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Health

Infant screen time could impact academic success, study says

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CNN
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Letting infants watch tablets and TV may be impairing their academic achievement and emotional well-being later on, according to a new study.

Researchers found that increased use of screen time during infancy was associated with poorer executive functioning once the child was 9 years old, according to the study published Monday in the journal JAMA Pediatrics.

Executive functioning skills are mental processes that “enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully,” according to the Harvard University Center on the Developing Child.

Those executive functioning skills are important for higher-level cognition, such as emotional regulation, learning, academic achievement and mental health, according to the study. They influence our success socially, academically, professionally and in how we care for ourselves, said Dr. Erika Chiappini, assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine in Baltimore.

“Though these cognitive processes naturally develop from infancy through adulthood, they are also impacted by the experiences that we have and when we have them in our development,” said Chiappini, who was not involved in the study, in an email.

The results support recommendations from the American Academy of Pediatrics, which discourages all screen time before 18 months old, with the exception of video chatting, said Dr. Joyce Harrison, associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. Harrison was not involved in the research.

The study looked at data from Growing Up in Singapore Towards healthy Outcomes, or GUSTO, which surveyed women from all socioeconomic backgrounds during their first trimester of pregnancy. The sample was made up of 437 children who underwent electroencephalography (EEG) scans, which are used to look at the neural pathways of cognitive functions in the brain, at age 1, 18 months and 9 years old.

The parents reported each child’s screen time, and researchers found there was an association between screen time in infancy and attention and executive function at 9 years old, according to the study.

Further research needs to be done, however, to determine if the screen time caused the impairments in executive function or if there are other factors in the child’s environment that predispose them to both more screen time and poorer executive functioning, the study noted.

In a learning-packed time like infancy, one of the big problems with screen use is that young children aren’t learning much from them, according to AAP.

“There is no substitute for adult interaction, modeling and teaching,” Harrison said.

Babies have a hard time interpreting information presented in two dimensions, such as on screens, and have trouble distinguishing fantasy from reality, Chiappini said.

“Babies and kids are also social learners and very much benefit from the back-and-forth interaction with others (adults and kids) which is hard to achieve with screens,” Chiappini said via email.

When it comes to emotional regulation, infants and toddlers can learn from their caregivers when they model self-control or help to label emotions and appropriate expressions, she added.

For example, you can give a young child options for what they can do when they are mad, like taking a break or breathing deeply instead of inappropriate behaviors like hitting, Harrison said.

Talking about emotions can be too abstract for preschool-age kids, and in those cases using color zones to talk about emotions can be helpful, said Dr. Jenny Radesky, a developmental behavioral pediatrician and associate professor of pediatrics at Michigan Medicine C.S. Mott Children’s Hospital. Radesky was not involved in the research.

Calm and content can be green; worried or agitated can be yellow; and upset or angry can be red, using graphics or images of faces to help kids match what they’re feeling with their color zone. To reinforce it, adults can talk about their own emotions in terms of colors in front of their kids, Radesky said in a CNN previous article.

Parents and children can go through the colors together and come up with calming tools for the different zones, she added.

To strengthen those executive function skills, Harrison says it’s important to provide structured engagement where a child can work through solving problems to the extent that they can at their developmental level — instead of having problems solved for them.

And yet, sometimes parents just need to get the laundry done or attend a work meeting, and screens can feel like an effective distraction.

For very young children, it’s probably still best to avoid screen time, Harrison emphasized.

Instead, try to involve the child in house chores, she said.

“Give your toddler some clothes to fold alongside you while you are trying to get laundry done or keep your infant safely in a position where you can make frequent eye contact while you are engaged your chore,” Harrison said via email.

For older preschoolers, save up your screen time to use strategically, she said.

“For example, their one hour of screen time can be reserved for a time when you have an important video meeting to attend,” Harrison said.

And there is some content that can help teach emotional regulation when your tank is empty. Finding media that is aimed at speaking to children directly about emotions — like Daniel Tiger or Elmo Belly Breathing — can be like a meditation instead of distraction, Radesky previously told CNN.

And you can make screen time works better by engaging your child while they watch, Chiappini said. Ask questions like “what is that character feeling?” and “what could they do to help their friend?” she added.

Raising children is a complex and sometimes overwhelming task, and no caregiver can give their child everything they want to all the time, Radesky said.

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FDA vaccine advisers vote to harmonize Covid-19 vaccines in the United States

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CNN
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A panel of independent experts that advises the US Food and Drug Administration on its vaccine decisions voted unanimously Thursday to update all Covid-19 vaccines so they contain the same ingredients as the two-strain shots that are now used as booster doses.

The vote means young children and others who haven’t been vaccinated may soon be eligible to receive two-strain vaccines that more closely match the circulating viruses as their primary series.

The FDA must sign off on the committee’s recommendation, which it is likely to do, before it goes into effect.

Currently, the US offers two types of Covid-19 vaccines. The first shots people get – also called the primary series – contain a single set of instructions that teach the immune system to fight off the original version of the virus, which emerged in 2019.

This index strain is no longer circulating. It was overrun months ago by an ever-evolving parade of new variants.

Last year, in consultation with its advisers, the FDA decided that it was time to update the vaccines. These two-strain, or bivalent, shots contain two sets of instructions; one set reminds the immune system about the original version of the coronavirus, and the second set teaches the immune system to recognize and fight off Omicron’s BA.4 and BA.5 subvariants, which emerged in the US last year.

People who have had their primary series – nearly 70% of all Americans – were advised to get the new two-strain booster late last year in an effort to upgrade their protection against the latest variants.

The advisory committee heard testimony and data suggesting that the complexity of having two types of Covid-19 vaccines and schedules for different age groups may be one of the reasons for low vaccine uptake in the US.

Currently, only about two-thirds of Americans have had the full primary series of shots. Only 15% of the population has gotten an updated bivalent booster.

Data presented to the committee shows that Covid-19 hospitalizations have been rising for children under the age of 2 over the past year, as Omicron and its many subvariants have circulated. Only 5% of this age group, which is eligible for Covid-19 vaccination at 6 months of age, has been fully vaccinated. Ninety percent of children under the age of 4 are still unvaccinated.

“The most concerning data point that I saw this whole day was that extremely low vaccination coverage in 6 months to 2 years of age and also 2 years to 4 years of age,” said Dr. Amanda Cohn, director of the US Centers for Disease Control and Prevention’s Division of Birth Defects and Infant Disorders. “We have to do much, much better.”

Cohn says that having a single vaccine against Covid-19 in the US for both primary and booster doses would go a long way toward making the process less complicated and would help get more children vaccinated.

Others feel that convenience is important but also stressed that data supported the switch.

“This isn’t only a convenience thing, to increase the number of people who are vaccinated, which I agree with my colleagues is extremely important for all the evidence that was related, but I also think moving towards the strains that are circulating is very important, so I would also say the science supports this move,” said Dr. Hayley Gans, a pediatric infectious disease specialist at Stanford University.

Many others on the committee were similarly satisfied after seeing new data on the vaccine effectiveness of the bivalent boosters, which are cutting the risk of getting sick, being hospitalized or dying from a Covid-19 infection.

“I’m totally convinced that the bivalent vaccine is beneficial as a primary series and as a booster series. Furthermore, the updated vaccine safety data are really encouraging so far,” said Dr. David Kim, director of the the US Department of Health and Human Services’ National Vaccine Program, in public discussion after the vote.

Thursday’s vote is part of a larger plan by the FDA to simplify and improve the way Covid-19 vaccines are given in the US.

The agency has proposed a plan to convene its vaccine advisers – called the Vaccines and Related Biological Products Advisory Committee, or VRBPAC – each year in May or June to assess whether the instructions in the Covid-19 vaccines should be changed to more closely match circulating strains of the virus.

The time frame was chosen to give manufacturers about three months to redesign their shots and get new doses to pharmacies in time for fall.

“The object, of course – before anyone says anything – is not to chase variants. None of us think that’s realistic,” said Jerry Weir, director of the Division of Viral Products in the FDA’s Office of Vaccines Research and Review.

“But I think our experience so far, with the bivalent vaccines that we have, does indicate that we can continue to make improvements to the vaccine, and that would be the goal of these meetings,” Weir said.

In discussions after the vote, committee members were supportive of this plan but pointed out many of the things we still don’t understand about Covid-19 and vaccination that are likely to complicate the task of updating the vaccines.

For example, we now seem to have Covid-19 surges in the summer as well as the winter, noted Dr. Michael Nelson, an allergist and immunologist at the University of Virginia. Are the surges related? And if so, is fall the best time to being a vaccination campaign?

The CDC’s Dr. Jefferson Jones said that with only three years of experience with the virus, it’s really too early to understand its seasonality.

Other important questions related to the durability of the mRNA vaccines and whether other platforms might offer longer protection.

“We can’t keep doing what we’re doing,” said Dr. Bruce Gellin, chief of global public health strategy at the Rockefeller Foundation. “It’s been articulated in every one of these meetings despite how good these vaccines are. We need better vaccines.”

The committee also encouraged both government and industry scientists to provide a fuller picture of how vaccination and infection affect immunity.

One of the main ways researchers measure the effectiveness of the vaccines is by looking at how much they increase front-line defenders called neutralizing antibodies.

Neutralizing antibodies are like firefighters that rush to the scene of an infection to contain it and put it out. They’re great in a crisis, but they tend to diminish in numbers over time if they’re not needed. Other components of the immune system like B-cells and T-cells hang on to the memory of a virus and stand ready to respond if the body encounters it again.

Scientists don’t understand much about how well Covid-19 vaccination boosts these responses and how long that protection lasts.

Another puzzle will be how to pick the strains that are in the vaccines.

The process of selecting strains for influenza vaccines is a global effort that relies on surveillance data from other countries. This works because influenza strains tend to become dominant and sweep around the world. But Covid-19 strains haven’t worked in quite the same way. Some that have driven large waves in other countries have barely made it into the US variant mix.

“Going forward, it is still challenging. Variants don’t sweep across the world quite as uniform, like they seem to with influenza,” the FDA’s Weir said. “But our primary responsibility is what’s best for the US market, and that’s where our focus will be.”

Eventually, the FDA hopes that Americans would be able to get an updated Covid-19 shot once a year, the same way they do for the flu. People who are unlikely to have an adequate response to a single dose of the vaccine – such as the elderly or those with a weakened immune system – may need more doses, as would people who are getting Covid-19 vaccines for the first time.

At Thursday’s meeting, the advisory committee also heard more about a safety signal flagged by a government surveillance system called the Vaccine Safety Datalink.

The CDC and the FDA reported January 13 that this system, which relies on health records from a network of large hospital systems in the US, had detected a potential safety issue with Pfizer’s bivalent boosters.

In this database, people 65 and older who got a Pfizer bivalent booster were slightly more likely to have a stroke caused by a blood clot within three weeks of their vaccination than people who had gotten a bivalent booster but were 22 to 42 days after their shot.

After a thorough review of other vaccine safety data in the US and in other countries that use Pfizer bivalent boosters, the agencies concluded that the stroke risk was probably a statistical fluke and said no changes to vaccination schedules were recommended.

At Thursday’s meeting, Dr. Nicola Klein, a senior research scientist with Kaiser Permanente of Northern California, explained how they found the signal.

The researchers compared people who’d gotten a vaccine within the past three weeks against people who were 22 to 42 days away from their shots because this helps eliminate bias in the data.

When they looked to see how many people had strokes around the time of their vaccination, they found an imbalance in the data.

Of 550,000 people over 65 who’d received a Pfizer bivalent booster, 130 had a stroke caused by a blood clot within three weeks of vaccination, compared with 92 people in the group farther out from their shots.

The researchers spotted the signal the week of November 27, and it continued for about seven weeks. The signal has diminished over time, falling from an almost two-fold risk in November to a 47% risk in early January, Klein said. In the past few days, it hasn’t been showing up at all.

Klein said they didn’t see the signal in any of the other age groups or with the group that got Moderna boosters. They also didn’t see a difference when they compared Pfizer-boosted seniors with those who were eligible for a bivalent booster but hadn’t gotten one.

Further analyses have suggested that the signal might be happening not because people who are within three weeks of a Pfizer booster are having more strokes, but because people who are within 22 to 42 days of their Pfizer boosters are actually having fewer strokes.

Overall, Klein said, they were seeing fewer strokes than expected in this population over that period of time, suggesting a statistical fluke.

Another interesting thing that popped out of this data, however, was a possible association between strokes and high-dose flu vaccination. Seniors who got both shots on the same day and were within three weeks of those shots had twice the rate of stroke compared with those who were 22 to 42 days away from their shots.

What’s more, Klein said, the researchers didn’t see the same association between stroke and time since vaccination in people who didn’t get their flu vaccine on the same day.

The total number of strokes in the population of people who got flu shots and Covid-19 boosters on the same day is small, however, which makes the association a shaky one.

“I don’t think that the evidence are sufficient to conclude that there’s an association there,” said Dr. Tom Shimabukuro, director of the CDC’s Immunization Safety Office.

Nonetheless, Richard Forshee, deputy director of the FDA’s Office of Biostatistics and Pharmacovigilance, said the FDA is planning to look at these safety questions further using data collected by Medicare.

The FDA confirmed that the agency is taking a closer look.

“The purpose of the study is 1) to evaluate the preliminary ischemic stroke signal reported by CDC using an independent data set and more robust epidemiological methods; and 2) to evaluate whether there is an elevated risk of ischemic stroke with the COVID-19 bivalent vaccine if it is given on the same day as a high-dose or adjuvanted seasonal influenza vaccine,” a spokesperson said in a statement.

The FDA did not give a time frame for when these studies might have results.

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Health

Decreasing rates of childhood immunization are a major concern. Our medical analyst explains why

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CNN
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Vaccine rates for measles, polio, diphtheria and other diseases are decreasing among US children, according to a new study from the US Centers for Disease Control and Prevention.

The rate of immunizations for required vaccines among kindergarten students declined from 95% to approximately 94% during the 2020-21 school year. It dropped further — to 93% — in the 2021-22 school year.

That’s still a high number, so why is this drop in immunization significant? What accounts for the decline? What might be the consequences if these numbers drop further? If parents are unsure about vaccinating their kids, what should they do? And what can be done on a policy level to increase immunization numbers?

To help us with these questions, I spoke with CNN Medical Analyst Dr. Leana Wen, an emergency physician, public health expert and professor of health policy and management at the George Washington University Milken Institute School of Public Health. She is also author of “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

CNN: Why is it a problem that childhood immunization rates are declining?

Dr. Leana Wen: The reduction of vaccine-preventable diseases is one of the greatest public health success stories in the last 100 years.

The polio vaccine was introduced in the United States in 1955, for example. In the four years prior, there were an average of over 16,000 cases of paralytic polio and nearly 2,000 deaths from polio each year across the US. Widespread use of the polio vaccine had led to the eradication of polio in the country by 1979, according to the CDC, sparing thousands of deaths and lifelong disability among children each year.

The measles vaccine was licensed in the US in 1963. In the four years before that, there were an average of over 500,000 cases and over 430 measles-associated deaths each year. By 1998, there were just 89 cases recorded — and no measles-associated deaths.

These vaccines are very safe and extremely effective. The polio vaccine, for example, is over 99% effective at preventing paralytic polio. The measles vaccine is 97% effective at preventing infection.

We can do this same analysis for other diseases for which there are routine childhood immunizations.

It’s very concerning that rates of immunization are declining for vaccines that have long been used to prevent disease and reduce death. That means more children are at risk for severe illness — illness that could be averted if they were immunized. Moreover, if the proportion of unvaccinated individuals increases in a community, this also puts others at risk. That includes babies too young to be vaccinated or people for whom the vaccines don’t protect as well — for example, patients on chemotherapy for cancer.

CNN: What accounts for the decline in vaccination numbers?

Wen: There are probably many factors. First, there has been substantial disruption to the US health care system during the Covid-19 pandemic. Many children missed routine visits to the pediatrician during which they would have received vaccines due to pandemic restrictions. In addition, some community health services offered also became disrupted as local health departments focused on Covid-19 services.

Second, disruption to schooling has also played a role. Vaccination requirements are often checked prior to the start of the school year. When schools stopped in-person instruction, that led to some families falling behind on their immunizations.

Third, misinformation and disinformation around Covid-19 vaccines may have seeded doubt in other vaccines. Vaccine hesitancy and misinformation were already major public health concerns before the coronavirus emerged, but the pandemic has exacerbated the issues.

According to a December survey published by the Kaiser Family Foundation, more than one in three American parents said vaccinating children against measles, mumps, and rubella shouldn’t be a requirement for them to attend public schools, even if that may create health risks for others. This was a substantial increase from 2019, when a similar poll from the Pew Research Center found only 23% of parents opposed school vaccine requirements.

CNN: What are some consequences if immunization rates drop further?

Wen: If immunization rates drop further, we could see more widespread outbreaks. Diseases that were virtually eliminated in the US could reemerge, and more people can become severely ill and suffer lasting consequences or even die.

We are already seeing some consequences: Last summer, there was a confirmed case of paralytic polio in an unvaccinated adult in New York. It’s devastating that a disease like polio has been identified again in the US, since we have an extremely effective vaccine to prevent it.

There is an active measles outbreak in Ohio. As of January 17, 85 cases have been reported. Most of the cases involved unvaccinated children, and at least 34 have been hospitalized.

CNN: If parents are unsure of vaccinating their kids, what should they do?

Wen: As parents, we generally trust pediatricians with our children’s health. We consult pediatricians if our kids are diagnosed with asthma and diabetes, or if they have new worrisome symptoms of another illness. We should also consult our pediatricians about childhood immunizations; parents and caregivers with specific questions or concerns should address them.

The national association of pediatricians, the American Academy of Pediatrics, “strongly recommends on-time routine immunization of all children and adolescents according to the Recommended Immunization Schedules for Children and Adolescents.”

CNN: What can be done to increase immunization numbers?

Wen: There needs to be a concerted educational campaign to address why vaccination against measles, mumps, rubella, chickenpox, polio and so forth is so crucial. One of the reasons for vaccine hesitancy, in my experience, is that these diseases have been rarely seen in recent years. Many people who are parents now didn’t experience the devastation of these diseases growing up, so may not realize how terrible it would be for them to return.

Specific interventions should be targeted at the community level. In some places, low immunization levels may be due to access. Vaccination drives at schools, parks, shopping centers, and other places where families gather can help increase numbers. In other places, the low uptake may be because of vaccine hesitancy and misinformation. There will need to be different strategies implemented in that situation.

Overall, increasing immunization rates for vaccine-preventable childhood diseases needs to be a national imperative. I can’t underscore how tragic it would be for kids to suffer the harms of diseases that could be entirely prevented with safe, effective and readily available vaccines that have been routinely given for decades.

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Health

When young children test positive for Covid-19 and another respiratory virus, their illness is much more severe, a new study suggests

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CNN
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When Covid-19 patients younger than 5 also test positive for another respiratory virus, they tend to become sicker and develop more severe disease, a new study suggests.

Among hospitalized children younger than 5, testing positive for both Covid-19 and another respiratory virus at the same time is associated with about twice the odds of severe respiratory illness than those who tested negative for other viruses, according to the study published Wednesday in the journal Pediatrics.

The study comes amid a harsh season of respiratory viruses, including RSV, flu, Covid-19 and other viruses that overwhelmed children’s hospitals. The findings demonstrate the impact respiratory viruses have on pediatric hospitals and how “continued surveillance” of circulating Covid-19 and other illnesses can help predict future surges in hospitalizations, wrote the researchers, from the US Centers for Disease Control and Prevention and various universities and health departments across the United States.

Caring for young children with overlapping respiratory illnesses was something Jenevieve Silva has experienced firsthand throughout the Covid-19 pandemic.

“The height of the illnesses was from September through mid-November, when our household just could not catch a break,” she said.

The mother of eight, based in San Jose, California, said that her toddler-age twin boys “have been battered by viruses” since they started preschool in May 2021.

Last October, Silva’s twins tested positive for Covid-19 and then developed what their pediatrician suspected was another respiratory viral infection, possibly respiratory syncytial virus or RSV, around the same time.

“Based on what the pediatrician told us, she said ‘I highly believe that they had these overlapping viruses,’” Silva said, adding that the boys’ symptoms included shortness of breath, cough, fatigue, and fever, with one twin having a 105-degree fever for four days straight.

Warm baths and massaging Vicks VapoRub onto their backs and chest helped ease their pain, but watching her boys battle these respiratory illnesses was “brutal,” Silva said.

“They had just looked so frail – they looked sick, like something deeper than just back-to-back viruses,” she said. “It was hell. I mean, it was really bad.”

The boys have recovered and are currently “doing great” and have gained healthy weight, Silva said, but she worries that they developed asthma following their illnesses.

Ever since October, when they had the overlapping viruses, “the doctor has now said it seems like that might have triggered asthma in them. And so now, ever since then, when they get a cold, they have asthma symptoms – violent episodes of coughing, sometimes throwing up,” Silva said.

“I can’t be the only mom dealing with virus after virus,” she said, adding that for other parents out there, she has a message of hope: “Be patient. Listen to your doctor.”

The new study included data on 4,372 children who were hospitalized with Covid-19. Among those who were tested for other respiratory viruses, 21% had a codetection, meaning another respiratory virus was also detected in their test results. The data came from the US Centers for Disease Control and Prevention’s Covid-19 hospitalization surveillance network called COVID-NET, with data from across 14 states.

The researchers noted that they focused on codetection, not coinfection, since testing wouldn’t necessarily show that a child was actively infected with both viruses just because they test positive.

Overall, “this study found that respiratory virus codetections were rare in the first year of the pandemic, RSV and rhinovirus or enterovirus codetections increased during the Delta-predominant period and influenza codetections were infrequent throughout the first 2 years of the pandemic,” the researchers wrote in their study.

The data also showed that children with codetections were more likely to be younger than 5, receive increased oxygen support, and be admitted to the intensive care unit. No significant associations were seen among children 5 and older.

Specifically for children younger than 2, testing positive for respiratory syncytial virus or RSV while having Covid-19 was significantly associated with severe illness.

More research is needed on the precise impact that two respiratory viruses can simultaneously have on the body, said Dr. William Schaffner, a professor in the Division of Infectious Diseases at Vanderbilt University Medical Center and medical director of the National Foundation for Infectious Diseases, who was not involved in the new study.

“But we do think that being attacked by two viruses, particularly if you are less than five years of age, it’s been clearly demonstrated by this study, it does tend to make your illness more severe, more likely to be prolonged in the hospital, more likely to be in the pediatric intensive care unit,” Schaffner said. “And so clearly, having your lungs and your throat and your body – generally your immune system – attacked by two viruses simultaneously, understandably might make some young children more severely ill.”

Dr. Asuncion Mejias, associate professor of pediatric infectious diseases at Nationwide Children’s Hospital, said hospitalized children she has treated for Covid-19 and codetections of other respiratory viruses often require increased oxygen support and treatment in the intensive care unit.

“Covid is a very proinflammatory virus, so it really weakens your immune response,” said Mejias. “And when you haven’t recovered yet, and you get a second hit, in this case, RSV or rhinovirus, you develop a more severe disease.”

Overall, Schaffner said that these new study findings are more reason why it remains important to make sure children are up to date on their Covid-19 vaccinations as well as vaccinated against the flu.

Mejias agreed, emphasizing the importance of safe practices to prevent the spread of viruses to children too young to be vaccinated.

“The pandemic taught us how contagious these viruses are,” Mejias said about respiratory pathogens.

“If somebody is sick, try to avoid contact,” she said. “These viruses are not only transmitted by saliva and secretions but by hands. It can survive in your hands for more than 30 minutes. So if you touch your mouth and then touch a little baby, the baby can self inoculate the virus and become infected. So washing hands and all these measures are very important.”

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Updated childhood obesity treatment guidelines include medications, surgery for some young people

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CNN
 — 

Updated American Academy of Pediatrics guidelines for treatment of obesity urge prompt use of behavior therapy and lifestyle changes, and say surgery and medications should be used for some young people.

The guidelines, published Monday in the journal Pediatrics, are the first comprehensive update to the academy’s obesity treatment guidelines in 15 years. They provide guidance for treatment of children as young as 2 and through the teen years.

The guidelines acknowledge that obesity is complex, and tied to access to nutritious foods and health care, among other factors.

Treatment for younger children should focus on behavior and lifestyle treatment for the entire family, including nutrition support and increased physical activity. For children 12 and older, use of weight loss medications is appropriate, in addition to health behavior therapy and lifestyle treatment, AAP says. Teens 13 and older with severe obesity should be evaluated for surgery, according to the guidelines.

“There is no evidence that ‘watchful waiting’ or delayed treatment is appropriate for children with obesity,” Dr. Sandra Hassink, an author of the guideline and vice chair of AAP’s Clinical Practice Guideline Subcommittee on Obesity, said in a statement. “The goal is to help patients make changes in lifestyle, behaviors or environment in a way that is sustainable and involves families in decision-making at every step of the way.”

For children and teens, overweight is defined as a body mass index at or above the 85th percentile and below the 95th percentile; obesity is defined as a BMI at or above the 95th percentile.

Myles Faith, a psychologist at the State University of New York at Buffalo who studies childhood eating behaviors and obesity, praised the new report both for acknowledging that the causes of childhood obesity are complex and that its treatments must be a team effort.

“It’s not one cause for all kids,” he says. “There’s not been this kind of report to say that there are more options and that we shouldn’t automatically discount the possibility of medication, that we shouldn’t discount the role of surgery. For some families, it might be something to consider,” said Faith, who was not involved in the creation of the guidelines.

The new guidelines do not discuss obesity prevention; it will be addressed in another AAP policy statement to come, it says.

“These are the most comprehensive, patient-centered guidelines we have had that address overweight and obesity within childhood,” Dr. Rebecca Carter, pediatrician at the University of Maryland Children’s Hospital and assistant professor at the University of Maryland School of Medicine, said in an email Monday.

“New to these recommendations are several new medication management strategies that have proven very successful in the treatment of obesity as a chronic disease for adults, and are now being recommended for use in children and adolescents,” Carter said. “This is a major step in allowing overweight and obesity to be considered as the chronic diseases that they are.”

She added that the recommendations also are a “major step forward” in helping both parents and medical teams “take ownership” over a child’s long-term health risks related to overweight and obesity.

“They give a variety of tools to help families feel empowered that there are ways to treat these medical conditions, and that there are nuanced causes for these conditions that go beyond easy solutions and certainly take our focus away from outdated or unhealthy dieting strategies,” Carter said.

The new guidelines are designed for health care providers, but Carter said parents should talk with their children’s doctor if there are concerns about weight, and discuss strategies to optimize health and monitor changes.

“It is also appropriate to do this in a child-focused manner, taking care not to stigmatize them or make them feel bad about their body, while empowering the child to feel they have the tools needed to keep their body healthy over time.”

The new guidelines are a “much-needed advancement” to align holistic care with current science, Dr. Jennifer Woo Baidal, assistant professor of pediatrics and director of the Pediatric Obesity Initiative at Columbia University in New York City, said in a separate email Monday.

“Uptake of the new guidelines will help reverse the epidemic of childhood obesity,” she said. “More work at policy levels will be needed to mitigate policies and practices that propagate racial, ethnic, and socioeconomic disparities in obesity starting in early life. Although the guidelines support advocacy efforts of pediatricians, we as a society need to voice our support for healthful environments for the nation’s children.”

AAP says more than 14.4 million children and teens live with obesity. Children with overweight or obesity are at higher risk for asthma, sleep apnea, bone and joint problems, type 2 diabetes and heart disease, according to the US Centers for Disease Control and Prevention.

Separate research, published last month in the American Diabetes Association journal Diabetes Care, suggests that the number of young people under age 20 with type 2 diabetes in the United States may increase nearly 675% by 2060 if current trends continue.

Last month, the CDC released updated growth charts that can be used to track children and teens with severe obesity.

Growth charts are standardized tools used by health care providers to track growth from infancy through adolescence. But as obesity and severe obesity became more prevalent in the last 40 years – more than 4.5 million children and teens had severe obesity in 2017-2018, the agency says – the charts hadn’t kept up.

The growth chart in use since 2000 is based on data from 1963 to 1980 and did not extend beyond the 97th percentile, the agency said. The newly extended percentiles incorporate more recent data and provide a way to monitor and visualize very high body mass index values.

The existing growth charts for children and adolescents without obesity will not change, the CDC said, while the extended growth chart will be useful for health care providers treating patients with severe childhood obesity.

“Prior to today’s release, the growth charts did not extend high enough to plot BMI for the increasing number of children with severe obesity. The new growth charts coupled with high-quality treatment can help optimize care for children with severe obesity,” Dr. Karen Hacker, director CDC’s National Center for Chronic Disease Prevention and Health Promotion, said in a statement. “Providers can work with families on a comprehensive care plan to address childhood obesity.

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Covid-19 vaccine boosters for kids age 5 and under

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CNN
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Last week, the US Food and Drug Administration authorized the bivalent Covid-19 booster for children 6 months to 5 years old. The US Centers for Disease Control and Prevention has since recommended the booster, and now everyone 6 months and older is able to receive the updated coronavirus vaccine except kids who got three doses produced by Pfizer/BioNTech.

Which young children are now eligible to receive the booster? What if kids haven’t started or completed the full series — do they now get the updated booster or the original monovalent vaccine? Can parents and guardians choose between the updated booster and the original shot? What are possible side effects? What if kids had Covid-19 already? And which families should consider the updated booster now and who could wait?

To help us answer these questions, I spoke with CNN Medical Analyst Dr. Leana Wen, an emergency physician, public health expert, and professor of health policy and management at the George Washington University Milken Institute School of Public Health. She is also author of “Lifelines: A Doctor’s Journey in the Fight for Public Health” and the mother of two young children, ages 2 and 5.

CNN: Let’s start with what has just changed in the recommendations: Which young children who received either the Pfizer or Moderna vaccine are now eligible to receive the booster?

Dr. Leana Wen: There are two vaccines authorized for young children: Moderna and Pfizer. For the youngest age group, the Moderna vaccine was designed to be a two-dose primary vaccine, while the Pfizer version was designed to be a three-dose primary vaccine. That means young children are considered to have completed their primary series if they completed two doses of the Moderna vaccine or if they completed three doses of Pfizer.

As a reminder, there is now a bivalent booster available for older children and adults. This combines the original (also called monovalent) vaccine with a vaccine that specifically targets the BA.4 and BA.5 Omicron subvariants. Because Omicron subvariants constitute virtually all new infections, the hope is that the bivalent booster will provide better, more directed protection.

What federal health officials have now said is that children 6 months through 5 years old who received both doses of the original Moderna vaccine are able to get the updated bivalent vaccine — if it has been at least two months since they completed the primary vaccine series.

For children who received the Pfizer vaccine, the guidance is a little different, because the primary series already involves three doses. Federal health officials have said that children 6 months through 4 years old who have not yet completed their three vaccine doses can receive the third dose as the bivalent vaccine. Let’s say a child has started this series and has had one or two doses of the original Pfizer vaccine. The third dose can now be the updated booster.

CNN: What if kids haven’t started or completed the full series — do they now get the updated booster or the original monovalent vaccine?

Wen: The answer is different for Moderna vs. Pfizer. For Moderna, the primary series is two doses, so a child needs to complete the two initial shots with the original formulation. The booster — the third dose — is the bivalent vaccine. For Pfizer, the primary series is three doses. The first two doses still need to be the original formulation, but the third shot is now the bivalent vaccine.

CNN: What about young children who completed three doses of the Pfizer vaccine — are they eligible for a fourth dose?

Wen: No. The FDA explicitly says that children 6 months through 4 years old who have completed their three-dose primary series with the original Pfizer vaccine are not eligible for a fourth shot of the bivalent booster. That’s because the primary series of three vaccine doses is still expected to have strong protection against severe illness to Omicron. This recommendation will be reevaluated as new data comes out.

CNN: Can parents and caregivers who have not completed the primary series of Moderna choose the bivalent vaccine as their second dose?

Wen: No. The FDA authorization for the adult primary series for Moderna — the two doses — is for the original monovalent vaccine. Similarly, there is no choice for which vaccine formulation is administered as the booster for Pfizer in adults. Only the bivalent booster is available as the third shot, not the original monovalent, which is still given as doses one and two. This mirrors the authorization given for adults — the primary series is the monovalent vaccine, with the only booster for Pfizer and Moderna for adults being the updated booster.

CNN: What are possible side effects from the updated booster?

Wen: It’s expected that children who get the updated booster will have similar types of side effects to the original vaccines. These side effects tend to be mild and short-lasting, usually resolving in the first 24 hours after inoculation. Adverse reactions can include pain and swelling in the injection site, fatigue, crankiness, sleepiness, headache, muscle aches and sometimes fever. Many children experience no side effects. The risk of serious side effects, such as myocarditis (an inflammation of the heart muscle), is expected to be exceedingly rare in this younger age group.

CNN: What if kids had Covid-19 already?

Wen: People who had Covid-19 can wait three months until after they have recovered from the coronavirus to receive another vaccine dose, according to the CDC. They probably have very good protection against infection in this period.

Many studies have shown that hybrid immunity — recovery from Covid-19 combined with vaccination — conveys very strong protection, arguably even more so than vaccination and boosters alone. In my opinion, I believe a case can be made that if a young child received the primary series and already had Covid, they could wait to receive another booster dose. This is especially true if they had Covid recently, in the last year. To my knowledge, there is no research that shows additional benefit of boosters to young children who recently had Covid-19 infection and who have received their primary vaccinations.

CNN: Which families should consider the updated booster now and who should wait?

Wen: First, I think it’s important to point out that the uptake of the primary series of the Covid-19 vaccines among young children is very low. According to the CDC, less than 5% of kids 5 and younger are fully vaccinated. That means we are referring to a very small pool of kids newly eligible for the updated boosters.

There’s one group that I would definitely recommend getting the updated booster. That’s the group of kids who received their first one or two doses of the Pfizer vaccine. These kids need to complete their primary series. The third dose of that series is now the updated bivalent booster. There’s no reason for families of these children to wait; they should complete the primary series, and it’s a bonus that the third dose is updated to target Omicron.

For children who received the two doses of the Moderna vaccine, I think the decision-making is different and will depend on families’ individual circumstances. Some families are very concerned about Covid-19 infection. Perhaps their child has underlying medical conditions, or they live with someone who is elderly, immunocompromised or otherwise very vulnerable to severe outcomes from Covid-19. Perhaps the family is welcoming a newborn soon, and that baby will be particularly vulnerable to coronavirus infection. I think it’s reasonable to decide that, since Covid-19 cases are rising, this is the time to get their young child the updated booster.

I also think it’s reasonable to wait. My children (ages 2 and 5) received the Moderna vaccines over the summer. They are eligible to be boosted, but I am holding off because the protection that they have against severe illness remains strong. The booster will convey additional protection against symptomatic infection, but that effect is probably short-lasting, according to a June study.

To be clear, I believe it’s crucial for older adults and vulnerable individuals to receive the updated booster. I also think it’s generally a good thing that people can choose the booster if they wish, as there are compelling individual reasons for different households.

Parents and caregivers who have questions should consult their pediatrician to decide the best course of action for their family’s specific circumstances. Finally, families whose children have yet to receive any Covid-19 vaccines should consider starting, especially if their kids are not known to have had Covid-19.

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Health

Measles outbreak in central Ohio grows to more than 50 children, driven by ‘lack of vaccination’

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CNN
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A measles outbreak in central Ohio is growing, sickening more than 50 children, with many of them needing hospitalization, according to data updated Tuesday by Columbus Public Health.

None of the children had been fully vaccinated against measles.

Since the start of the outbreak in November, at least 58 measles cases have been identified in Columbus and Franklin, Ross and Richland counties, and there have been 22 hospitalizations, according to Columbus Public Health.

Of those cases, 55 were in unvaccinated children. The other three were only partially vaccinated, meaning they received one dose of their MMR or measles, mumps and rubella vaccine when two are needed for a person to be considered fully vaccinated.

Experts recommend that children get the vaccine in two doses: the first between 12 months and 15 months of age, and a second between 4 and 6 years old. One dose is about 93% effective at preventing measles if you come into contact with the virus. Two doses are about 97% effective.

Nationwide, more than 90% of children in the US have been vaccinated against measles, mumps and rubella by age 2, according to the US Centers for Disease Control and Prevention.

“Measles can be very serious, especially for children under age 5,” Columbus Public Health spokesperson Kelli Newman wrote in an email Monday.

All of the Columbus cases have been in children: 12 in infants younger than 1, 28 in toddlers ages 1 to 2, 13 in children ages 3 to 5, and five in ages 6 to 17.

That corresponds to about 71% of cases being reported in 1- to 5-year-olds.

While the specifics of each hospitalized measles case can vary, “many children are hospitalized for dehydration,” Newman wrote. “Other serious complications also can include pneumonia and neurological conditions such as encephalitis. There’s no way of knowing which children will become so sick they have to be hospitalized. The safest way to protect children from measles is to make sure they are vaccinated with MMR.”

Some of the children visited a grocery store, a church and department stores in a mall while they were contagious, according to Columbus Public Health’s list of exposure sites.

Measles is a highly infectious disease that can spread through the air when an infected person coughs or sneezes or if someone comes into direct contact with or shares germs by touching contaminated objects or surfaces.

“Measles can be a severe illness and can commonly lead to complications which require hospitalization, especially in young children,” Dr. Matthew Washam, medical director of epidemiology and infection control at Nationwide Children’s in Columbus, wrote in an email Tuesday.

In the Ohio outbreak, the hospitalized children have been seen at Nationwide Children’s Hospital.

“Most children can usually recover at home with supportive care and can receive antibiotics for less severe complications, such as ear infections. Some children develop more severe complications, such as dehydration requiring intravenous fluids, pneumonia and/or croup which require respiratory support, or rarely more severe complications such as encephalitis,” Washam wrote.

“The mainstay of treatment for all children with measles is supportive care,” he added. “In the hospital, this can include intravenous fluids, antibiotics for secondary bacterial infections, and respiratory support amongst other supportive care measures. Some children with measles may also be treated with vitamin A given the association of lower vitamin A levels with more severe measles illness.”

The measles outbreak is “very concerning,” said Dr. Nora Colburn, an adult infectious diseases physician at The Ohio State University Wexner Medical Center in Columbus, who has been watching the outbreak closely along with her colleagues.

“What’s really driving this is unfortunately a lack of vaccination, which is just heartbreaking,” said Colburn, who also serves as the medical director of clinical epidemiology for the Richard M. Ross Heart Hospital at the OSU Wexner Medical Center.

“For measles, it is the most infectious disease we have,” she said. “And so it is very concerning as an infectious disease physician, as also a mother of a young child and as a community member.”

During the early days of the Covid-19 pandemic, while most people stayed home and some health-care facilities were closed, many children missed their routine immunizations, including the MMR vaccine – and they still may not have gotten all their recommended shots. That’s true around the world as well as in the US.

“The concern now is that we’ve had this global dip in vaccination coverage as a result of the pandemic, probably not actually from vaccine hesitancy or refusal but just there were a lot of kids that missed their checkups during the pandemic, and we really haven’t completely caught those kids up,” said Dr. Sean O’Leary, chair of the American Academy of Pediatrics’ Committee on Infectious Diseases and professor of pediatric infectious disease at the University of Colorado School of Medicine and Children’s Hospital Colorado.

“Measles is such a contagious disease that when you see those dips, we really worry about the potential for large outbreaks,” he said. “You need to really maintain a high vaccination coverage to keep measles from spreading.”

About 90% of unvaccinated people who are exposed to measles will become infected, according to Columbus Public Health, and about 1 in 5 people in the US who get measles will be hospitalized.

While the measles outbreak spreads across central Ohio, the United States has been battling a surge of respiratory illnesses, such as flu and RSV, or respiratory syncytial virus, and the ongoing Covid-19 pandemic.

Pediatric hospitals nationwide have been overwhelmed by this rise in respiratory infections and are bracing for the possibility of even more cases over the holiday season.

“I can’t even imagine if your hospital is already chock full and all of a sudden you’ve got to deal with measles, because measles is a really problematic infection-control situation, too. You need negative-pressure rooms, everyone has to wear N95 masks, and it’s incredibly contagious in a hospital,” O’Leary said.

“There’s a lot of risk particularly to immunocompromised patients that are also in children’s hospitals,” he said. “It’s a real problem.”

Nationwide Children’s Hospital confirmed to CNN in an email Tuesday that it has seen a surge in other respiratory illnesses, such as flu and RSV, but remains able to keep caring for patients.

“The current surge in respiratory illnesses such as the flu and RSV is being seen locally. While we are experiencing some visits and admissions related to measles, volumes are relatively low compared to flu and RSV. Measles poses a greater strain on resources related to public health efforts, including contact tracing, containment, education, and immunizations,” the hospital statement said. “While busy, our hospital remains able to continue to provide care for patients.”

With each of these respiratory illnesses, it sometimes can be difficult to determine which infection a person has as the symptoms – such as fever, cough, and runny nose – can be similar.

“To have RSV, influenza, Covid at the same time as the holidays, and then now we have measles on top of it, which can have overlapping symptoms of fever and cough and fatigue, it can be really challenging to kind of sort out which infection is what,” Colburn said, adding that it is important for anyone with symptoms to stay home and get tested.

Measles symptoms may include fever, cough, runny nose, watery eyes and a rash of red spots. In rare cases, it may lead to pneumonia, encephalitis or death.

“Wearing your mask, especially in crowded areas, is really important, especially for our immunocompromised patients. I really worry about measles in adult patients who cannot get the MMR vaccines,” she said. “We can’t give it to severely immunocompromised patients or pregnant women. So it’s really important that everybody else gets vaccinated to cocoon those very vulnerable people and decrease the circulation of measles in our community.”

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RSV, flu and colds: How to tell when your child is too sick for school

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CNN
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A sniffle, a sneeze or a cough can set off alarm bells these days for families with young children.

Mother of two Vickie Leon said her kids, ages 4 and 2, can sometimes go a month or two without bringing anything back from day care. Then there are times when it seems the family in Aurora, Colorado, is sniffling with a virus every other week.

“Once that hits, we are just in it for a while,” she said.

Many kids have spent years socially distancing to protect against Covid-19, and now health care systems are being overloaded with cases of the respiratory virus RSV — which can cause a runny nose, decreased appetite, coughing, sneezing, fever and wheezing.

The viral infection has always been common. Almost all children catch RSV at some point before they turn 2, the US Centers for Disease Control and Prevention says. And immunity developed after an infection often wanes over time, leading people to have multiple infections in a lifetime, said Dr. William Schaffner, a professor in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.

The public health challenge this year is that while many children were kept home to protect against Covid-19, they were also isolated from RSV, meaning more are having their first — and therefore most severe — infection now, said CNN Medical Analyst Dr. Leana Wen, an emergency physician and professor of health policy and management at the George Washington University Milken Institute School of Public Health.

An RSV infection is often mild but could be a cause for concern for young infants, children with underlying conditions and older adults, said Schaffner, who is also medical director of the National Foundation for Infectious Diseases.

That doesn’t mean it is time to panic, added Wen, who is also author of “Lifelines: A Doctor’s Journey in the Fight for Public Health.” Catching RSV and other viral and bacterial infections is a part of children growing up and developing their immune system.

Here’s how to assess when to keep your child home from school and when to visit the pediatrician, according to experts.

Between colds, influenza, strep throat, RSV and lingering Covid-19, there are a lot of infections swirling about this winter — and they can often look a lot alike in terms of symptoms, Schaffner said. Even astute doctors may have trouble telling them apart when a patient is in the office, he added.

However, pediatricians are well practiced and equipped to treat upper respiratory infections, even if it isn’t possible to distinguish exactly which virus or bacteria is the cause, Wen said.

Whatever virus or bacteria is stirring up sniffles, headache or a sore throat in your household, the age, symptoms and health status of your child will likely make a difference in how you proceed, she said.

Ideally, public health professionals would like it if no child showing symptoms were sent to school or day care, where they could potentially spread infections Schaffner said. But — especially for single parents or caregivers who need to be at work — that is not always the most practical advice, he added.

At-home tests may signal if a child has a Covid-19 infection, he added. But for other viruses like a cold, there may not be a good way to know for sure.

Some symptoms that might really signal it is time to keep your child home from school or day care include high fever, vomiting, diarrhea, trouble eating, poor sleep or problems breathing, Wen said.

Donna Mazyck, a registered nurse and executive director of the National Association of School Nurses, breaks it down into two primary considerations: Does the child have a fever and are they too ill to engage with learning fully?

Families should also check their school’s guidelines, some of which can be detailed on when a child needs to be kept home from school, while others will rely more on parental judgment, she said.

“When in doubt, consult the school policies and have a plan with a pediatrician,” Wen said.

And for children at higher risk because of other medical conditions, consult with your pediatrician before your child gets sick so you know what to look for.

Again, here is where schools may have different policies and it becomes important to check with written information, a school administrator or school nurse, Wen said.

“Generally, the schools will ask that the child be fever free without the use of fever-reducing medications” before returning to the classroom, she said.

For children with asthma or allergies, it may not be reasonable to keep them out of school whenever they show any coughing or sniffling symptoms, Wen said. That could very well keep them out half the year.

And some symptoms, like a continued cough, may linger as an infection clears and a child recovers. In those cases, it may be appropriate to send a child back to school, Mazyck said, reiterating that it is important to check on the school’s guidelines.

Families are often good at bringing their children into the pediatrician when they seem unwell, Schaffner said. Still, with so many things going around, it is important to remind families that doctors would rather see kids who aren’t feeling well earlier than later, he added.

If they seem lethargic, stop eating or have difficulty breathing, parents and caregivers would also be justified in taking their kids to the pediatrician and seeking medical attention — especially if the symptoms worsen, Schaffner said.

“This is not something that they should hesitate about,” he said.

For younger babies and infants, it might be time to go to the emergency room if they are struggling to take in liquid or have dry diapers, flared nostrils, trouble breathing and a chest that contracts when it should expand, Wen added.

Families should seek emergency treatment for school-age kids who have trouble breathing and speaking in complete sentences, Wen said. Fortunately, most will not need emergency treatment — and those who do are usually back home and doing well in a couple days, Schaffner said.

“Parents should know that treating RSV and other respiratory infections is the bread and butter of pediatricians and emergency physicians,” Wen said. “This is what we do.”

To prevent these respiratory illnesses, teach your children to utilize the hygiene practices health care professionals were promoting long before the pandemic, like washing hands, using hand sanitizer when a sink isn’t available, coughing and sneezing into an elbow or tissue, and not sharing food or utensils with friends, Wen said.

There is not yet a vaccine for RSV approved by the US Food and Drug Administration, but there are effective ones available for influenza and Covid-19, Schaffner said.

If your child is not yet vaccinated, talk to their doctor about protecting them against these viruses, he added.

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