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E-Cigarette Chapter Champion

Sara Siddiqui, MD, FAAP

Sara Siddiqui, MD, FAAP

E-Cig Chapter Champion

Sara Siddiqui MD, FAAP is pediatrician in Huntington.  She is Co-chair of the Legislative Advocacy Committee and Chapter Champion for Vaping Awareness and Cessation for NYS AAP Chapter 2.

If you have or take care of children above the age of ten, I can rightly say that they have been exposed to one of the many Electronic Nicotine Delivery Systems (ENDS).  As we know, nicotine in ENDS products can be extremely addicting to those that are initially exposed under the age of 26.  Nicotine salts found in ENDS products have an increased bioavailability in the adolescent brain.  It can lead to addiction, anxiety, depression along with rapid heart rate, rise in blood pressure, headaches and irritability (1).

As a pediatrician and a mom, I have seen the professional and personal impacts of exposure to ENDS products.  I first learned of the concept of electronic cigarettes from my son, a freshman in high school in 2014.  Since then, I have been involved in schools, educational forums for parents, and legislation to remove availability of ENDS products, from the hands of those under twenty-one.  I was honored to be the Chapter Champion for Vaping Awareness and Cessation for New York AAP Chapter 2.  We have meetings and educational seminars with other pediatricians then share with our respective chapters.  I have exchanged ideas and met some great people within our group.  Two main objectives I had for my own chapter were to increase resources for helping adolescents to quit nicotine, and helping to promote alternatives to suspension for those adolescents found to be vaping in schools.  As pediatricians, we are the first line when our patients disclose a history of vaping.   A teen or young adult may need Nicotine Replacement Therapy (NRT) to successfully quit.  All pediatricians should be comfortable in prescribing NRT.  The New York State Quitline is one resource I have found to be of great assistance by using programs which include a quit coach, online resources and a Text to Quit® program.  As a member of the NYS Quitline Healthcare Task Force, I was invited to participate in a recent webinar entitled “Addressing Nicotine and Tobacco use in Youth and Young Adults”, which also included resources for pediatricians and parents to aid in prevention and quitting.

The Clear the Vapor 2022 conference, a fabulous online event put together by Parents Against Vaping E-cigarettes (PAVe), included a session I was asked to moderate.  Four delightful adolescents and young adults shared their heartbreaking stories about nicotine addiction and ultimately a successful path to quitting.  It was an eye-opener as to how easy it is for our youth to not only obtain vaping products but to become unknowingly addicted.

When children are addicted, they need to be led towards ways to help them quit with multiple areas of support.  Children who get caught vaping in school are likely exhibiting signs of addiction.  Tobacco Prevention Toolkit at Stanford Medicine has developed evidence-based interventions for teachers and administrators starting at the elementary school level to start pathways to encourage rehabilitation and resources for quitting, along with learning modules to prevent starting.  I am proud to be the New York AAP Chapter 2 Champion for Vaping Awareness and Cessation.  I am hopeful to continue helping to increase awareness of the dangers of ENDS products in children and help our young people avoid starting usage of ENDS products — a journey I will continue for as long as I can!

Reference:

  1. “Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults,” https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

Gun Violence

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Lois Lee, MD, MPH, FAAP

Lois Lee, MD, MPH, FAAP

Shetal Shah MD, FAAP is neonatologist at Maria Fareri Children’s Hospital and Immediate Past President of the NYS AAP-Chapter 2.  He is the Chair of the Pediatric Policy Council. 

Lois Lee, MD, MPH, FAAP, is a pediatric emergency medicine physician, member of the Pediatric Policy Council and co-editor of the book, “Pediatric Firearm Injuries and Fatalities: The Clinician’s Guide to Policies and Approaches to Firearm Harm Prevention.”  This op-ed was published in Tampa Bay Times on June 2, 2022.

After Uvalde, we should agree on these 3 things to stem gun violence against kids.  This is a public health issue, and we must treat it — and fund it — as such.

We grieve with the mothers, fathers, loved ones and the community of the 19 children and two adults gunned down in the school shooting in Uvalde, Texas.  As pediatricians who’ve dedicated almost three decades of education — and our entire professional career — to keeping children safe, we are outraged to live in a country that has allowed the massacre of elementary school age children to happen again.

In 2012, we vividly remember locking eyes with other parents as we picked up our elementary-school age children after the massacre at Sandy Hook Elementary School.  We recall the school board meetings announcing that forever after, our schools would be locked down for safety — and parents would need security guard escorts directly to the office if picking up a child early.  Coming less than two weeks after the shooting in Buffalo, this latest act of violence has again re-ignited discussion about how best to address America’s epidemic of gun violence.  As physicians and researchers, we urge consensus on three aspects of this issue.

Increase funding for gun violence research

In 2020, gun violence became the leading cause of death for children between 1 and 19 years old — surpassing motor vehicle accidents, cancer and drug overdoses.  According to the Centers for Disease Control and Prevention, 4,368 children and youth died by firearms in 2020.  This represents a 33% increase from 2019.  There were 1,293 (32%) firearm suicides and 2,811 (68%) firearm homicides.  Gun injuries also present a serious health disparity issue.  Black non-Hispanic youth have homicide rates (14.5 per 100,000 youth from birth to 19 years old) 14 times higher than white non-Hispanic youth (0.97 per 100,000 youth from birth to 19 years old).

Regardless of politics, we must invest in more research to better understand how to reduce child firearm injuries and deaths from assaults, homicides, suicides and unintentional shootings.  We must fund pediatric researchers who can identify children most at-risk of firearm injury and death, as well as protective factors.  In the past 3 years, Congress has appropriated only $25 million per year to address the public health issue of gun violence.  In contrast, the National Heart, Lung and Blood Institute, which partially funds research on heart disease, the No. 1 killer of adults, hosts a of budget of $3.8 billion.  This year, President Joe Biden has requested $60 million for funding gun violence prevention research.  This is a small national price to save the lives of children.

State-based solutions are limited

In the aftermath of the Sandy Hook murders, several states passed stricter gun control regulations.  However, those who live in states with tighter gun restrictions can’t be lulled to complacency.  The Buffalo shooter purchased his assault rifle in New York, a state with more restrictive gun laws.  In states with tighter restrictions on the sales, possession and use of firearms, upwards of 75% of guns used in crimes come from other states.  The public must realize limitations on firearm use are only as good as the interstate highway system.  No region of the country can enact meaningful reform alone.  The only true path toward creating policy to reduce the public health impact of gun violence on children runs through Washington, D.C., and must occur nationally.  For this to occur, there must be a reversal of the current polarizing state of politics that deprioritizes our children and public safety.

Public health must be part of this conversation

Whether in an emergency room, operating room or trauma center, every victim of firearm injury becomes a patient.  Physician researchers provide a unique perspective on gun violence, both as the medical responders with firsthand experience treating these patients and their families and by conducting studies to reduce its impact.

Yet in 2018, upon release of a paper reviewing public health strategies to reducing firearm injuries by the American College of Physicians, the National Rifle Association mocked the report.  The NRA warned doctors to “stay in their lane,” and demeaned physicians by calling them “anti-gun,” and “self-important.”  A social media backlash ensued, appropriately called “This is our lane.”  Nonetheless, the message sent by the most prominent pro-firearm advocate group in the nation stigmatized doctors and researchers by labeling their work as politically motivated.  Gun violence is a public health issue, and physicians, public health professionals and researchers must be part of a diverse group of voices that are heard.

Since the Columbine shooting in 1999, more than 550 children and school staff have been killed by guns.  The ripple effects of gun violence have affected an estimated 311,000 additional kids.  But the true emotional and mental health toll on the individuals and communities are unmeasurable.  The pace of these events is accelerating, demanding renewed commitment to protect children and families.  Our children are already forever marked by these events and the resultant active shooter drills they participate in at school.  We can’t just accept that firearm injuries and deaths to our children are inevitable.  We must begin creating solutions by agreeing on these simple, but small, pieces of a larger uniquely American argument.


Take PRIDE in New York

Warren Seigel, MD, FAAP

Warren Seigel, MD, FAAP

(Warren M. Seigel, MD, MBA, FAAP, FSAHM is Chair of Pediatrics and Director of Adolescent Medicine at Coney Island Hospital.  He is the current AAP District II Chair representing New York State.  He was past Secretary/Treasurer of the AAP Executive Committee of the Board of Directors, past AAP District II Vice Chair, past president of the NYS AAP-Chapter 2, and past president of Brooklyn Pediatric Society and New York Regional Society of Adolescent Medicine.)

 It has been over 50 years since the Stonewall Inn uprising in New York City on June 28, 1969, and we commemorate that event by celebrating “Pride Month” every June.

As a society, we’ve made large strides in LGBTQ+ rights over the past 50 years.  As a gay man, there was a time I couldn’t marry, raise children or even be by my partner’s bedside if he were ill.  Now, I happily raise my children and deal with the issues ALL families with teenage kids face.  But I also live in New York, recently ranked by USA Today as the most welcoming state for the LGBTQ+ community.

Despite progress, our LGBTQ+ youth are under attack and we are moving backwards.  The wave of recent anti-LGBTQ+ legislation is widening the gap between states that are inclusive, and those willing to demonize this community and interfere with the doctor-patient relationship.  Despite the scientific evidence that gender-affirming care is of benefit for transgender youth, many legislators seek ways to dictate the practice of medicine!  Our community still faces stigma and trouble accessing health care in many areas across this country.

Recently the attorney general in Texas issued a decision making gender affirming medical treatment for transgender adolescents such as puberty-suppressing hormones illegal.  A directive that was issued requires all licensed professionals “who have direct contact with children” to report any parent who seeks treatment for their transgender child to be reported for child abuse in Texas.  And unfortunately Texas is not alone!  To date, 34 states have introduced almost 150 anti-transgender bills, making gender-affirming care illegal.

It is now harder than ever for pediatricians to care for LGBTQ+ youth.  Despite the overwhelming epidemiologic data that transgender youth experience significantly higher rates of depression, anxiety, suicidal ideation and suicide attempts when they do not receive gender affirming care, legislators continue to seek ways to withhold life-saving gender-affirming care from those who seek it.

The AAP, as well as other leading medical, psychiatric and public health organizations including the American Psychological Association (APA), the Centers for Disease Control and Prevention (CDC), the Society for Adolescent Health and Medicine (SAHM) and the American Medical Association (AMA) all support young people’s access to safe, inclusive and competent health care.  Actions by politicians to spread misinformation, disinformation and fear cannot be tolerated.  Their attacks target an already marginalized group of children and allow them to substitute politics for expert, consensus, and evidenced-based medicine.

As an adolescent medicine physician, my practice is based on helping children navigate the complexities of realizing their sexual identify, and when appropriate – providing for them the care that is required so their internal and external identities match.  They are in my exam rooms talking about depression, self-harm, crippling anxiety and inability to sleep.  The reward in helping to turn my patient’s despair into hope and eventually joy is – like all of us – the driving reason I went into pediatrics.

Thanks to many years of hard work and advocacy by people since the Stonewall Riots, here in New York LGBTQ+ individuals have legal protections.  In 2019, the Human Rights Law was amended to explicitly include gender identity and gender expression as a protected category making discrimination on the basis of gender identity or expression illegal.  But we cannot grow complacent and think of this as an “other state” problem.

We must work hard to protect LGBTQ+ rights here in New York and throughout the country.  If we take these protections for granted, we will lose them.  As pediatricians, we are at our best when we raise our collective voice on behalf of our patients.  We must help every child, adolescent and young adult receive access to competent medical care, and achieve their fullest potential.

We cannot forget the lessons learned from the Stonewall Riots of 1969.


From Jogger to Plogger

Steven Goldstein, MD, FAAP

Steven Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP is a general pediatrician in Queens and Climate Heath Organizing Fellow at the Center for Health Equity Education and Advocacy (CHEEA).  He is AAP Chapter Climate Advocate for District II and Chair of NYS AAP-Chapter 2 Committee on Environmental Health and Climate Change.  He is past president of the NYS AAP-Chapter 2.

“Plans to protect air and water, wilderness and wildlife are in fact plans to protect man.”
– Stewart Udall
, former US Secretary of the Interior

I spend a lot of time walking with my dog Bella and those walks help keep us both fit and grounded.  When I was younger, I was an avid jogger, but injury and time have slowed my pace to walker and hiker.

As I walk around the neighborhood it is striking that there is so much litter and debris in our streets, and in common areas.  This is a quality of life issue and the litter is not only hard on the eyes but also on the environment and ultimately on our health and that of other species.

Much of the litter I see comes from uncovered trashcans that gets blown around, but if you spend some time on the roadways you will see much thrown from vehicles and by people on the street.  Litter seems to attract more, and in areas with an abundance, it seems that people in the vicinity don’t care, so more is deposited.  A lot of litter in our neighborhood is pandemic related.  There are used masks and gloves everywhere.  Less people smoke cigarettes now, but you see vaping canisters in abundance instead of butts and used packs.  This refuse ends up in our waterways, and often wends its way into bays and the ocean, poisoning or choking sea life, and may end up in the food chain. Plastics rings often strangle birds and can choke other animals.

It is interesting that in Japan, one rarely sees a trash can.  The train stations and streets are spotless.  Everyone holds their trash and disposes of it properly.  We need to make it unacceptable to litter here as well.

In the meantime, on my walks, I have become a plogger.  Plogging is a portmanteau word and what follows is an explanation of what it is and how to do it from the technology site BGR India:

Plogging means pick up and run.  Here, you pick up any trash you see on your way, put it in a trash bag, and run.  Sweden has people running with trash bags, and it’s slowly catching up globally.  Called Plogging, the Swedish word is formed by combining ‘pick up’ and ‘run.’  And with the new trend, trash bags are what people are picking up and running.  You see trash on your way, you pick it up.  In all, it’s good for your body, good for your mind and good for the environment around you.  Though it started off with Sweden, it is catching up all around the world.  Instagram is buzzing with the new plogging hashtag.  If you look it up, you can see ploggers from all over the world sharing their routes, and their trash bags.

Terry Swearingen, winner of the Goldman Environmental Prize for her work on dioxin and heavy metal emissions, said this: “We are living on this planet as if we had another one to go to.”  I would argue that things haven’t changed much since she made this statement in 1997.  We can make a small contribution to change that.

I invite you to carry a trash bag on your walks and help improve our environment, make litter unacceptable, and the neighborhood more beautiful.


Time is Running Out for Critical Children’s Programs

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

DeWayne Pursley, MD, MPH, FAAP

DeWayne Pursley, MD, MPH, FAAP

Shetal Shah MD, FAAP is neonatologist at Maria Fareri Children’s Hospital and Immediate Past President of the NYS AAP-Chapter 2.  He is Chair of the Pediatric Policy Council.  DeWayne Pursley, MD, MPH, FAAP is Chief of Neonatology and Director of the Slarman Family Neonatal Intensive Care Unit at Beth Israel Deaconess Medical Center.  He is a member of the Pediatric Policy Council.  This op-ed was published in Tampa Bay Times on March 8, 2022.

Time is Running Out for Critical Children’s Programs

The clock is ticking for children.  Time runs out this Friday, which is when the short-term spending bill keeping the federal government open expires.  As Congress finalizes funding proposals for federal agencies and programs, we urge lawmakers to make strong investments that support the health and well being of our nation’s children, such as opportunities to improve access to health care, help find cures for pediatric cancers, and prevent gun violence.

Children’s hospitals train half of America’s pediatricians, and the significant expense of funding pediatric training has been supported by the federal Children’s Hospital Graduate Medical Education Program.  Unlike a similar Medicare program for physician training, when adjusted for inflation and the number of pediatricians-in-training, financial support of this essential program has decreased over the past two decades.

In our country, there already are significant areas of child health physician shortages, particularly in rural areas.  The pandemic made clear the devastating consequences for patients when doctors are in short supply. For some parents, failing to support children’s hospitals potentially means no doctor for their child, no one to call when their infant has a high fever, and no one to evaluate their baby’s heart murmur.  Congress cannot miss the opportunity to fund this program.

Access to subspecialty pediatricians – doctors specially trained in treating children with complex health care needs – is also faltering.  Unlike adult specialists, many pediatric specialists earn less than their generalist colleagues.  This means fewer pediatricians, who average more than $200,000 in medical education debt, pursue such careers.  The result is long wait times, especially for children who need infectious disease, developmental-behavioral, or psychiatric specialists.  Nationally, the average wait time for a child with a suspected autism diagnosis is four months, which means a toddler could spend almost 20 percent of his lifetime waiting to be seen after their primary doctor suspects the diagnosis.

Congress has the critical opportunity to address these shortages through funding the Pediatric Subspecialty Loan Repayment Program.  This program will help bolster the pediatric workforce and ensure that children can receive the specialized care they need when they need it.

It is also important that Congress funds research that supports and promotes child health.  For instance, the National Institutes of Health plays a pivotal role in investigating cures and treatments for pediatric diseases.  In fact, the patients who we care for are born premature and critically-ill newborns, and much of the care we provide has been informed by NIH-funded research.

Research funding can also help prevent firearm injuries.  At the onset of the pandemic, unintended guns deaths increased 31 percent, according to Everytown for Gun Safety, the largest gun violence prevention organization in the country.  And those increases came on top of gun deaths that were already far too high.  For example, in 2016, the New England Journal of Medicine reported that 3,143 children died from firearm-related injuries, including homicide and suicide.

Researchers at the National Institutes of Health and Centers for Disease Control and Prevention are now investigating the safest ways to prevent firearm injuries by identifying children at highest risk, studying what gun safety measures are most effective, and even how to best treat children in the event of a shooting.  Congress must continue to show its strong support for this research so that we can end preventable deaths caused by gun violence.

Together, we call on lawmakers to put the needs of children first and invest in programs that will help children to thrive.  With the Friday deadline quickly approaching, the time to act is now.


Build Back Better is a Child Health Bill in Disguise

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Dr. Shetal Shah MD, FAAP is neonatologist at Maria Fareri Children’s Hospital and Immediate Past President of the NYS AAP-Chapter 2.  He is Chair of the Pediatric Policy Council.  This op-ed was published in Tampa Bay Times on December 28, 2021.

Build Back Better is a Child Health Bill in Disguise

The recent setback to the Senate’s consideration of President Joe Biden’s Build Back Better Plan is a major loss for America’s children.  As pediatricians, we see the social spending proposal for what it really is: a child health bill.  While reluctance to support the measure imperils the overall plan, parents, grandparents, teachers and those who care about children’s well-being should hope the individual and uncontroversial, child-friendly aspects of the bill receive strong legislative support.

Lacking health insurance is a major reason children become sicker than necessary.  Countless times, I’ve seen children come to the emergency room simply because they are uninsured and waited until a small cut became a massive, infected wound or an annoying cough became a major asthma attack now requiring intensive care.  The Build Back Better Plan would make the Children’s Health Insurance Program (CHIP) permanent – preventing 9.6 million kids from losing health coverage and eliminating the need for Congress to haggle periodically over reauthorizing a critical child health insurance program.

The plan also continues coverage for children in Medicaid and CHIP for a full year, so children can see a doctor through the first 12 months of life, a time when children develop rapidly and also receive most standard vaccinations, along with preventive health tests like lead screening.  This would be especially helpful in Florida, which has roughly 330,000 uninsured children.

It also means parents will not got to a pharmacy and be denied lifesaving medicine like insulin for their first year because they didn’t navigate the tortuous, bureaucratic process of reauthorizing their children’s health insurance.  If you think that’s easy, I have personally helped patients through the process, and it takes a doctor, care coordinator and social worker hours on the phone to simply renew insurance for which our patients were already eligible.

The proposal would also fix loopholes in health insurance for new mothers by extending Medicaid coverage to low-income women for a year after birth, instead of the usual 60 days.  Since this cost is shared with states, this extension is an inexpensive way to increase rates of breastfeeding- which benefits mothers and babies – reduce maternal smoking and provide access to contraception.

It will also save mothers’ lives.  Among developed countries the U.S. has the highest rates of maternal mortality.  New moms in the United States die at double the rate of French moms and triple the rate of Australian mothers.  If enacted, this fix to Medicaid would reduce Florida’s rate of maternal death from 22 to 15 per 100,000.

Other bipartisan programs include historic investments in pre-K, childcare and school nutrition programs.  Federal and state support for Pre-K program would provide financial relief for millions of families, allow both parents to continue to participate in the workforce and provide the early education pivotal to later school success.  The brain achieves 90% of its growth in the first 6 years and early education improves comprehension, memory, emotional regulation, information processing and language.

For more than a decade, less than half of children born into low-income families had access to Pre-K, creating a generation of educationally-disadvantaged early learners.  Investments in early child education yield 2-10 times the cost savings through adulthood.  The preterm infants we care for, all have under-developed brains and would all benefit from Pre-K, but for too many of my babies’ parents, it’s unaffordable, compounding the handicaps these infants will face across child and early adulthood.

Growing childhood brains takes nutrition and energy.  Children simply cannot learn if they are hungry.  The pandemic has sharpened the national focus on child food insecurity, and aspects of the Build Back Better plan provide long-sought after bolsters to school nutrition programs.  Pediatricians know school meal programs, like free breakfast and lunch are a lifeline for low-income students and families.  But every summer, we look out for “summer hunger” cause by disconnecting these kids from those meals.  Enhancing grocery benefits for families who qualify for these meals would prevent kids from going hungry from June to September.  The bill also allows states to give free meals to all students in high-risk areas, reducing the stigma of free school meals and unburdening school districts of the need of qualifying each individual student and allowing them to spend those resource directly on education.

While other key supports for children such as tax credits and paid family leave are hotly deliberated, we should not miss the bipartisan opportunities to make historic leaps for children.  These programs should not be collateral damage to contested debates on these policies.

Congress has asked for more time to debate the overall measure, but the kids cannot wait.


ACES: Dynamic Developmental Disruptors

Richard Honigman, MD, FAAP

Richard Honigman, MD, FAAP

(Richard Honigman, MD, FAAP is a pediatrician in Levittown.  Dr. Honigman is Chair of NYS AAP-Chapter 2 Developmental/Behavioral Pediatrics/Children with Disabilities Committee.  He is the Chair of Research and Education Team at Reach Within (based in Grenada).  This article was published online in PREE Views 3: ACES and Caribbean Children)

The initial Adverse Childhood Experiences (ACEs) Study published in 1998 correlated 10 instances of early life adversity to poor adult life outcomes.  The instances were physical, emotional, and sexual abuse; physical and emotional neglect; and household dysfunction: growing up in a home with a member incarcerated, a member with mental illness, a member with substance use problems, parental separation, or where there was domestic violence.

Results indicated that ACEs tended to occur in clusters – experiencing one type makes experiencing other types more likely – and that an increase in ACEs correlated with poorer physical, behavioural and social outcomes.  How or by what mechanism(s) these findings occur within the individual has not been fully elucidated.  Taking an approach that views ACEs and toxic stress as parts of an overall dynamic developmental disruption may shed some clarity on the processes, as it appears that after experiencing a certain threshold of adversity the child’s developmental trajectory is negatively altered.

The foundational base for a growing child’s dynamic developmental life is shaped through meaning-making interactions with its environments and caregivers. Past experiences become the templates through which ongoing present and future interactions are interpreted.  These repeated meaning-making processes constantly remodel body structures (such as the developing brain), sculpt or refine the functioning of these structures (i.e. regulatory systems), and influence how the child relates to changes in its internal and external environments.  This is especially significant in early childhood when new relationships, functional connections, networks, systems, capacities and capabilities rapidly emerge.  Typically, during early life, it is the primary caregivers who form the first extra-uterine interactive environment from which the new-born gains developmental and regulatory directives and perspectives.  It is here where nature and nurture begin their ongoing reciprocal interactions.

One can therefore appreciate how important the quality of early childhood relationships with primary caregivers are for the present and future life of the growing child.

Daily repetitive caregiver and environmental encounters shape the child’s present and future regulatory capacities and capabilities, especially as newer hierarchically defined brain regions fully emerge and mature.  These complex structures and their functions are woven into the child’s previously defined interpretive templates and go on to influence further sequential development.  Over time, as the child encounters new people and environments, more complex bio-psycho-social realms coalesce and form the basis for the child’s view of him/herself, the world around them, and  their place in it.  The nature and quality of the child’s experiences can either reinforce or modify previous positive or disruptive meaning-making encounters.

It is well-known that safe, loving, secure relationships improve both short- and long-term bio-psycho-social outcomes.  These relationships that provide positive, predictable, rewarding interactions strengthen the child’s relational ties, buffer the child against major stressors and reinforce the child’s evolving ability to regulate emotions.  These factors facilitate complex emotional and cognitive growth and decreased survival-based (fight, flight, freeze) functioning.  As a result, the child’s systems orientate towards experiencing positive social engagements and gaining agency in adapting to changes with minor stressful episodes.

A child who is exposed to dysfunctional early relationships and environments is more likely to manifest poor physical, behavioural and social-emotional outcomes.  Due to the unsafe nature of these early environments, there is a fracturing of the foundational needs of the child to be protected and nurtured. Its world becomes unsafe and unpredictable, often with no one to relieve its distress.  New environments and relationships are to be avoided. The child feels helpless to effect change in its environment and its ability to relate to or reason with others in a healthy manner is compromised.  Ongoing bio-psycho-social development is impaired as the child anticipates future adverse experiences.  Over time, defensive regulatory systems become hyper-aroused and difficult to down-regulate, resulting in deleterious side effects including chronic illness and even premature death.

For the child whose development has been impaired by past adverse experiences, its hyperacute defensive survival reactions take precedence.  As a consequence, the child’s ability to integrate and utilize higher cortical functioning is compromised.  For example, the affected child becomes hypervigilant to minor changes in its surroundings, the rigours of school (sitting still, focusing, following directions, relating to others) may become too demanding and difficult, leading to academic underachievement. Many of these children are misdiagnosed with attention deficit disorder and various intellectual disabilities due to a lack of informed approaches to recognizing symptoms of childhood adversity. Once labelled, they are often treated in ways that further exacerbate their developmental dysfunctions.  If, on the other hand, their challenges are properly recognized and they are placed in environments that promote safety, regulation and healing, the vast majority of them will acquire or regain positive functioning and excel.

Recognizing individual ACEs as parts of a cumulative disruptive process that initiates changes in a child’s life will help us understand many of the challenges our children face.


Children Deserve Every Protection COVID-19 Vaccine Provides

Eve Meltzer-Krief, MD, FAAP

Eve Meltzer-Krief, MD, FAAP

Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington.  Dr. Meltzer-Krief is the NYS AAP-Chapter 2 Treasurer and Co-Chair of the NYS AAP-Chapter 2 Legislative Advocacy Committee.  This op-ed was published in Huntington Now on November 9, 2021.

Last week, I was COVID testing a young child outside my office when a woman driving by shouted at my patient’s mother: “You might want to reconsider getting your child tested – 99.99 percent of children survive COVID!”  As shocking as that unsolicited drive-by intrusion was, it was what she said that has troubled me throughout the pandemic — the statistic I have heard used over and over again to somehow suggest that children don’t deserve to be safely protected from a potentially very serious disease.

While that survival rate is indeed correct, it also means that .01% of children who contract COVID will die.  Of the 6.4 million children who have been infected with COVID in the U.S., that amounts to the 691 pediatric deaths that have been reported (1).  I can assure you that the parents of those that died don’t care about any statistic.

While the hundreds of children who have died from COVID cannot compare in number to the hundreds of thousands of deaths in adults, each one violates the central societal belief that children are not supposed to die.  As a community, we continually implement measures to avoid unnecessary harm and death to children wherever we can, for nothing is more tragic than the death of a child that was preventable.  We require car seats for babies, gates around pools, life jackets on boats, and seat belts in cars.

Vaccination programs are a big part of how public health measures prevent disease, hospitalization and death in children.  All vaccines, including the COVID vaccine for children, undergo a rigorous testing process and are never approved for use unless the benefits definitively outweigh any potential or theoretical risk.  Period.

This vaccine was approved because the risk of your child contracting severe illness from COVID is far greater than the risk of any potential side effects from the vaccine.  To date, there are no serious side effects at all from the COVID vaccine for 5-11 years old.  The trial included 4,600 participants (3,100 vaccine, 1,538 placebo).  Most commonly, children experience only mild tenderness, fatigue or achiness after vaccination (1).

Although most children do fare well if they contract COVID, it is not a benign disease.  Specifically in the 5-11 year old age group there have been 146 deaths.  But it’s not just about mortality.  8,300 children in that age group have been hospitalized (1).  Almost 1/3 of those children require intensive care treatment and 30% of hospitalized children have no underlying medical condition (2).  When there is an underlying condition, it’s most often obesity or asthma which are common in children.

More concerning, pediatric hospitalizations are rising. vThe more transmissible delta strain led to a five-fold increase in hospital admissions among children just over the course of last summer (3).  Children between the ages of 6-11 have had the highest incidence of cases of Multi System Inflammatory Syndrome of Children (MIS-C).  Seen several weeks after initial infection, MIS-C can affect multiple organs and has occurred in over 5,000 children, leading to 48 deaths (4).  Children can also experience long COVID.  One in 7 children who had the disease have respiratory or neurological symptoms up to 15 weeks after infection (5-6).  Pediatricians remain concerned about what may still be unknown regarding the long term physical health of infected children.

It’s natural for parents to have questions about the COVID vaccine for children, particularly given the amount of misinformation they may be encountering.  Pediatricians are here to explain how lucky we are to live during such a scientifically advanced time that a vaccine based on decades of research was able to be created so quickly, and why that speed should not be viewed with skepticism but with relief.  Pediatricians can explain that there is no connection between COVID vaccination and infertility and that in fact the American College of Obstetricians and Gynecologists strongly recommends all pregnant women or those planning to get pregnant get vaccinated against COVID (7).  Pediatricians can explain how vaccines work and how the COVID vaccine for children employs the same concept as any other vaccine in giving the body a “sneak peek” at a potentially dangerous virus so it can be prepared to fight it.

Pediatricians can explain that there has never been a vaccine that had to be pulled from the market years or decades after licensure because of unforeseen effects.  Pediatricians can explain that never in the history of vaccination has there been an immunization more closely monitored and scrutinized than this one.  While some parents are planning on watching and waiting, pediatricians caution against this.  As colder temperatures are now upon us, families will be gathering more indoors and will be traveling during the holiday season.  With a much more transmissible virus circulating and higher COVID positivity rates than this time last year, pediatricians hope to protect children before a potential new wave of illness.

Children deserve the safe and effective protection that the COVID vaccine provides against symptomatic infection, hospitalization and death.  The COVID vaccine is recommended by the American Academy of Pediatrics representing the 67,000 pediatricians across the country whose job it is to safeguard the health of children.

Pediatricians welcome parents’ questions and are eager to help them feel more secure in their decision to vaccinate.  No child should succumb to a disease that could have been safely prevented with a vaccine.

References:


MIS-C Update for Pediatricians

Asif Noor, MD, FAAP

Asif Noor, MD, FAAP

Selina Bowler, MD

Selina Bowler, MD

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. Selina Bowler is a Fellow in Infectious Diseases at NYU Long Island.

COVID-19 pandemic brought a unique challenge to pediatricians in the form of a post-inflammatory condition followed by acute COVID-19 infection in children.  It was termed by the Centers for Disease Control and Prevention as multisystem inflammatory syndrome in children (MIS-C) in May 2020.

The emergence of MIS-C cases in the New York region succeeded the peaks of spring and winter COVID outbreaks by 2-4 weeks.  In the New York State, there have been between 200-249 reported cases, with between 150-199 reported cases in New York City alone.  Nationally, as of October 4, 2021, there have been 5,217 reported cases and a total of 46 MIS-C deaths in the US.

What do we know about MIS-C?

CDC Case Definition for MIS-C: https://emergency.cdc.gov/han/2020/han00432.asp

Based on current CDC data, MIS-C cases so far appear to be more common in males (60.1%), Black and Hispanic/Latinx individuals (61.1%), and children aged 6-11 years (38.6%) with a median age of 9 years.

The exact mechanisms at play in MIS-C are currently unknown.  However, the majority of children have serologic evidence of infection with SARS-CoV-2, suggesting a post-infectious etiology.  This is further supported by the timing of presentation following the rise in COVID-19 cases and high SARS-CoV-2 cycle thresholds found in patients with MIS-C.  Evidence from several smaller studies exploring immunologic features of MIS-C compared to COVID-19 suggests T-cell-biased lymphopenia and increased T-cell activation, including increased activation of vascular patrolling CD8+ T-cells.

Spectrum of disease

Based on the current literature of MIS-C, the spectrum of disease severity appears to range from a milder febrile inflammatory state to Kawasaki disease-like illness and severe disease with multiorgan involvement presenting with shock.

MIS-C Presentation Compared to Severe Covid-19 in Children

The February 2021 JAMA article by Feldstein and colleagues compares MIS-C and severe pediatric COVID-19 infections and found that MIS-C patients were more likely to be without underlying conditions.  Common initial presenting signs and symptoms in MIS-C compared to severe COVID-19, respectively, included constitutional (99.4% vs 81.8%), gastrointestinal (90.2% vs 57.5%), mucocutaneous (66.8% vs 10.2%), upper respiratory (34.1% vs 32.1%), lower respiratory (43.0% vs 62.2%) and neurologic (40.4% vs 32.2%) involvement.  MIS-C patients were more likely to have mucocutaneous findings, cardiovascular involvement, and more severe inflammation (i.e. higher median neutrophil-to-lymphocyte ratio [NLR] and CRP levels, lower platelet counts).  Additionally, patients presenting with NLR >5, platelets <150,000, and/or CRP >100 within 48 hours of admission were more likely to be diagnosed with MIS-C versus severe COVID-19 infection.

Management

Who to Evaluate?

Most institutions in New York State have established protocols for the evaluation of suspected cases of MIS-C.  These clinical pathways mirror the American Academy of Pediatrics (AAP) guidelines with few changes tailored to the institutional workflow.

According to AAP, children presenting with fever for ≥3 days without another clear diagnosis who are ill-appearing or with GI symptoms, rash, conjunctivitis, oral mucosal changes, extremity changes, neurologic or psychiatric symptoms and/or lymphadenitis should be evaluated for possible MIS-C.

How to evaluate (A 2 Tier Approach)

At NYU, we use a 2-tier approach to evaluate suspected MIS-C cases, similar to the AAP and American College of Rheumatology (ACR)’s clinical guidance on MIS-C and hyperinflammation in pediatric COVID-19.

Per NYU protocol, Tier 1 evaluation includes CBC, CMP, CRP, troponin, and EKG in addition to any other pertinent labs for the individual clinical scenario.  All suspected MIS-C patients should get tested for SARS-CoV-2 PCR and SARS-CoV-2 serology.  Other tests to be considered include blood culture, urinalysis with reflex urine culture, and/or respiratory viral panel to exclude other etiologies.

If troponin is elevated, obtain BNP (B-type natriuretic peptide) level, consult Pediatric Cardiology service, and proceed with Tier 2 evaluation.  If CRP >20 mg/L and alternative diagnoses have been ruled out, proceed with Tier 2 evaluation.  Tier 2 evaluation includes VBG with lactate, D-dimer, troponin, ESR, procalcitonin, LDH, PT/PTT, ferritin, respiratory viral panel, urinalysis, blood cultures (if not already done).  Additionally, include BNP, COVID PCR and IgG levels and CXR if not obtained during Tier 1 evaluation.

NYU’s Tier 1 evaluation includes initial workup to assess cardiac function (i.e. troponin and EKG), whereas AAP and ACR recommends assessing cardiac function as part of Tier 2 evaluation.

Who to treat?

Cases of mild inflammation are typically managed with supportive care only.  Treatment of moderate to severe cases is based on the phenotype.

PRESENTATION

1st LINE

ANTI-INFLAMMATORY THERAPY

ANTIHROMBOTIC THERAPY
Kawasaki-like features IVIG Aspirin
Cardiovascular dysfunction IVIG + Glucocorticoids Anticoagulation (e.g. Lovenox)
Shock IVIG + Glucocorticoids Anticoagulation (e.g. Lovenox)

What’s new on the treatment front?

In June 2021, NEJM published an article on the initial therapy and outcomes for MIS-C and found that giving IVIG and steroids as initial therapy decreased risk of new or persistent cardiovascular dysfunction by decreasing risk of LV dysfunction and shock requiring vasopressor support when compared to IVIG alone.  Patients who were initially treated with IVIG and steroids were also less likely to receive adjunctive therapy compared to those initially treated with IVIG alone.  Concurrent initial treatment of IVIG and steroids did not affect risk of fever compared to IVIG alone.  Thus, in those initially presenting with signs and symptoms of cardiac dysfunction, it is recommended to start initial therapy with IVIG and steroids together.

In a pre-print retrospective cohort study published by Vukomanovic and colleagues (due for publication November 2021) in the Pediatric Journal of Infectious Disease, initial treatment with corticosteroids in patients with MIS-C-associated cardiovascular dysfunction was associated with more rapid normalization of LVEF, fever and CRP levels and shorter ICU stays when compared to initial IVIG therapy.  Furthermore, patients in the study initially treated with IVIG alone had higher prevalence of treatment failure compared to those initially treated with corticosteroids.

Based on these studies, it is suggested that those with evidence of cardiac involvement at presentation should be initially treated with corticosteroids.

REFERENCES

  1. CDC Reported MIS-C Cases: https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance
  2. CDC MIS-C Case Definition: https://emergency.cdc.gov/han/2020/han00432.asp
  3. Diorio C, Henrickson SE, Vella LA, et al. Multisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS-CoV-2. J Clin Invest 2020; published online July 30. https://doi.org/10.1172/JCI140970
  4. Vella, L. A., Giles, J. R., Baxter, A. E., Oldridge, D. A., Diorio, C., Kuri-Cervantes, L., Alanio, C., Pampena, M. B., Wu, J. E., Chen, Z., Huang, Y. J., Anderson, E. M., Gouma, S., McNerney, K. O., Chase, J., Burudpakdee, C., Lee, J. H., Apostolidis, S. A., Huang, A. C., Mathew, D., … Wherry, E. J. (2021). Deep immune profiling of MIS-C demonstrates marked but transient immune activation compared to adult and pediatric COVID-19. Science immunology6(57), eabf7570. https://doi.org/10.1126/sciimmunol.abf7570
  5. Carter, M. J., Fish, M., Jennings, A., Doores, K. J., Wellman, P., Seow, J., Acors, S., Graham, C., Timms, E., Kenny, J., Neil, S., Malim, M. H., Tibby, S. M., & Shankar-Hari, M. (2020). Peripheral immunophenotypes in children with multisystem inflammatory syndrome associated with SARS-CoV-2 infection. Nature medicine26(11), 1701–1707. https://doi.org/10.1038/s41591-020-1054-6
  6. Lee, P. Y., Day-Lewis, M., Henderson, L. A., Friedman, K. G., Lo, J., Roberts, J. E., Lo, M. S., Platt, C. D., Chou, J., Hoyt, K. J., Baker, A. L., Banzon, T. M., Chang, M. H., Cohen, E., de Ferranti, S. D., Dionne, A., Habiballah, S., Halyabar, O., Hausmann, J. S., Hazen, M. M., … Son, M. (2020). Distinct clinical and immunological features of SARS-CoV-2-induced multisystem inflammatory syndrome in children. The Journal of clinical investigation130(11), 5942–5950. https://doi.org/10.1172/JCI141113
  7. Feldstein, L. R., Tenforde, M. W., Friedman, K. G., Newhams, M., Rose, E. B., Dapul, H., Soma, V. L., Maddux, A. B., Mourani, P. M., Bowens, C., Maamari, M., Hall, M. W., Riggs, B. J., Giuliano, J. S., Jr, Singh, A. R., Li, S., Kong, M., Schuster, J. E., McLaughlin, G. E., Schwartz, S. P., … Overcoming COVID-19 Investigators (2021). Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA325(11), 1074–1087. https://doi.org/10.1001/jama.2021.2091
  8. Whittaker, E., Bamford, A., Kenny, J., Kaforou, M., Jones, C. E., Shah, P., Ramnarayan, P., Fraisse, A., Miller, O., Davies, P., Kucera, F., Brierley, J., McDougall, M., Carter, M., Tremoulet, A., Shimizu, C., Herberg, J., Burns, J. C., Lyall, H., Levin, M., … PIMS-TS Study Group and EUCLIDS and PERFORM Consortia (2020). Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2. JAMA324(3), 259–269. https://doi.org/10.1001/jama.2020.10369
  9. https://emergency.cdc.gov/coca/calls/2020/callinfo_051920.asp?deliveryName=USCDC_1052-DM28623
  10. Henderson, L. A., Canna, S. W., Friedman, K. G., Gorelik, M., Lapidus, S. K., Bassiri, H., Behrens, E. M., Ferris, A., Kernan, K. F., Schulert, G. S., Seo, P., F Son, M. B., Tremoulet, A. H., Yeung, R., Mudano, A. S., Turner, A. S., Karp, D. R., & Mehta, J. J. (2020). American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version

How to get children the medical care they need now and in the future

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

Tina Cheng, MD, MPH, FAAP

Tina Cheng, MD, MPH, FAAP

Dr. Shetal Shah MD, FAAP is neonatologist at Maria Fareri Children’s Hospital and Immediate Past President of the NYS AAP-Chapter 2.  He is Chair of the Pediatric Policy Council.  Dr. Tina Cheng, MD, MPH, FAAP is the B.K. Rachford Memorial Chair of Pediatrics, Chief Medical Officer, and Research Foundation Director of Cincinnati Children’s Hospital Medical Center.  She is a member of the Pediatric Policy Council representing the Association of Medical School Pediatric Department Chairs (AMSPDC).  This op-ed was published in Tampa Bay Times on August 20th, 2021.

As we emerge from the pandemic, pediatric clinicians will have to make up for time lost to child well-being and health over the last 18 months.  Five million children face chronic medical conditions or special health care needs, and 20 percent of parents report that their children’s mental health has worsened.  Since last March, the Centers for Disease Control and Prevention estimate children have missed over 11 million routine vaccines.  This includes 1.4 million measles vaccines – risking outbreaks like the one in 2019 that infected more than 1,200 individuals.

These unmet needs will require a surge of pediatric clinicians – yet we already face a longstanding shortage of pediatric specialists.  Shortages exist in both general pediatrics and in subspecialties like rheumatology and child psychiatry.  And the trained clinicians we have tend to cluster in major cities.  The resulting rural health care “deserts” force families in some states to travel hundreds of miles to see a pediatric specialist.

Our own states of New York and Ohio feature world-class children’s hospitals, but also a dearth of specialists in many communities.  Further limiting access to care, many general pediatricians and child psychiatrists don’t take Medicaid, the nation’s largest insurer of children, because of low payments.

Addressing these challenges requires a three-part strategy.  We must invest in clinical training, attract physicians to work in the geographic areas and specialties of greatest need, and fix the problem of Medicaid under-payment.  Only then will we ensure that every child who needs care can reasonably obtain it.

Increasing the number of pediatric clinicians should be a national priority.  This year, the national Pediatric Policy Council and the American Academy of Pediatrics are requesting $485 million in federal support for training the next generation of children’s doctors – a small amount compared to the $16 billion spent to train adult specialists.

For more than 20 years, the federal government has supported training the next generation of doctors through the Children’s Health Graduate Medical Education Program.  Yet, funding for this program has been neither sufficient nor equitable.  Funding has not kept pace with inflation, and currently is less than half, per doctor, the amount allocated to train physicians who will specialize in adult care.  Despite growing child health need there has been a relative decline in the number of pediatric doctors.

The most effective way to incentivize doctors to train in under-staffed pediatric specialties is through federal loan forgiveness or repayment subsidies.  Graduating medical students face, on average, over $230,000 in educational debt; for one in five, the amount exceeds $300,000.  Such burdensome debt dissuades many from pursuing pediatrics, which is among the lowest paying specialties in the medical field.

Unlike the world of adult care, a pediatrician in specialized fields such as cardiology or oncology will often earn less than a community general pediatrician – even though they have at least 3 additional years of post-medical-school training.  One study found that, over the course of a career, such specialists can earn up to $1.6 million less than if they had entered a general pediatrics private practice.  The same study found that even a partial loan repayment program would significantly offset the financial burden doctors incur when pursuing specialized training.

But boosting the supply of pediatricians will be only a partial solution unless we also fix the problem of Medicaid payments and maldistribution.  For the nearly 40 percent of America’s children who rely on it, finding a doctor that will accept Medicaid payments can be impossible.  Medicaid pays, on average, 72 percent of the Medicare rate for all services, 66 percent for primary care services.

In some states, the Medicaid rate is 33 percent of Medicare’s, which makes it difficult to sustain a practice.  It is imperative that there exist minimum national standards to ensure that U.S. children and young adults in need of publicly funded health insurance have equitable access to affordable, timely, quality, and comprehensive health care through Medicaid and related programs, and that there be parity of Medicaid payments to Medicare.

Although children account for only a small percentage of health care spending, they represent 100 percent of our future.  In an era when chronic childhood diseases are on the rise, raising healthy children increasingly relies on pediatric trained clinical specialists.  Without strong support for their training and a plausible path through the financial hurdles of medical education, we risk a future in which growing numbers of sick children have no doctor to care for them.