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Five Steps Toward Becoming an Anti-Racist Pediatrician

Carley Gomes, MD

Carley Gomes, MD, FAAP

 

Carly Gomes, MD, FAAP, is a Neonatologist at Stony Brook Medical Center.  She serves as the Equity, Diversity and Inclusion Chair for New York Chapter 2

This year’s virtual American Academy of Pediatrics National Conference and Exhibition (NCE) featured perspectives of leading researchers and child health advocates on the adverse health and social/behavioral outcomes impacting non-white children and their families.  Systemic racism in the United States influences social determinants of health and contributes to inequities in health among minority children.  Although the clearest path towards improving the health outcomes of children of color would be to abolish racism, this is an overwhelming task to consider.  How do you begin to dismantle systemic racism when it is so ingrained in societal norms?  What can pediatricians do to elicit change and be advocates for minority children?

The AAP has taken the crucial first steps towards abolishing racism by formally identifying racism as an independent driver for health inequity in children and by apologizing for our organization’s own racist history.  Although many other medical groups have released statements addressing racial health disparities, the AAP is among the few to publicly acknowledge past discriminatory practices and the harm these institutional actions caused.

Through this process of recognition and reconciliation, the AAP has established itself as an anti-racist organization dedicated to promoting the health and well-being of all children.  As pediatricians and members of the AAP we can also do our part to establish ourselves as anti-racist health-care providers.

Below are 5 tips to get you started.

  1. Increase your exposure to different types of people and experiences.  Surround yourself with diversity.  This can be as simple as trying foods from different countries or learning about holiday traditions in other cultures.  Take a critical look at your social media profiles and photos to see who your friends and acquaintances are.  Though it’s comforting to associate with individuals with similar backgrounds and interests, challenge yourself to interact with someone very different from yourself.
  2. Self-reflect and identify your own biases.  Unconscious biases can increase during periods of stress or when you feel time-pressured.  Understanding your personal biases and being cognizant of times when these biases may become more pronounced is important in ensuring that they don’t significantly influence your thoughts and actions.
  3. Educate yourself.  Consider adding Ibram X. Kendi’s book, “How to be an antiracist,” to your queue.   Kendi served as the virtual NCE’s closing plenary speaker this year.  Familiarize yourself with the AAP policy statement on the impact of racism on child and adolescent health and learn more about how all children are adversely affected by systemic racism.
  4. Create a home and working environment that embraces inclusivity.  Set an expectation that racist commentary is unwelcome and encourage friends, family members, and colleagues to hold each other accountable for the use of racist or discriminatory dialogue.
  5. Advocate for change.  Find an outlet where you can safely speak up against racial injustice.  Make your voice and opinions heard by exercising your right to vote.  Let us all do our part to elect anti-racist officials who are committed to decreasing health inequities in children.  This year, more than ever, we need to vote like children’s futures depend on it.

References:


Vote for Children

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

(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 Orlando Sentinel on September 16, 2020)

With only a few weeks until Election Day, voters are feverishly hearing from candidates running for offices from your local town board to president of the United States.  Though rallies, town halls and campaigning are mostly virtual this election season, candidates are articulating their visions and appealing to voters’ interests.  As an electorate, we are being demographically portioned into groups such as the “suburban” voter, the “millennial” voter or the “single-issue” voter.

However, one major constituency is not being highlighted in the current debate, which is why, as a pediatrician, I plan to vote like children’s futures depend on it in November.  Children are 20% of the population but 0% of the vote, and their problems don’t get addressed unless physicians, parents, teachers and those who care for kids make their issues are own.

Nothing is more fundamental to child health than health insurance and the ability to see a doctor when your child is ill.  For healthy children, insurance coverage allows kids to access preventive care like autism screening, vision/hearing/dental screening and life-saving immunizations.

But while the current COVID pandemic has highlighted disparities in children’s access to internet and quality virtual education, long-standing income-based gaps in children’s health insurance coverage have gone largely unnoticed.

Medicaid is the largest insurer of children, and along with Child Health Plus, covers about 39 million kids, including children in foster care and with special healthcare needs.  Deeper cuts to the millions of children covered by public insurance were only forestalled by the COVID-19 pandemic, but will be front-and-center next legislative session in every state as they grapple with budget deficits and coronavirus-related financial strain.

Nationally, we’ve seen an increase in the rate of uninsured children over the past few years. The COVID-19 pandemic, regulatory obstacles and reduced funding have led to over 425,000 children losing health coverage.  This reverses almost a decade-long trend of annual reductions in the number of uninsured kids. In 2016, only 4.7% of children were uninsured, the lowest rate ever recorded.

What did that mean?  It meant my patients with asthma could get inhalers and say away from the emergency room.  It meant more children with diabetes had access to insulin.  It meant more patients on my hospital’s oncology ward could receive chemotherapy.

I will be voting for kids because reduced Medicaid funding will harm my patients.  Patients like the extremely premature babies in my intensive care unit who — born the size of an iPhone — need special ventilators to breathe, medications to keep their hearts beating and customized intravenous fluids prescribed daily and adjusted hourly.  Half of all premature babies are covered by Medicaid and without a strong, well-funded program to support them, I fear they won’t get the physical, occupational and speech therapy they need to thrive.

Decades of data show children insured by Medicaid do better in school, graduate college and become healthier adults than if left uninsured and without access to a physician.  This makes Medicaid a good long-term investment as well. For every dollar invested in the program, the state receives a dollar in federal funds.

Protecting Medicaid locally and across the county is essential to the health of children.  That is why I plan to cast my vote with children’s needs in mind. The policies and laws and candidates we support today will impact our children.  Kids can’t vote, but I can vote like their futures depend on it.


Schools Prepare for Reopening

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Schools Prepare for Reopening:  COVID-19 and MIS-C and How it Relates to Parents, Teachers, Students, and Pediatricians

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

Kyle Russell, DO, PGY3
Chief Pediatric Resident
Wyckoff Heights Medical Center

Chenyu Zhang, B.S., OSM-IV
Medical Student
New York Institute of Technology College of Osteopathic Medicine

            As schools prepare for reopening, there are multiple factors to consider in order to ensure the best chance at a safe and secure reopening for children, teachers, and families. Schools across the country and the world have reopened with mixed results, which is why it is imperative to follow guidelines to give the schools the best chance of success.

Schools around the country have recently opened with various outcomes. Some school districts are able to have classes with no increase of spread yet while others have had staff deaths and subsequent closures. Community transmission rates have a significant impact on safely opening schools. New York City has had a positive test rate of less than 1% for the weeks up to the proposed school opening date4. The lower positivity rate leads to less asymptomatic carriers to potentially spread the disease.

However, recent reports show that 55 Department of Education employees have tested positive for COVID-19 in the week prior to the potential start date. Of those 55, at least 45 are teachers. This number is out of 17,000 tested, and marks a positivity rate around 0.3%4. While this number may be small, the potential for this to spread exponentially remains high, especially considering the amount of students, parents, and staff each of these people may come into contact with. To further complicate matters, these results are from tests administered two weeks prior to results, which allows a large window of potential infection time.

In order to decrease the spread of COVID-19 as much as possible, it is critical for students, staff, and teachers to stay home when symptomatic. The CDC reports symptoms of the SARS-Cov-2 virus may appear 2-14 days after exposure and include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. However, there are known asymptomatic carriers that can spread infection. Among them, children tend to be asymptomatic more frequently than adults3.  While previously believed that children were not significant carriers of the SARS-CoV-2 virus, recent studies have shown that they may carry similar or risk of transmission. While children tend to not have as severe of an illness than adults, they may be a significant vector to community spread 1.

Children are also at risk for developing Multisystem Inflammatory Syndrome in Children or MIS-C. MIS-C is known to be a possible sequela of  COVID-19. This is a serious inflammatory syndrome and your child’s doctor should be notified. Prevention for this syndrome is the same as prevention for COVID-19.

MIS-C Symptoms:

  • 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 order to protect yourself, your child, and school staff members, simple prevention techniques should be used.

  1. Hand hygiene is critical, especially after touching door handles, subway rails, or other objects that come into contact with others.
  2. Social distancing, or staying 6 feet apart from others, helps decrease the odds that one comes into contact with respiratory droplets from another person who may be infected.
  3. Face coverings, such as surgical masks, fabric masks, or any other covering that covers both the nose and mouth decreases the droplets the wearer produces and therefore protects others. This is critical because even if one does not have symptoms, they may be an asymptomatic carrier or be early in the disease course and unknowingly infect many others.
  4. Eye shields could also prevent respiratory droplets from coming into contact with the mucosa of one’s eyes and may prevent transmission.

Schools have adapted methods in order to increase safety. Each day, children and staff members should have their temperatures checked and fill out a health screen prior to admittance. Schools are also offering different teaching styles to decrease interaction between children. The hybrid model includes a mixture of online learning from home and in-person learning, with many schools having students in school every other day to decrease exposure. For schools offering in-person learning, many are offering pod style classrooms. These pods have a smaller number of children in each classroom with an assigned teacher. This allows for less in person interaction by eliminating multiple teachers or staff members in classrooms, eliminating the need to change rooms, and limiting the number of children each student comes into contact with each day. In addition, school districts may also offer a full remote option, with all classes and assignments done virtually from home.

However, all of these options have both advantages and disadvantages. While a completely remote option is the safest for students and teachers alike, it requires supervision. A parent or caregiver would need to be home during learning. This inherently favors the wealthy, which are able to hire help to care for their children, afford to not work, or have a job where they are able to work from home. There is also concern for how effective remote teaching is when compared to in person learning. Pod style learning allows for children to continue in person learning and peer interaction with other students, but limits their potential exposure. By limiting the amount of people that work with the children restricts access to additional support, such as counselors and specialty teachers. Complete in person learning has the most traditional style that students are used to. Even with the improved methods for screening and sanitizing the environment, it has the highest exposure risk to teachers, students, and families alike.

Regardless of the route chosen by schools and parents alike, schools will require more resources. Schools will need staff to conduct symptom and temperature screenings, provide sanitizing solutions, and extra staff for smaller classes for in person training. For virtual learning, schools will need computers and cameras for staff to teach classes. Students will also need computers with cameras and microphones, as well as stable internet. This is difficult to ensure for all students, as 1 in 5 teenagers were unable to complete schoolwork at home due to the lack of a computer or internet connection5. This disproportionately affects Black, Hispanic, and low-income families.

Extracurricular activities are another benefit of attending school in person. Be it from participating in PE and art classes to the various clubs and sports most Middle Schools and High Schools offer, extracurriculars provide another layer of education and enrichment to our children. While this may not impact families with access to plentiful resources, in school art, music and PE classes may be the only exposure that a child from a low income family would have to certain art resources, a musical education, and various sports equipment. On the other hand, involvement in sports teams, especially contact sports, in school may increase the risk of transmission. Outdoor sports such as tennis, cross country and track would be less likely to be impacted by this pandemic. However sports such as football, soccer, lacrosse, baseball, and basketball involve moments where COVID would be spread. Swimming would be another activity where it would be especially hard for students to comply with mask regulations. As we learn more about the inflammatory and long term effects of COVID-19, we are also finding that patients are at a higher risk of myocarditis than other diseases, which is dangerous and could be fatal, especially with exertion during sports6.

Opening schools carries both significant positives and negatives. For those who opt into in person schooling, personal protection and infection control is critical. Schools should have a protocol in place for returning to school when sick, especially with influenza season arriving. In order to protect our children, their families, and school staff, self-quarantine when symptomatic, social distancing, and masking methods are imperative to curb the spread of COVID-19.

References:

1) https://jamanetwork.com/journals/jamapediatrics/fullarticle/2768952
2) https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
3) https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/symptom-screening.html
4) https://www1.nyc.gov/site/doh/covid/covid-19-data.page
5) https://www.pewresearch.org/fact-tank/2018/10/26/nearly-one-in-five-teens-cant-always-finish-their-homework-because-of-the-digital-divide/
6)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314071/

 

 

 

 

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/


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.