVID-19 in New York: What Pediatricians need to know!

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

Folks rumble on Corona
All along from Wuhan to Barcelona
A virus damned for misery and fear
A virus you need to brace as it comes near

The emergence of the new coronavirus aka COVID-19 in New York was inevitable.  As of March 5th, New York State has reported eleven confirmed cases. Nine of them can be linked directly to one particular person residing in Westchester.  This suggests local transmission of COVOID-19 in New York.

I would like to share:

  1. Important facts about COVID-19,
  2. Comparison of COVID -19 versus influenza
  3. Approach to COVID -19 in office setting
  4. Preparedness tips

If you are crunched for time there are a few tables at the end for quick reference.

Background: A novel animal coronavirus launched its spread from the industrial city of Wuhan in China few months ago, in late December 2019.  A cluster of atypical pneumonia cases linked to the Huanan wholesale seafood market in Wuhan prompted the initial investigation. By early January 2020, outbreak was declared as a public health emergency in China. Rapid spread and link to Wuhan during the prime stages of the outbreak in China was dealt with strict quarantine laws. As weeks passed by, cases without link to Wuhan emerged within China. On January 13th the first case outside China was reported.  The following month of February was marked with an alarming situation. The number of new cases of COVID-19 surpassed in countries other than China.  These included imported cases but the worry was local transmission. South Korea, Iran, Italy and Japan currently have the highest COVID-19 counts outside mainland China with evidence of local transmission. Worldwide over 70 countries have confirmed cases and the list keeps on growing daily.

WHO and CDC predict an alarming situation. Travel restrictions, quarantines, hospital preparedness plans are in full swing since late February. Resources are being diverted to manage a catastrophe posed by COVID-19.  Experts are encouraging the need to prepare for a Pandemic!  Every new case is a Breaking News.

So what is this presumed apocalyptic virus? COVID -19’s uncertain potential creates many what’s, when’s and How’s. We need answers and we need them quick! Answers are indeed trickling in. An outpouring of initial evidence from large case series, epidemiological studies and histopathological analysis is now available. PubMed have over 500 articles and numerous expert opinions. At the same time many are trying to extrapolate COVID-19s potential by comparing it to seasonal influenza as well the other 21st century’s novel coronaviruses such as SARS 1 and MERS.

COVID -19: Name and the Virus

Coronavirus disease in 2019 aka COVID 19 is a novel human infecting betacoronavirus (of animal origin). It is similar to the two other bat derived coronaviruses, the 2002 SARS and 2012 MERS virus. SARS 1 hopped over from bats to civet (a small nocturnal mammal) and then to human. MERS virus jumped from bats to camels and then human, this current COVID-19 started with bats with intermediate host Pangolin (a scaly anteater) and then to humans.

The coronavirus is a single stranded RNA virus with crown like spikes over the surface, hence the name coronavirus. These spikes allow attachment to upper respiratory tract epithelium. A spectrum of respiratory illness follows invasion, a pattern seen similar to other high impact viruses. Severity mainly depends upon the host. Symptoms range from asymptomatic state, mild symptoms of upper respiratory tract infection to severe manifestations of pneumonia and respiratory failure (ARDS, septic shock).

Large case series clearly show that COVID-19 has affected disproportionately the elderly and people with underlying medical problems. Children less than 18 years account for only 2 % of the affected group. Majority of these children had mild upper respiratory symptoms. This is in contrast to seasonal influenza where 20 -30 % of infections are in children and the diseases is associated with complication. So far in the 2019-20 influenza season 125 pediatric deaths have been reported!

COVID-19: How does it spread and the incubation period.

It is spread from person to person. Humans are immune naive to this virus. It can be transmitted from person to person in close contact (< 6 feet) through respiratory droplet produced by coughing and sneezing. Transmission is almost always from symptomatic people. There are a few case reports citing presumed asymptomatic carrier transmission however it’s exceptionally infrequent.

The incubation period (interval between exposure and onset of symptoms) is cited to be a median of 5 days (range 1-14 days). Getting this incubation period right is important for purposeful quarantine of asymptomatic individuals. A few anecdotal case reports from China mention incubation period of 27 days but that’s not the standard and asymptomatic individuals will not be responsible for the vast majority of transmission.

COVID-19:  Infection potential and Mortality

In order to estimate impact of this virus, we need to understand two features of COVID 19, its contagiousness and mortality (case fatality rate). Remember these are just approximations and not true predictions.

Potential to spread:  How an infection spreads in a population is measured statistically by a “basic reproduction number”, also called R0. This number will predict how many new people each infected person will end up infecting if the infection is left unchecked.  If R0 is < 1 the infection will typically vanish over time. R0 more than one implies that a sick person can infect one person at least, who will infect others leading to spread. To provide a context, seasonal influenza has an R0 of 1.2, which means every five infected people will transmit it to a new sixth person. In 2019, we were faced with the highly contagious measles outbreak in NY. Measles has an R0 of 12-18 which implies each measles case will spread infection to 12-18 new unvaccinated people.

COVID-19 has an estimated R0 between 1.4 and 4 which is within range for other coronaviruses. Spread is inevitable given lack of vaccine and no herd immunity.

Potential to cause death: Another important aspect is the case fatality rate. The mortality rate of COVID-19 was initially reported as 2.3 %. However, earlier rates was calculated based on cases of pneumonia. As the number of laboratory confirmed cases includes the asymptomatic and minimally symptomatic, the case fatality rate continues to fall. It was revealed to be 1.4 % in 1099 laboratory confirmed cases by Guan et al. This rate is considerably lower than other animal coronaviruses: SARS (9.6 %) and MERS (34 %).

COVID 19: Testing

Common human coronaviruses (HKU1, NL63, 229E, OC43) detected by the widely available respiratory multiplex PCR panel or Film array are responsible for one quarter of common colds during winter months. It does not detect COVID -19.

New York State has the capability to perform real-time polymerase chain reaction assay to identify COVID-19. Large academic centers and commercial laboratories soon will have the ability to run the test.  If you suspect a child potentially can have COVID-19 on basis of exposure, travel to outbreak regions, and a work up is negative for common respiratory pathogens, you should send the test and also call local department of health: NYC (866)-692-3641, Nassau (516) 227-9639 and Suffolk (631) 854-0333 to discuss the potential case.

There is no vaccine, no approved treatment no prophylaxis. There are anecdotal reports on chloroquine, lopinavir/ritonavir use and some success with investigational use of remdesivir for compassionate use.

Undoubtedly, COVID-19 poses a public health threat. It requires a balanced response using appropriate resources to tackle it. An exaggerated response may overwhelm our healthcare and divert resources from where they are needed the most. Being prepared is what we should do. We should refrain at all cost from spreading fear and anxiety.

WHO and CDC predict an alarming situation.  Travel restrictions, quarantines, hospital preparedness plans are in full swing since late February. Resources are being diverted to manage a catastrophe posed by COVID-19.  Experts are encouraging the need to prepare for a Pandemic!  Every new case is Breaking News.

A few tables for your quick references: –

Table 1

COVID-19 versus Influenza
COVID-19 Influenza

Children under 18 have low prevalence (2%)  and mild disease (no pediatric deaths )

Overall mortality is 2.3 % (continues to decline), disproportionately effecting the elderly and those with medical problems

Spread is efficient (estimated R0 is 1.4-4) but containment is possible

No mutations

No vaccine

No standard treatment (only anecdotal and experimental drugs)

Annual influenza prevalence is 20-30 % in children

So far in 2019-20 season there were 125 pediatric deaths in United States alone

Spread is efficient (R0 is 1.3) and containment for seasonal flu is not possible

Mutations (shifts and drifts even in a single season are common)

Vaccine is available

Treatment is available

 

Table 2

Approach to COVID -19 in your pediatric office

1-      Encourage patients with fever and respiratory symptoms (URI, cough, difficulty breathing) to stay home and provide phone/virtual consultation.

2-      If symptomatic patients have mild symptoms returning from China, South Korea, Italy , Japan and Iran, inform to self-quarantine for 14 days. The list of countries with widespread sustained transmission is expected to grow

3-      If a symptomatic patient needs to be seen. Inquire about exposure to a person with known COVID-19 or travel to a region with high local transmission (China, South Korea, Japan, Italy, and Iran). If positive, provide masks upon arriving to the office and escort them into a separate room. Providers should use appropriate personal protective equipment (surgical mask with eye protection at least).

4-      Call your respective local health department.

 

Table 3

Tips for patients and families

1-      Wash hands frequently

2-      Wash hands before touching your face

3-      Buy hand sanitizers instead of masks (masks if incorrectly used can increase risk of infection)

4-      Get your flu shot, it’s not too late.

5-      Prepare in case you need to stay home if there is a community wide isolation.  It will be wise to stock food, water and essential supplies.


Viewpoint: Get vaccine information from reliable sources

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and Chair of the NYS AAP Chapter 2 Legislative Advocacy Committee.

  Dr. Shetal Shah, MD, FAAP is a neonatologist at Maria Fareri Children’s Hospital.  He is NYS AAP Chapter 2 President. 

This op-ed was published on timesunion.com on February 26, 2020.)

 

Pediatricians across New York are concerned about the spread of misinformation regarding vaccination against human papilloma virus.

A proposed bill in the state Legislature would require HPV vaccination for middle school students.  Though there has been significant uproar about this bill raised at school board meetings and across social media, the bill is not new and has been proposed annually for several years.  Like thousands of other bills in the Legislature, the proposal has never been deliberated.

The very existence of the bill, however, has been seized upon by the anti-vaccine community, which has spread a tremendous amount of false information and needless apprehension about the vaccine and about the likelihood of this bill being considered by the Legislature.  The ultimate intention is likely to nurture opposition to existing vaccine laws that keep children safe and to gain allies for their position against the law that disallowed religious exemptions to vaccination.

Passed last June amidst the worst measles epidemic in decades, that law allows only legitimate medical exemptions to school vaccination requirements.  The measure was supported by more than 25 medical and public health organizations.  Polling last year found 87 percent of New Yorkers supported the law, which allows children and teachers with conditions like cancer to attend school without fear of contracting a potentially fatal disease from an unvaccinated student.

HPV vaccination is safe and effective.  HPV is the most common STD in the U.S.  Approximately 34,000 HPV-associated cancers occur yearly.  The HPV vaccine prevents 90 percent of these cancers.  Contrary to what parents might read on social media, side effects are mild, and pale in comparison to treatment for the types of cancer prevented by immunization.

The decision to vaccinate against HPV should be made after discussion with your child’s pediatrician.  As the virus is not transmissible in the school setting, we don’t necessarily believe it needs to be a mandated requirement for school attendance.  However, we very strongly recommend parents vaccinate their children against HPV to protect their future health.  We encourage parents to get their information regarding vaccination from pediatricians and from reliable sources, including the Centers for Disease Control and the American Academy of Pediatrics.

LARC in Adolescents

Khalida Itriyeva, MD, FAAP

Khalida Itriyeva, MD, FAAP

(Dr. Khalida Itriyeva, MD, FAAP is adolescent specialist at Cohen Children’s Medical Center.  She is a NYS AAP Chapter 2 Youth and Adolescence Committee Member.)

Use of Long-Acting Reversible Contraceptives (LARC) in Adolescents

The American Academy of Pediatrics (AAP) encourages pediatricians to familiarize themselves with, and to counsel adolescent patients on, all methods of contraception including LARCs.  LARCs represent the most effective methods of birth control, with efficacy rates greater than 99 percent.  As they are not user dependent and do not require patients to remember to take them, they are more effective than short-acting contraceptive methods, such as the oral contraceptive pill, transdermal patch, and vaginal ring.

LARCs include two types of contraceptives: the subdermal implant, which is placed under the skin of the non-dominant upper inner arm, and the intrauterine device (IUD).  The subdermal implant currently available in the United States is the Nexplanon®, containing the progestin etonogestrel.  Pediatric providers may learn to insert and remove the device by completing the mandatory training course offered by the manufacturer.  Insertion of the implantis a 5-10 minute outpatient office procedure performed under local anesthesia.  The implant is approved by the Food and Drug Administration (FDA) for 3 years of use, although recent studies have demonstrated extended use efficacy (off-label) for up to 5 years of use.  The most common side effect of the subdermal implant is irregular menstrual bleeding, which is also the most common reason for discontinuation of the implant among users.

The second LARC method is the IUD.  There are two types of IUDs currently available: the copper IUD (Paragard®) and 4 hormonal IUDs containing varying amounts of the progestin levonorgestrel (Mirena®, Liletta®, Kyleena®, and Skyla®).  IUD insertions require provider training and are performed in the outpatient office setting.  Duration of use varies among the different types of IUDs, from 3 years (Skyla®) to 10 years (Paragard®).  Common side effects of the IUD include irregular bleeding and cramping during the first several months after insertion.  Paragard may also result in heavier, longer, and more painful menses.  Menstrual bleeding with Mirena and Lilettatypically decreases over time, and many women will ultimately experience amenorrhea.  Women who choose the Kyleena and Skyla IUDs may continue to experience monthly periods or irregular spotting, as they contain smaller amounts of levonorgestrel.  An added benefit of the copper IUD is that it can be used as emergency contraception for up to 5 days after unprotected sex, and it is the only non-hormonal IUD available, for women who would prefer a hormone-free birth control method.

Despite the myths surrounding the safety of IUDs for adolescents, studies have shown that IUDs are safe, highly effective methods of contraception for teenagers.  IUDs may be inserted without technical difficulty in most nulliparous women and adolescents.  Adolescents may be screened for sexually transmitted infections (STIs) at the time of IUD insertion and are not required to have a separate visit for STI screening or a pelvic exam prior to their IUD insertion.  IUDs can be placed at any time during the menstrual cycle as long as pregnancy can be reasonably excluded.  Modern IUDs do not cause ectopic pregnancy, pelvic inflammatory disease (PID), or infertility.  The risk of PID is only increased during the first 3 weeks after IUD insertion, and is likely due to the insertion procedure and not the device itself.  As pregnancy is a very rare occurrence with IUDs, in the unlikely event that a woman becomes pregnant with an IUD in place, there may be a greater likelihood of ectopic pregnancy.

There are few conditions that are contraindications to the use of LARCs in adolescents.  These conditions are summarized in the U.S Medical Eligibility for Contraceptive Use, referenced below.  Most adolescents can safely use the LARC methods and pediatric providers should familiarize themselves with these methods in order to provide comprehensive, objective, fact-based, patient-centered contraceptive counseling to their patients.

References:

  • Committee on Adolescence.  Contraception for adolescents.  Pediatrics.  2014 Oct;134(4):e1244-56. doi: 10.1542/peds.2014-2299.
  • Curtis KM et al.  U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.  MMWR Recomm Rep.  2016 Jul 29;65(3):1-103. doi: 10.15585/mmwr.rr6503a1.

Making Sure Every Child Counts in the 2020 Census

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

(Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and member of the NYS AAP Chapter 2 Immigration and Legislative Advocacy Committees.)

Dr. Eve Meltzer Krief calls on pediatricians in this AAP Voices article to help make sure Every Child Counts in the 2020 census so communities receive funding for child-health programs that many patients rely on.  Follow her on Twitter at @eveamk.


 

Screening for Postpartum Depression and Anxiety: A Perfect Pediatric Opportunity!

Jack Levine, MD, FAAP

Jack Levine, MD, FAAP

Dr. Levine is a pediatrician at Kew Gardens Hills Pediatrics and an Executive Committee member of the National AAP Section on Developmental Behavioral Pediatrics. 

Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.
One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2019 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.
2020 is the perfect time to begin screening for postpartum depression in the pediatric primary care setting! The American Academy of Pediatrics (AAP) recently published an extensive and comprehensive policy on “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice.” According to the AAP, pediatric providers can use CPT code 96161 and bill with the infant’s visit. New York State Medicaid billing guidance can be found at https://www.health.ny.gov/health_care/medicaid/program/update/2016/aug16_mu.pdf. Pediatric providers see new mothers earlier and more frequently than other physicians, giving multiple opportunities to assess and screen parental mental health.
Perinatal Mood and Anxiety Disorders: Different Terminology
Anxiety is a common characteristic of mothers’ feelings both during and after pregnancy and is very common in postpartum depression. Additionally, depression can effect up to 20% of pregnant woman. Along with “baby blues” and postpartum depression and anxiety disorders there is also psychosis, obsessive-compulsive disorder and PTSD. Fathers may also develop postpartum depression.
Why screen?
Postpartum depression is common (8%-25%) and in some low income populations may include close to 50% of all new mothers! It is the most common cause of infant toxic stress in the United States. There are significant and highly detrimental effects to developing infants (Table 1). Screening helps assess the baby’s environment and to establish a positive helpful relationship with the family.
Table 1. Effects of Postpartum Depression on Infants
Decreased breastfeeding
Failure to thrive
Developmental delay
  • Cognitive deficits
  • Less language stimulation
  • Less play time
  • Less reading stimulation
  • Less engagement with mother
School problems
Sleep problems
Mental health concerns
  • Social withdrawal
  • Fussy, irritable
  • Poor self control, impulsivity
  • Anxiety/depression
  • Attachment disorders
  • Aggression
Poor safety: car seats, plug covers, sleep
Over/under use of health care and ER
Difficulty managing health conditions
What to ask at every visit?
Assessing the risk factors for postpartum depression should be part of every well visit (Table 2). Maternal history of mood disorders and/or anxiety is an important risk factor and should be carefully assessed. Discontinuation of anti-depressant medication during pregnancy is a particularly important risk factor.
Table 2. Risk Factors for Postpartum Depression
Psychosocial Risk Factors
  • Poverty
  • Maternal chronic illness
  • History of depression, anxiety, mood disorder, substance abuse
  • Adolescent pregnancy
  • Social isolation
  • Stressful life events, miscarriage
Infant behavior
  • Decreased activity
  • Increased crying
  • Poor feeding
  • Failure to thrive
  • Sleeping problems
  • Increased accidents
Maternal behavior (observed or expressed by mother, father, grandparents)
  • Depressed affect
  • Sleeping more or trouble sleeping
  • Lack of enjoyment of usual activities/avoidance of usual activities
  • Withdrawal from family
  • Neglect of newborn or other children
  • Questions reflecting self-doubt/ severe anxiety
  • Inaccurate expectations of behavior and/or development
  • Punitive child rearing attitudes or discipline
  • Irritable/disruptive in office/frequent visits
Infant risk factors
  • Prematurity
  • Congenital problems
  • “Vulnerable child” syndrome
  • Fussy temperament
When to screen and what tools are available? 
Depressive symptoms peak at 6 weeks, 2-3 months and 6 months.  “Baby blues” usually resolve by two weeks so that earlier screening may over identify, but post-partum depressive symptoms can be delayed or persist for up to one year or longer!  Screening at one month, 2 months, 4 months and 6 months is recommended in the new AAP policy. Additional screening at 2 weeks and one year can be added. The Patient Health Questionnaire (PHQ-2, PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS) are commonly used, readily available, well researched, easy to administer, free, and have been translated into many languages (See References).
The EDPS has 10 questions and includes both anxiety and suicidal intent. The PHQ-2 is brief and contains only two questions. The PHQ-9 (which also includes suicidal intent but not anxiety) can be given alone or with the PHQ-2 to determine the extent of depression. The Survey of Well-Being of Young Children (SWYC) is a screening instrument that assesses a broad range of issues including maternal depression (PHQ-2 and EPDS), other family risk factors and child development and behavior.
Remember: Whenever inquiring about postpartum depression there must be a determination of suicide intent and safety of the mother and infant.
What are available resources?
Treatment for postpartum depression must include both treatment for the mother and the mother-infant dyad. Reassurance and parent education can be provided along with specific referrals. Medication is usually not needed but can be provided by obstetricians, internists or psychiatric providers. A pediatric office should have plans available for the rare event of emergency referral (911) or in case of safety issues.
Providers can use Project TEACH’s Maternal Mental Health Initiative (MMHI) – https://projectteachny.org/mmh/ for direct access to expert psychiatrists in maternal mental health, and for assistance with linkages to care and supports in the community. You can also access training – including two online trainings, “Diagnosis and Treatment of Depression during Pregnancy” and “Screening and Treatment of Postpartum Depression.”
Resource material, like the flyer shown here, and guidance for both providers and parents are available through the Postpartum Resource Center of NY www.postpartumny.org and Postpartum Support International www.postpartum.net. Resource material should be available for immediate referrals. Appointments should be confirmed in the pediatric office and frequent follow-up provided. Early treatment results in the best outcomes for mother and baby and should be obtained as quickly as possible (within a day or two).
Identifying and treating postpartum depression are effective ways to ensure optimal early infant brain development – which is after all, why we all do what we do!
References:
  1. Earls MF, Yogman MW, Mattson G, et al; AAP Committee on Psychosocial Aspects of Child and Family Health. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183259PHQ-2
  2. S. Kurtz, J Levine, M. Safyer. Ask the Question: Screening for Postpartum Mood and Anxiety Disorders in Pediatric Primary Care. Curr Probl Pediatr Adolesc Health Care. 2017: 47(10) 241-253.
  3. PHQ-2 download: https://brightfutures.aap.org/Bright%20Futures%20Documents/PHQ-2%20Questionnaire.pdf
  4. PHQ-2 scoring: https://brightfutures.aap.org/Bright%20Futures%20Documents/PHQ-2%20Instructions%20for%20Use.pdf
  5. PHQ-9 download: https://projectteachny.org/wp-content/uploads/2017/09/phq9_adult.pdf  
  6. Edinburgh Postnatal Depression Scale download: https://projectteachny.org/wp-content/uploads/2017/09/Edinburgh_Postnatal_Depression_Scale.pdf
  7. Survey of Well-Being of Young Children: https://www.floatinghospital.org/the-survey-of-wellbeing-of-young-children/overview