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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



  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.


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

Making Sure Every Child Counts in the 2020 Census

Eve Meltzer-Krief MD, FAAP

Eve Meltzer-Krief MD, FAAP

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

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


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

Jack Levine, MD, FAAP

Jack Levine, MD, FAAP

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

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


Dealing with Climate Grief

Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens.  He is the immediate past president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health)

     Committed pediatricians address the problems and consequences of gun violence, hunger, homelessness, immigration status, healthcare coverage, and anti-vaccine sentiment daily, and there is progress, albeit slow, on many fronts.  But there is an over-riding issue with little progress being made that will affect all of us, and children disproportionately, and is inescapable on the daily news.  I am referring to Climate Change.
     As large portions of California burned, and now as Australia sees unprecedented destruction, there are daily reports that the early predictions of the effects of climate change were underestimates, and the response of our country (and others as well) to both these issues seems feeble at best.  And lest pediatricians think that in their locales the effects of climate change are going to be a long time coming, witness the respiratory issues in states adjacent to the wildfires, the rising sea levels in Miami and other coastal locales necessitating raising the streets, and the almost daily reports of extreme weather events both here and abroad-including flooding, tornadoes, high winds, and drought.  This global change will result in island nations that, if trends continue, will no longer exist or lose vast amounts of land due to rising seas.  And the slow northward march of tropical diseases previously unknown in North America will change how we practice medicine.  The devastation of pines in northern habitats killed by a blight that now overwinters successfully due to rising temperatures affects whole ecosystems.  These seemingly distant examples of climate change will cumulatively affect all of us and our patients, no matter where we live or practice.
     If these occurrences weren’t worrisome enough, we are also faced with a rollback of protections for clean air, water and food by an administration that fosters business interests over public health ones.  And this denial of science is not limited to our country.  This past week the Australian Prime Minister denied the role of climate change in the wildfires and pledged to support the coal industry (Washington Post).  In the US, the administration discounts daily the role of science in public policy, and those at the head of the EPA and other governmental organizations charged with protecting the public interest, including once sacrosanct National Parks, now protect the fossil fuel industry  ( NY Times).  Chipping away at the protections designed to protect future generations put in place by previous administrations and slowly replacing advocates for children and the future with advocates for fossil fuels is the new normal.  Two examples: Dr. Ruth Etzel, a pediatrician and epidemiologist well-known to many of us was removed from her position as head of the EPA’s Office of Child Protection in 2018 and efforts to undermine protections against asbestos exposure were detailed by Dr. Phil Landrigan in August in the New England Journal of Medicine .
     The psychological effects of climate change issues on children and families is profound, and only adds to the burden of already existing stressors.  Some populations, like the Inuit and Pacific Islanders, are already dealing with these issues on a daily basis as rising seas and melting ice threaten their way of life, their physical and mental health and their futures.  These issues and how to help our patients build resilience are addressed in a report from the American Psychological Association and ecoAmerica (Access the report here).  The report details recommendations we can use to help individuals, communities and leaders to foster resilience, action, and mental health.
     Undoubtedly there are children and families under our care that are worried and stressed by this issue-experiencing what has come to be known as Climate Grief.  I am proposing that we discuss these global issues at office visits and see this as an opportunity to educate and enlist families in adjusting their lifestyles, building resilience, and advocating for the future not only of themselves, but also the planet.
     I believe that pediatricians should make it a priority to learn more about environmental health, climate change, and ecology.  Joining the AAP Council on Environmental Health and working with the Chapters on their new initiative to raise consciousness about climate change will add our voices to the national conversation and help us chart the future for ourselves and future generations.

Gun Violence: What is Our Role as Pediatricians?

Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

(Patel Sanjivan, MD, FAAP is Chairman of the Department Of Pediatrics and Director of Newborn services and NICU at Wyckoff Heights Medical Center.
Nguyen-Thao Tran, DO, PGY2 is a Pediatric resident at Wyckoff Heights Medical Center)

Gun violence is recognized as a public health crisis with devastating effects on children, adolescents, and young adults.  Death caused by firearms is the third most common cause among children aged 1 to 17 years (1).  Furthermore, the United States leads the industrialized world in youth homicide and suicide rates (2).  What are the circumstances surrounding firearm-related injuries and deaths in children, and what exactly are we as Pediatricians doing to combat this crisis?

According to data from the Centers for Disease Control and Prevention (CDC) from 2002 to 2014, approximately 1,300 children die and 5,790 are hospitalized for gunshot wounds each year in the United States (1, 2).  Nearly half of these were due to homicides where younger children were bystanders in a violent conflict between intimate partners.  One-third of firearm-related injuries among adolescents and young adults are triggered by relationship problems with family, friends, or intimate partners.  Underlying mental health factors such as depression, developmental, and behavioral problems are also key contributors.  The remaining deaths were due to unintentional firearm deaths which are frequently due to unsafe storage of guns (1, 2).

In response to the rising youth violence prevention movement, the AAP issued guidelines and recommendations stressing the importance of Pediatricians becoming familiar with Connected Kids: Safe, Strong, Secure (2, 3).  This nationally-accepted program is a comprehensive effort by the AAP that serves as a primary care violence prevention protocol.  It serves as a clinical guide, provides 21 information brochures for parents and patients, and offers training materials that are accessible online for healthcare providers.

As Pediatricians we routinely have front-line access to our young patients with co-morbid mental health problems and those with involvement in high risk or violent behaviors (2).  It has been shown in a randomized, controlled study by Barkin et al that when pediatricians take the time to discuss gun issues during clinical care visits, patients and their families follow-through with their pediatrician’s recommendations on gun safety (3, 4).

The implementation of this anticipatory guidance and screening during routine health maintenance examinations touches on the importance of fostering resilient factors “that enable children and young adults to adapt successfully to stress, including exposures to violence (2).”  It is essential to note that when we take the time to advocate and provide support for early parenting behaviors in areas that help their child build interpersonal skills, peer relationships, staying safe, healthy dating, bullying prevention, firearms and media violence, and mental health, among other topics; children develop greater resilience early-on and more successfully, safely, effectively, and healthfully navigate and handle conflicts.

The AAP encourages pediatricians to routinely ask questions to screen for firearms in the home of their patients.  If present, we should counsel regarding safe gun storage (storing the unloaded gun in a locked safe, storing ammunition separately, etc.) or gun removal.  An adolescent’s access to firearms is usually obtained illegally through a family member or friend.  A recent cross-sectional study by Timsina et al found that the National Instant Criminal Background Check System (NICS) by itself does not decrease gun-carrying behaviors in adolescents.  However, they found that in states where universal background checks on all gun purchases are combined with the implementation of NICS, there is a reduction in adolescents having access to guns (6).  Our purpose as Pediatricians is to educate and ensure the safety as well as the health of our children and to not infringe on the Constitutional right to bear arms (5).

Overall, youth morbidity and mortality due to firearms is preventable with Pediatricians’ collective efforts to educate and advocate.  We need to educate and advise our patients on gun safety.  We need to advocate at the federal level for policies and legislation on violence prevention and mental health surveillance and resources that is pro-child health and safety (5).


  1. Fowler KA, Dahlberg LL, Haileyesus T, et al. Childhood Firearm Injuries in the United States. Pediatrics. 2017; 140(1): e20163486.
  2. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. Role of the Pediatrician in Youth Violence Prevention. Pediatrics 2009;124;393.
  3. Palfrey JS, Palfrey S. Preventing Gun Deaths in Children. NEJM 2013;368;5.
  4. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, time-outs, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics 2008l;12(1)2:e15-e25.
  5. Jones N, Nguyen J, Strand NK, et al. What Should Be the Scope of Physicians’ Roles in Responding to Gun Violence? AMA Journal of Ethics 2018; 20 (1):84-90.
  6. Timsina LR, Qiao N, Mongalo AC, et al. National Instant Criminal Background Check and Youth Gun Carrying. Pediatrics. 2020;145(1):e20191071.

The Immunization Exemption Crisis


Ron Marino, DO, MPH, FAAP

Ron Marino, DO, MPH, FAAP

 (Dr. Ron Marino, DO, MPH, FAAP is a pediatrician and Associate Chairman and Director of General Pediatrics at NYU Winthrop Hospital.  He is co-chairman of the Yoga and Meditation Committee of the New York State (District II), Chapter 2 (Long Island) of the American Academy of Pediatrics.)

I Found Religion, Then Lost It: The Immunization Exemption Crisis

The New York State Legislature passed regulations in June 2019 removing the religious exemption for vaccination of children entering the school system in 2019.  This appropriate Public health policy, supported by AAP Chapter 2 and numerous other advocates for child health, has given rise to new and creative approaches in the anti-vax community.  Parents are confronted with the prospect of home schooling or exclusion from school if they do not comply with the legislation which is founded on the CDC’s immunization schedule.  The legislation also provides that medical exemptions will be consistent with currently published CDC contraindications and precautions.  As Medical Director for a variety of school systems, medical exemption requests come to my attention for validation.  Somehow parents are finding doctors willing to write exemption requests that are not consistent with CDC guidelines.  When I respond to the school administration that the exemption request is not based on current evidence based recommendations the fireworks begin.  School administrators have been verbally abused, my phone rings off the hook from parents, some doctors call to plead their case; I even received a call from a state assembly person who voted for the legislation asking me to make an exception for her constituent!

Colleagues, please do not write exemption requests that are not consistent with published guidelines!!  There may be some situations that are grey and require discussion, however it is clear that some licensed medical practitioners are writing clearly inappropriate and unsubstantiated medical exemptions.  Ultimately this will place the practitioner at risk and will not prevent the student from being subject to the immunization regulations.  Currently the New York State Department of Health is dealing with requests that need secondary review.  I am sure they are receiving lots of questions.  Parents should know that they can appeal the exemption denial to the state education Department, in the interim they may request a brief stay of the requirement.

We are clearly, as a Society, victims of our great success with immunizations.  Parents no longer see the diseases and have lost fear of what might be if their child contracted the disease and replaced it with distrust of the medical establishment and government.  We need only look back 30-60 years to epidemics of polio, measles, and invasive bacterial diseases to recognize the benefit that immunizations have given us.  Parents of the 1950s clamored to have their children immunized and that effort resulted in a much healthier population.  Every licensed physician in New York State should think carefully before providing a bogus, inappropriate, and professionally unethical immunization exemption request.  Medical Directors and the state office of professional misconduct are watching.  We must take a strong stand to be part of the solution and not part of the problem.

2019 Legislative Session Update: WHAT WE ACCOMPLISHED!

Elie Ward

Elie Ward

Mrs. Elie Ward, MSW is the Director of Policy, Advocacy, and External Relations for NYS AAP Chapters 1, 2 &3.  She provides an update on the status of issues for which pediatricians across the state strongly advocated.

As you may have read or heard, this year’s legislative session has been extremely productive. I am very pleased to report that it has also been very productive and positive for the children of New York.  Many of our key legislative priorities, like the repeal of Religious Exemption to Immunization, Lowering Blood Action Level from 10 mg/dl to 5 mg/dl, and passage of a Gun Safe Storage Act, were achieved.  In addition, we had several significant legislative successes in the areas of child safety, the environment, and further curbs of tobacco access for young people.

The following is a summary of our victories in the legislative arena.  Many of our bills which passed both houses still need to be signed by the Governor.  Most have been agreed to and the Executive has indicated that they will be signed.  If we encounter resistance or an assault by opponents, such as the chemical industry fighting the Child Safe Products Act, I will let you know, and we will activate our Advocacy Action Alert system.

But for now, enjoy the fruits of your labor. We couldn’t have done this without the active participation of you, our members, as well as the close support and coordination from our partners in medicine, public health, early childhood development, child safety, child well-being, and environmental health.  Our friends and supporters in the legislature and in the Executive were also helpful.

Together we raised a strong and multi-focused voice for the children of New York. Here is what we accomplished:

  • 2371a/S.2994a: Medical Exemption Only for Immunization – Passed both Houses and signed by Governor all in one day!
  • 2686/S.2450: Gun Safe Storage – Passed both Houses
  • 0558/S.02833: Tobacco 21 (No one under 21 can purchase tobacco products) – Passed both Houses
  • 00217a/S.3788a: Crib Bumpers (Crib bumpers cannot be sold in NYS) – Passed both Houses
  • 7371/S.5341: Kids Safe Products (Banning & disclosure of dangerous chemicals in children’s products) – Passed both Houses
  • 576/S.1046: Conversion Therapy (No longer legal in NYS) – Passed both Houses and signed by Governor
  • 2477/S.5343: Chlorpyrifos Ban – Passed both Houses
  • 164/S.2387: Period Products Disclosure – Passed both Houses
  • 6295/S.4389: 1,4 Dioxane Ban – Passed both Houses

I will keep you informed as these bills move forward. In addition, there are several other bills directly related to children’s health and well-being that we will be watching that may move toward the Governor’s Office.

Now it’s time to refocus our work for next session and onto some of the serious child and family immigration issues that are currently impacting the health and well-being of thousands of children in our country and our state.