Eevar Benjamin Rossavik, DO

Healthcare providers caring for children are frequently asked about water safety practices during the summer months. Drowning prevention is one of the most important topics of discussion for anticipatory guidance in the pediatric population, especially for toddlers. It is important to be comfortable in bringing up this topic and providing resources for families.

The American Academy of Pediatrics (AAP) has multiple resources available through their website and various other online platforms affiliated with the organization.

 Drowning is the leading cause of injury death in US children between 1-4 years of age and is a significant morbidity well into early adulthood.

 Some studies have indicated that the majority of preschool-aged children drown in swimming pools, and this has been linked to a lack of barriers to prevent unsupervised access to water.

 As children get older, they become more likely to drown in open water areas, whereas infants are more likely to drown at home. Medical conditions, notably epilepsy, autism, and cardiac arrhythmias, have also been shown to be contributing factors to incidence of drowning.

 The AAP Policy Statement, the “Prevention of Drowning,” provides education and recommendations for parents and caregivers on how to prevent drowning within their communities.

The AAP also offers a drowning prevention campaign/toolkit for parents and caregivers, including videos with sobering infographics such as morbidity statistics.

 The Centers for Disease Control and Prevention (CDC) also have epidemiologic data readily available such as the fact that 3960 fatal unintentional drownings occur daily in the US every year.

 That number nearly doubles when considering nonfatal drownings, which can result in long-term health consequences especially related to brain injuries. Not wearing life jackets also has a significant impact when considering drowning deaths. Life jackets prevent drowning, especially during boating and swimming accidents. In 2019, the US Coast Guard reported 613 boating-related deaths, 79% being drowning related. Of those drowning deaths, 86% did not wear life jackets.

Healthychildren.org is another incredible website that provides useful information on various pediatric topics including drowning prevention. One of the most effective ways to reduce drownings in young children is to prevent unintended, unsupervised access to water. Some important steps include at least having a 4-foot-high fence surrounding all sides of a pool and removal of backyard water hazards, full supervision of children when they are around a body of water, emptying water containers (buckets, bathtubs, wading pools) after each use, and blocking unsupervised access to bathrooms.

These steps are all directly associated with close supervision of children around water – and life jackets are important to use whenever possible. The AAP recommends swim lessons as an additional way to protect against drowning that can begin for many children as early as one year of age.

 Infant swim classes are currently not recommended by the AAP – although it is considered acceptable for families to enroll in parent-child water play classes for infants.

There are various online resources to provide education to families and caregivers about drowning prevention. During these summer months, anticipatory guidance should be given to anyone caring for children whenever possible. Depending on the age of the child or the sources of water, guidance can change, but supervision is something that is a constant regardless of the situation. Having these difficult conversations early-on can prevent mortality and make our children safer year-round.

Eevar Benjamin Rossavik, DO, is a chief pediatrics resident who will soon join his program’s faculty to be a pediatrics attending. He has a specific interest in allergy, asthma, and immunology.

Clinicians and experts interested in responding to this piece, or submitting their own articles to HCPLive, 

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/child_death_review/Pages/Water-Safety.aspx

https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Water-Safety-And-Young-Children.aspx

https://pediatrics.aappublications.org/content/94/2/137?ijkey=48abaf71ce0749bca0cdb88072e7fa3779651438&keytype2=tf_ipsecsha

https://pediatrics.aappublications.org/content/108/1/85?ijkey=094f3918fdc227864aa10052c1ca371e62e63ebe&keytype2=tf_ipsecsha

https://pediatrics.aappublications.org/content/143/5/e20190850#ref-8

https://services.aap.org/en/news-room/campaigns-and-toolkits/drowning-prevention/

https://www.cdc.gov/drowning/facts/index.html

https://www.uscgboating.org/library/accident-statistics/Recreational-Boating-Statistics-2019.pdf

https://www.healthychildren.org/English/safety-prevention/at-play/Pages/swim-lessons.aspx

Articles

A variety of online drowning prevention resources can be accessed by parents and health care professionals, promoting safe swimming in the summer.

Water Safety and Drowning Prevention for Children

, millions are finally able to return to activities they have not been able to do for more than a year—and travel seems to be on the top of many lists for summer plans. Of the increasing options, Europe seems to be a popular destination for many. 

Per the Centers for Disease Control and Prevention (CDC) guidelines, fully vaccinated individuals can resume activities without wearing a mask or physically distancing, unless they’re specifically told otherwise based on federal, state, local, tribal, or territorial regulations.

 Furthermore, vaccines are increasingly easier to find with online resources.

 It is important to note, however, that health disparities have been revealed both during the pandemic and by the process of widespread vaccine administration.

Nevertheless, having a return to previous routines and activities is bringing a welcome change compared to more than a year of quarantining and social distancing. The European Union (EU) recently reached a deal to approve a ‘digital COVID certificate’ to make travel easier this summer and revive their tourism industry.

 Many scientists, physicians, and various other healthcare agencies will be watching how the next few months play out as the doors open in June once international travel resumes between both continents. It is also important for travelers to know what to expect as they travel abroad.

The CDC has international travel guidance available on their website that is updated frequently.

 Travel advisories are listed on the United States (US) Department of State website for specific countries.

 The European Centre for Disease Prevention and Control also offers weekly surveillance reports on COVID-19 for the general public.

 The 14-day case notification rate for the European Union on data based from 30 countries has been decreasing for weeks, giving many a sense of ease when planning European travel. Mortality has also been decreasing. 

As for those who are vaccinated—during travel, it is important to realize that wearing a mask is still required on planes, buses, trains, and other forms of transportation. Having a viral test 3 to 5 days after travel is also recommended, as is self-monitoring for COVID-19 symptoms. Expectations and recommendations are stricter for those who are unvaccinated. It is also important to note that different individual European countries may have different regulations, so this should also be investigated prior to any purchasing of plane tickets.

Although we are now in a period where we can talk about travel planning, it is still important to realize that the COVID-19 pandemic continues. It should also be emphasized that these travel opportunities and easing restrictions are for those who are vaccinated. Only about 37% of the US population has been vaccinated at this time.

 Community programs still need to be in place to get vaccines and education out to people in need both nationally and internationally. 

As the EU opens up its borders to Americans who are vaccinated, an ‘emergency brake’ will also be in place to halt travel from countries where infection rates are rising.

 Variants are posing several concerns across the globe, so caution should still be practiced if one decides to travel abroad.

Clinicians and experts interested in responding to this piece, or submitting their own articles to

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/How-Do-I-Get-a-COVID-19-Vaccine.html

https://www.nytimes.com/interactive/2021/03/05/us/vaccine-racial-disparities.html

https://www.dw.com/en/eu-reaches-deal-on-approving-covid-travel-pass/a-57601963

https://www.cdc.gov/coronavirus/2019-ncov/travelers/international-travel-during-covid19.html

https://travel.state.gov/content/travel/en/traveladvisories/traveladvisories.html/

https://www.ecdc.europa.eu/en/covid-19/surveillance/weekly-surveillance-report

https://www.cnn.com/travel/article/eu-to-allow-entry-to-vaccinated-travelers/index.html

https://www.nbcnews.com/news/us-news/fauci-says-public-misinterpreting-latest-cdc-mask-guidance-n1268000

As the world begins to open its borders, international travelers need to remain diligent of limitations and risks.

How Americans Should Navigate Traveling to Europe During COVID-19

As May 9-15, 2021 is Food Allergy Awareness Week, there is an opportunity to raise awareness for 

. Fortunately, the incidence of fatal food anaphylaxis for an individual is low and adds little mortality risk.

 However, as food allergy anaphylaxis can nevertheless be fatal, it is important to highlight food allergy awareness to provide appropriate treatment and counseling for patients.

Food allergy is an allergic reaction that involves the immune system. For food allergies—specifically immunoglobulin E (IgE)-mediated food allergic reactions—there are specific food proteins against which the body mounts an immune response. In the most common type of food allergy, IgE antibodies target certain proteins in food that they mistakenly see as a threat. Food-specific IgE antibodies are formed that bind to receptors on mast cells, basophils, macrophages, and dendritic cells, and when allergens reach cell-bound IgE antibodies in susceptible individuals, mediators are released that induce allergy symptoms. There are non-IgE-mediated or mixed IgE-mediated reactions, as well, but the IgE-mediated immunologic basis is key to understanding how food allergies work.

Research from 2019 suggests that at least 10.7% (>26 million) of US adults are food allergic, whereas 19% of US adults believe they have a food allergy.

 Having confirmatory testing with a strong clinical history is important to avoid undue quality of life burden and to provide appropriate counseling, treatment, and dietary management, if necessary.

Anaphylaxis is a multisystemic, severe, and potentially life-threatening allergic reaction. Symptoms can vary from confusion and agitation to lip and mouth swelling, difficulty breathing, wheezing, hypotension/weak pulse, and/or hives or redness all over the body. Epinephrine is the treatment of choice for this reaction. Many patients with food allergies have epinephrine autoinjectors. Epinephrine is generally not needed for mild hives—but if there is any concern for respiratory symptoms or persistent vomiting or abdominal pain, epinephrine is typically necessary. Delayed epinephrine administration has been cited as the most common cause of death from food allergies.

 In addition, as we enter the summer months, patients and providers need to be aware that epinephrine autoinjectors may lose potency within hours if stored in a heated car.

Any food can cause an allergic reaction. However, there are 8 types of food that account for about 90% of all reactions: milk, wheat, egg, peanuts, tree nuts, fish, crustacean shellfish, and soy.

 For those affected, education in treatment and prevention of food allergy reactions is crucial—which is why patients should be provided help in reading and understanding food labels.

 This is especially true for children with food allergies, who should be encouraged to start reading food labels as soon as they can read with practice at home from caregivers.

There are multiple organizations that can provide assistance for food allergy education, diagnosis, treatment, and advocacy. These include, but are not limited to:

The American Academy of Allergy, Asthma & Immunology (AAAAI)

The American College of Allergy, Asthma & Immunology (ACAAI)

The Food Allergy Research & Education Organization (FARE)

Kids With Food Allergies (KFA), a division of the Asthma and Allergy Foundation of America

These organizations have various online resources also available for patients and providers.

Turner PJ, Jerschow E, Umasunthar T, Lin R, Campbell DE, Boyle RJ. Fatal Anaphylaxis: Mortality Rate and Risk Factors. 

. 2017;5(5):1169-1178. doi:10.1016/j.jaip.2017.06.031

Umasunthar T, Leonardi-Bee J, Hodes M, et al. Incidence of fatal food anaphylaxis in people with food allergy: a systematic review and meta-analysis. 

. 2013;43(12):1333-1341. doi:10.1111/cea.12211

Gupta RS, Warren CM, Smith BM, et al. Prevalence and Severity of Food Allergies Among US Adults. 

. 2019;2(1):e185630. Published 2019 Jan 4. doi:10.1001/jamanetworkopen.2018.5630

Chooniedass R, Temple B, Becker A. Epinephrine use for anaphylaxis: Too seldom, too late: Current practices and guidelines in health care. 

. 2017;119(2):108-110. doi:10.1016/j.anai.2017.06.004

Lieberman P. Biphasic anaphylactic reactions. 

. 2005;95(3):217-258. doi:10.1016/S1081-1206(10)61217-3

https://www.aaaai.org/about-aaaai/newsroom/news-releases/epipens-heat#:~:text=Epinephrine%20autoinjectors%20(EAIs)%20have%20recommended,59%20%E2%80%93%2086%20degrees%20Fahrenheit%20permitted

https://www.fda.gov/food/buy-store-serve-safe-food/food-allergies-what-you-need-know

https://www.foodallergy.org/resources/how-read-food-label

https://www.aaaai.org/conditions-and-treatments/library/allergy-library/food-allergy

https://acaai.org/allergies/types/food-allergy

https://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/food-allergy

An expert writes on the value of shared knowledge into the intricacies of allergic risks.

Food Allergy and Anaphylaxis: Promoting Awareness and Understanding

Now that vaccines that target severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are becoming more available to the public, providing these vaccines to children is an important step in fighting the COVID-19 pandemic. Vaccine development occurred early on during the COVID-19 pandemic in parallel with simultaneous manufacturing.

 This process was expedited by an Emergency Use Authorization by the Food and Drug Administration (FDA) for the COVID-19 vaccine.

 Although this process was significantly quicker than what is expected in traditional timelines, there was significant effort done to ensure the utmost safety and efficacy of these vaccines—just like what would be expected with any vaccine or medical product. 

The director of the Center for Biologics Evaluation and Research (CBER) at the FDA, Peter Marks, MD, PhD, reiterated in an interview that the FDA shortened vaccine timelines "without compromising vaccine safety and efficacy."

 Although the timeline was expedited, the process was not any different in terms of the studies and review of data by independent scientific experts that is done with any vaccine. The entire review process was transparent, and there have been several meetings available to the public in which safety and efficacy have been addressed and demonstrated. Industry data are available to the general public, as well. Furthermore, post-deployment surveillance continues for clinical trial participants. The vaccines that have been deployed to the community are safe, and all COVID-19 vaccines currently available in the United States are highly effective at preventing COVID-19 and building protection.

However—like with any vaccine or medical product—now that we are seeing the benefits in adults with COVID-19 vaccination, the next question many are asking is: when do we start vaccinating children? Early on in the pandemic there were ethical issues brought up with COVID-19 vaccination in minors—notably waiting until safety and efficacy have been established in adults.

 However, it was also thought that by waiting too long, this also had the potential to delay the potential benefits of vaccination for the individual and community. Many authors such as Mintz et al have called for the need for a systematic approach to determine the safest way to enroll pediatric patients in COVID-19 vaccine trials.

There is a definite need for vaccination in the pediatric population. The American Academy of Pediatrics and the Children’s Hospital Association have been working together to collect COVID-19 data on pediatric patients.

 Current available data are encouraging, as COVID-19-associated hospitalization and mortality are uncommon in pediatric patients. However, a rare but serious medical condition in the pediatric population called Multisystem Inflammatory Syndrome in Children (MIS-C) is still under investigation and causing concern.

Although COVID-19 cases are declining, there are still millions of children who have tested positive for COVID-19. Un addition to the risks to the children themselves, these infections pose risks when spread to others. There are also financial effects to consider that this pandemic has had on local communities. Quarantining and social distancing alone have caused serious economic consequences globally, and local school districts are not immune to these effects, either.

The CDC’s Advisory Committee on Immunization Practices (ACIP) meets regularly to provide updates on a variety of vaccine-related issues, but for months now, there has been a call for the need for pediatric COVID-19 vaccine trials.

 Moderna has begun testing its vaccine in children ranging from 6 months of age to 12 years old.

 Pfizer-BioNTech also has vaccine trials that are currently being performed in adolescents.

 Johnson & Johnson is expected to follow suit, and trial investigators have already begun with the Oxford-AstraZeneca vaccine in children 6 years and older.

 The Moderna study is being conducted in collaboration with the National Institute of Allergy and Infectious Diseases (NIAID), and the process thus far has been as equally transparent as initial vaccine development.

Getting as many people vaccinated as possible is a major goal to help beat COVID-19 globally—and it is important that we get to a point where vaccines are available to all patients, especially those in the pediatric population. The COVID-19 vaccines available thus far are safe and effective, and vaccinating children will be an important step in continuing the fight against this pandemic.

Eevar B Rossavik, DO, is a chief pediatrics resident who will soon join his program’s faculty to be a pediatrics attending. He has a specific interest in allergy, asthma, and immunology.

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Mintz K, Jardas E, Shah S, Grady C, Danis M, Wendler D. Enrolling Minors in COVID-19 Vaccine Trials. Pediatrics. 2021;147(3):e2020040717. doi:10.1542/peds.2020-040717

Children and COVID-19: State-Level Data Report - 

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/mis-c.html

https://www.brookings.edu/blog/brown-center-chalkboard/2020/04/09/how-the-coronavirus-shutdown-will-affect-school-district-revenues/

Experts provide update on ‘essential’ COVID-19 vaccine trials in children, teens -https://www.aappublications.org/news/2021/01/27/acip-covid-vaccine-pediatric-trials-012721

https://www.nytimes.com/2021/03/16/health/moderna-vaccine-children.html

https://www.aappublications.org/news/2021/03/16/moderna-covid-trials-children-031621

An expert writes on the scope of the next great COVID-19 vaccine challenge: pediatric assessment and administration.