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.

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(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.

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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:

• https://www.fda.gov/news-events/press-announcements/fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use-children-5-through-11-years-age
• https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780708
• https://www.cdc.gov/mmwr/volumes/70/wr/mm7036e2.htm
• https://covid.cdc.gov/covid-data-tracker
• https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Long-Haul-COVID-19-in-Children-and-Teens.aspx
• https://www.bmj.com/content/374/bmj.n2157
• https://www.acog.org/en/news/news-releases/2021/08/statement-of-strong-medical-consensus-for-vaccination-of-pregnant-individuals-against-covid-19

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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 immunology, 6(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 medicine, 26(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 investigation, 130(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. JAMA, 325(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. JAMA, 324(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

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.

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Dr. Eve Meltzer-Krief MD, FAAP is a pediatrician in Huntington and Co-Chair of the NYS AAP-Chapter 2 Legislative Advocacy Committee.  Dr. Sara Siddiqui, MD, FAAP is pediatrician and Co-Chair of the NYS AAP-Chapter 2 Legislative Advocacy Committee. This op-ed was published on Huntington Now on August 8th, 2021.

What if there was a deadly virus that had already killed hundreds of children – over four times more than during a typical flu season? (1, 2)

What if that virus had hospitalized thousands of children, leaving many of them with long-term health complications? (3)

What if that virus was mutating to a now twice-as-contagious version, readily finding children still too young to get vaccinated or whose parents are vaccine-hesitant or flat-out refuse to vaccinate their vulnerable children?

What if that virus had caused an 84% spike in pediatric cases in the last week alone and was filling pediatric intensive care units to capacity across the country with critically ill children?  And, what if that virus was in the community where you live with local rates rising exponentially – wouldn’t you want to do everything you could to protect your child?  Wouldn’t you want experts in public health and pediatrics to determine the most effective ways to keep your child safe?

There is such a virus.  It is, of course, Covid-19.  And serious cases among unvaccinated children are escalating.  This is fact.  Medical fact that is easily confirmed by researching non-biased and reputable medical and scientific sources.  As our children return to school in a matter of a few short weeks, experts advise that children two-years-old and up wear masks inside schools to keep them safe from Covid.

Public health decisions designed to keep children healthy and safe should not be made by superintendents and school districts without direct consultation with, and confirmation by, reputable medical health experts. Period. They should not be determined by popular demand or by the loudest voice in the room.

Long before Covid, pediatricians have been the trusted source of advice for parents about how to keep children healthy and safe.  With the advent of vaccination, pediatricians like ourselves see far fewer deaths and seriously ill children today than generations before us.

Parents used to fear diseases like polio and measles that could kill their children or leave them with permanent disabilities.   Widespread vaccination has eliminated those fears.

A large part of what we do as pediatricians is preventive: preventing injury by teaching parents how to properly use car seats, by educating parents to place sleeping infants on their backs, by counseling pre-teens about the dangers of vaping before they start, by encouraging vaccination to protect against vaccine-preventable disease.  We have dedicated our lives to and are passionate about the health and well-being of our young patients.

There is nothing more tragic than the death or injury of a child that could have been prevented; nothing that tears apart a family more than a child’s serious illness, injury or death that did not have to happen, that could have been prevented if only medical advice had been heeded.

We know that vaccinating all eligible adults and children will help protect children still too young to get vaccinated.  We know that wearing masks inside school prevents transmission of Covid (4) and worked last year to keep levels of Covid in schools the same as or lower than community rates.  Pediatricians across the country are raising the alarm that without universal masking in schools this year, we will continue to see an exponential rise in pediatric Covid infections that will have devastating consequences.

Pediatricians want our children back in school but we want them back safely.  Despite the misinformation circulating about mask-wearing in young children, the good news is that the CDC and the American Academy of Pediatrics have determined that mask-wearing is safe for children. (5)

Mask wearing does not cause carbon dioxide poisoning, oxygen deprivation, colonization with deadly bacteria, or weakened immune systems.  We understand these parental concerns and continue to work to debunk this troublesome misinformation.(6)

Along with pediatricians and public health experts across the country, we urge parents to vaccinate their vaccine-eligible children against Covid.  Speaking from science, we demand that school superintendents and school boards across the country follow the recommendations of the CDC, the American Academy of Pediatrics and local health departments advising that children wear masks inside schools.  Our ultimate responsibility is to the children.  Their health and well being is in our hands.

References:

1. https://www.cdc.gov/flu/spotlights/2020-2021/pediatric-flu-deaths-reach-new-high.htm
2. http://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/
3. https://www.aappublications.org/news/2021/03/23/townhall03-18-21
4. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html
5. https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Cloth-Face-Coverings-for-Children-During-COVID-19.aspx
6. https://www.reuters.com/article/factcheck-masks-children-idUSL1N2P929B

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

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

Myocarditis and Pericarditis following COVID-19 vaccination: Reviewing Risk and Recommendations

On May 10, 2021, Pfizer-BioNTech COVID-19 vaccines became approved to be given to adolescent teens by the Food and Drug Administration (FDA) after trials showed good efficacy in the ages of 12-15.  This marked the first available vaccination for this age group as the Moderna and Johnson and Johnson vaccines were still in the trial phase.  Amidst the current COVID-19 pandemic, the widening of access to vaccinations to younger and younger age groups marks the next stage in the fight towards controlling the spread of COVID-19.  However, in a recent release from the Centers for Disease Control and Prevention (CDC), news of increased incidence of myocarditis and pericarditis following COVID-19 vaccination was reported around the time of the expansion of availability to this age group.¹  This information has caught the eyes of many pediatricians who can now offer their adolescent patients the vaccine.  In this post, it is important to review the reported risks of myocarditis and pericarditis associated with the COVID-19 vaccine as well as the CDC recommendations to administering the vaccine to our adolescent population.

With the multitude of complications that occur with COVID-19 infections, acute cardiovascular complications are not excluded. In both adults and children affected by COVID-19, myocarditis and pericarditis are two of the included complications.  In a case series study by Tao Guo et al, myocardial injuries resulting from COVID-19 were shown to result in fatal consequences due to cardiac dysfunction and arrhythmias.²  In a meta-analysis by Raghavan et al. looking at 1,527 patients over 6 studies, it was found that around 8% of inpatients were reported with acute cardiomyopathy.³  In children, there have been studies showing increased risk of myocarditis after COVID-19 infections due to the “multisystem inflammatory syndrome in children” (MIS-C).  In a review article by Yuyi et al. collecting 48 articles on MIS-C, it was found that myocarditis was the most found radiologic finding on echocardiogram with 61% of the cases examined.⁴

With increased availability for adolescent teens to the COVID-19 vaccine, the news of increased incidence of myocarditis and pericarditis especially in the male population has been brought to light.  As of June 23, 2021, the CDC listed more than 1000  reports of myocarditis and pericarditis, with 616 of the cases seen among people ages 30 and younger who received COVID-19 vaccines with confirmation of 393 of these cases.⁵  These cases were found after one of the two mRNA COVID-19 vaccines, Pfizer and Moderna vaccines. CDC further found that cases were reported:

• Mostly in male adolescent and young adults age 16 years and older.
• More often after the second dose of one of the two COVID-19 mRNA vaccines than after the first dose
• Typically within several days after COVID-19 vaccination¹

CDC also reported that patients who did receive care for this adverse effect responded well to medicine and rest and quickly recovered.

Despite these current findings of increased incidence of myocarditis and pericarditis potentially due to the COVID-19 mRNA vaccines, CDC recommendations remain firm for offering the vaccine to the adolescent population. In the latest virtual town hall held by the U.S. Surgeon General Vivek H. Murphy, M.D., M.B.A, stated that the overall number of cases did not outweigh the benefits of vaccination, stating that “when you compare the risk of cardiac complications among adolescents who have had COVID-19 vs. the numbers that we’re seeing here, it is very clear to us at this point in time that the benefits still outweigh the risk when it comes to vaccination.”⁶

Recommendations from the CDC include:

• Continue to recommend COVID-19 vaccination for everyone 12 years of age and older given the greater risk of other serious complications related to COVID-19, such as hospitalization, MIS-C, or death.
• Report all cases of myocarditis and pericarditis post COVID-19 vaccination to Vaccine Adverse Event Reporting System (VAERS)
• Consider myocarditis and pericarditis in adolescent or young adults with acute chest pain, shortness of breath, or palpitations as coronary events are less likely to be a source of symptoms
• Ask about prior COVID-19 vaccination if you identify these symptoms
• For initial evaluation, consider an Electrocardiogram, troponin level, and inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate. In the setting of normal ECG, troponin, and inflammatory markets, myocarditis or pericarditis are unlikely.
• For suspected cases, consider consultation with cardiology for assistance with cardiac evaluation and management.
• For follow-up of patients with myocarditis, consult the recommendations from the American Heart Association and the American College of Cardiology
• Rule out other potential causes of myocarditis and pericarditis. Consider consultation with infectious disease and/or rheumatology to assist in evaluation¹

References:

1. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2021, May 27). Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination.  Retrieved June 23, 2021, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html
2. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu Z. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020 Jul 1;5(7):811-818. doi: 10.1001/jamacardio.2020.1017.  Erratum in: JAMA Cardiol. 2020 Jul 1;5(7):848. PMID: 32219356; PMCID: PMC7101506.
3. Raghavan S, Gayathri R, Kancharla S, Kolli P, Ranjitha J, Shankar V. Cardiovascular Impacts on COVID-19 Infected Patients.  Front Cardiovasc Med. 2021;8:670659. Published 2021 May 13. doi:10.3389/fcvm.2021.670659
4. Tang Y, Li W, Baskota M, et al. Multisystem inflammatory syndrome in children during the coronavirus disease 2019 (COVID-19) pandemic: a systematic review of published case studies. Transl Pediatr. 2021;10(1):121-135. doi:10.21037/tp-20-188
5. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2021, June 11). Selected Adverse Events Reported after COVID-19 Vaccination.  Retrieved June 23, 2021, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html
6. Korioth T. (2021, June 11). Surgeon general addresses myocarditis, pediatricians’ role in COVID-19 vaccination efforts Retrieved June 14, 2021, https://www.aappublications.org/news/2021/06/11/townhall061121

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(Dr. Robert Lee, DO, MS, FAAP is a pediatrician and Associate Pediatric Residency Program Director at NYU Langone Hospital – Long Island.  He is the Chair for the AAP Section on Osteopathic Pediatricians, Vice President for NYS AAP Chapter 2, and Co-Chair of the NYS AAP Chapter 2 Foster/Kinship Care Committee.)

 Telehealth during the COVID-19 Pandemic

The AAP believes the best place for infants, children, and adolescents to receive preventative services and problem-oriented care is at a pediatrician’s office.  Telehealth or “virtual visits” with the pediatrician using technologies such as live, interactive audio and video became an option and necessity during the peak of the COVID-19 pandemic with stay-at-home orders and families not wanting to engage with others.  Pediatricians were able to leverage telehealth with the relaxation of regulations and adequate payments in order to sustain their businesses.

According to Physician Xpress, the average total visit count per pediatric office was 52% less in April 2020 as compared to April 2019.  Of the total visits in April 2020, the average pediatric office had 40% of visits conducted via telehealth.  As the economy opened and children/parents started to engage in activities, the average total in-person visits each month increased, however, it was still 5% less overall compared to 2019.  The percentage of visits each months that were telehealth also reduced each month.  In September 2020, ~8% of total visits were telehealth although many practices reported having less than 3% of their visits as telehealth.

This percentage of telehealth visits is similar here in New York Chapter 2 as well.  Pediatricians who I spoke to in January 2021 reported between 5-10% of total visits were telehealth.

Future of Telehealth

In an independent study reported in Healthcare IT News, 92% of pediatricians believe that telehealth will remain part of pediatric practices in the future. All of the 787 pediatricians who responded to the survey reported currently using a telemedicine platform, with 96% saying they offered telehealth during regular business hours.

More than 60% of respondents reported that families and patients find it relatively easy to use.  The number-one factor that is driving the use of telehealth in pediatric practices is patient demand.  Other factorssuch asstate levelpayment parityand revenue potential have been driving adoption.

The most common types of visits that lend themselves to telehealth include behavioral/mental health concerns, simple sick visits (e.g. URI, rashes, or pinkeye), refills for medication, and chronic condition check-ins.

The majority of respondents conducted telehealth on an app on their smartphone.Respondents reported that they would seek EHR integration, connectivity, price and flexible workflows from telemedicine platforms in the future.  Respondents also say they would love to see peripheral device integrations, translation services during visits, documentation and platform availability in multiple languages. And respondents say audio-visual quality, ease of use and connectivity, flexible workflows and live support are essential technical components that affect both patients and pediatricians.

AAP Chapter Telehealth ECHO Project 

The AAP Chapter Telehealth ECHO project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $6,000,000.  AAP Chapter 2 is a recipient of the grant and we just completed a 3-month tele-mentoring program with expert faculty team from AAP Chapters 2 and 3.  Over the six sessions, AAP Chapters 2 and 3 members learned through didactic and case-based presentations on a wide range of topics to help pediatricians incorporate best practices for telehealth.  All the didactic video recordings are available.

• ECHO Session 1: Telehealth 101– Marc Lashley, MD, FAAP
• ECHO Session 2: Coding and Billing for Telehealth – Steven Goldstein, MD, FAAP and Jesse Hackell, MD, FAAP
• ECHO Session 3: Using Telehealth for Behavioral/Developmental Concerns – Jack Levine, MD, FAAP
• ECHO Session 4: Confidentiality and Telehealth for Adolescents – Linda Carmine, MD, FAAP
• ECHO Session 5: Liability Issues in Telehealth – Jesse Hackell, MD, FAAP
• ECHO Session 6: Other Telehealth Considerations – Robert Lee, DO, FAAP

Conclusion

Telehealth will never be the right answer for all pediatric visits.  There are times when pediatricians still need to perform a comprehensive physical exam and administer immunizations.  If the relaxation of regulations and adequate payments become permanent, telehealth can become an integral part of the medical home.  And if telehealth is here to stay then pediatricians have to increase their knowledge, competency, and self-efficacy regarding the use of telehealth to provide care within the medical home.

Resources

1. AAP Telehealth Support Compendium
2. Northeast Telehealth Resource Center
3. HSS.gov

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Michael Kho, DO,  is a PGY1 resident at Wyckoff Heights Medical Center

“We must dismantle racism at every level, from individual to institutional to systemic,” stated pastAAP President Sara “Sally” H. Goza, M.D., FAAP on June 1, 2020 one week after the killing of George Floyd.¹  In August 2019, the American Academy of Pediatrics issued a policy statement entitled, The Impact of Racism on Child and Adolescent Health.  In this policy, the state of racism which children and parents may face from the school to the clinic was analyzed, and the AAP expressed urgency in combating racism as pediatricians.  The policy also provided guidance and advice for pediatricians to improve our own practices to counsel families, improve our as staff, and better our community to better ensure that all patients are treated with respect and free of bias.²

However, since the publication of the policy, the US has continued to face numerous challenges involving racism.  From the shooting of Ahmaud Arbery, the death of Breonna Taylor, the killing of George Floyd, and the increase of racially-driven attacks on the Asian community due to the COVID-19 pandemic, racism has continued to show how prevalent it remains in our society.  With increased visibility through social media and the internet, more and more incidences of racism have been sparking conversations and movements across the nation.  As this movement for activism and the fight for equality in the US continue, now is a good time to review the impact of racism on children and adolescent health and the AAP policy statement to reaffirm the need for improvement to better treat our patients, families, and communities.

Racism has been identified as a core determinant of health that has been found to be associated with poorer mental health, physical health, and general health.³  In children and adolescents, the impact of racism has been linked to complications from birth throughout development.  Studies have shown that racial disparities have resulted in low birth weights and increased infant mortality rates due to perceived racial discrimination and maternal stress.⁴  Throughout their school years, children may be exposed to incidences of racism through school teachers or fellow schoolmates both implicitly and explicitly.  These early incidents can lead to permanent impact in forming social connections as well as damage a child’s mental health.  Even children who were not directly exposed to explicit racism, but rather a bystander to racism and other forms of victimization have been shown to have psychological and physiological effects later in life as well.⁵  As these children face continued exposure to these stressors, they can produce increased stress hormones, such as cortisol, which can predispose these children to chronic disease.⁶  With all of the potential exposure to racism throughout childhood, and with the consequences that come with each event, it is our job as physicians to both address and ease these effects.

In AAP’s 2019 policy, a series of guidelines were provided for physicians to improve racial sensitivity within our clinical practices, professional education, as well as in our community.

For our own clinical practices, some strategies provided by the AAP are to:

• Create a culturally safe medical home where providers acknowledge and are sensitive to racism that children and families experience.
• Use strategies such as the Raising Resisters approach during anticipatory guidance to provide support for youth and families to recognize racism in all forms, differentiate racism from other forms of unfair treatment and/or routine developmental stressors, safely oppose negative messages and/or behaviors of others, and counter or replace those messages and experiences with something positive.
• Train clinical and office staff in culturally competent care.
• Assess patient for stressors and social determinants of health often associated with racism.
• Assess patients reporting to have experienced racism for mental health conditions with validated screening tools and a trauma-informed approach.²

For Professional education and Workforce Development:

• Advocate for pediatric training programs that are girded by competencies and sub-competencies related to effective patient and family communication across differences in pediatric populations.
• Encourage policies to foster interactive learning communities to promote cultural humility and provide simulation opportunities.
• Integrate active learning strategies such as simulation and language immersion.
• Advocate for policies and programs that diversify the pediatric workforce and provide ongoing professional education for pediatricians in practice to reduce implicit biases.²

For Community engagement, advocacy, and public policy:

• Engage community leaders to create safe playgrounds and healthy food markets to reduce disparities in obesity and undernutrition in neighborhoods affected by poverty.
• Advocate for improvement in the quality of education in segregated urban, suburban, and rural communities.
• Support local educational systems by connecting with and supporting school staff.
• Advocate for federal and local policies that support implicit-bias training in schools and robust training of educators in culturally competent classroom management.
• Advocate for increased access to support for mental health services in schools.
• Advocate for curricula that are multicultural, multilingual, and reflective of the communities in which children in their practices attend school.
• Advocate for policies and programs that diversify the teacher workforce to mitigate effects of current demographic mismatch of teachers and students.
• Advocate for evidence-based programs that combat racism in the education setting.²

As physicians, it is our duty to create an environment to provide quality care to every patient regardless of race, sex, sexual orientation, religion, economic status, disability, or any other feature.  Despite our continued efforts, there remains room for improvement as explicit or implicit biases may remain while treating our patients.  As racism can impact a child and adolescent’s overall health both psychiatrically and physically, we must continue to review and improve ways to eliminate all forms of bias and racism in our practice and the community in which we serve.

References:

1. Jenco, M. (2021, March 05). ‘Dismantle racism at EVERY level’: AAP President.  Retrieved March 10, 2021, from https://www.aappublications.org/news/2020/06/01/racism060120
2. Trent M, Dooley DG, Dougé J; SECTION ON ADOLESCENT HEALTH; COUNCIL ON COMMUNITY PEDIATRICS; COMMITTEE ON ADOLESCENCE. The Impact of Racism on Child and Adolescent Health. Pediatrics. 2019 Aug;144(2):e20191765. doi: 10.1542/peds.2019-1765. PMID: 31358665
3. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511pmid:26398658
4. Beck, A. F., Edwards, E. M., Horbar, J. D., Howell, E. A., McCormick, M. C., &Pursley, D. M. (2020). The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatric research, 87(2), 227–234. https://doi.org/10.1038/s41390-019-0513-6
5. Janson GR, Hazler RJ. Trauma reactions of bystanders and victims to repetitive abuse experiences. Violence Vict. 2004;19(2):239–255pmid:15384457
6. Cohen S,Janicki-Deverts D, Doyle WJ, et al. Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. ProcNatlAcadSci USA. 2012;109(16):5995–5999pmid:22474371

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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. Theresa Fiorito, MD, FAAP is a member of the Infectious Disease Society of America, Society for Pediatric Research, Pediatric Infectious Diseases Society, American Academy of Pediatrics, and the International Society of Travel Medicine with a Certificate in Travel Health.

An entire year has elapsed since the first confirmed case of COVID-19 infection in New York. Pediatricians were in the forefront of an uphill battle during the spring outbreak and continue battling COVID-19 during the winter months.

Although children were largely spared, pediatricians encountered multiple challenges to which they responded methodically.  Whether it was protecting a newborn from maternal COVID-19, providing care to sick children in the office setting, dealing with mental health issues associated with the pandemic, or managing a novel condition in children, multisystem inflammatory syndrome in children (MIS-C), pediatricians promptly adapted.

On December 11, 2020, the FDA granted emergency use authorization (EUA) for the first COVID-19 vaccine by Pfizer/BioNTech.  As of February 6^th, 2021, 59 million doses have been manufactured and 39 million have been administered in the U.S. Currently, the COVID-19 vaccine is being offered to the high-risk groups identified by the Advisory Committee on Immunization Practices (ACIP) based on the ethical principles of initial allocation. This includes pediatricians.  Many of us are thankful to receive it immediately after the EUA, particularly if we were associated with a hospital or medical center.  However, many of us working in an office witnessed firsthand the uncoordinated vaccine distribution with no clear guidance.

Children under 18 years comprise a quarter of the U.S. population and their immunization is vital to attain a goal of herd immunity.  Pediatricians are commonly questioned on the availability of COVID-19 vaccine in children.  The pediatric population needs to be immunized to not only protect them directly, but also to indirectly insulate the most vulnerable populations.

We, the pediatricians, serve as the primary advocate to deliver a clear and compassionate message on vaccine safety and efficacy.  Conducting COVID-19 vaccine trials in children is imperative alongside the vaccine rollout to the elderly and most vulnerable populations.

In this blog, we will review the basics of COVID-19 vaccines, vaccine eligibility, vaccination in pregnancy& lactating persons, vaccination in children, and an update on MIS-C.

COVID Vaccine: Pipeline

As of February 6, 2020, there are 67 vaccine candidates in human trials, with 4 vaccines fully approved for use worldwide. In the United States, the mRNA vaccines from Pfizer/BioNtech and Moderna are currently being utilized.

Vaccine target: The major antigenic target for COVID-19 is the large surface spike protein.  This antigen allows the virus to bind to angiotensin-converting enzyme 2 (ACE-2) on the host cell and induce membrane transfusion.  A vaccine that can induce antibodies against the receptor binding protein of spike protein can prevent attachment to the host cell and neutralize the virus.

Vaccine platforms:COVID-19 vaccines are being developed using different platforms. As pediatricians, we are familiar with the traditional approaches applied to inactivated vaccine (e.g. inactivated influenza) and live vaccine (e.g. measles) technology.  The genetic sequence of COVID-19 published on January 11, 2020, led to a rapid emergence of new vaccine research and collaboration. It paved the path for the first two vaccine candidates currently authorized for use in the United States, using an mRNA platform.  Other vaccine candidates use replication–incompetent vector vaccines, recombinant protein vaccines, etc.

COVID-19 vaccines in the United States
	Approved vaccines		Upcoming vaccine candidates
Candidate	BNT 162b2 Pfizer/BioNTech	mRNA1273 Moderna	Janssen Johnson & Johnson	AZD1222 AstraZeneca	NVX-CoV 2373 Novavax
Platform	mRNA	mRNA	Adenovirus 26	Chimpanzee adenovirus	Recombinant nanoparticle
Doses	2 doses, 21 days apart	2 doses, 28 days apart	Single dose	2 doses, 28 days apart	2 doses, 21 days apart
Efficacy	95%	94.1%	77% phase III in U.S.	70.4 % phase III in U.K and Brazil	89.3 % phase III in U.K

 

mRNA technology: The mRNA is delivered in lipid vesicles. After administration, the mRNA is translated into the target protein which is intended to elicit an immune response.  The mRNA does not enter the nucleus or interact with host DNA.  The normal cellular processes degrade it quickly.

Immunogenicity and efficacy: Phase 2 (small scale immunogenicity, safety and efficacy trials) and phase 3 trials (large-scale safety and efficacy trials) have demonstrated the production of neutralizing antibody responses comparable to those in convalescent plasma from patients with asymptomatic to moderate COVID-19 infection.  Clinical trials have demonstrated vaccine efficacy of 95 and 94.1% in the Pfizer/BioNTech and Moderna studies, respectively, in preventing symptomatic COVID-19 infection after receipt of 2 doses.

Reactogencity (reactions that occur soon after vaccination; a physical manifestation of response): There are no serious safety concerns.  All vaccines elicit systemic adverse effects or reactogenicity such as fevers, chills, headaches, fatigue, and/or myalgias in a small portion of participants.  Most adverse effects are mild to moderate, and occur in the first 3 days after receiving the vaccine.  Symptoms are more frequent after the second dose, and in younger persons compared to older recipients.  Antipyretics or analgesics may be taken for post-vaccination local or systemic symptoms, however, routine prophylactic administration is not currently recommended.

Anaphylaxis following vaccination has been reported in an approximate rate of 5 events per 1 million doses. Out of these cases, 80% occurred in persons with a history of anaphylaxis, and 90% occurred within 30 minutes of vaccine receipt.

Vaccine effectiveness against variants: In the Pfizer/BioNTech cohort, the plasma from vaccinated clinical trial participants appeared to maintain neutralizing activity against the B.1.1.7, or the U.K. variant strain.  It also neutralized virus containing the key mutations in the B.1.351, or the South African variant, however the neutralizing titers were lower with South African strain.   Similar results have been found in Moderna’s in vitro neutralization studies.

COVID vaccine: Pregnant and lactating women

There are currently no safety data available on COVID-19 vaccines in pregnant persons. Data extrapolated from animal studies did not demonstrate any safety concerns in pregnant rats receiving the Moderna vaccine. Studies in pregnant animal models receiving the Pfizer/BioNTech vaccine are ongoing; it is of note that during the Pfizer/BioNTech clinical trials in humans, 23 persons became pregnant after receiving the vaccine, and to date, no adverse effects in these patients have been reported.

While absolute risk is low, pregnant women are at increased risk of severe illness from COVID-19 infection.  They may also be at increased risk of pregnancy complications, such as preterm labor. As per the ACOG (American College of Obstetricians and Gynecologists), COVID-19 vaccines should not be withheld from pregnant or lactating individuals if they are part of a group recommended to receive the vaccine (e.g., health care personnel, essential workers).  The Centers for Disease Control and Prevention (CDC) and ACIP also recommend that pregnant or lactating persons within eligible populations be offered the COVID-19 vaccine.  The Society for Maternal Fetal Medicine (SFM) advocates for all pregnant persons to have access to COVID-19 vaccines.

These organizations emphasize the importance of shared clinical-decision making; the decision for pregnant persons to get vaccinated should be based on an individual’s unique risk for infection.  For example, someone who is able to work from home through the entirety of the pregnancy has a low exposure risk, and may want to wait to get vaccinated until after the birth of the child.

Those trying to become pregnant do not need to avoid pregnancy after receipt of COVID-19 vaccination, nor is there any evidence that COVID-19 vaccination has any effect on fertility.

COVID vaccine: Children

Currently, the Pfizer-BioNtech mRNA vaccine is approved for ages 16 and up, and the Moderna mRNAvaccine is approved for ages 18 and up.

There is currently no COVID-19 vaccine available for children under age 16. However, studies in pediatric populations are ongoing.  Moderna is currently enrolling patients for a phase 2/3 randomized study to evaluate the safety, effectiveness, and reactogenicity in those 12-18 years of age. Pfizer is conducting a similar study in those 12-15 years of age.   Results of clinical trials on children under age 12 for both vaccines will likely take much longer, as dosing adjustments for age will need to be made.  AstraZeneca, whose COVID-19 vaccine is not yet approved in the United States (but is approved for use in the U.K.), also plans to commence clinical trials for those ages 5-18 years.  It is of note that obtaining study patients under age 12 is currently proving difficult; parents are finding it hard to justify enrolling their children in these trials.  While there is clearer evidence of spread of COVID-19 among teenaged children, transmission has been reported in those as young as age 8.  Given the accelerated nature of vaccine development, there is a preponderance of misinformation circulating, particularly online, regarding vaccine safety, which can contribute to skepticism and vaccine hesitancy.  As a pediatrician, we can identify concerns, educate patients on vaccine risks and benefits, and dispel the myths.  The most effective intervention against vaccine hesitancy is communication by a primary care provider.

Winter outbreak and multisystem inflammatory syndrome in children (MIS-C):  The initial emergence of MIS-C in New York was observed in May and June of 2020.  This preceded the peak of the COVID-19 epidemic in New York by 1-2 months.  In winter, a similar trend of MIS-C cases is being observed in January and February of 2021.

Much has been learned about the wide spectrum of clinical presentations and management of MIS-C.  Presentation ranges from a shock–like picture, to a Kawasaki disease-like presentation, to milder forms with brief febrile illnesses.  The median age of patients is 9 years.  All of them have fever, 88% have gastrointestinal (GI) symptoms, 60% have a rash, and 50% have conjunctivitis.  Children with fever ≥ 4 days without any source, with either GI symptoms, rash, conjunctivitis, oral mucosal changes, extremity changes, neurological symptoms, or lymphadenitis should be evaluated for MIS-C.

Some interventions such as intravenous immunoglobulin (IVIG)and/or prophylactic antithrombotic therapy are appropriate for most children presenting with moderate to severe disease, regardless of the dominant type of presentation. Children presenting with Kawasaki-type disease should receive standard therapies for Kawasaki disease such as IVIG and aspirin.  Children with cardiac involvement may present with arrhythmia and hemodynamic compromise.  Although IVIG can be used in myocarditis, the conclusive evidence of benefit is lacking.  In addition, based on severity of illness, low-dose methylprednisolone (2 mg/kg/day twice daily) or pulse steroids (30 mg/kg/day for three days) should be considered in hospitalized children.

Over the next 1 to 2 months, pediatricians should stay vigilant in triaging febrile illnesses that may be consistent with MIS-C in the office setting.

References:

1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6947e3.htm
2. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html
3. https://www.cdc.gov/mmwr/volumes/69/wr/mm695152e2.htm?s_cid=mm695152e2_w
4. https://www.acog.org/covid-19/covid-19-vaccines-and-pregnancy-conversation-guide-for-clinicians
5. https://s3.amazonaws.com/cdn.smfm.org/media/2591/SMFM_Vaccine_Statement_12-1-20_(final).pdf
6. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html
7. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19
8. https://www.clinicaltrials.gov/ct2/show/NCT04649151?term=pediatric&cond=covid-19+vaccine&draw=2&rank=3
9. https://www.clinicaltrials.gov/ct2/show/NCT04368728?term=pediatric&cond=covid-19+vaccine&draw=2&rank=4
10. https://www.nichd.nih.gov/sites/default/files/inline-files/NICHDCouncil_Erbelding_090720V2.pdf

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