From the Armchair: Tips for school return from a Child Psychologist

Betsy Gard, Ph.D.

  Drbetsy5151@comcast.net

In April 2020, schools were suspended in 188 countries and over 2.5 billon young people worldwide were not in school. As of February 2021, school systems are reopening, but with tremendous variability in policies.  Almost all children and youth have missed at least 25% of teacher-led instruction.  Some children are actually “missing” and have rarely attended virtually. This is more common in those who come from disadvantaged environments or have special learning needs.  These youngsters will need to be reconnected to their school system. In addition, children have missed being in a social structure,  have not been monitored for academic progress, and in many situations, may not be receiving adequate nutrition,  sleep, or exercise.  They also may not be receiving services such as speech, physical, occupational therapy, or educational assistance as specified in their Individualized Education Plans (IEPs).

Although returning to school may be a relief for many children and their families, the impact of the stressors families and children have experienced over the duration of COVID may be exacerbated, for some, by returning to school. Stress affects physiological, psychological and behavioral reactions but can vary by child. It is common that parents and teachers may be distressed by the child’s externalizing behaviors- irritability, oppositionality, anger outbursts, talking back, quarreling with siblings, or unwillingness to cooperate in the family. They may not realize that these behaviors may be due to their child’s fear, anxiety or depression.

Firearm Injury Prevention: The Importance of Safe Firearm Storage

Sofia Chaudhary

sofia.s.chaudhary@emory.edu

A 12-year-old boy with a gunshot wound (GSW) to the chest is wheeled into the trauma bay, unresponsive, pulseless and undergoing CPR and subsequently dies. The patient’s 6-year old brother found their father’s gun while playing and pointed it at him. The parents now face the shattering loss of their older son and also the psychological impacts for their younger son, the second victim. Tragedies such as this have become too familiar for emergency departments across the US as the number of pediatric firearm deaths continue to climb annually

Firearms are the second leading cause of pediatric death in the US taking the lives of over 1,700 and injuring more than 6,500 children and teens (ages 0-17) in 2019.1 Homicide accounted for a majority of these deaths, but 40% were from firearm-assisted suicide and 5% from unintentional injuries. Middle schoolers and high schoolers in the US are now more likely to die from a gun than from any other cause, including motor vehicle collisions.2 Additionally, 4.6 million children in the US live in a home with at least one unlocked and loaded gun, double the rates of firearm exposure from a decade earlier.3 Access to an improperly stored firearm in the home increases the risk of both pediatric unintentional firearm injury and firearm assisted-suicide (by 2-5x).4-7

Childrens’ (CHOA) ED COVID-19/Flu Testing Algorithm

by Thuy Bui

thuy.bui@pemaweb.com

According to the Centers for Disease Control and Prevention (CDC), COVID-19 cases, hospitalizations, and deaths across the United States are rising.  With the socialization that comes with the holiday season and the arrival of cold weather driving more people indoors, this rise in COVID cases will not likely improve any time soon.  Due to the concern of a worsening COVID surge, the possibility of a “twindemic” with the arrival of influenza, and continued limited testing capacity at our hospitals and EDs, medical leadership from Emergency Medicine and Infection Prevention at Children’s Healthcare of Atlanta created an algorithm to help determine how to best utilize available tests for SARS-CoV-2.  

This testing algorithm, which takes into account CDC recommendations, provides a general framework for testing in our emergency departments.  Basic considerations of the algorithm include:

  1. Has the patient had a recent positive COVID PCR or antigen test?
  2. Does the patient exhibit symptoms of COVID-19?
  3. Will the results of the COVID test directly impact acute clinical care or medical management of this patient?
  4. Will the results of the COVID test help in management of a child with a chronic or underlying medical condition?
  5. Will testing impact a child or parent’s ability to return to school or work?

These are the questions our ED providers will have in mind if a child presents or is referred to any of our emergency departments with a concern of COVID-19.

The first consideration is whether or not the child has had a positive COVID PCR or antigen test in the past 3 months.  Since it has been shown that patients may test positive for up to 3 months after recovering from an acute COVID infection and not be contagious to others, COVID testing is not routinely recommended during this time frame.  Testing for other etiologies including influenza and Multisystem Inflammatory Syndrome in Children (MIS-C) may need to be considered.

Adolescent Mental Health During COVID-19 Pandemic and Beyond

Quote

by Kristin Weinschenk kristin.weinschenk@choa.org
By Becky Burger
BeckyBurger@emory.edu

The year 2020 has presented tremendous challenges and changes to all fields of medicine.  As this pandemic has grown in size and impact, there has been growing concern about the impact of social, economic and political stressors on mental health (MH).  Early data from the CDC has shown rising prevalence of symptoms of anxiety, substance abuse, suicidal ideations, and depressive disorders across all ages, with a disproportionate prevalence amongst young adults (62.9% in 18-24yo vs 30.9% in all ages) and racial minorities.1 Data on children and teens is still being collected, but thus far points to similar increases in children and teens. As COVID continues to affect our communities, physicians must be on alert for these growing psychiatric concerns.  

One of the major changes for youth has been the closure of schools and subsequent shift to online education. Children of all ages across the state are now learning virtually and screen time is surpassing the limits recommended by AAP.  While public opinion often considers social media as having a negative impact on MH, the data around this is mixed.4,5   Rather than focusing on social media use itself, it may be more helpful to look at specific exposures to negative aspects of social media, such as online bullying, sexual exploitation, and trauma exposure.5,6  An example that has received considerable media attention this year is the prevalence across social media platforms of videos depicting police brutality of minorities.  The American Academy of Child and Adolescent Psychiatry (AACAP) recommends parents have an active, hands on role in helping children process information they have learned from the news about tragedies. When children view these images on social media, they often lack the parental support and context, and may experience higher stress related responses.7   As screen time increases, parents should be advised to remain engaged in what their children are viewing and how they are processing that information.  Physicians should also be ready to discuss in detail how patients are using their screen time and how it may be affecting their mood and thoughts. 

THE HIGH AND LOWS OF CANNABIS

Ricardo Jimenez, MD

Cannabis, also known as Marijuana, remains the most used illegal drug in the United States. National estimates suggest that 22.2 million people 12 years or older are current users of Cannabis. The primary cannabinoids in cannabis are 9-Tetrahydrocannabinol (THC) and cannabinol (CBD). THC is primarily responsible for the psychoactive properties of cannabis. Cannabinoids are thought to exert their pharmacological activity via several mechanisms. The most studied  is the receptor mediated mechanism that includes two receptors, Cannabinoid-binding receptor 1 (CB1) and Cannabinoid-binding receptor 2 (CB2). CB1 receptors are located throughout the central nervous system (CNS) and CB2 are only found in the peripheral tissues. Stimulation of the receptors in the CNS produces hallucinations, memory loss, dyskinesia, and sedation. The actions of CB2 are receptors are not yet clear. 

            The increase in legalization, availability, and marketing of cannabis, correlates to an increase in unintentional pediatric exposures. Pediatric exposures to cannabis rose from 148% from 2006 to 2013. Since the decriminalization of cannabis, there has been an explosion of dispensaries that have catapulted cannabis to be a major industry generating $ 2.3 billion dollars in sales in Colorado alone. Part of this growth has included expansion in the available forms of cannabis, including edible products, concentrated tinctures, and e-cigarettes. Many commercial cannabis-infused edibles are produced in the form of cookies, cakes, candy bars, and even drinks, which are indistinguishable to children from their non-cannabis counterparts. Edibles have become the most common form of unintentional cannabis exposure in pediatrics. 

Safe Sleep and Sudden Unexpected Infant Death-Preparing for Safe Sleep Awareness Month in October

Sarah Lazarus, MD

The Center for Disease Control and Prevention (CDC) defines sudden unexpected infant death (SUID) as “the sudden death of an infant under 1 year of age that cannot be explained after a thorough investigation.” SUID is routinely classified as: 1) sudden infant death syndrome (SIDS), 2) accidental suffocation and strangulation in bed (ASSB), or 3) death from unknown causes. Each year, around 4,000 U.S. babies die from SUID, making it an important topic to understand and effect change. In Georgia, there are three deaths every week from SUID. Between 1990 and 1999, the SUID rate drastically declined following numerous safe sleep campaigns, the most notable being the “Back to Sleep” campaign in 1994. In 2012, the AAP expanded their focus to include environmental recommendations (such as sleep location and environment) and renamed it the “Safe to Sleep” campaign. Since 1997, SIDS deaths have become less common; however, rates of infant death due to unknown causes and ASSB are stagnant. With proper safe sleep education and adherence to the American Academy of Pediatrics (AAP) safe sleep recommendations, the risk of sleep-related infant death can be reduced.

Update on SARS-CoV-2 in Children and Multisystem Inflammatory Syndrome in Children

A 12-year-old boy presented to the emergency department with 3 days of fever, vomiting for one day and rash. On presentation he was febrile to 38.5 C, tachycardic to 122, and had normal blood pressure, oxygen saturations and respiration rate. His exam was notable for a sandpaper rash and mild conjunctivitis. He later tested positive for SARS-CoV-2 antibodies. This is an example of a patient who was determined to have Multisystem Inflammatory Syndrome in Children (MIS-C), understood to be a post-viral inflammatory response to SARS-CoV-2. This article will briefly review SARS-CoV-2 infections in children, the MIS-C phenomenon, and recommendations for transfer.

While the majority of children exhibit mild symptoms when infected with SARS-CoV-2, a unique picture of how the virus impacts children continues to evolve. Early epidemiological studies from China and Italy showed that up to one-fifth of infected children were asymptomatic, half were mild and had only upper respiratory symptoms, about a third had pneumonia but without respiratory distress or hypoxemia, and 1% had severe infections.

In late March, physicians in Italy and the United Kingdom noticed higher numbers children presented to their hospitals with some stigmata of Kawasaki disease. Some became very ill with vasodilatory shock and some showed signs of severe inflammatory reactions consistent with macrophage activation syndrome. Many exhibited cardiovascular compromise and needed various forms of support: intubation, inotropes, and even extracorporeal membrane oxygenation. They tended to be lymphopenic and thrombocytopenic, with high inflammatory markers like CRP, ESR, ferritin, d-dimer, and cardiac markers if the disease progressed to the cardiovascular system. They tended to be older than traditional Kawasaki disease pateints.4,5

Soon after, similar cases were noticed in the United States, initially in New York. To better define this phenomenon, it was given the name MIS-C Associated with Coronavirus Disease 2019. The New York experience largely corroborates the European experience and adds that many of these children were resistant to intravenous immunoglobulin (IVIG), the typical treatment for Kawasaki disease, and needed steroids and sometimes immunomodulatory medication. Judicious fluid administration was also emphasized as many of these children have cardiovascular compromise. 6

Adolescent Gynecology at Children's Healthcare of Atlanta

Krista Childress, MD

Adolescent females can present with a wide spectrum of gynecologic complaints and the differential diagnosis can be broad. It is important for providers to be familiar with common gynecologic conditions and their treatment, and when it is appropriate to refer to or consult a gynecologic specialist or refer to the emergency room (ER). Below is an overview of some of the most common adolescent gynecologic diagnoses and management recommendations. 

Abnormal Uterine Bleeding (AUB)

AUB is defined as menses outside the range of normal defined as: every 21-45 days, last < 7 days, and < 6 pads or tampons per day. Menses can be irregular for 2-3 years after menarche, however, no adolescent should go more than 3 months without a menses. The most common causes of irregular menses and/or prolonged heavy menses include anovulation due to endocrine causes or immaturity of the hypothalamic pituitary axis and bleeding disorders, the most common being Von Willebrand Disease. Work up for irregular menses includes TSH, Prolactin, LH, FSH, Estradiol, 17 OHP, testosterone, and gonorrhea/chlamydia if sexually active. A bleeding disorder work up is warranted if girls are consistently having prolonged heavy menses leading to anemia, flooding, doubling up pads, or other concerning symptoms such as easy bruising or gum bleeding. Recommended work up includes CBC, coagulation panel, TSH, and Von Willebrand Panel. Menses can be controlled with combined (estrogen/progesterone) hormonal contraceptives (pill, patch, ring) or progesterone only options (pill, injection, arm implant, and intrauterine device) which are ideally initiated after hormone work up for AUB is completed. Girls warrant referral to the ER if they have prolonged bleeding leading to significant anemia (hemoglobin < 8), soaking 1 pad or tampon per hour, or have symptomatic anemia. Heavy menstrual bleeding can be stopped acutely with the assistance of combined hormone pill taper or progesterone only pill taper (e.g. norethindrone acetate).

Abdominal and Pelvic Pain

The differential diagnosis for gynecologic causes of abdominal pain is broad including: dysmenorrhea, ovarian masses, pelvic inflammatory disease, and mullerian anomalies. Treatment for dysmenorrhea includes scheduled NSAIDS starting 1-2 days prior to menses and lasting throughout followed by hormonal contraception if treatment fails. Persistent abdominal pain not relieved by NSAIDS or acute severe pelvic pain warrants a pelvic ultrasound to evaluate the uterus and adnexa (ovaries/fallopian tubes).  Adnexa > 5 cm with severe abdominal pain, nausea and vomiting warrant ER evaluation given the concern for ovarian torsion. Pelvic inflammatory disease is defined as uterine, adnexal, or cervical tenderness plus abdominal pain and should be prophylactically treated in any girl who is sexually active. Reasons for referral to the ER include nausea/vomiting, unable to tolerate oral medications, fever, or failed outpatient treatment. Obstructive mullerian anomalies such as imperforate hymen or non-communicating uterine remnants should also be considered when a patient has cyclical monthly pain or on examination has breast development and no vaginal opening. Patients with these diagnoses warrant ER evaluation if they have uncontrolled pain or difficulty with urination. 

Vulvar Trauma and Genital Ulcers

Straddle injuries are very common and warrant ER evaluation when a large laceration is present, persistent bleeding, or large vulvar hematoma causing severe pain or inability to urinate. Most vulvar hematomas, though frightening on examination, will resolve with conservative management (NSAIDS, ice, rest) on their own. Lipshultz or aphthous vulvar ulcers should be in the differential for genital ulcers. It is a diagnosis of exclusion after diagnoses such as HSV. They are commonly caused by a viral illness (e.g. upper respiratory illness or gastroenteritis) and typically present 3-4 days after prodromal viral symptoms. Treatment is symptomatic including scheduled pain medication and topical or oral steroids. Indications for referral to the ER include uncontrolled pain and difficulties with urination. 

Pediatric and Adolescent Gynecology in Atlanta!

Krista Childress, MD and Abigail Smith, PA-C are two pediatric gynecology providers at Children’s Healthcare of Atlanta that see patients birth to 21 years of age and treat a broad spectrum of gynecologic conditions from menstrual issues, contraceptive counseling, pre-pubertal complaints to surgical conditions including ovarian cysts and uterine/vaginal abnormalities. Don’t hesitate to reach out to Krista Childress, MD or Abigail Smith, PA-C for consultations, clinical questions, or patient referrals. They can be contacted at krista.childress@emory.edu or Abigail.smith@choa.org or Pediatric and Adolescent Gynecology Clinic at (404)-785-1491. Please see their website for information and referral links: https://www.choa.org/medical-services/gynecology.

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Eating Disorders Management at Children's Healthcare of Atlanta


Laura Elizabeth Doerr, MD, FAAP


When Karen Carpenter died of heart failure in 1983 from Anorexia nervosa, it raised awareness about the complications of eating disorders. Before her death there wasn’t much discussion about eating disorders and the dangers of rapid weight loss. Until recently, eating disorders were considered the most lethal of the mental health disorders. Now it is only second to opiate abuse as the most lethal of these conditions. 

Eating Disorder Admissions at Children’s Healthcare of Atlanta
            Recently, we have seen an exponential increase in the admissions of patients with Eating Disorders at Children’s Healthcare of Atlanta. The incidence has increased exponentially from 18 admissions in 2010 to over 110 in 2018. Eating Disorders are mental illnesses that can have serious medical complications that can affect almost every organ system. The median age of onset is 12-13 years of age, and it can affect both genders. There has also been an increase in the diagnosis of eating disorders among the transgender population.
            At Children’s Healthcare of Atlanta, there are protocols in place for the management of these patients in the ED and inpatient services. This assists in early recognition and triage of these patients as they are evaluated to see if they warrant admission for medical stabilization (see chart end of article). The American Academy of Pediatrics has come up with a list of objective criteria to help with determining who warrants admission to the hospital. This includes such objective measures as vital signs (i.e. heart rates < 50 beats per minute), electrolyte criteria (such as phosphorus < 3.0), and consideration of patients that are most at risk of refeeding syndrome. It is the hope that this triage system will help with early recognition of patients with these disorders and help with admitting those who warrant medical stabilization.

Atypical Anorexia Nervosa
            Some of the most challenging patients to recognize are those with atypical Anorexia nervosa. By definition these patients would meet DSM-V criteria for the condition except that they may present with a normal weight and/or BMI. This can make it a challenge to recognized and this is why these patients may present later or more ill-appearing, given if they are looked at as a single plot on the growth chart they may look like their weight or BMI is within normal range. 
            In conclusion, it is important to ask questions when a symptom raises a concern about an eating disorder. Is the patient overly concerned about his or her weight? Have they recently adopted a radical diet change, such as converting to a vegan diet? Have they developed primary or secondary amenorrhea? Or on their growth chart, have they plateaued or failed to achieve appropriate increases in their growth over time.?
            If you do have concerns about a patient that may have an eating disorder, it may be worth having them triaged at one of our Children’s Healthcare of Atlanta facilities. There if they meet criteria for medical stabilization, they can be admitted to our inpatient unit at Scottish Rite. We have a multidisciplinary team that includes psychiatry, hospitalist medicine, case management, nutrition and child life. Our goal is to help manage these patients medically and then transition them to an appropriate level of care post-discharge that could involve inpatient eating disorder treatment or outpatient therapy, depending on the needs of the patient and family. 
Contact information: Laura Doerr, MD, FAAP. Laura.doerr@choa.org
 

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Not everything is Louis Vuitton -New Designer Drugs of Abuse

Ricardo Jimenez, Pediatric Emergency Medicine Physician

As physicians working in acute care centers or emergency departments, it’s a daily challenge dealing with patients who are intoxicated. But as new street drugs emerge in the community this challenge is even more difficult. Street drugs or designer drugs, are those drugs that are produced by “street pharmacists” at home or in clandestine laboratories. The goal of these drugs is to mimic the most common general classes of drugs that are abused. These new designer drugs are more easily found and affordable than their counterparts, most of them can be found on the internet or local smoke shops, and are considered “legal highs”. Because the street drug’s chemical composition is different from those that they try to mimic, in most cases the US DEA has no jurisdiction over them. At the same speed that the DEA is developing laws to govern these new chemicals, the street pharmacists can easily change the chemical composition,  thus  avoiding the DEA’s jurisdiction. To be prepared to manage intoxications from these new designer drugs, the physician must have a strong knowledge of the common drugs of abuse toxidromes. It’s impossible in the length of this article to discuss all the common designer drugs.  I will discuss those that mimic the most common general classes of drugs of abuse; Synthetic Cannabinoids, Synthetic Cathinones and opioid analogues.  

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