Protecting Breastfeeding during the COVID-19 Pandemic.

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has impacted all patient populations including pregnant mothers. There is an incomplete understanding of SARS-CoV-2 pathogenesis and transmission potential at this time and the resultant anxiety has led to variable breastfeeding recommendations for suspected or confirmed mothers with novel coronavirus disease 2019 (COVID-19). Due to the potential concern for transmission of infection from maternal respiratory secretions to the newborn, temporary separation of the maternal-baby dyad, allowing for expressed breast milk to be fed to the infant, was initially recommended but later revised to include breastfeeding by the American Academy of Pediatrics in contrast to international societies, which recommend direct breastfeeding. This separation can have negative health and emotional implications for both mother and baby. Only two publications have reported SARS-CoV-2 in human breast milk but the role of breast milk as a vehicle of transmission of COVID-19 to the newborns still remains unclear and may indeed be providing protective antibodies against SARS-CoV-2 infection even in infected neonates. Other modes of transmission of infection to neonates from infected mothers or any care providers cannot be overemphasized. Symptomatic mothers on hydroxychloroquine can safely breastfeed and no adverse effects were reported in a baby treated with remdesivir in another drug trial. The excretion of sarilumab in human breast milk is unknown at this time. Hence, given the overall safety of breast milk and both short-term and long-term nutritional, immunological, and developmental advantages of breast milk to newborn, breast milk should not be withheld from baby. The setting of maternal care, severity of maternal infection and availability of resources can impact the decision of breastfeeding, the role of shared decision making on breastfeeding between mother and physician needs to be emphasized. We strongly recommend direct breastfeeding with appropriate hygiene precautions unless the maternal or neonatal health condition warrants separation of this dyad. KEY POINTS: · Breastmilk does not appear to play a significant role in transmission of SARS-CoV-2.. · Mother-baby separation has negative health and emotional consequences.. · Mothers with suspected or confirmed COVID-19 can directly breastfeed with appropriate precautions..

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

The COVID-19 pandemic has created multiple, complex and intense demands on hospitals, including the need for surge planning in the many locations outside epicenters such as northern Italy or New York City. We here describe such surge planning in an Academic Health Center that encompasses a children's hospital. Interprofessional teams from every aspect of inpatient care and hospital operations worked to prepare for a COVID-19 surge. In so doing, they successfully innovated ways to integrate pediatric and adult care and maximize bed capacity. The success of this intense collaborative effort offers an opportunity for ongoing teamwork to enhance efficient, effective, and high-quality patient care.

Raccoon Roundworm Infection Associated with Central Nervous System Disease and Ocular Disease - Six States, 2013-2015.

Baylisascaris procyonis, predominantly found in raccoons, is a ubiquitous roundworm found throughout North America. Although raccoons are typically asymptomatic when infected with the parasite, the larval form of Baylisascaris procyonis can result in fatal human disease or severe neurologic outcomes if not treated rapidly. In the United States, Baylisascaris procyonis is more commonly enzootic in raccoons in the midwestern and northeastern regions and along the West Coast (1). However, since 2002, infections have been documented in other states (Florida and Georgia) and regions (2). Baylisascariasis is not a nationally notifiable disease in the United States, and little is known about how commonly it occurs or the range of clinical disease in humans. Case reports of seven human baylisascariasis cases in the United States diagnosed by Baylisascaris procyonis immunoblot testing at CDC are described, including review of clinical history and laboratory data. Although all seven patients survived, approximately half were left with severe neurologic deficits. Prevention through close monitoring of children at play, frequent handwashing, and clearing of raccoon latrines (communal sites where raccoons defecate) are critical interventions in curbing Baylisascaris infections. Early treatment of suspected cases is critical to prevent permanent sequelae.

Communicating about vaccines and vaccine safety: what are medical residents learning and what do they want to learn?

OBJECTIVE: Physicians spend significant amounts of time discussing vaccine safety concerns with patients and parents. This study aimed to better understand the educational needs of US residents regarding vaccine safety communication, primarily by quantifying the vaccine safety communication training that residents currently receive and elucidating residents' preferences around education about vaccines and vaccine safety communication. DESIGN: A mixed-methods needs assessment consisting of focus groups and a survey. SETTING/PARTICIPANTS: A convenience sample of 303 medical residents in pediatrics, family medicine, and internal medicine from across the United States participated in an online, anonymous survey from March through June 2010. In addition, 9 focus groups with 47 resident participants were held. MAIN OUTCOME MEASURES/RESULTS: The sample included residents in pediatrics (239, 80.2%), internal or family medicine (30, 10.1%), and dual medicine-pediatrics (29, 9.7%); 20.6% of the residents reported "not learning" about vaccine safety communication in their residency programs. Preferred learning methods, which were also the most commonly used methods, included didactic lectures and role-modeling/cases. Electronic teaching method were not only less desired but also very rarely utilized. More than 95% of residents reported thinking that vaccine safety communication would be very or somewhat important in their careers. CONCLUSIONS: Improving education on vaccine safety communication within US residency programs, as well as offering self-learning opportunities, can better prepare physicians for their careers.

Mpox Infection in Children-Infection Control Implications for Household Contacts.

Mpox has recently re-emerged as a global entity of concern. We report one of the first pediatric cases in the United States and provide updated recommendations relevant to infection control and prevention measures of those in close contact with mpox.

Demystifying the Op-Ed. A Novel Group Writing Workshop to Improve Upon Existing Pediatric Advocacy Training.

An op-ed writing workshop utilizing a group compilation exercise increases participant self-reported comfort in writing op-eds and has led to published op-eds. An experiential op-ed writing workshop could be incorporated into advocacy curricula in pediatric residency programs.

Understanding Laboratory Testing for SARS-CoV-2.

The SARS-CoV-2 pandemic has impacted millions of lives worldwide. Molecular assays and serological tests have been approved under EUA (emergency use authorization) by the FDA (food and drug administration), given these unprecedented times. These tests are not only critical for confirming the clinical diagnosis and making therapeutic decisions but also play an important role in the understanding of the epidemiology of the pandemic. There is limited experience with currently available tests and differences may exist among tests even using similar technology. The focus of this review is to improve clinicians' understanding of SARS-CoV-2 test procedures including their limitations. We discuss the impact of different host and environmental factors on test results.

Prevention of spinal fusion post-operative wound infections in pediatric patients with scoliosis: a quality improvement initiative.

PURPOSE: Post-operative wound infections increase patient morbidity and mortality as well as the length of hospital stay, with a profound personal and institutional cost. The aim of this study was to decrease post-operative infections through development of a surgical antibiotic prophylaxis policy based on institution-specific risk factors and microbiology data. METHODS: We conducted a retrospective review of deep wound infections at our institution over a 5-year period (2014-2018). 399 spinal fusion procedures were performed with a 2.5% post-operative infection rate. Patients with neuromuscular scoliosis were six times more likely to develop deep wound infections (7.6%) compared to patients with congenital and idiopathic scoliosis (combined rate of 1.25%). The microbiology data revealed that polymicrobial, extended spectrum beta-lactamase (ESBL) gram negative organisms predominated in patients with neuromuscular scoliosis. Based on these findings, we implemented an evidence-based quality improvement intervention: all patients with neuromuscular scoliosis undergoing spinal fusion were given a single 15 mg/kg dose of amikacin, in addition to our standard practice of perioperative cefazolin plus vancomycin with intra-operative betadine wash and vancomycin powder application. This intervention was put into practice in January 2019. RESULTS: Since the implementation of our quality improvement initiative, the overall post-operative infection rate decreased to 1.1% (2 infections in 176 cases). Ninety-eight percent of the 43 neuromuscular scoliosis patients who underwent spinal fusion in the post-intervention time frame have remained infection free. CONCLUSION: Examination of post-operative infection and microbiology data at the institution level can guide the development of institution specific, evidence-based quality improvement initiatives that reduce post-operative wound infections.

Perinatal SARS-CoV-2 Infection and Neonatal COVID-19: A 2021 Update.

The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has swept across the world like an indiscriminating wildfire. Pregnant women and neonates are particularly vulnerable to this infection compared with older children and healthy young adults, with unique challenges in their management. Unfamiliarity with the consequences of this novel virus and lack of high-quality data led to considerable heterogeneity in obstetrical and neonatal management early in the pandemic. The aim of the this review is to summarize the impact of SARS-CoV-2 infection on pregnancy and childbirth and to examine care and possible outcomes for neonates with Covid-19-positive mothers. A brief review of vaccines currently approved by the United States Food and Drug Administration for emergency use and their potential effects on pregnant and lactating women in included.

Evaluation of Seasonal Respiratory Virus Activity Before and After the Statewide COVID-19 Shelter-in-Place Order in Northern California.

Importance: Public health initiatives that include shelter-in-place orders are expensive and unpopular. Demonstrating the success of these initiatives is essential to justify their systemic or individual cost. Objective: To examine the association of a shelter-in-place order with lower rates of seasonal respiratory viral activity. Design, Setting, and Participants: This cohort study with interrupted time series analysis obtained monthly counts of respiratory virus testing results at UC Davis Health from August 1, 2014, to July 31, 2020. Patients of all ages underwent testing conducted by the laboratory at UC Davis Health, a referral center for a 65 000-square-mile area that includes 33 counties and more than 6 million Northern California residents. Exposures: A statewide shelter-in-place order was instituted on March 19, 2020, restricting residents to their homes except for traveling for essential activities. Large social gatherings were prohibited, schools were closed, and nonessential personnel worked remotely. Those who had to leave their homes were mandated to wear face masks, engage in frequent handwashing, and maintain physical distancing. Main Outcomes and Measures: Positivity rates of common respiratory viruses within the community served by UC Davis Health. Results: A total of 46 128 tests for viral respiratory pathogens over a 6-year period were included in the analysis. For the postexposure period (March 25-July 31), approximately 168 positive test results occurred for the studied organisms in the 2020 virus year, a positivity rate of 9.88 positive results per 100 tests that was much lower than the positivity rate of 29.90 positive results per 100 tests observed for this date range in the previous 5 virus years. In contrast, the positivity rates were similar for the preexposure time frame (August 1-March 24) in the 2020 virus year and for the same time periods in the 5 previous years (30.40 vs 33.68 positive results per 100 tests). In the regression analyses, statistically significant decreases in viral activity were observed in the postexposure period for influenza (93% decrease; incidence rate ratio [IRR], 0.07; 95% CI, 0.02-0.33) and for rhinovirus or enterovirus (81% decrease; IRR, 0.19; 95% CI, 0.09-0.39) infections. Lower rates of postexposure viral activity were seen for respiratory syncytial virus, parainfluenzavirus, coronaviruses, and adenoviruses; however, these associations were not statistically significant. Conclusions and Relevance: Using interrupted time series analysis of testing for viral respiratory pathogens, this study found that statistically significant lower rates of common community respiratory viruses appeared to be associated with a shelter-in-place order during the coronavirus disease 2019 pandemic.

Patient and clinician factors associated with uptake of the human papillomavirus (HPV) vaccine among adolescent patients of a primary care network.

BACKGROUND: Human papillomavirus (HPV) vaccination rates for adolescents remain relatively low. The purpose of this study is to examine patient and clinician factors associated with HPV vaccination among patients, ages 11-17, of a large community-based primary care network. METHODS: Electronic health records and administrative data from a large primary care network from January 2017 - June 2018 for patients ages 11-17 (n = 10,682) and the 198 primary care clinicians that saw them were analyzed. Mixed effects logistic regression models examined the association of patient and clinician factors with HPV vaccine uptake. RESULTS: Most patients (63.0%) had at least one dose of the HPV vaccine, and 37.7% were up to date. In adjusted analyses, patients who received the tetanus, diphtheria, and pertussis (Tdap) vaccine (OR = 2.8, 95% CI: 2.1-3.9) compared to those who did not receive the vaccine and patients with five or more medical visits (OR = 1.9, 95% CI: 1.6-2.2) had the greatest odds of being up to date with the HPV vaccine series. Compared to White patients, African American/Black (OR = 0.8, 95% CI: 0.6 - 1.0) and Alaskan Native/American Indian (OR = 0.5, 95% CI: 0.3-0.9) patients were less likely to be up to date. Boys were also less likely to be up to date with the HPV vaccine series compared to girls (OR = 0.7, 95% CI: 0.7-0.8). Additionally, patients with family/general practice primary care clinicians were less likely to have their patients up to date than those with pediatricians (OR = 0.8, 95% CI: 0.6 - 1.0). CONCLUSION: HPV vaccine uptake varied by patient characteristics, heath care utilization and primary care clinician specialty. These findings may inform future evidence-based interventions aimed at increasing HPV vaccine uptake among adolescents by targeting patient sub-groups and reducing missed opportunities for vaccination.

Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of Clinical Presentation, Hypothetical Pathogenesis, and Proposed Management.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in the multisystem inflammatory syndrome in children (MIS-C). The clinical presentation of MIS-C includes fever, severe illness, and the involvement of two or more organ systems, in combination with laboratory evidence of inflammation and laboratory or epidemiologic evidence of SARS-CoV-2 infection. Some features of MIS-C resemble Kawasaki Disease, toxic shock syndrome, and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. The relationship of MIS-C to SARS-CoV-2 infection suggests that the pathogenesis involves post-infectious immune dysregulation. Patients with MIS-C should ideally be managed in a pediatric intensive care environment since rapid clinical deterioration may occur. Specific immunomodulatory therapy depends on the clinical presentation. The relationship between the immune response to SARS-CoV-2 vaccines in development and MIS-C requires further study.

"There's Always Next Year": Primary Care Team and Parent Perspectives on the Human Papillomavirus Vaccine.

Acceptance of the human papillomavirus (HPV) vaccination among parents and clinicians is high, but uptake remains low. Little is known about organizational and primary care team factors that influence the uptake of the HPV vaccine. Interviews with clinicians, clinic support staff, and parents of adolescent patients were conducted to better understand the interrelationships among the people and the organizational processes that influence HPV vaccine uptake at the point of care. Between July 2016 and February 2017, semi-structured interviews of 40 participants (18 clinicians, 12 clinic support staff, and 10 parents of adolescent patients) in a primary care network were conducted. Organizational structures and processes, such as electronic provider reminders, availability of "vaccination only" appointments, and knowledgeable primary care team members contributed to HPV vaccine uptake. Consistently high support of HPV vaccination was found among key informants; however, rather than refuse HPV vaccination, parents are opting to delay vaccination to a future visit. When parents express the desire to delay, clinicians and care team members described often recommending addressing HPV vaccination at a future visit, giving parents the impression that receiving the vaccine was not time-sensitive for their child. Discordance in HPV vaccination recommendations among providers and clinic support staff may contribute to delayed HPV vaccination. Strong, high-quality HPV vaccine recommendations are needed from all primary team members. Clinic interventions to accelerate HPV vaccine uptake may benefit from a team-based approach where every member of the primary care team is delivering the same consistent messaging about the importance of timely HPV vaccination.

Five-fold increase in pediatric parapneumonic empyema since introduction of pneumococcal conjugate vaccine.

A retrospective review of medical records for all pediatric parapneumonic empyema (PPE) patients admitted to our hospital from 1996 to 2006 revealed that PPE increased 5-fold in the post-heptavalent pneumococcal conjugate vaccine (PCV7) period (2001-2005) relative to the pre-PCV7 period (1996-2000), from 13 cases to 65. Most of this increase was associated with culture-negative empyema, which accounted for 61% of all post-2000 cases; 19% was culture-positive pneumococcal empyema. Our analysis indicates that non-PCV7 serotypes became more prevalent at our institution after introduction of the vaccine.

An Observational Study of Severe Pertussis in 100 Infants ≤120 Days of Age.

BACKGROUND: Pertussis in young infants is a unique, severe, afebrile, cough illness that is frequently fatal. METHODS: All pertussis cases ≤120 days of age admitted to a pediatric intensive care unit in California between October 1, 2013, and April 25, 2015, were evaluated. RESULTS: Of 100 pertussis patients ≤120 days of age admitted to pediatric intensive care unit, there were 5 deaths. The white blood cell counts in the fatal cases were significantly higher than in the nonfatal cases. Thirty-four percent of patients were intubated, 18% received inotropic and/or vasoactive support, 22% received steroid, 4% received extracorporal membrane oxygenation, and 3% underwent exchange blood transfusion. The median age at the time of illness onset in the patients who died was 23 days. CONCLUSIONS: These data, as well as data from previous California studies, suggest updated strategies for the management of severe pertussis. These include perform serial white blood cell counts, treat all presumptive cases with azithromycin, evaluate for pulmonary hypertension, intubate and administer oxygen for apneic episodes and administer inotropic/vasoactive agents for cardiogenic shock. Do not administer steroids or nitric oxide. Criteria for exchange blood transfusion therapy for leukocytosis with lymphocytosis are suggested.

Stage model of recovery for chemically dependent adolescents: part 2--Model evaluation and treatment implications.

This qualitative study, presented in two parts, refines the model of how chemically dependent adolescents initiate and engage in the recovery process. Part 1 (published in 2004) described the research process and results used to derive the model. In Part 2, this model is compared with extant theories on stages of recovery in chemically dependent adults. Participants' stories in large part followed the stages of Stephanie Brown's adult-based Developmental Model of Recovery, but the intensity and focus of some issues (e.g., relationships) and tasks (e.g., separation/individuation) are different for adolescents than for adults. Consequently, the markers of entry into each stage, the focus of tasks within each stage, and the time required to traverse some stages and phases are different for adolescents. Treatment implications for the adolescent population on the basis of these differences are reviewed, and topics for further research are suggested.

Stage model of recovery for chemically dependent adolescents: part 1--methods and model.

This qualitative study, presented in two parts, refines the model of how chemically dependent adolescents initiate and engage in the recovery process. Part 1 describes the research process and results used to derive the model. The model was derived from theory grounded in verbatim reports of 30 chemically dependent participants who first attempted recovery from chemical dependence during adolescence. The constant comparative method of grounded theory was used to analyze the data. This stage model of adolescent recovery includes the using/precontemplation, transition, early recovery, and ongoing recovery stages; the transition stage is divided into contemplation and action phases. The stages, phases, and significant events are similar, but not identical to, those presented in adult-based models of recovery from chemical dependence. In Part 2, the resulting theory is compared with extant theories on stages of recovery in chemically dependent adults, treatment implications for the adolescent population are reviewed, and topics for further research are suggested.