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Advances in Pediatrics

Emerging from the Pandemic: Taking Up Where We Left Off with Newer Modalities, Assessment, and Treatment

      During the past year, COVID-19 continued to be a prominent topic for lectures, conferences, and webinars. The medical environment was transformed into a virtual arena, where audiences were able to hear speakers from around the nation without their need to travel. Resident and fellow recruitment also became virtual, leading to increased numbers of applicants, some of whom had limited clinical opportunities during medical school. Even in-person patient contact dropped, especially initially, and telemedicine replaced the in-person visit. Increasingly sophisticated virtual medical encounters continue to be offered, using video interviews. We now face new challenges, including the need for evidence-based guidelines and concerns about equity, where computer and internet access may be marginal. Many children were taught virtually, which was particularly challenging for children with special needs. The absence of in-person visits impacted the ability of physicians to do developmental screening and assess for autism. Therapeutic services for autistic children were severely impacted. Overall approaches to disruptive behaviors in children by “HOT DOC” (Helping Our Toddlers, Developing Our Children’s Skills), a community-based group invention, was less accessible during the pandemic. The program was successfully taught to pediatric residents, providing them with practical training to help families. Among other children with special health care needs are deaf or hard of hearing (DHH [the preferred terminology]) individuals. Public awareness of the deaf culture was showcased by the academy award-winning movie “CODA” (Children of Deaf Adults).
      While there has been a plethora of new drugs to treat epilepsy, some children remain drug-resistant, and brain surgery provides a reduced seizure burden and increased quality of life. Early referral to a pediatric epilepsy center is recommended as a means to reduce the risk of a secondary epileptic focus. Chronic sinusitis and obstructive sleep apnea (OSA) each involve both medical and surgical management. If chronic sinusitis persists after nasal irrigation, nasal or systemic steroids and/or antibiotics, adenoidectomy, and FESS (functional endoscopic sinus surgery) need to be considered. The Childhood Adenotonsillectomy Trial reported that adenotonsillectomy (T and A) had a beneficial effect on OSA, but there are times when OSA is not relieved by a T and A, and other anatomical findings, such as craniofacial anomalies, have to be considered.
      Chronic childhood diseases are a testimony to improved care so that children grow into adolescents and adulthood. Antiphospholipid syndrome is a rare pediatric disorder that may be life-threatening. While the symptoms are suggestive of lupus, any child with thrombosis should be screened for antiphospholipid syndrome. Managing children with advanced stage kidney disease has improved the longevity and quality of life of these children. Like other chronic conditions, these children are best managed by a multidisciplinary team that also manages the comorbid conditions, including bone disease, anemia, growth failure, and psychosocial issues. Hemophilia A is an inherited insufficiency of Factor VIII and is sometimes referred to as the “Royal Disease.” Queen Victoria was a carrier, and the condition was thought to contribute to the Russian Revolution of 1917. Replacement factor and newer therapeutic options, including emicizumab, a biphasic monoclonal antibody, could have changed the course of history had they been available back then!
      Ultimately, the ability of children to return to in-person school was assisted by the development of COVID-19 vaccines and the eventual approval the vaccine for children older than 5 years. As with other vaccines, there was vaccine hesitancy, with some parents choosing not to vaccinate their children often based on misinformation that was in the media. The issue of vaccine hesitancy was addressed by the World Health Organization, who convened a working group in 2012. In the absence of in-person visits, many children fell behind on their immunizations. With the return to in-person visits, this gap is still being filled. It is hoped we will not see a resurgence of some of the diseases that vaccines had virtually eliminated, such as polio and measles. Unfortunately, there is not a vaccine for all diseases, and genital herpes simplex virus (HSV) is still a problem, especially for pregnant women and their newborn infants. Fortunately, there are nucleoside analogues that reduce the frequency and severity of primary and episodic HSV infection.
      Short statue has always been high on the list of conditions that pediatricians manage. While short statue is a frequent component of Turner syndrome, it has become apparent that the spectrum of Turner syndrome is much broader than the classic image of the short girl with primary amenorrhea and a shieldlike chest. In fact, a retrospective study of 522 women with Turner syndrome reported that 16% had spontaneous menarche and 3 had become pregnant. Growth hormone is part of the management of Turner syndrome as well as a host of other entities, such as Prader-Willi syndrome, Noonan syndrome, and chronic renal insufficiency. Just as the use of growth hormone has advanced, the treatment of hyperthyroidism has also changed, with methimazole being first-line therapy, and the use of methimazole for up to 8 years in children is associated with remission. Pilonidal cysts are best managed by a minimally invasive approach, including an endoscopic procedure with removal of pits and sinuses. While one always expects that surgery is needed in all cases of small bowel obstructions, the advice now is to distinguish between those requiring urgent surgical management and those who qualify for initial nonoperative care. When operative management is critical, postoperative care is equally important. Pain management in children is just as important as in adults and requires the same level of attention and expertise. Physicians should be cognizant of unconscious bias in pain management strategies when caring for minority children and their families. Opiates may not be used by families after discharge, and families need to be advised about safe storage and disposal.
      Though it may feel as though time has stood still for the past 2½ years, newer treatments, approaches, and management have continued during this time. Advances in Pediatrics remains in the forefront of bringing together a wide range of topics with which pediatricians deal on a daily basis, virtually or in-person.