Lessons from the "non-critical" patient during a pandemic: developmental-behavioural pediatric populations & COVID-19

Seemingly overnight, in March 2020, the world was turned upside down by the global SARS-CoV 2 (novel coronavirus) pandemic. As COVID-19 affected all aspects of clinical care, Canadian ambulatory clinics for any service deemed "non-urgent" or "non-critical," were suspended for several months. When outpatient care slowly resumed during the summer and fall of 2020, the backlog of patients in these areas and subsequent requests for follow-up significantly outpaced the number of available appointments. In fact, it became apparent that certain patients' needs had grown in unprecedented ways during the pandemic, even though their issues had previously been given low priority during the acute crisis period. Among these groups were youth with underlying mental health conditions, those with chronic but non-life-threatening illnesses, and the subgroups seen in Developmental-Behavioural Pediatrics. In Montréal, they were among the least likely to have their needs met as the waves of COVID-19 moved through the community, and many still struggle to find relevancy in the discussions about the hidden impacts of the coronavirus pandemic, even one year later. What can the experiences of these marginalised youth teach us about what our system labels less relevant care in the context of an acute health care crisis? A short narrative presentation will demonstrate insights gleaned from 2020 & early 2021 to underscore the often unrecognised challenges faced by these populations and their families.

An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities

Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.

Moraxella-dominated pediatric nasopharyngeal microbiota associate with upper respiratory infection and sinusitis

Background Distinct bacterial upper airway microbiota structures have been described in pediatric populations, and relate to risk of respiratory viral infection and, exacerbations of asthma. We hypothesized that distinct nasopharyngeal (NP) microbiota structures exist in pediatric populations, relate to environmental exposures and modify risk of acute sinusitis or upper respiratory infection (URI) in children. Methods Bacterial 16S rRNA profiles from nasopharyngeal swabs (n = 354) collected longitudinally over a one-year period from 58 children, aged four to seven years, were analyzed and correlated with environmental variables, URI, and sinusitis outcomes. Results Variance in nasopharyngeal microbiota composition significantly related to clinical outcomes, participant characteristics and environmental exposures including dominant bacterial genus, season, daycare attendance and tobacco exposure. Four distinct nasopharyngeal microbiota structures (Cluster I-IV) were evident and differed with respect to URI and sinusitis outcomes. These clusters were characteristically either dominated by Moraxella with sparse underlying taxa (Cluster I), comprised of a non-dominated, diverse microbiota (Cluster II), dominated by Alloiococcus/Corynebacterium (Cluster III), or by Haemophilus (Cluster IV). Cluster I was associated with increased risk of URI and sinusitis (RR = 1.18, p = 0.046; RR = 1.25, p = 0.009, respectively) in the population studied. Conclusion In a pediatric population, URI and sinusitis associate with the presence of Moraxella-dominated NP microbiota.

A Retrospective Review of Opioid Prescribing Practices for At-Risk Pediatric Populations Undergoing Ambulatory Surgery

OBJECTIVE Pediatric patients with sleep-disordered breathing (SDB) and obesity are at risk for opioid-induced respiratory depression. Although monitoring in the inpatient setting allows for early recognition of opioid-related adverse events, there is far less vigilance after ambulatory surgery as patients are discharged home. Guidelines for proper opioid dosing in these pediatric subsets have not been established. We sought to determine if at-risk children were more likely to receive doses of opioids outside the recommended range. METHODS Baseline opioid prescribing data for all outpatient surgery patients receiving an opioid prescription between January 2019 and June 2020 were retrospectively reviewed. Patients with SDB or obesity were identified. To obtain more information about prescribing practices, we analyzed patient demographics, size descriptors used for calculations, and prescription characteristics (dose, duration, and prescribing surgical service). RESULTS A total of 4674 patients received an opioid prescription after outpatient surgery. Of those, 173 patients had SDB and 128 were obese. Surgical subspecialties rendering most of the opioid prescriptions included otolaryngology and orthopedics. Obese patients were more likely (64%) to be prescribed opioids using ideal weight at higher mg/kg doses (>0.05 mg/kg; 83.3%; p < 0.0001). When providers used actual body weight, lower mg/kg doses were more likely to be used (53.7%; p < 0.0001). No prescriptions used lean body mass. CONCLUSIONS Overweight/obese children were more likely to receive opioid doses outside the recommended range. Variability in prescribing patterns demonstrates the need for more detailed guidelines to minimize the risk of opioid-induced respiratory complications in vulnerable pediatric populations.

Therapeutic Opportunities for Headaches and Migraines in Pediatric Populations: A Review

Headaches, migraine-like episodes, and other associated conditions are increasingly becoming the most frequent occurrence and a threat to the pediatric population in today’s world. It has become the most sought-after therapeutic opportunity in the clinical setting in a way that can help to treat, diagnose and minimize its ill effects or side effects in today’s world which has witnessed all severe forms of diseases and hopefully will witness more severe forms because of the everlasting unhealthy lifestyle and prevalent hypertension which can be maternal or paternal and can affect the newborn as well as all the pediatric age groups in today’s world. Severe forms of Headachin children or pediatric age groups can be a massive challenge for the clinician to identify, diagnose, and provide effective treatment that can be curable in most cases but can be fatal. In pediatric populations, headaches or migraines can result from underlying conditions, pathologies, or effects of maternal and paternal habits or lifestyles that need more attention than the symptom itself. The treatment spectrum ranges from pharmacological interventions to more unconventional options like acupuncture and alternative medicine. All these options are worth considering, as several studies show high efficacy and success rates with each of these conditions and etiology discussed above. In this review, the authors aim to discuss these different therapeutic options and weigh out their pros and cons, which can help in better and effective treatment to control or eliminate this disease.

Immune Dysregulation Is Associated with Neurodevelopment and Neurocognitive Performance in HIV Pediatric Populations—A Scoping Review

HIV-1 is known for its complex interaction with the dysregulated immune system and is responsible for the development of neurocognitive deficits and neurodevelopmental delays in pediatric HIV populations. Considering that HIV-1-induced immune dysregulation and its association with neurodevelopmental and neurocognitive impairments in pediatric populations are not well understood, we conducted a scoping review on this topic. The study aimed to systematically review the association of blood and cerebrospinal fluid (CSF) immune markers with neurocognitive deficits and neurodevelopmental delays in pediatric HIV populations. PubMed, Scopus, and Web of Science databases were searched using a search protocol designed specifically for this study. Studies were selected based on a set eligibility criterion. Titles, abstracts, and full texts were assessed by two independent reviewers. Data from the selected studies were extracted and analyzed by two independent reviewers. Seven studies were considered eligible for use in this context, which included four cross-sectional and three longitudinal studies. An average of 130 (±70.61) children living with HIV, 138 (±65.37) children exposed to HIV but uninfected and 90 (±86.66) HIV-negative participants were included across the seven studies. Results indicate that blood and CSF immune markers are associated with neurocognitive development/performance in pediatric HIV populations. Only seven studies met the inclusion criteria, therefore, these limited the number of significant conclusions which could have been made by using such an approach. All considered, the evidence suggests that immune dysregulation, as in the case of adult HIV populations, also has a significant association with neurocognitive performance in pediatric HIV populations.

Somatic and Abdominal Acupuncture for Pain Treatment in Adolescent Complex Regional Pain Syndrome (CRPS) of the Upper Limb: A Case Report

Complex regional pain syndrome (CRPS) is still poorly understood. It is a pain disorder in which pain is disproportionate to the initial stimulus. There is no specific therapy for CRPS, but it can be managed by a combination of treatments. We report a 13-year-old girl with CRPS of the upper limb treated with somatic and abdominal acupuncture. She described a severe, pulsating pain in the left wrist and hand, with hypersensitivity, allodynia, a marked reduction in strength, and swelling and sweating at the level of the fingers. Pain began three months previously, after a trauma to the left wrist. The diagnostic tests performed were negative. At the first visit we recommended oral tramadol. During the first two sessions we used somatic acupuncture. At the third session, the girl reported suffering intolerable pain in the affected limb during the previous sessions, so we decided to use abdominal acupuncture. After 8 sessions of abdominal acupuncture the pain completely disappeared. Acupuncture could be a potential alternative when conservative therapy with physical and medical treatment fails, but more often parents and adolescents prefer this therapy since other comorbidities are often present in pediatric populations and abdominal acupuncture could be a valuable alternative aid.

Factors Influencing US Hospital and Medical School Participation in Pediatric COVID-19 Research

BACKGROUND AND OBJECTIVES: Literature suggests that funding for pediatric clinical trials is inequitably awarded. Furthermore, although coronavirus disease 2019 (COVID-19) affected all hospitals, institutions with already limited resources were more severely impacted. We hypothesized that there would be difference in schools and hospitals that were able to participate in the initial round of pediatric COVID-19 clinical research. METHODS: We searched online databases for preregistered studies using the keywords “COVID-19,” “COVID,” “SARS-CoV-2,” “2019-nCov,” “2019 novel coronavirus,” and “severe acute respiratory syndrome coronavirus 2.” Search results were limited to studies enrolling participants from birth to 17 years, studies started in 2020, and studies originating in the United states. We calculated the proportion of institutions with active COVID-19 pediatric clinical studies in 2020 and compared institutional characteristics between institutions with and without at least one qualifying COVID-19 study, using rank-sum tests, χ2 tests, or Fisher’s exact tests, as appropriate. RESULTS: We identified 150 allopathic medical schools, 34 osteopathic medical schools, and 178 children’s hospitals meeting inclusion criteria. Among included institutions, 25% of medical schools and 20% children’s hospitals participated in 1 of the registered pediatric COVID-19 studies the year before the study period. Institutions that participated in pediatric COVID-19 studies had more publications, more National Institutes of Health funding, and more studies registered on Clinicaltrials.gov in 2019. CONCLUSIONS: Despite the pandemic affecting everyone, participation in early clinical research on the impact of COVID-19 in pediatric populations was concentrated in a few well-resourced institutions that were highly experienced in research.

The Epidemiology of Neurological Complications in Adults With Sickle Cell Disease: A Retrospective Cohort Study

Introduction: Risk factors for neurological complications in sickle cell disease differ in the adult and pediatric populations. Here, we focused on neurological complications in adults with sickle cell disease.Methods: Patients were selected using the audit data from the St George's Hospital Red Cell Database. The genotyping, demographics, clinical data, and investigation findings were collected.Results: A total of 303 patients were enrolled in the study: hemoglobin S homozygosity (HbSS) genotype 56%, hemoglobin S and C coinheritance (HbSC) genotype 35%, and hemoglobin S and β-thalassemia coinheritance (HbSβ) thalassemia genotype 9%; the mean age was 38.8 years (±13.5 SD) with 46% males. The most common neurological complication was cerebrovascular disease (n = 37, 12%) including those with ischemic stroke (10%), cerebral vasculopathy (3%), and intracranial hemorrhage (1%). Ischemic stroke was common among the HbSS genotype compared with other genotypes (8 vs. 1.6%, p = 0.001). Comparing the patients with sickle cell disease who had suffered a stroke to those who had not, there was a higher proportion of intracranial vasculopathy (p = 0.001, in particular, Moyamoya) and cognitive dysfunction (p < 0.0001).Conclusion: Our cohort supports previous reports that the most common neurological complication in adult sickle cell patients is cerebrovascular disease. Strategies to prevent cerebral vasculopathy and cognitive impairment should be explored.