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Health

Surgeon General says 13 is ‘too early’ to join social media

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CNN
 — 

US Surgeon General Vivek Murthy says he believes 13 is too young for children to be on social media platforms, because although sites allow children of that age to join, kids are still “developing their identity.”

Meta, Twitter, and a host of other social media giants currently allow 13-year-olds to join their platforms.

“I, personally, based on the data I’ve seen, believe that 13 is too early … It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships and the skewed and often distorted environment of social media often does a disservice to many of those children,” Murthy said on “CNN Newsroom.”

The number of teenagers on social media has sparked alarm among medical professionals, who point to a growing body of research about the harm such platforms can cause adolescents.

Murthy acknowledged the difficulties of keeping children off these platforms given their popularity, but suggested parents can find success by presenting a united front.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” he told CNN.

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New research suggests habitually checking social media can alter the brain chemistry of adolescents.

According to a study published this month in JAMA Pediatrics, students who checked social media more regularly displayed greater neural sensitivity in certain parts of their brains, making their brains more sensitive to social consequences over time.

Psychiatrists like Dr. Adriana Stacey have pointed to this phenomenon for years. Stacey, who works primarily with teenagers and college students, previously told CNN using social media releases a “dopamine dump” in the brain.

“When we do things that are addictive like use cocaine or use smartphones, our brains release a lot of dopamine at once. It tells our brains to keep using that,” she said. “For teenagers in particular, this part of their brain is actually hyperactive compared to adults. They can’t get motivated to do anything else.”

Recent studies demonstrate other ways excessive screen time can impact brain development. In young children, for example, excessive screen time was significantly associated with poorer emerging literacy skills and ability to use expressive language.

Democratic Sen. Chris Murphy, who recently published an op-ed in the Bulwark about loneliness and mental health, echoed the surgeon general’s concerns about social media. “We have lost something as a society, as so much of our life has turned into screen-to-screen communication, it just doesn’t give you the same sense of value and the same sense of satisfaction as talking to somebody or seeing someone,” Murphy told CNN in an interview alongside Murthy.

For both Murphy and Murthy, the issue of social media addiction is personal. Both men are fathers – Murphy to teenagers and Murthy to young children. “It’s not coincidental that Dr. Murthy and I are probably talking more about this issue of loneliness more than others in public life,” Murphy told CNN. “I look at this through the prism of my 14-year-old and my 11-year-old.”

As a country, Murphy explained, the U.S. is not powerless in the face of Big Tech. Lawmakers could make different decisions about limiting young kids from social media and incentivizing companies to make algorithms less addictive.

The surgeon general similarly addressed addictive algorithms, explaining pitting adolescents against Big Tech is “just not a fair fight.” He told CNN, “You have some of the best designers and product developers in the world who have designed these products to make sure people are maximizing the amount of time they spend on these platforms. And if we tell a child, use the force of your willpower to control how much time you’re spending, you’re pitting a child against the world’s greatest product designers.”

Despite the hurdles facing parents and kids, Murphy struck a note of optimism about the future of social media.

“None of this is out of our control. When we had dangerous vehicles on the road, we passed laws to make those vehicles less dangerous,” he told CNN. “We should make decisions to make [social media] a healthier experience that would make kids feel better about themselves and less alone.”

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Health

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

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CNN
 — 

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

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

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CNN
 — 

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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Health

At 3 weeks old, she caught RSV, the virus that’s packing hospitals across the US

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CNN
 — 

As Abhishesh Pokharel carried his 3-week-old daughter into the emergency department, her fingers and toes were turning blue.

Other parts of her tiny body were yellow.

Something was very wrong.

The triage nurse at Greater Baltimore Medical Center knew it, too. She took one look at baby Ayra and gave her father an order:

Run!

Across the building he sped, his wife right behind him – to the pediatric emergency department.

By then, Ayra was sometimes not breathing at all, clinicians later told CNN.

The rapid response team went to work.

Still, “she was not responding to anything that they were doing,” Pokharel recalled.

“My mind just froze and thought I may not get her back.”

Ayra – born a preemie at just 36 weeks and 6 days – had already proved to be a fighter: Her first day on Earth was spent in the NICU because of fluid in her lungs.

Since then, she’d been healthy, her father said.

But now, her fragile body was caving to one of several respiratory illnesses spreading across the US: respiratory syncytial virus, or RSV, which often is most severe in young children and older adults.

While for most it causes a mild illness that can be managed at home, RSV – alongside flu, the coronavirus that causes Covid-19 and other common respiratory viruses – has driven an increase in hospitalizations nationwide. And pediatric hospitals are feeling the strain, with more than three-quarters of their hospital and ICU beds occupied for the past few months.

More than half of US states report high or very high respiratory illness activity, and US officials are begging people, including kids, to get the flu shot and Covid boosters ahead of Thanksgiving.

But for RSV, there is not yet a vaccine – nor an antiviral or specific treatment.

As baby Ayra’s blood oxygen level hit 55% – far from the 95% or better it should be – her parents could only watch, tears filling their eyes as they overheard clinicians say their newborn wasn’t responding.

“I was lost,” recalled Ayra’s mom, Menuka KC. “It was a nightmare.”

The staff at the pediatric ER in Towson, Maryland, was already overwhelmed by a crush of respiratory illnesses so severe it had for weeks claimed virtually every pediatric ICU bed in the state.

But as Ayra lay before them, they knew they had to act.

Fast.

Knowing Ayra could have gone into respiratory arrest right there in the waiting room “sent heart palpitations through all of us,” said Dr. Theresa Nguyen, the center’s interim chair of pediatrics.

The infant was lethargic, breathing quickly – sometimes not breathing at all. Thick mucus filled her nose and went down as far as her lungs, Nguyen said.

Her prematurity “increased her risk of how her body would react to the RSV virus,” the doctor explained.

It had been just 10 days since the older Pokharel daughter, 4-year-old Aavya, had gotten sick with a fever and runny nose that her pediatrician diagnosed as viral and ear infections, their dad said.

Five days later, on October 13, the couple noticed Ayra started having a runny nose and mucus that they had to remove with a suction ball, Pokharel said. They took her to her doctor for a scheduled check-up and were told she had a viral infection, though her lungs were clear and she had no fever.

But monitor her, they were told.

Three days after that, they took Ayra back because she had a bad cough, and the couple could barely hear her cry.

Two days later, here they were in the pediatric emergency department, with doctors now telling them intubation was Ayra’s best bet.

Inserting a tube into Ayra’s airway and attaching a breathing machine would give the infant the oxygen she needed, the doctors explained.

Ayra was on the brink of death.

She needed to be intubated immediately, the doctors said, before she stopped breathing.

Her parents waited just outside the room and prayed for God to save her and bring her back to them as the medical team carefully and swiftly intubated Ayra.

Immediately, her blood oxygen bounced back to a safer level.

But more hurdles lay ahead.

Greater Baltimore Medical Center could not keep Ayra – or any intubated child who needs to be on a ventilator – because that level of care requires a pediatric ICU, Nguyen explained.

The discussion quickly turned to where to send her for more care.

Hospital staff took to the phones.

Sending patients to other facilities for treatment is common during the height of flu and RSV seasons, Nguyen said.

But this year, the need had started rising much earlier.

RSV symptoms

  • RSV is a common virus, but it can cause serious illness, especially in younger infants and older adults. Symptoms may appear in stages and not all at once, according to the US Centers for Disease Control and Prevention.
  • Symptoms include:
  • Runny nose
  • Decrease in appetite
  • Coughing and sneezing
  • Fever
  • Wheezing
  • “In very young infants with RSV, the only symptoms may be irritability, decreased activity, and breathing difficulties,” according to the CDC.

    • Greater Baltimore Medical Center last month had to transfer twice as many pediatric patients as it did last October, hospital data show. And October transfers were double what they were in September, with respiratory transfers accounting for 80%.

    “My doctors are seeing patients in the hallways every day,” Nguyen said, adding some have waited up to 16 hours to be seen.

    And this was far from the only facility squeezed by the surge in child respiratory illnesses.

    “There haven’t been pediatric ICU beds available in the state of Maryland since mid-September,” Nguyen said. “We’ve had to send children out of state.”

    Searching out a landing spot for Ayra, they dialed hospitals in Washington, DC, and Virginia and Delaware, Pokharel said.

    “‘Worse comes to worst, we have to airlift her and take her to another state,’” he remembered a clinician telling him as they called facilities as far away as Georgia and Florida.

    It didn’t dawn on Pokharel to even think about how his family would get to wherever Ayra was sent.

    She needed care, and it didn’t matter where.

    An hour passed.

    Then, a single phone call changed everything.

    “There was one bed available,” Pokharel said, “at Children’s National Hospital in DC.”

    Ayra was transferred in an ambulance, her father seated beside the driver. Pokharel stayed the night with his ailing daughter.

    The next morning, KC was ferried 90 minutes from Perry Hall, Maryland, to the hospital by Pokharel’s brother, who also cared for Aavya while the girls’ parents focused on her sick sibling.

    In the pediatric ICU, Ayra lay on a tiny, heated hospital bed. She was connected to blue and white ventilator tubes, her miniscule feet and wrists restrained so she wouldn’t pull at anything. Doctors pulled fluid out of her lungs and gave her an antibiotic, her dad said.

    On each of the next two days, Pokharel’s brother chauffeured his sister-in-law home, then back to her vigil at Ayra’s bed.

    All the while, their tiny fighter battled for every breath.

    Her parents didn’t know how long they’d have to wait.

    Then, on the third day: a breakthrough.

    Less mucus filled Ayra’s lungs, and she was getting only minimal support from the ventilator, Pokharel said. So, the doctors extubated her.

    She still needed a CPAP machine – the kind adults sometimes use to deal with sleep apnea – to get enough oxygen, her father said. And she later would require a nasal cannula – the tube outfitted with prongs going into the nostrils – to help administer lower amounts of oxygen.

    But Ayra was pulling through.

    Even as the doctors started talking about discharging her, KC grew nervous and started checking and rechecking to make sure her daughter was breathing.

    Soon, though, Ayra’s fever broke and she began drinking again from a bottle.

    On the fourth day, a friend drove KC to see Ayra – and the whole family went home together.

    Being back home has been an adjustment.

    The family of four is isolating until Ayra is at least 2 months old, said Pokharel, who works a hybrid schedule and goes out for errands.

    “We haven’t allowed any visitors to come home,” he said. “My wife hasn’t left home since then. She doesn’t want to go anywhere.”

    They also pulled Aavya out of day care, hoping to keep the germs at bay – and posing an extra challenge for everyone.

    “We have a baby who is sick, just came out of the hospital. We are giving 100% focus on the little one,” Pokharel said. “And on another side, I have a 4-year-old who needs my attention, like, 24/7.”

    Pokharel, while working some days from home, gives Aavya pre-K workbooks so she can draw, trace or paint, he said. When he’s off work, they go for a walk or a bike ride.

    KC spends her days caring for Ayra. Sleep, she said, comes in two- or three-hour stints.

    Back at Greater Baltimore Medical Center, the throngs of children with serious respiratory symptoms keep coming, Nguyen said. “Our staff, our physicians, advance practitioners and nursing staff are, for a lack of a better word, they’re overwhelmed.”

    “They’re burnt out because this has been ongoing for two months,” the doctor said. “And there’s no end in the near future because … you start seeing RSV and then you see the flu,” which can stick around until April.

    “This is really the children’s version of the Covid crisis in adults,” Nguyen said. “I don’t think it’s gotten as much attention as it needs because it’s kids, they’re little. It’s the pediatricians who advocate for them, but we’re actually really, really busy taking care of the kids.”

    As Ayra’s parents keep vigil at home over their tiny fighter, their want other families to know: With this virus still surging, be ready for anything.

    “I didn’t think RSV would go to this extent,” her dad said. “I never thought I would see a baby intubated – and not my baby intubated.”

    “I’m glad she’s doing OK and she’s feeding and sleeping well,” added her mother. “Thank you to all those doctors and the nurses who saved her life.”

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    Health

    Respiratory illness: When to go to the ER

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    CNN
     — 

    Respiratory viruses including flu and RSV are circulating across the United States at high levels, overwhelming children’s hospitals and prompting concern among parents of young children. Most kids who get sick this season will recover quickly with home care, but some will need medical attention. What should parents watch for, and how might they know it’s time to call their pediatrician or go to the ER?

    CNN spoke with Dr. Edith Bracho-Sanchez, director of pediatric telemedicine at Columbia University Irving Medical Center, about warning signs of serious illness and the steps parents and children can take to help protect themselves from germs. The following is an edited version of that conversation.

    CNN: How quickly can a baby or a small child go from being totally fine to needing urgent medical care?

    Dr. Edith Bracho-Sanchez: Every child is different in terms of when they’re going to show signs that it’s time to go into the emergency room or to the pediatrician’s office. I worry the most about the very small babies, the babies under 6 months of age, because their airways are so small. For kids of different ages, they might get worse at different points in any illness.

    Kids who are less than 6 months of age can really turn the corner really quickly and get worse at home, really out of nowhere, so it’s so important that parents learn the signs and know when to look for help. Older kids tend to get sick more gradually. It is important in that case as well to know when to look for help.

    CNN: As a pediatrician, what warning signs do you look for when it comes to these respiratory viruses that mean it might be time for someone to go to the hospital?

    Bracho-Sanchez: Any time a child is starting to have trouble breathing – by that I mean they’re getting tired, they look like it’s effort that they have to put in with breathing, it’s time to come into the emergency room. Any time a child is getting dehydrated or any time a fever is not coming down at home or has been there for more than three days, it’s time to come in and see us.

    CNN: We hear people talk about signs of “respiratory distress,” but what does that look like?

    Bracho-Sanchez: Signs of trouble include starting to use muscles that they don’t usually use to breathe – by that I mean using the muscles of the nostrils and then using muscles in between their ribs. Any time you’re noticing that a child is starting to use those additional muscles to breathe or is starting to breathe fast, that means they’re really having a hard time breathing, and it’s time to go to the emergency room.

    CNN: Is there any point in trying to treat these things at home? Or is it already time to get in the car?

    Bracho-Sanchez: If you’re starting to see signs of respiratory distress at home, call your pediatrician. If you know that it’s going to take several hours or a couple of days to reach your pediatrician, go to the emergency room. Your child needs to be seen more and more urgently at that point.

    CNN: Once you start to notice that something is wrong, how do you make the decision on where to go for help?

    Bracho-Sanchez: First and foremost, when you’re deciding where to take your child, I think it’s important to listen to your own gut and intuition as a parent. If you feel that your child needs medical attention right now, go to the emergency room, no questions asked. We’re always so glad to help you.

    If you think your child has been getting worse gradually or your child is not improving, you may be able to call the pediatrician first.

    If your child gets sick on weekends or at a time when you cannot reach your pediatrician, that might be a good place to go to urgent care instead of going to the emergency room first.

    CNN: Many children’s hospitals across the country are operating at capacity. If I look online and see that the hospital wait times are just outrageous, what is my best bet as a parent?

    Bracho-Sanchez: If your child is showing signs of respiratory distress and you feel that it’s time to go to the emergency room, go to the emergency room.

    I think it’s important for parents to know that when you come in to see us, we do what’s called triaging. Kids who need urgent, immediate medical attention are seen first. So that is slightly unfortunate for parents who might be there for a broken bone or because their kids might have fallen. I think those parents are unfortunately going to have a longer wait. But if your child is having respiratory distress, we are not going to make you wait. We’re going to help your child right away.

    CNN: A lot of children get sick. Not all of them need this kind of care. How many kids are going to be able to be treated at home?

    Bracho-Sanchez: It’s important to note that almost all kids are going to catch a cold or some sort of respiratory illness this season. Most kids are going to recover at home and are going to be totally, totally fine with a little bit of rest and extra fluids and a parent who’s watching them at home. It is a very small minority of children who are going to get enough complications or respiratory distress that it is going to need medical attention.

    CNN: In addition to a thermometer, are there any devices that might be helpful for parents to have at home, such as a pulse oximeter?

    Bracho-Sanchez: The best device you can have at home as a parent is your own educated intuition. Any time that you are noticing signs of respiratory distress, I don’t think you should waste time trying to get a blood oxygen measurement or trying to do an additional maneuvers at home. When you are spotting those signs, it is time to come in and see us – at least, at a minimum, give us a call if you know that you’re going to be able to get a hold of us right away. But please don’t delay getting your child’s medical attention.

    CNN: There are vaccines for flu and Covid-19 but not for RSV. How can you protect yourself from all of these things?

    Bracho-Sanchez: During respiratory season, there are so many things that we as parents cannot control, but there are some ways to protect our kids from severe respiratory illnesses and the complications of those severe respiratory illnesses. That includes getting a flu shot and getting the Covid vaccine, including all of the boosters they’re eligible for.

    Kids adapt and learn so many things as long as we adults set the example for them. So this respiratory season, it’s so important that we teach them to wash their hands frequently, to cough into their elbows, to cover their coughs and sneezes with tissues when appropriate and to stay home if they’re not feeling well.

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    Health

    What to do if your child has a respiratory infection? Our medical analyst explains

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    CNN
     — 

    A common respiratory virus, respiratory syncytial virus, is surging in the United States, leading to some children’s hospitals being overwhelmed. The influenza virus is also on the rise, along with other viruses — such as adenovirus and rhinovirus — that cause the common cold.

    At the same time, children are back at school and families are returning to many in-person activities, often without the mitigation measures applied during Covid-19, heightening the possibility for viral spread.

    What kinds of respiratory infections can be treated at home — and with what treatments? Which symptoms should prompt a call to the doctor, or for parents and caregivers to bring their children to the hospital? When should children stay out of school? And what are the precautions families can take to reduce the spread of respiratory viruses?

    To help us with these questions and more, 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.

    CNN: Why are respiratory infections on the rise?

    Dr. Leana Wen: They have always been common among children. Before Covid-19, it was the norm, especially during the fall and winter, for schoolkids to have runny noses and coughs.

    Now, they may be increasing in part because mitigation measures taken during the pandemic — like social distancing, masking and avoiding large gatherings — resulted in fewer respiratory viruses being spread over the past two winters. As a result, a lot of kids don’t have the immunity they normally would.

    My own kids have already had at least three bouts of respiratory illness each since they started back at kindergarten and preschool less than two months ago. Thankfully, they recovered well and did not get severely ill, but I certainly understand the worry and distress that parents and caregivers feel when our children are sick.

    CNN: Which respiratory infections can be dealt with at home?

    Wen: The vast majority of respiratory infections in children can be managed at home with fluids, fever-reducing medicines and rest. What’s causing the infection is generally not the key determining factor in whether a child needs hospital care — it’s how the child is doing.

    Respiratory syncytial virus, also known as RSV, is concerning on a public health level because some hospitals are getting full with children who have it. Prior to the Covid-19 pandemic, the US Centers for Disease Control and Prevention estimated that virtually all children will get RSV before their second birthday — and that some 58,000 kids will end up being hospitalized for it every year. Clearly, RSV is a very serious infection among some children, and parents should know what to watch for to spot severe illness. But also keep in mind that the vast majority will have mild, cold-like symptoms and will not need to be hospitalized.

    The same goes for other viruses. Influenza can cause very severe illness, as can Covid-19. However, most cases in children do not result in hospitalization, and symptoms can be managed at home. On the other hand, there are viruses that one typically associates with a mild cold, like adenovirus, that can cause some children to become very sick.

    If you end up going to the emergency department, your child will probably get tested for Covid-19, influenza and RSV. Some pediatricians would do this too. If your child were hospitalized, they might get additional virus testing. But a lot of doctor’s offices wouldn’t provide such care because, again, the actual virus leading to the illness is less important in determining whether your child needs to be hospitalized than how your child is doing.

    The exception is very young infants — generally those under 2 months of age — who are typically tested and monitored more.

    CNN: What other risk factors should lead to parents watching for severe illness?

    Wen: Newborns are very vulnerable. They have little immunity and not much physiological reserve, meaning that once they get sick they could become very ill very quickly. Premature babies are also at risk. Many of them have underdeveloped lungs. A baby born two months premature has a physiological age two months younger than a baby born at term on the same day.

    There are other factors to consider, too, including for young kids who have significant heart and lung disease, or are severely immunocompromised. In all these situations, families should have a low threshold for calling their physician.

    CNN: If a child is generally healthy and develops a fever, cough or runny nose, should parents and caregivers call the doctor? When should they rush to the hospital?

    Wen: There are two major symptoms that should prompt concern in respiratory infections. The first is breathing difficulties. Look for struggled and fast breathing. For example, if your children are wheezing or grunting; if their nostrils are flaring; if they are belly breathing, meaning that the chest caves in during breathing and the belly goes out; or if their breathing rate is higher than normal.

    The second is difficulty keeping hydrated. This is particularly a problem in babies. If they get stuffed noses, it can be hard for them to drink breastmilk and formula, and they could get dehydrated very quickly. If your child looks sleepy and isn’t drinking, or if your baby is having a decrease in the number of wet diapers, call your doctor sooner rather than later.

    Ongoing issues — for example, a mild fever that’s been going for a few days — could probably wait for your pediatrician’s office hours.

    I’d advise that you have a plan before your child gets sick. A lot of pediatricians have an on-call service where you can reach your doctor or another health care provider within an hour, even at night and on weekends. Know if this possibility exists and have that number easily available to call. If your pediatrician is not reachable after hours, you should know which hospital you’d bring your child to if they were to become seriously ill. Ideally, it’s a hospital close to you and that’s staffed with pediatric emergency medicine specialists.

    If you can’t easily reach your doctor by phone in emergencies, have a low threshold to bring your child to the hospital, especially if you have a newborn or young baby. Breathing difficulties and inability to keep hydrated are good reasons to immediately go to the hospital.

    CNN: When should kids stay out of school?

    Wen: That depends on the policies at your child’s school. Many schools ask that kids stay at home while they have fevers. They also shouldn’t be in attendance if they are throwing up. Some schools may also require Covid-19 testing to make sure that what’s causing the symptoms is not the coronavirus.

    That said, it’s probably not reasonable to ask that kids stay home if they have any hint of the sniffles. That could mean kids miss many weeks of school during winter months. Parents and caregivers should assume there are kids who are infected with some respiratory pathogens in their child’s class at all times and take precautions accordingly. Some families may choose to mask. Others may go back to what they did pre-Covid, which is to stick with good hand hygiene and not being around vulnerable people when sick.

    CNN: What types of precautions should parents and caregivers take?

    Wen: Handwashing is a big one. Many of these respiratory pathogens travel through droplets: When someone sneezes or coughs, those droplets land on surfaces that someone else touches and then touch their nose or mouth. Encourage your kids to wash their hands frequently, and if they need to cough or sneeze, they should do so into their elbow or a tissue to reduce the spread of the droplets.

    If a person in your household has a respiratory infection, it can be easily spread to other household members. You can reduce that risk by not sharing utensils or drinks with the person who is ill, and keeping the person who is sick away from vulnerable household members like newborns and the elderly. In general, families should also limit exposure for newborns and premature babies as much as possible.

    There is no approved vaccine for RSV, but there is for the flu. Parents should get their kids the flu shot. They should get their kids vaccinated against Covid-19 if they haven’t already, and assess their own family circumstances to determine whether they should get their children aged 5 or older the new bivalent booster.

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    Health

    RSV in children: Symptoms, treatment and what parents should know

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    CNN
     — 

    In September, an 8-month-old baby came into Dr. Juanita Mora’s office in Chicago with an infection the doctor hadn’t expected to see for another two months: RSV.

    Like her peers across the country, the allergist and immunologist has been treating little ones with this cold-like virus well before the season usually starts.

    “We’re seeing RSV infections going rampant all throughout the country,” Mora said.

    Almost all children catch RSV at some point before they turn 2, the US Centers for Disease Control and Prevention says. Most adults who catch it have a mild illness; for those who are elderly or who have chronic heart or lung disease or a weakened immune system, it can be dangerous. But RSV can be especially tricky for infants and kids.

    Mora, a volunteer medical spokesperson for the American Lung Association, says it’s important for parents, caregivers and daycare workers to know what to watch for with RSV, which stands for respiratory syncytial virus. That way, they know whether a sick child can be treated at home or needs to go to a hospital.

    “The emergency department is getting completely flooded with all these sick kids, so we want parents to know they can go to their pediatrician and get tested for RSV, influenza and even Covid-19,” Mora said.

    Here’s what else parents need to know amid the surge of respiratory illnesses.

    For many, RSV causes a mild illness that can be managed at home.

    On average, an infection lasts five days to a couple of weeks, and it will often go away on its own, the CDC says. Sometimes, the cough can linger for up to four weeks, pediatricians say.

    Symptoms may look like a common cold: a runny nose, a decreased appetite, coughing, sneezing, fever and wheezing. Young infants may seem only irritable or lethargic and have trouble breathing.

    Not every child will have every potential RSV symptom.

    “Fevers are really hit or miss with RSV infections, especially in young infants,” said Dr. Priya Soni, assistant professor of pediatric infectious diseases at Cedars Sinai Medical Center.

    Parents should watch for any changes in behavior, she said, including taking longer to eat or not being interested in food at all. The child can also develop a severe cough and some wheezing.

    It’s also important to watch for signs that your child is struggling to breathe or breathing with their ribs or belly – “symptoms which may kind of overlap with many of the other viruses that we’re seeing a resurgence of,” Soni added.

    Since it’s not easy for parents to tell the difference between respiratory illnesses like, say, RSV and flu, it’s good to take a sick child to a pediatrician, who can run tests to pinpoint the cause.

    “You may need to take your baby to be evaluated sooner rather than later,” Soni said.

    When it comes to RSV, parents should be especially cautious if their children are preemies, newborns, children with weakened immune systems or neuromuscular disorders, and those under age 2 with chronic lung and heart conditions, the CDC says.

    “Parents should be really astute to any changes, like in their activity and their appetite, and then pay particular attention to any signs of respiratory distress,” Soni said.

    Testing is important because treatment for things like flu and Covid-19 may differ.

    There’s no antiviral or specific treatment for RSV like there is for the flu, nor is there a vaccine. But if your child is sick, there are things you can do to help.

    Fever and pain can be managed with non-aspirin pain relievers like acetaminophen or ibuprofen. Also make sure your child drinks enough fluids.

    “RSV can make kids very dehydrated, especially when they’re not eating or drinking, especially when we’re talking infants,” Mora said. “Once they stop eating or their urine output has decreased, they’re not having as many wet diapers, this is a sign they may have to go to the pediatrician or emergency department.”

    Talk to your pediatrician before giving your child any over-the-counter cold medicines, which can sometimes contain ingredients that aren’t good for kids.

    Your pediatrician will check the child’s respiratory rate – how fast they’re breathing – and their oxygen levels. If your child is very sick or at high risk of severe illness, the doctor may want them to go to a hospital.

    “RSV can be super dangerous for some young infants and younger kids, particularly those that are less than 2 years of age,” Soni said.

    Mora said labored breathing is a sign that a child is having trouble with this virus. RSV can turn into more serious illnesses such as bronchiolitis or pneumonia, and that can lead to respiratory failure.

    If you see that a child’s chest is moving up and down when they breathe, if their cough won’t let them sleep or if it’s getting worse, “that might be a sign that they need to seek help from their pediatrician or take them to the emergency department, because then they might need a supplemental oxygen, or they may need a nebulization treatment.”

    CNN medical analyst Dr. Leana Wen says this respiratory difficulty – including a bobbing head, a flaring nose or grunting – is one of two major trouble signs with any respiratory infection. The other is dehydration. “That particularly applies to babies with stuffy noses. They may not be feeding.”

    Much of the care provided by hospital staff will be to help with breathing.

    “We provide supportive measures for RSV and these kids with oxygen, IV fluids and respiratory therapies, including suctioning,” Soni said.

    A thin tube may need to be inserted into their lungs to remove mucus. A child can get extra oxygen through a mask or through a tube that attaches to their nose. Some children may need to use an oxygen tent. Those who are struggling a lot may need a ventilator.

    Some babies might also need to be fed by tube.

    The best ways to prevent RSV infections, doctors say, is to teach kids to cough and sneeze into a tissue or into their elbows rather than their hands. Also try to keep frequently touched surfaces clean.

    If a caregiver or older sibling is sick, Mora says, they should wear a mask around other people and wash their hands frequently.

    And most of all, if anyone is sick – child or adult – they should stay home so they don’t spread the illness.

    There is a monoclonal antibody treatment for children who are at highest risk for severe disease. It’s not available for everyone, but it can protect those who are most vulnerable. It comes in the form of a shot that a child can get every month during the typical RSV season. Talk to your doctor about whether your child qualifies.

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    Health

    Paxlovid: Covid-19 treatment can interact with common heart medications, doctors warn

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    CNN
     — 

    Covid-19 patients with a history of cardiovascular disease are at an increased risk of developing severe illness and could benefit most from the Covid-19 treatment Paxlovid – but there’s a catch.

    Paxlovid can have dangerous interactions with some of the most common medications for cardiovascular disease, including certain statins and heart failure therapies, a new paper warns.

    The review paper, published Wednesday in the Journal of the American College of Cardiology, lists dozens of cardiovascular medications and whether they are safe to give along with Paxlovid or whether they could have interactions.

    Some medications such as aspirin are safe to take with Paxlovid, according to the paper, but other drugs could have interactions, and therefore, their dosage should be adjusted or temporarily discontinued while a patient is taking Paxlovid.

    When President Joe Biden tested positive for Covid-19 and started Paxlovid in July, his physician Dr. Kevin O’Connor temporarily took him off Crestor and Eliquis, two heart medications that the President takes for his pre-existing conditions. Doctors say there is no short-term risk to stopping these drugs.

    The review paper says that interactions between Paxlovid and certain blood thinners can cause an increased risk of bleeding. Interactions between Paxlovid and some cholesterol medications such as statins can be toxic to the liver, and interactions between Paxlovid and certain blood pressure medications could cause low blood pressure, flushing and swelling.

    “There are some drugs that you simply will not be able to stop, and a doctor will have to make a decision. It’s a risk-benefit analysis,” said Dr. Jayne Morgan, a cardiologist and clinical director of the Covid Task Force at Piedmont Hospital/Healthcare in Atlanta, who was not involved in the new paper.

    For cardiovascular medications that patients could discontinue in order to take Paxlovid, Morgan noted that the Covid-19 treatment is a five-day regimen.

    “You’ve got to make the diagnosis and then stop your drugs and have all of that done in time to still meet that five-day window,” Morgan said, adding that people will have to consult with their doctors about what’s best for them.

    The authors of the new paper – from Lahey Hospital and Medical Center, Harvard Medical School and other US institutions – wrote that Paxlovid should be avoided when potentially interacting cardiovascular medications cannot be “safely interrupted.”

    Paxlovid, an oral antiviral drug, was authorized in December for the treatment of mild to moderate Covid-19 in people 12 and older who are at high risk of severe illness, hospitalization or death.

    “Awareness of the presence of drug-drug interactions of Paxlovid with common cardiovascular drugs is key. System-level interventions by integrating drug-drug interactions into electronic medical records could help avoid related adverse events,” the paper’s senior author, Dr. Sarju Ganatra, director of the cardio-oncology program at Lahey Hospital and Medical Center in Massachusetts, said in a news release.

    “The prescription of Paxlovid could be incorporated into an order set, which allows physicians, whether it be primary care physicians or cardiology providers, to consciously rule out any contraindications to the co-administration of Paxlovid. Consultation with other members of the health care team, particularly pharmacists, can prove to be extremely valuable,” Ganatra said. “However, a health care provider’s fundamental understanding of the drug-drug interactions with cardiovascular medications is key.”

    Interactions between Paxlovid and common heart medications are well known, said Dr. Dan Barouch, director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center in Boston, who was not involved in the new paper.

    “Drug interactions have been reported, but I think that Paxlovid has been prescribed so widely that some doctors and patients may not be as attuned as they should be,” Barouch said.

    Paxlovid is made of two antivirals, nirmatrelvir and ritonavir.

    “The second drug, ritonavir, is a nonspecific drug that inhibits metabolism and increases the dose of the other drug. But the ritonavir in Paxlovid also can inhibit the metabolism of other drugs. So you have to be really careful when you prescribe Paxlovid for people who are on certain blood thinners, cardiac medications, statins and other drugs,” Barouch said. “So it’s not just a free pass.”

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    US

    Parkland shooter’s death penalty trial nears its end as the prosecution and defense make closing arguments

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    CNN
     — 

    Prosecutors have called on a Florida jury to recommend the Parkland school shooter be put to death, saying in a closing argument Tuesday he meticulously planned the February 2018 massacre, and that the facts of the case outweigh anything in his background that defense attorneys claim warrant a life sentence.

    “What he wanted to do, what his plan was and what he did, was to murder children at school and their caretakers,” lead prosecutor Michael Satz said of Nikolas Cruz, who pleaded guilty to 17 counts of murder and 17 counts of attempted murder for the shooting at Marjory Stoneman Douglas High School, in which 14 students and three school staff members were killed. “That’s what he wanted to do.”

    But Cruz “is a brain damaged, broken, mentally ill person, through no fault of his own,” defense attorney Melisa McNeill said in her own closing argument, pointing to the defense’s claim that Cruz’s mother used drugs and drank alcohol while his mother was pregnant with him, saying he was “poisoned” in her womb.

    “And in a civilized humane society, do we kill brain damaged, mentally ill, broken people?” McNeill asked Tuesday. “Do we? I hope not.”

    With closing arguments, the monthslong sentencing phase of Cruz’s trial is nearing its end, marking prosecutors’ last chance to convince the jury to recommend a death sentence and defense attorneys’ last opportunity to lobby for life in prison without parole.

    Prosecutors have argued Cruz’s decision to commit the deadliest mass shooting at an American high school was premeditated and calculated, while Cruz’s defense attorneys have offered evidence of a lifetime of struggles at home and in school.

    Each side was allotted two and a half hours to make their closing arguments.

    Jury deliberations are expected to begin Wednesday, during which time jurors will be sequestered, per Broward Circuit Judge Elizabeth Scherer.

    If they choose to recommend a death sentence, the jurors must be unanimous, or Cruz will receive life in prison without the possibility of parole. If the jury does recommend death, the final decision rests with Judge Scherer, who could choose to follow the recommendation or sentence Cruz to life.

    In his remarks, Satz outlined prosecutors’ reasoning, including the preparations Cruz made. For a “long time” prior to the shooting, Satz said, Cruz thought about carrying it out.

    Revisiting ground covered in the trial, the prosecutor said Cruz researched mass shootings and their perpetrators, including those at a music festival in Las Vegas; at a movie theater in Aurora, Colorado; at Virginia Tech; and at Colorado’s Columbine High School.

    Cruz modified his AR-15 to help improve his marksmanship; he accumulated ammunition and and magazines; and he searched online for information about how long it would take police to respond to a school shooting, Satz said.

    Then, the day of, Satz said, Cruz hid his tactical vest in a backpack and took an Uber to the school, wearing a Marjory Stoneman Douglas JROTC polo shirt to blend in. Based on his planning, he told the Uber driver to drop him off at a specific pedestrian gate, knowing it would be open soon before school let out.

    “All these details he thought of, and he did,” Satz said.

    Satz also detailed a narrative of the shooting, which he called a “systematic massacre,” recounting how the shooter killed or wounded each of his victims, whose families and loved ones filled the courtroom gallery.

    Cruz, wearing a striped sweater and flanked by his public defenders, looked on expressionless, occasionally looking down at the table in front of him or talking to one of his attorneys.

    “The appropriate sentence for Nikolas Cruz is the death penalty,” Satz concluded.

    In her own statement, McNeill stressed to jurors that defense attorneys were not disputing that Cruz deserves to be punished for the shooting.

    “We are asking you to punish him and to punish him severely,” she said. “We are asking you to sentence him to prison for the rest of his life, where he will wait to die, either by natural causes or whatever else could possibly happen to him while he’s in prison.”

    The 14 slain students were: Alyssa Alhadeff, 14; Martin Duque Anguiano, 14; Nicholas Dworet, 17; Jaime Guttenberg, 14; Luke Hoyer, 15; Cara Loughran, 14; Gina Montalto, 14; Joaquin Oliver, 17; Alaina Petty, 14; Meadow Pollack, 18; Helena Ramsay, 17; Alex Schachter, 14; Carmen Schentrup, 16; and Peter Wang, 14.

    Geography teacher Scott Beigel, 35; wrestling coach Chris Hixon, 49; and assistant football coach Aaron Feis, 37, also were killed – each while running toward danger or trying to help students to safety.

    The lengthy trial – jury selection began six months ago, in early April – has seen prosecutors and defense attorneys present evidence of aggravating factors and mitigating circumstances, reasons Cruz should or should not be put to death.

    The state has pointed to seven aggravating factors, including that the killings were especially heinous, atrocious or cruel, as well as cold, calculated and premeditated, Satz said Tuesday. Other aggravating factors include the fact the defendant knowingly created a great risk of death to many people and that he disrupted a lawful government function – in this case, the running of a school.

    Together, these aggravating factors “outweigh any mitigation about anything about the defendant’s background or character,” Satz said.

    Satz rejected the mitigating circumstances presented during trial by the defense, including that Cruz’s mother smoked or used drugs while pregnant with him. Those factors would not turn someone into a mass murderer, Satz argued, adding it was the jury’s job to weigh the credibility of the defense witnesses who testified to those claims.

    Satz cast doubt on the defense’s other proposed mitigators. In response to a claim that Cruz has neurological or intellectual deficits, Satz pointed to the gunman’s ability to carefully research and prepare for the Parkland shooting.

    In response to claims Cruz was bullied by his peers, Satz argued Cruz was an aggressor, pointing to testimony that he walked around in high school with a swastika drawn on his backpack, along with the N-word and other explicit language.

    “Hate is not a mental disorder,” Satz said.

    During trial, prosecutors presented evidence showing the gunman spent months searching online for information about mass shootings and left behind social media comments sharing his express desire to “kill people,” while Google searches illustrated how he sought information about mass shootings. On YouTube, Cruz left comments like “Im going to be a professional school shooter,” and promised to “go on a killing rampage.”

    “What one writes,” Satz said, referencing Cruz’s online history Tuesday, “what one says, is a window to someone’s soul.”

    In their own case, the public defenders assigned to represent Cruz have asked the jury to take into account his troubled history, from a dysfunctional family life to serious mental and developmental issues, with attorney McNeill describing him earlier in the trial as a “damaged and wounded” person.

    “His brain is broken,” she said during her opening statement in August. “He’s a damaged human being.”

    Among the first witnesses was Cruz’s older sister, Danielle Woodard, who testified their mother, Brenda Woodard, used drugs and drank alcohol while pregnant with him – something McNeill said made his brain “irretrievably broken” through no fault of his own.

    “She introduced me to a life that no child should be introduced to,” she said. “She had no regards for my life or his life.”

    The defense also called teachers and educators who spoke to developmental issues and delays Cruz exhibited as a young child, including challenges with vocabulary and motor skills. Various counselors and psychiatrists also testified, offering their observations from years of treating or interacting with Cruz.

    Former Broward County school district counselor John Newnham testified Cruz’s academic achievements in elementary school were below expectations. Cruz would describe himself as “stupid” and a “freak,” Newnham said.

    Despite these apparent issues, Cruz’s adoptive mother, the late Lynda Cruz, was reluctant to seek help, according to the testimony of a close friend who lived down the street from the family, Trish Devaney Westerlind.

    Newnham’s testimony echoed that: While Lynda Cruz was a caring mother, after the death of her husband, she would ask for help but not use the support available.

    “She was overwhelmed,” Newnham said. “She appeared to lack some of the basic foundations of positive parenting.”

    Westerlind still accepts calls from Cruz and, says though he’s in his 20s, Cruz still talks like an 11-year-old child.

    Cruz’s attorneys acknowledged as he grew older he developed a fascination with firearms, and school staff raised concerns about his behavior to authorities, McNeill said.

    In June 2014, an adolescent psychiatrist and a school therapist at the school Cruz attended at the time wrote a letter to an outside psychiatrist treating Cruz, in which they expressed concern Cruz had become verbally aggressive and had a “preoccupation with guns” and “dreams of killing others.”

    The psychiatrist, Dr. Brett Negin, who testified he treated Cruz between the ages of 13 and 18, said he never received the letter.

    As part of the prosecution’s case, family members of the victims were given the opportunity this summer to take the stand and offer raw and emotional testimony about how Cruz’s actions had forever changed their lives. At one point, even members of Cruz’s defense team were brought to tears.

    “I feel I can’t truly be happy if I smile,” Max Schachter, the father of 14-year-old victim Alex Schachter, testified in August. “I know that behind that smile is the sharp realization that part of me will always be sad and miserable because Alex isn’t here.”

    Before the prosecution rested, jurors also visited the site of the massacre, Marjory Stoneman Douglas’ 1200 building, which had been sealed since the shooting to preserve the crime scene – littered with dried blood, Valentine’s Day cards and students’ belongings – for the trial.

    The defense’s case came to an unexpected end last month when – having called just 26 of 80 planned witnesses – public defenders assigned to represent Cruz abruptly rested, leading the judge to admonish the team for what she said was unprofessionalism, resulting in a courtroom squabble between her and the defense (the jury was not present).

    Defense attorneys would later file a motion to disqualify the judge for her comments, arguing in part they suggested the judge was not impartial and Cruz’s right to a fair trial had been undermined. Prosecutors disagreed, writing “judicial comments, even of a critical or hostile nature, are not grounds for disqualification.”

    Scherer ultimately denied the motion.

    Prosecutors then presented their rebuttal, concluding last week following a three-day delay attributed to Hurricane Ian. Their case included footage of Cruz telling clinical neuropsychologist Dr. Robert Denney he chose to carry out the shooting on Valentine’s Day because he “felt like no one loved me, and I didn’t like Valentine’s Day and I wanted to ruin it for everyone.”

    Denney, who spent more than 400 hours with the gunman, testified for the prosecution that he concluded Cruz has borderline personality disorder and anti-social personality disorder. But Cruz did not meet the criteria for fetal alcohol spectrum disorder, as the defense has contended, Denney testified, accusing Cruz of “grossly exaggerating” his “psychiatric problems” in tests Denney administered.

    When read the list of names of the 17 people killed and asked if fetal alcohol spectrum disorder explained their murders, Denney responded “no” each time.

    Correction: An earlier version of this story misspelled the first name of defense attorney Melisa McNeill.

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