Pediatrics

The treatment of atopic dermatitis (AD) is undergoing a revolution thanks to biologics. Now, an allergist and a dietitian told pediatric dermatologists that the treatment of a related condition – food allergy – is also undergoing a dramatic transformation as the management approach evolves away from blanket avoidance of allergens.

“Over the past 15 years, we’ve seen a shift from a very passive approach where generally we just advised patients to avoid the things they’re allergic to,” said U.K. pediatric allergist Adam Fox, MBBS, MD, in a presentation at The World Congress of Pediatric Dermatology (WCPD) 2021 Annual Meeting. “Now, we have a much better understanding of how allergy develops and strategies to minimize the risk of allergy happening in the first place,” he said.

According to Carina Venter, PhD, RD, associate professor of pediatrics-allergy/immunology at the University of Colorado, Denver, who also spoke at the conference, an estimated 20% to 30% of patients with AD also have food allergies, and up to 90% of infants with cow’s milk allergy develop skin symptoms.

It may not be necessary for a breastfeeding mother to avoid food allergens if a child is allergic, said Dr. Fox, of Guy’s and St. Thomas’ NHS Foundation Trust, London. “A lot of parents will automatically assume that if their child has an egg or milk allergy, then it’s a good idea to completely eliminate that from their diet if they’re breastfeeding,” but it is “surprisingly uncommon” that this approach makes a difference, he said. “Less goes through the breast milk than people imagine,” he said.

He noted that eliminating foods from the breastfeeding mother’s diet may have negative consequences. “There’s always that risk that if you make life harder for the breastfeeding mom because they’re going to have to avoid all sorts of foods, they’ll be more likely to discontinue breastfeeding. You really need a compelling reason to stop the food.”

As for children themselves, Dr. Fox suggested that there’s often no connection between AD and food allergies. “What will commonly happen when you see and diagnose these kids is that their eczema has been quite significantly undertreated,” he said. “Once you just get them on the right [regimen], they don’t need to be cutting the food out of their diet. It’s just making their life unnecessarily harder.”

Dr. Venter said there may be little choice but to avoid a trigger food if a child develops AD with exposure. However, she noted, it’s important to understand that avoidance of certain foods could make the allergy – and AD – worse. “If you have a child or an adult with atopic dermatitis that’s not controlled by an optimal topical treatment, and you do consider avoidance, we need to be aware that development of more severe IgA-mediated symptoms can happen in a short period of time,” she said.

In a slide that Dr. Venter presented, the dilemma for physicians was expressed this way: “The potential benefit of food avoidance as a management strategy for some patients with AD must now be weighed against the strong evidence that unnecessarily avoiding a food in kids with AD increases the risk of developing anaphylaxis to that food.”

What should pediatric dermatologists do to balance the risks of allergen exposure to the risks that children will develop permanent allergies? Dr. Venter pointed to guidelines about AD that were developed by the U.K.’s National Institute for Health and Care Excellence. She also highlighted the International Milk Allergy in Primary Care recommendations.

She suggested considering creative ways to bypass complete avoidance and boost a child’s tolerance of allergens if possible. “If we’re going to keep a child with eczema on a mold-free diet for a longer period of time, is there perhaps a role for regularly introducing small amounts of yogurt or even small amounts of milk in the child’s diet to at least keep immune tolerance without necessarily aggravating eczema symptoms?”

Dr. Fox has consulted for DBV and Aimmune through his employer, NHS Trust. He serves as president of the British Society for Allergy and Clinical Immunology and as chair of the Allergy UK Health Advisory Board, both of which receive funding from drug companies. Dr. Venter has received support for allergy-related research from the National Peanut Board.

A version of this article first appeared on Medscape.com.

The treatment of atopic dermatitis (AD) is undergoing a revolution thanks to biologics. Now, an allergist and a dietitian told pediatric dermatologists that the treatment of a related condition – food allergy – is also undergoing a dramatic transformation as the management approach evolves away from blanket avoidance of allergens.

“Over the past 15 years, we’ve seen a shift from a very passive approach where generally we just advised patients to avoid the things they’re allergic to,” said U.K. pediatric allergist Adam Fox, MBBS, MD, in a presentation at The World Congress of Pediatric Dermatology (WCPD) 2021 Annual Meeting. “Now, we have a much better understanding of how allergy develops and strategies to minimize the risk of allergy happening in the first place,” he said.

According to Carina Venter, PhD, RD, associate professor of pediatrics-allergy/immunology at the University of Colorado, Denver, who also spoke at the conference, an estimated 20% to 30% of patients with AD also have food allergies, and up to 90% of infants with cow’s milk allergy develop skin symptoms.

It may not be necessary for a breastfeeding mother to avoid food allergens if a child is allergic, said Dr. Fox, of Guy’s and St. Thomas’ NHS Foundation Trust, London. “A lot of parents will automatically assume that if their child has an egg or milk allergy, then it’s a good idea to completely eliminate that from their diet if they’re breastfeeding,” but it is “surprisingly uncommon” that this approach makes a difference, he said. “Less goes through the breast milk than people imagine,” he said.

He noted that eliminating foods from the breastfeeding mother’s diet may have negative consequences. “There’s always that risk that if you make life harder for the breastfeeding mom because they’re going to have to avoid all sorts of foods, they’ll be more likely to discontinue breastfeeding. You really need a compelling reason to stop the food.”

As for children themselves, Dr. Fox suggested that there’s often no connection between AD and food allergies. “What will commonly happen when you see and diagnose these kids is that their eczema has been quite significantly undertreated,” he said. “Once you just get them on the right [regimen], they don’t need to be cutting the food out of their diet. It’s just making their life unnecessarily harder.”

Dr. Venter said there may be little choice but to avoid a trigger food if a child develops AD with exposure. However, she noted, it’s important to understand that avoidance of certain foods could make the allergy – and AD – worse. “If you have a child or an adult with atopic dermatitis that’s not controlled by an optimal topical treatment, and you do consider avoidance, we need to be aware that development of more severe IgA-mediated symptoms can happen in a short period of time,” she said.

In a slide that Dr. Venter presented, the dilemma for physicians was expressed this way: “The potential benefit of food avoidance as a management strategy for some patients with AD must now be weighed against the strong evidence that unnecessarily avoiding a food in kids with AD increases the risk of developing anaphylaxis to that food.”

What should pediatric dermatologists do to balance the risks of allergen exposure to the risks that children will develop permanent allergies? Dr. Venter pointed to guidelines about AD that were developed by the U.K.’s National Institute for Health and Care Excellence. She also highlighted the International Milk Allergy in Primary Care recommendations.

She suggested considering creative ways to bypass complete avoidance and boost a child’s tolerance of allergens if possible. “If we’re going to keep a child with eczema on a mold-free diet for a longer period of time, is there perhaps a role for regularly introducing small amounts of yogurt or even small amounts of milk in the child’s diet to at least keep immune tolerance without necessarily aggravating eczema symptoms?”

Dr. Fox has consulted for DBV and Aimmune through his employer, NHS Trust. He serves as president of the British Society for Allergy and Clinical Immunology and as chair of the Allergy UK Health Advisory Board, both of which receive funding from drug companies. Dr. Venter has received support for allergy-related research from the National Peanut Board.

A version of this article first appeared on Medscape.com.

The treatment of atopic dermatitis (AD) is undergoing a revolution thanks to biologics. Now, an allergist and a dietitian told pediatric dermatologists that the treatment of a related condition – food allergy – is also undergoing a dramatic transformation as the management approach evolves away from blanket avoidance of allergens.

“Over the past 15 years, we’ve seen a shift from a very passive approach where generally we just advised patients to avoid the things they’re allergic to,” said U.K. pediatric allergist Adam Fox, MBBS, MD, in a presentation at The World Congress of Pediatric Dermatology (WCPD) 2021 Annual Meeting. “Now, we have a much better understanding of how allergy develops and strategies to minimize the risk of allergy happening in the first place,” he said.

According to Carina Venter, PhD, RD, associate professor of pediatrics-allergy/immunology at the University of Colorado, Denver, who also spoke at the conference, an estimated 20% to 30% of patients with AD also have food allergies, and up to 90% of infants with cow’s milk allergy develop skin symptoms.

It may not be necessary for a breastfeeding mother to avoid food allergens if a child is allergic, said Dr. Fox, of Guy’s and St. Thomas’ NHS Foundation Trust, London. “A lot of parents will automatically assume that if their child has an egg or milk allergy, then it’s a good idea to completely eliminate that from their diet if they’re breastfeeding,” but it is “surprisingly uncommon” that this approach makes a difference, he said. “Less goes through the breast milk than people imagine,” he said.

He noted that eliminating foods from the breastfeeding mother’s diet may have negative consequences. “There’s always that risk that if you make life harder for the breastfeeding mom because they’re going to have to avoid all sorts of foods, they’ll be more likely to discontinue breastfeeding. You really need a compelling reason to stop the food.”

As for children themselves, Dr. Fox suggested that there’s often no connection between AD and food allergies. “What will commonly happen when you see and diagnose these kids is that their eczema has been quite significantly undertreated,” he said. “Once you just get them on the right [regimen], they don’t need to be cutting the food out of their diet. It’s just making their life unnecessarily harder.”

Dr. Venter said there may be little choice but to avoid a trigger food if a child develops AD with exposure. However, she noted, it’s important to understand that avoidance of certain foods could make the allergy – and AD – worse. “If you have a child or an adult with atopic dermatitis that’s not controlled by an optimal topical treatment, and you do consider avoidance, we need to be aware that development of more severe IgA-mediated symptoms can happen in a short period of time,” she said.

In a slide that Dr. Venter presented, the dilemma for physicians was expressed this way: “The potential benefit of food avoidance as a management strategy for some patients with AD must now be weighed against the strong evidence that unnecessarily avoiding a food in kids with AD increases the risk of developing anaphylaxis to that food.”

What should pediatric dermatologists do to balance the risks of allergen exposure to the risks that children will develop permanent allergies? Dr. Venter pointed to guidelines about AD that were developed by the U.K.’s National Institute for Health and Care Excellence. She also highlighted the International Milk Allergy in Primary Care recommendations.

She suggested considering creative ways to bypass complete avoidance and boost a child’s tolerance of allergens if possible. “If we’re going to keep a child with eczema on a mold-free diet for a longer period of time, is there perhaps a role for regularly introducing small amounts of yogurt or even small amounts of milk in the child’s diet to at least keep immune tolerance without necessarily aggravating eczema symptoms?”

Dr. Fox has consulted for DBV and Aimmune through his employer, NHS Trust. He serves as president of the British Society for Allergy and Clinical Immunology and as chair of the Allergy UK Health Advisory Board, both of which receive funding from drug companies. Dr. Venter has received support for allergy-related research from the National Peanut Board.

A version of this article first appeared on Medscape.com.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Childhood and adolescence are periods with marked psychobehavioral development of the brain. The sense of self, identity, and role are established. This process is not without risk because brain regions governing reward, impulsivity, and sensation-seeking are relatively more developed and influential than higher-order cognitive regions regulating behavioral inhibition, decision-making, and planning, which continue to mature into one’s early to mid-20s. Consequently, while the developing brain is “under construction” by forging new pathways and taking advantage of its immense neuroplasticity, it is also prone to psychological insults under exposure to stressful events, attitudes, and behaviors, including those that can arise in the family.¹

Most people would agree that there is no stronger emotion than parental love. The origins of this powerful biobehavioral bonding with a child have been attributed to maternal release of oxytocin, known colloquially as the “love hormone,” during the birthing process, and to both biological parents experiencing psychosocial attachment with their infant. Therefore, common sense dictates that parents would do anything to protect their offspring, and that no parent would deliberately behave in a manner that harms their child.

Common sense notwithstanding, reports of both child neglect and abuse are common. States have established agencies to protect children from their own parents. The answers to the question “Whose kids are they?” and under what circumstances the state has the authority to warn or reprimand parents, or even temporarily or permanently separate minors from their parents, are complex and vary by state.

In this commentary, we describe harmful actions committed by parents with the intention of protecting the impressionable minds of their children from malevolent forces or intrusive and unhealthy ideas. Second, we examine how to protect a minor from parental actions that are well-meaning but potentially harmful.

Parent-child communication

Delusional family interactions. Originally described in 1877 as “folie à deux,”² shared madness is an extreme and uncommon parental psychiatric condition harmful to a child’s mental health. It is primarily characterized by parental-initiated delusions shared with the child that are typically persecutory and attributed to danger from vengeful folks or grandiose in nature. The question of whether the “folie” or “madness” is contagious arises due to the propensity of the child to adopt these delusions under an imposed insular or restrictive environment. Separating the child from the environment dominated by the delusional adult usually is sufficient to reverse the symptoms due to reality testing.

Normative familial communication. In contrary to a delusional familial interaction, normative family traditions and values are a unifying psychosocial force and a source of bonding and loyalty from an early age. A ubiquitous example is the support of a local sports team, and the emotional turmoil associated with the team’s wins and losses, accompanied by “hating” a rival. These family rituals are commonly devoid of emotional negative consequences for an impressionable young mind unless the child is exposed to unsportsmanlike emotional, verbal, or aggressive behavior by an adult at home in front of the television or in the stands at a game.

Continue to: Unfortunately...

Unfortunately, the “love-hate” dichotomy rooted in family-generated traditions of loyalty is becoming more evident in today’s turbulent sociopolitical environment. Children and young adolescents are not prepared to cope with the stressful effects of repeated exposure to intense conflictual events at home when parents adopt opposing sociopolitical ideologies. Furthermore, a parent might intentionally expose their child to emotionally conflictual circumstances in the name of a perceived value that might create and exacerbate stress, fear, and self-loathing. Ironically, by doing what a parent believes is right for their child, they might be transforming the child without their consent into a variant of a “toy soldier by proxy.” Such a child is a tool expected to follow the parental pathway and belief system without questioning, or even having the cognitive ability to do so, given their ongoing bio-behavioral and moral developmental phase.³

This new normative exposure to conflictual situations at the will of the parent is not only limited to watching them remotely but also may include participating in what is meant to be a peaceful protest or march. As we all witnessed in 2020, such events can easily deteriorate into unsafe environments rife with lawlessness and uncontrolled violence. This has included clashes between opposing groups who are matched in zeal and conviction, as well as opposition to or endangerment by law enforcement personnel trying to restore order by force. This is not where a responsible parent should take their child. Furthermore, there is the danger of loss of privacy of children exposed by media following their participation in public activity. This may lead to hate mail as that would further confuse and jeopardize a peaceful lifestyle, which is highly desirable for a developing child.

Cognitive dissonance. Have these parents temporarily allowed the limbic system to trump the restraints of the prefrontal cortex, as exhibited by an impulsive and risky behavior driven by poor insight? Have these parents thoughtfully weighed the balance between the merit of a child’s exposure to such conflictual circumstances and the peril of negative emotional consequences? This is illustrated by a mother who has been taking her preadolescent son to demonstrations regularly because “I want him to see how democracy works.”

Might this be a case of cognitive dissonance (CD) that amounts to unwitting mental child abuse if it happens repeatedly? According to the CD theory, there is a tendency to seek consistency between cognitions (eg, beliefs, opinions) and attitudes or behaviors. Inconsistency between these variables is termed “dissonance.”^4,5 The importance attached to the dissonant belief affects the severity of the dissonance. The dissonance occurs when a parent must choose between 2 incompatible beliefs or actions. A classic demonstration of CD is when an adult requests that an adolescent follows his instructions (eg, “do not smoke or drink alcohol”), yet the adult does not act accordingly (eg, they smoke or drink). Role modeling demonstrated by such a discrepancy is a cause of confusion in the child. In terms of this article, the CD is between what the parent believes is an important learning experience by exercising the perceived right to pass to the child the parental value system vs compromising the protection of the child by exposing them to the potential negative consequences of a risky situation.

What can parents and therapists do?

Usually, parents mean well. It is important to communicate to parents the importance of refraining from forcing their children to join their battles. Calculating risks based on an intuitive approach is flawed because doing so is based on beliefs and emotions that originated in the limbic system (“I feel that”…) and are neither precise nor accurate.⁶ Teaching our youth in the school system how to think (eg, the science of logic and history of science) vs what to think (ie, indoctrination) is a key to healthy cognitive development. Furthermore, children need to have the time, space, and opportunities (learning moments) to develop this capacity. It is not until approximately age 16 that abstract thinking capabilities are developed. Cognitive dissonance can be eliminated by reducing the valence of the conflicting beliefs or by removing the conflicting attitude or behavior.

As parents and as mental health professionals, we should carry the necessary burden of responsibility to prevent the risk of “lost childhood” due to parental emotional zeal and righteousness that lead to early exposure to damaging adversity. We cannot afford to turn our children into exploitable tools (ie, toy soldiers) in conflicts they do not fully grasp.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Childhood and adolescence are periods with marked psychobehavioral development of the brain. The sense of self, identity, and role are established. This process is not without risk because brain regions governing reward, impulsivity, and sensation-seeking are relatively more developed and influential than higher-order cognitive regions regulating behavioral inhibition, decision-making, and planning, which continue to mature into one’s early to mid-20s. Consequently, while the developing brain is “under construction” by forging new pathways and taking advantage of its immense neuroplasticity, it is also prone to psychological insults under exposure to stressful events, attitudes, and behaviors, including those that can arise in the family.¹

Most people would agree that there is no stronger emotion than parental love. The origins of this powerful biobehavioral bonding with a child have been attributed to maternal release of oxytocin, known colloquially as the “love hormone,” during the birthing process, and to both biological parents experiencing psychosocial attachment with their infant. Therefore, common sense dictates that parents would do anything to protect their offspring, and that no parent would deliberately behave in a manner that harms their child.

Common sense notwithstanding, reports of both child neglect and abuse are common. States have established agencies to protect children from their own parents. The answers to the question “Whose kids are they?” and under what circumstances the state has the authority to warn or reprimand parents, or even temporarily or permanently separate minors from their parents, are complex and vary by state.

In this commentary, we describe harmful actions committed by parents with the intention of protecting the impressionable minds of their children from malevolent forces or intrusive and unhealthy ideas. Second, we examine how to protect a minor from parental actions that are well-meaning but potentially harmful.

Parent-child communication

Delusional family interactions. Originally described in 1877 as “folie à deux,”² shared madness is an extreme and uncommon parental psychiatric condition harmful to a child’s mental health. It is primarily characterized by parental-initiated delusions shared with the child that are typically persecutory and attributed to danger from vengeful folks or grandiose in nature. The question of whether the “folie” or “madness” is contagious arises due to the propensity of the child to adopt these delusions under an imposed insular or restrictive environment. Separating the child from the environment dominated by the delusional adult usually is sufficient to reverse the symptoms due to reality testing.

Normative familial communication. In contrary to a delusional familial interaction, normative family traditions and values are a unifying psychosocial force and a source of bonding and loyalty from an early age. A ubiquitous example is the support of a local sports team, and the emotional turmoil associated with the team’s wins and losses, accompanied by “hating” a rival. These family rituals are commonly devoid of emotional negative consequences for an impressionable young mind unless the child is exposed to unsportsmanlike emotional, verbal, or aggressive behavior by an adult at home in front of the television or in the stands at a game.

Continue to: Unfortunately...

Unfortunately, the “love-hate” dichotomy rooted in family-generated traditions of loyalty is becoming more evident in today’s turbulent sociopolitical environment. Children and young adolescents are not prepared to cope with the stressful effects of repeated exposure to intense conflictual events at home when parents adopt opposing sociopolitical ideologies. Furthermore, a parent might intentionally expose their child to emotionally conflictual circumstances in the name of a perceived value that might create and exacerbate stress, fear, and self-loathing. Ironically, by doing what a parent believes is right for their child, they might be transforming the child without their consent into a variant of a “toy soldier by proxy.” Such a child is a tool expected to follow the parental pathway and belief system without questioning, or even having the cognitive ability to do so, given their ongoing bio-behavioral and moral developmental phase.³

This new normative exposure to conflictual situations at the will of the parent is not only limited to watching them remotely but also may include participating in what is meant to be a peaceful protest or march. As we all witnessed in 2020, such events can easily deteriorate into unsafe environments rife with lawlessness and uncontrolled violence. This has included clashes between opposing groups who are matched in zeal and conviction, as well as opposition to or endangerment by law enforcement personnel trying to restore order by force. This is not where a responsible parent should take their child. Furthermore, there is the danger of loss of privacy of children exposed by media following their participation in public activity. This may lead to hate mail as that would further confuse and jeopardize a peaceful lifestyle, which is highly desirable for a developing child.

Cognitive dissonance. Have these parents temporarily allowed the limbic system to trump the restraints of the prefrontal cortex, as exhibited by an impulsive and risky behavior driven by poor insight? Have these parents thoughtfully weighed the balance between the merit of a child’s exposure to such conflictual circumstances and the peril of negative emotional consequences? This is illustrated by a mother who has been taking her preadolescent son to demonstrations regularly because “I want him to see how democracy works.”

Might this be a case of cognitive dissonance (CD) that amounts to unwitting mental child abuse if it happens repeatedly? According to the CD theory, there is a tendency to seek consistency between cognitions (eg, beliefs, opinions) and attitudes or behaviors. Inconsistency between these variables is termed “dissonance.”^4,5 The importance attached to the dissonant belief affects the severity of the dissonance. The dissonance occurs when a parent must choose between 2 incompatible beliefs or actions. A classic demonstration of CD is when an adult requests that an adolescent follows his instructions (eg, “do not smoke or drink alcohol”), yet the adult does not act accordingly (eg, they smoke or drink). Role modeling demonstrated by such a discrepancy is a cause of confusion in the child. In terms of this article, the CD is between what the parent believes is an important learning experience by exercising the perceived right to pass to the child the parental value system vs compromising the protection of the child by exposing them to the potential negative consequences of a risky situation.

What can parents and therapists do?

Usually, parents mean well. It is important to communicate to parents the importance of refraining from forcing their children to join their battles. Calculating risks based on an intuitive approach is flawed because doing so is based on beliefs and emotions that originated in the limbic system (“I feel that”…) and are neither precise nor accurate.⁶ Teaching our youth in the school system how to think (eg, the science of logic and history of science) vs what to think (ie, indoctrination) is a key to healthy cognitive development. Furthermore, children need to have the time, space, and opportunities (learning moments) to develop this capacity. It is not until approximately age 16 that abstract thinking capabilities are developed. Cognitive dissonance can be eliminated by reducing the valence of the conflicting beliefs or by removing the conflicting attitude or behavior.

As parents and as mental health professionals, we should carry the necessary burden of responsibility to prevent the risk of “lost childhood” due to parental emotional zeal and righteousness that lead to early exposure to damaging adversity. We cannot afford to turn our children into exploitable tools (ie, toy soldiers) in conflicts they do not fully grasp.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Childhood and adolescence are periods with marked psychobehavioral development of the brain. The sense of self, identity, and role are established. This process is not without risk because brain regions governing reward, impulsivity, and sensation-seeking are relatively more developed and influential than higher-order cognitive regions regulating behavioral inhibition, decision-making, and planning, which continue to mature into one’s early to mid-20s. Consequently, while the developing brain is “under construction” by forging new pathways and taking advantage of its immense neuroplasticity, it is also prone to psychological insults under exposure to stressful events, attitudes, and behaviors, including those that can arise in the family.¹

Most people would agree that there is no stronger emotion than parental love. The origins of this powerful biobehavioral bonding with a child have been attributed to maternal release of oxytocin, known colloquially as the “love hormone,” during the birthing process, and to both biological parents experiencing psychosocial attachment with their infant. Therefore, common sense dictates that parents would do anything to protect their offspring, and that no parent would deliberately behave in a manner that harms their child.

Common sense notwithstanding, reports of both child neglect and abuse are common. States have established agencies to protect children from their own parents. The answers to the question “Whose kids are they?” and under what circumstances the state has the authority to warn or reprimand parents, or even temporarily or permanently separate minors from their parents, are complex and vary by state.

In this commentary, we describe harmful actions committed by parents with the intention of protecting the impressionable minds of their children from malevolent forces or intrusive and unhealthy ideas. Second, we examine how to protect a minor from parental actions that are well-meaning but potentially harmful.

Parent-child communication

Delusional family interactions. Originally described in 1877 as “folie à deux,”² shared madness is an extreme and uncommon parental psychiatric condition harmful to a child’s mental health. It is primarily characterized by parental-initiated delusions shared with the child that are typically persecutory and attributed to danger from vengeful folks or grandiose in nature. The question of whether the “folie” or “madness” is contagious arises due to the propensity of the child to adopt these delusions under an imposed insular or restrictive environment. Separating the child from the environment dominated by the delusional adult usually is sufficient to reverse the symptoms due to reality testing.

Normative familial communication. In contrary to a delusional familial interaction, normative family traditions and values are a unifying psychosocial force and a source of bonding and loyalty from an early age. A ubiquitous example is the support of a local sports team, and the emotional turmoil associated with the team’s wins and losses, accompanied by “hating” a rival. These family rituals are commonly devoid of emotional negative consequences for an impressionable young mind unless the child is exposed to unsportsmanlike emotional, verbal, or aggressive behavior by an adult at home in front of the television or in the stands at a game.

Continue to: Unfortunately...

Unfortunately, the “love-hate” dichotomy rooted in family-generated traditions of loyalty is becoming more evident in today’s turbulent sociopolitical environment. Children and young adolescents are not prepared to cope with the stressful effects of repeated exposure to intense conflictual events at home when parents adopt opposing sociopolitical ideologies. Furthermore, a parent might intentionally expose their child to emotionally conflictual circumstances in the name of a perceived value that might create and exacerbate stress, fear, and self-loathing. Ironically, by doing what a parent believes is right for their child, they might be transforming the child without their consent into a variant of a “toy soldier by proxy.” Such a child is a tool expected to follow the parental pathway and belief system without questioning, or even having the cognitive ability to do so, given their ongoing bio-behavioral and moral developmental phase.³

This new normative exposure to conflictual situations at the will of the parent is not only limited to watching them remotely but also may include participating in what is meant to be a peaceful protest or march. As we all witnessed in 2020, such events can easily deteriorate into unsafe environments rife with lawlessness and uncontrolled violence. This has included clashes between opposing groups who are matched in zeal and conviction, as well as opposition to or endangerment by law enforcement personnel trying to restore order by force. This is not where a responsible parent should take their child. Furthermore, there is the danger of loss of privacy of children exposed by media following their participation in public activity. This may lead to hate mail as that would further confuse and jeopardize a peaceful lifestyle, which is highly desirable for a developing child.

Cognitive dissonance. Have these parents temporarily allowed the limbic system to trump the restraints of the prefrontal cortex, as exhibited by an impulsive and risky behavior driven by poor insight? Have these parents thoughtfully weighed the balance between the merit of a child’s exposure to such conflictual circumstances and the peril of negative emotional consequences? This is illustrated by a mother who has been taking her preadolescent son to demonstrations regularly because “I want him to see how democracy works.”

Might this be a case of cognitive dissonance (CD) that amounts to unwitting mental child abuse if it happens repeatedly? According to the CD theory, there is a tendency to seek consistency between cognitions (eg, beliefs, opinions) and attitudes or behaviors. Inconsistency between these variables is termed “dissonance.”^4,5 The importance attached to the dissonant belief affects the severity of the dissonance. The dissonance occurs when a parent must choose between 2 incompatible beliefs or actions. A classic demonstration of CD is when an adult requests that an adolescent follows his instructions (eg, “do not smoke or drink alcohol”), yet the adult does not act accordingly (eg, they smoke or drink). Role modeling demonstrated by such a discrepancy is a cause of confusion in the child. In terms of this article, the CD is between what the parent believes is an important learning experience by exercising the perceived right to pass to the child the parental value system vs compromising the protection of the child by exposing them to the potential negative consequences of a risky situation.

What can parents and therapists do?

Usually, parents mean well. It is important to communicate to parents the importance of refraining from forcing their children to join their battles. Calculating risks based on an intuitive approach is flawed because doing so is based on beliefs and emotions that originated in the limbic system (“I feel that”…) and are neither precise nor accurate.⁶ Teaching our youth in the school system how to think (eg, the science of logic and history of science) vs what to think (ie, indoctrination) is a key to healthy cognitive development. Furthermore, children need to have the time, space, and opportunities (learning moments) to develop this capacity. It is not until approximately age 16 that abstract thinking capabilities are developed. Cognitive dissonance can be eliminated by reducing the valence of the conflicting beliefs or by removing the conflicting attitude or behavior.

As parents and as mental health professionals, we should carry the necessary burden of responsibility to prevent the risk of “lost childhood” due to parental emotional zeal and righteousness that lead to early exposure to damaging adversity. We cannot afford to turn our children into exploitable tools (ie, toy soldiers) in conflicts they do not fully grasp.

One week after reporting promising results from the trial of their COVID-19 vaccine in children ages 5-11, Pfizer and BioNTech announced they’d submitted the data to the Food and Drug Administration. But that hasn’t stopped some parents from discreetly getting their children under age 12 vaccinated.

“The FDA, you never want to get ahead of their judgment,” Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told MSNBC on Sept. 28. “But I would imagine in the next few weeks, they will examine that data and hopefully they’ll give the okay so that we can start vaccinating children, hopefully before the end of October.”
 

Lying to vaccinate now

More than half of all parents with children under 12 say they plan to get their kids vaccinated, according to a Gallup poll. Among those who say they’re “very worried” or “somewhat worried” about their children catching COVID, that number goes up to 90% and 72%, respectively.

And although the FDA and the American Academy of Pediatrics have warned against it, some parents whose children can pass for 12 have lied to get them vaccinated already.

Dawn G. is a mom of two in southwest Missouri, where less than 45% of the population has been fully vaccinated. Her son turns 12 in early October, but in-person school started in mid-August.

“It was scary, thinking of him going to school for even 2 months,” she said. “Some parents thought their kid had a low chance of getting COVID, and their kid died. Nobody expects it to be them.”

In July, she and her husband took their son to a walk-in clinic and lied about his age.

“So many things can happen, from bullying to school shootings, and now this added pandemic risk,” she said. “I’ll do anything I can to protect my child, and a birthdate seems so arbitrary. He’ll be 12 in a matter of weeks. It seems ridiculous that that date would stop me from protecting him.”

In northern California, Carrie S. had a similar thought. When the vaccine was authorized for children ages 12-15 in May, the older of her two children got the shot right away. But her youngest doesn’t turn 12 until November.

“We were tempted to get the younger one vaccinated in May, but it didn’t seem like a rush. We were willing to wait to get the dosage right,” she ssaid. “But as Delta came through, there were no options for online school, the CDC was dropping mask expectations –it seemed like the world was ready to forget the pandemic was happening. It seemed like the least-bad option to get her vaccinated so she could go back to school, and we could find some balance of risk in our lives.”
 

Adult vs. pediatric doses

For now, experts advise against getting younger children vaccinated, even those who are the size of an adult, because of the way the human immune system develops.

“It’s not really about size,” said Anne Liu, MD, an immunologist and pediatrics professor at Stanford (Calif.) University. “The immune system behaves differently at different ages. Younger kids tend to have a more exuberant innate immune system, which is the part of the immune system that senses danger, even before it has developed a memory response.”

The adult Pfizer-BioNTech vaccine contains 30 mcg of mRNA, while the pediatric dose is just 10 mcg. That smaller dose produces an immune response similar to what’s seen in adults who receive 30 mcg, according to Pfizer.

“We were one of the sites that was involved in the phase 1 trial, a lot of times that’s called a dose-finding trial,” said Michael Smith, MD, a coinvestigator for the COVID vaccine trials done at Duke University. “And basically, if younger kids got a higher dose, they had more of a reaction, so it hurt more. They had fever, they had more redness and swelling at the site of the injection, and they just felt lousy, more than at the lower doses.”

At this point, with Pfizer’s data showing that younger children need a smaller dose, it doesn’t make sense to lie about your child’s age, said Dr. Smith.

“If my two options were having my child get the infection versus getting the vaccine, I’d get the vaccine. But we’re a few weeks away from getting the lower dose approved in kids,” he said. “It’s certainly safer. I don’t expect major, lifelong side effects from the higher dose, but it’s going to hurt, your kid’s going to have a fever, they’re going to feel lousy for a couple days, and they just don’t need that much antigen.”

A version of this article first appeared on WebMD.com.

One week after reporting promising results from the trial of their COVID-19 vaccine in children ages 5-11, Pfizer and BioNTech announced they’d submitted the data to the Food and Drug Administration. But that hasn’t stopped some parents from discreetly getting their children under age 12 vaccinated.

“The FDA, you never want to get ahead of their judgment,” Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told MSNBC on Sept. 28. “But I would imagine in the next few weeks, they will examine that data and hopefully they’ll give the okay so that we can start vaccinating children, hopefully before the end of October.”
 

Lying to vaccinate now

More than half of all parents with children under 12 say they plan to get their kids vaccinated, according to a Gallup poll. Among those who say they’re “very worried” or “somewhat worried” about their children catching COVID, that number goes up to 90% and 72%, respectively.

And although the FDA and the American Academy of Pediatrics have warned against it, some parents whose children can pass for 12 have lied to get them vaccinated already.

Dawn G. is a mom of two in southwest Missouri, where less than 45% of the population has been fully vaccinated. Her son turns 12 in early October, but in-person school started in mid-August.

“It was scary, thinking of him going to school for even 2 months,” she said. “Some parents thought their kid had a low chance of getting COVID, and their kid died. Nobody expects it to be them.”

In July, she and her husband took their son to a walk-in clinic and lied about his age.

“So many things can happen, from bullying to school shootings, and now this added pandemic risk,” she said. “I’ll do anything I can to protect my child, and a birthdate seems so arbitrary. He’ll be 12 in a matter of weeks. It seems ridiculous that that date would stop me from protecting him.”

In northern California, Carrie S. had a similar thought. When the vaccine was authorized for children ages 12-15 in May, the older of her two children got the shot right away. But her youngest doesn’t turn 12 until November.

“We were tempted to get the younger one vaccinated in May, but it didn’t seem like a rush. We were willing to wait to get the dosage right,” she ssaid. “But as Delta came through, there were no options for online school, the CDC was dropping mask expectations –it seemed like the world was ready to forget the pandemic was happening. It seemed like the least-bad option to get her vaccinated so she could go back to school, and we could find some balance of risk in our lives.”
 

Adult vs. pediatric doses

For now, experts advise against getting younger children vaccinated, even those who are the size of an adult, because of the way the human immune system develops.

“It’s not really about size,” said Anne Liu, MD, an immunologist and pediatrics professor at Stanford (Calif.) University. “The immune system behaves differently at different ages. Younger kids tend to have a more exuberant innate immune system, which is the part of the immune system that senses danger, even before it has developed a memory response.”

The adult Pfizer-BioNTech vaccine contains 30 mcg of mRNA, while the pediatric dose is just 10 mcg. That smaller dose produces an immune response similar to what’s seen in adults who receive 30 mcg, according to Pfizer.

“We were one of the sites that was involved in the phase 1 trial, a lot of times that’s called a dose-finding trial,” said Michael Smith, MD, a coinvestigator for the COVID vaccine trials done at Duke University. “And basically, if younger kids got a higher dose, they had more of a reaction, so it hurt more. They had fever, they had more redness and swelling at the site of the injection, and they just felt lousy, more than at the lower doses.”

At this point, with Pfizer’s data showing that younger children need a smaller dose, it doesn’t make sense to lie about your child’s age, said Dr. Smith.

“If my two options were having my child get the infection versus getting the vaccine, I’d get the vaccine. But we’re a few weeks away from getting the lower dose approved in kids,” he said. “It’s certainly safer. I don’t expect major, lifelong side effects from the higher dose, but it’s going to hurt, your kid’s going to have a fever, they’re going to feel lousy for a couple days, and they just don’t need that much antigen.”

A version of this article first appeared on WebMD.com.

One week after reporting promising results from the trial of their COVID-19 vaccine in children ages 5-11, Pfizer and BioNTech announced they’d submitted the data to the Food and Drug Administration. But that hasn’t stopped some parents from discreetly getting their children under age 12 vaccinated.

“The FDA, you never want to get ahead of their judgment,” Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told MSNBC on Sept. 28. “But I would imagine in the next few weeks, they will examine that data and hopefully they’ll give the okay so that we can start vaccinating children, hopefully before the end of October.”
 

Lying to vaccinate now

More than half of all parents with children under 12 say they plan to get their kids vaccinated, according to a Gallup poll. Among those who say they’re “very worried” or “somewhat worried” about their children catching COVID, that number goes up to 90% and 72%, respectively.

And although the FDA and the American Academy of Pediatrics have warned against it, some parents whose children can pass for 12 have lied to get them vaccinated already.

Dawn G. is a mom of two in southwest Missouri, where less than 45% of the population has been fully vaccinated. Her son turns 12 in early October, but in-person school started in mid-August.

“It was scary, thinking of him going to school for even 2 months,” she said. “Some parents thought their kid had a low chance of getting COVID, and their kid died. Nobody expects it to be them.”

In July, she and her husband took their son to a walk-in clinic and lied about his age.

“So many things can happen, from bullying to school shootings, and now this added pandemic risk,” she said. “I’ll do anything I can to protect my child, and a birthdate seems so arbitrary. He’ll be 12 in a matter of weeks. It seems ridiculous that that date would stop me from protecting him.”

In northern California, Carrie S. had a similar thought. When the vaccine was authorized for children ages 12-15 in May, the older of her two children got the shot right away. But her youngest doesn’t turn 12 until November.

“We were tempted to get the younger one vaccinated in May, but it didn’t seem like a rush. We were willing to wait to get the dosage right,” she ssaid. “But as Delta came through, there were no options for online school, the CDC was dropping mask expectations –it seemed like the world was ready to forget the pandemic was happening. It seemed like the least-bad option to get her vaccinated so she could go back to school, and we could find some balance of risk in our lives.”
 

Adult vs. pediatric doses

For now, experts advise against getting younger children vaccinated, even those who are the size of an adult, because of the way the human immune system develops.

“It’s not really about size,” said Anne Liu, MD, an immunologist and pediatrics professor at Stanford (Calif.) University. “The immune system behaves differently at different ages. Younger kids tend to have a more exuberant innate immune system, which is the part of the immune system that senses danger, even before it has developed a memory response.”

The adult Pfizer-BioNTech vaccine contains 30 mcg of mRNA, while the pediatric dose is just 10 mcg. That smaller dose produces an immune response similar to what’s seen in adults who receive 30 mcg, according to Pfizer.

“We were one of the sites that was involved in the phase 1 trial, a lot of times that’s called a dose-finding trial,” said Michael Smith, MD, a coinvestigator for the COVID vaccine trials done at Duke University. “And basically, if younger kids got a higher dose, they had more of a reaction, so it hurt more. They had fever, they had more redness and swelling at the site of the injection, and they just felt lousy, more than at the lower doses.”

At this point, with Pfizer’s data showing that younger children need a smaller dose, it doesn’t make sense to lie about your child’s age, said Dr. Smith.

“If my two options were having my child get the infection versus getting the vaccine, I’d get the vaccine. But we’re a few weeks away from getting the lower dose approved in kids,” he said. “It’s certainly safer. I don’t expect major, lifelong side effects from the higher dose, but it’s going to hurt, your kid’s going to have a fever, they’re going to feel lousy for a couple days, and they just don’t need that much antigen.”

A version of this article first appeared on WebMD.com.

It took years for Elle Moxley to get a diagnosis that explained her crippling gastrointestinal pain, digestion problems, fatigue, and hot, red rashes. And after learning in 2016 that she had Crohn’s disease, a chronic inflammation of the digestive tract, she spent more than 4 years trying medications before getting her disease under control with a biologic drug called Remicade.

So Ms. Moxley, 33, was dismayed to receive a notice from her insurer in January that Remicade would no longer be covered as a preferred drug on her plan. Another drug, Inflectra, which the Food and Drug Administration says has no meaningful clinical differences from Remicade, is now preferred. It is a “biosimilar” drug.

“I felt very powerless,” said Ms. Moxley, who recently started a job as a public relations coordinator for Kansas City (Mo.) Public Schools. “I have this decision being made for me and my doctor that’s not in my best interest, and it might knock me out of remission.”

After Ms. Moxley’s first Inflectra infusion in July, she developed a painful rash. It went away after a few days, but she said she continues to feel extremely fatigued and experiences gastrointestinal pain, constipation, diarrhea and nausea.

Many medical professionals look to biosimilar drugs as a way to increase competition and give consumers cheaper options, much as generic drugs do, and they point to the more robust use of these products in Europe to cut costs.

Yet the United States has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015. That’s partly because of concerns raised by patients like Moxley and their doctors, but also because brand-name biologics have kept biosimilars from entering the market. The companies behind the brand-name drugs have used legal actions to extend the life of their patents and incentives that make offering the brand biologic more attractive than offering a biosimilar on a formulary, listing which drugs are covered on an insurance plan.

“It distorts the market and makes it so that patients can’t get access,” said Jinoos Yazdany, MD, MPH, a professor of medicine and chief of the rheumatology division at Zuckerberg San Francisco General Hospital.

The FDA has approved 31 biosimilar medications since 2015, but only about 60% have made it to market, according to an analysis by NORC, a research organization at the University of Chicago.

Remicade’s manufacturer, Johnson & Johnson, and Pfizer, which makes the Remicade biosimilar Inflectra, have been embroiled in a long-running lawsuit over Pfizer’s claims that Johnson & Johnson tried to choke off competition through exclusionary contracts with insurers and other anticompetitive actions. In July, the companies settled the case on undisclosed terms.

In a statement, Pfizer said it would continue to sell Inflectra in the United States but noted ongoing challenges: “Pfizer has begun to see progress in the overall biosimilars marketplace in the U.S. However, changes in policy at a government level and acceptance of biosimilars among key stakeholders are critical to deliver more meaningful uptake so patients and the health care system at large can benefit from the cost savings these medicines may deliver.”

Johnson & Johnson said it is committed to making Remicade available to patients who choose it, which “compels us to compete responsibly on both price and value.”

Biologic medicines, which are generally grown from living organisms such as animal cells or bacteria, are more complex and expensive to manufacture than drugs made from chemicals. In recent years, biologic drugs have become a mainstay of treatment for autoimmune conditions like Crohn’s disease and rheumatoid arthritis, as well as certain cancers and diabetes, among other conditions.

Other drugmakers can’t exactly reproduce these biologic drugs by following chemical recipes as they do for generic versions of conventional drugs.

Instead, biosimilar versions of biologic drugs are generally made from the same types of materials as the original biologics and must be “highly similar” to them to be approved by the FDA. They must have no clinically meaningful differences from the biologic drug, and be just as safe, pure and potent. More than a decade after Congress created an approval pathway for biosimilars, they are widely accepted as safe and effective alternatives to brand biologics.

Medical experts hope that as biosimilars become more widely used they will increasingly provide a brake on drug spending.

From 2015 to 2019, drug spending overall grew 6.1%, while spending on biologics grew more than twice as much – 14.6% – according to a report by IQVIA, a health care analytics company. In 2019, biologics accounted for 43% of drug spending in the United States

Biosimilars provide a roughly 30% discount over brand biologics in the United States but have the potential to reduce spending by more than $100 billion in the next 5 years, the IQVIA analysis found.

In a survey of 602 physicians who prescribe biologic medications, more than three-quarters said they believed biosimilars are just as safe and effective as their biologic counterparts, according to NORC.

But they were less comfortable with switching patients from a brand biologic to a biosimilar. While about half said they were very likely to prescribe a biosimilar to a patient just starting biologic therapy, only 31% said they were very likely to prescribe a biosimilar to a patient already doing well on a brand biologic.

It can be challenging to find a treatment regimen that works for patients with complicated chronic conditions, and physicians and patients often don’t want to rock the boat once that is achieved.

In Ms. Moxley’s case, for example, before her condition stabilized on Remicade, she tried a conventional pill called Lialda, the biologic drug Humira and a lower dose of Remicade.

Some doctors and patients raise concerns that switching between these drugs might cause patients to develop antibodies that cause the drugs to lose effectiveness. They want to see more research about the effects of such switches.

“We haven’t seen enough studies about patients going from the biologic to the biosimilar and bouncing back and forth,” said Marcus Snow, MD, chair of the American College of Rheumatology’s Committee on Rheumatologic Care. “We don’t want our patients to be guinea pigs.”

Manufacturers of biologic and biosimilar drugs have participated in advertising, exhibit or sponsorship opportunities with the American College of Rheumatology, according to ACR spokesperson Jocelyn Givens.

But studies show a one-time switch from Remicade to a biosimilar like Inflectra does not cause side effects or the development of antibodies, said Ross Maltz, MD, a pediatric gastroenterologist at Nationwide Children’s Hospital in Columbus, Ohio, and former member of the Crohn’s & Colitis Foundation’s National Scientific Advisory Committee. Studies may be conducted by researchers with extensive ties to the industry and funded by drugmakers.

Situations like Ms. Moxley’s are unusual, said Kristine Grow, senior vice president of communications at AHIP, an insurer trade group.

“For patients who have been taking a brand-name biologic for some time, health insurance providers do not typically encourage them to switch to a biosimilar because of a formulary change, and most plans exclude these patients from any changes in cost sharing due to formulary changes,” she said.

Drugmakers can seek approval from the FDA of their biosimilar as interchangeable with a biologic drug, allowing pharmacists, subject to state law, to switch a physician’s prescription from the brand drug, as they often do with generic drugs.

However, the FDA has approved only one biosimilar (Semglee, a form of insulin) as interchangeable with a biologic (Lantus).

Like Ms. Moxley, many other patients using biologics get copay assistance from drug companies, but the money often isn’t enough to cover the full cost. In her old job as a radio reporter, Ms. Moxley said, she hit the $7,000 maximum annual out-of-pocket spending limit for her plan by May.

In her new job, Ms. Moxley has an individual plan with a $4,000 maximum out-of-pocket limit, which she expects to blow past once again within months.

But she received good news recently: Her new plan will cover Remicade.

“I’m still concerned that I will have developed antibodies since my last dose,” she said. “But it feels like a step in the direction of good health again.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

It took years for Elle Moxley to get a diagnosis that explained her crippling gastrointestinal pain, digestion problems, fatigue, and hot, red rashes. And after learning in 2016 that she had Crohn’s disease, a chronic inflammation of the digestive tract, she spent more than 4 years trying medications before getting her disease under control with a biologic drug called Remicade.

So Ms. Moxley, 33, was dismayed to receive a notice from her insurer in January that Remicade would no longer be covered as a preferred drug on her plan. Another drug, Inflectra, which the Food and Drug Administration says has no meaningful clinical differences from Remicade, is now preferred. It is a “biosimilar” drug.

“I felt very powerless,” said Ms. Moxley, who recently started a job as a public relations coordinator for Kansas City (Mo.) Public Schools. “I have this decision being made for me and my doctor that’s not in my best interest, and it might knock me out of remission.”

After Ms. Moxley’s first Inflectra infusion in July, she developed a painful rash. It went away after a few days, but she said she continues to feel extremely fatigued and experiences gastrointestinal pain, constipation, diarrhea and nausea.

Many medical professionals look to biosimilar drugs as a way to increase competition and give consumers cheaper options, much as generic drugs do, and they point to the more robust use of these products in Europe to cut costs.

Yet the United States has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015. That’s partly because of concerns raised by patients like Moxley and their doctors, but also because brand-name biologics have kept biosimilars from entering the market. The companies behind the brand-name drugs have used legal actions to extend the life of their patents and incentives that make offering the brand biologic more attractive than offering a biosimilar on a formulary, listing which drugs are covered on an insurance plan.

“It distorts the market and makes it so that patients can’t get access,” said Jinoos Yazdany, MD, MPH, a professor of medicine and chief of the rheumatology division at Zuckerberg San Francisco General Hospital.

The FDA has approved 31 biosimilar medications since 2015, but only about 60% have made it to market, according to an analysis by NORC, a research organization at the University of Chicago.

Remicade’s manufacturer, Johnson & Johnson, and Pfizer, which makes the Remicade biosimilar Inflectra, have been embroiled in a long-running lawsuit over Pfizer’s claims that Johnson & Johnson tried to choke off competition through exclusionary contracts with insurers and other anticompetitive actions. In July, the companies settled the case on undisclosed terms.

In a statement, Pfizer said it would continue to sell Inflectra in the United States but noted ongoing challenges: “Pfizer has begun to see progress in the overall biosimilars marketplace in the U.S. However, changes in policy at a government level and acceptance of biosimilars among key stakeholders are critical to deliver more meaningful uptake so patients and the health care system at large can benefit from the cost savings these medicines may deliver.”

Johnson & Johnson said it is committed to making Remicade available to patients who choose it, which “compels us to compete responsibly on both price and value.”

Biologic medicines, which are generally grown from living organisms such as animal cells or bacteria, are more complex and expensive to manufacture than drugs made from chemicals. In recent years, biologic drugs have become a mainstay of treatment for autoimmune conditions like Crohn’s disease and rheumatoid arthritis, as well as certain cancers and diabetes, among other conditions.

Other drugmakers can’t exactly reproduce these biologic drugs by following chemical recipes as they do for generic versions of conventional drugs.

Instead, biosimilar versions of biologic drugs are generally made from the same types of materials as the original biologics and must be “highly similar” to them to be approved by the FDA. They must have no clinically meaningful differences from the biologic drug, and be just as safe, pure and potent. More than a decade after Congress created an approval pathway for biosimilars, they are widely accepted as safe and effective alternatives to brand biologics.

Medical experts hope that as biosimilars become more widely used they will increasingly provide a brake on drug spending.

From 2015 to 2019, drug spending overall grew 6.1%, while spending on biologics grew more than twice as much – 14.6% – according to a report by IQVIA, a health care analytics company. In 2019, biologics accounted for 43% of drug spending in the United States

Biosimilars provide a roughly 30% discount over brand biologics in the United States but have the potential to reduce spending by more than $100 billion in the next 5 years, the IQVIA analysis found.

In a survey of 602 physicians who prescribe biologic medications, more than three-quarters said they believed biosimilars are just as safe and effective as their biologic counterparts, according to NORC.

But they were less comfortable with switching patients from a brand biologic to a biosimilar. While about half said they were very likely to prescribe a biosimilar to a patient just starting biologic therapy, only 31% said they were very likely to prescribe a biosimilar to a patient already doing well on a brand biologic.

It can be challenging to find a treatment regimen that works for patients with complicated chronic conditions, and physicians and patients often don’t want to rock the boat once that is achieved.

In Ms. Moxley’s case, for example, before her condition stabilized on Remicade, she tried a conventional pill called Lialda, the biologic drug Humira and a lower dose of Remicade.

Some doctors and patients raise concerns that switching between these drugs might cause patients to develop antibodies that cause the drugs to lose effectiveness. They want to see more research about the effects of such switches.

“We haven’t seen enough studies about patients going from the biologic to the biosimilar and bouncing back and forth,” said Marcus Snow, MD, chair of the American College of Rheumatology’s Committee on Rheumatologic Care. “We don’t want our patients to be guinea pigs.”

Manufacturers of biologic and biosimilar drugs have participated in advertising, exhibit or sponsorship opportunities with the American College of Rheumatology, according to ACR spokesperson Jocelyn Givens.

But studies show a one-time switch from Remicade to a biosimilar like Inflectra does not cause side effects or the development of antibodies, said Ross Maltz, MD, a pediatric gastroenterologist at Nationwide Children’s Hospital in Columbus, Ohio, and former member of the Crohn’s & Colitis Foundation’s National Scientific Advisory Committee. Studies may be conducted by researchers with extensive ties to the industry and funded by drugmakers.

Situations like Ms. Moxley’s are unusual, said Kristine Grow, senior vice president of communications at AHIP, an insurer trade group.

“For patients who have been taking a brand-name biologic for some time, health insurance providers do not typically encourage them to switch to a biosimilar because of a formulary change, and most plans exclude these patients from any changes in cost sharing due to formulary changes,” she said.

Drugmakers can seek approval from the FDA of their biosimilar as interchangeable with a biologic drug, allowing pharmacists, subject to state law, to switch a physician’s prescription from the brand drug, as they often do with generic drugs.

However, the FDA has approved only one biosimilar (Semglee, a form of insulin) as interchangeable with a biologic (Lantus).

Like Ms. Moxley, many other patients using biologics get copay assistance from drug companies, but the money often isn’t enough to cover the full cost. In her old job as a radio reporter, Ms. Moxley said, she hit the $7,000 maximum annual out-of-pocket spending limit for her plan by May.

In her new job, Ms. Moxley has an individual plan with a $4,000 maximum out-of-pocket limit, which she expects to blow past once again within months.

But she received good news recently: Her new plan will cover Remicade.

“I’m still concerned that I will have developed antibodies since my last dose,” she said. “But it feels like a step in the direction of good health again.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

It took years for Elle Moxley to get a diagnosis that explained her crippling gastrointestinal pain, digestion problems, fatigue, and hot, red rashes. And after learning in 2016 that she had Crohn’s disease, a chronic inflammation of the digestive tract, she spent more than 4 years trying medications before getting her disease under control with a biologic drug called Remicade.

So Ms. Moxley, 33, was dismayed to receive a notice from her insurer in January that Remicade would no longer be covered as a preferred drug on her plan. Another drug, Inflectra, which the Food and Drug Administration says has no meaningful clinical differences from Remicade, is now preferred. It is a “biosimilar” drug.

“I felt very powerless,” said Ms. Moxley, who recently started a job as a public relations coordinator for Kansas City (Mo.) Public Schools. “I have this decision being made for me and my doctor that’s not in my best interest, and it might knock me out of remission.”

After Ms. Moxley’s first Inflectra infusion in July, she developed a painful rash. It went away after a few days, but she said she continues to feel extremely fatigued and experiences gastrointestinal pain, constipation, diarrhea and nausea.

Many medical professionals look to biosimilar drugs as a way to increase competition and give consumers cheaper options, much as generic drugs do, and they point to the more robust use of these products in Europe to cut costs.

Yet the United States has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015. That’s partly because of concerns raised by patients like Moxley and their doctors, but also because brand-name biologics have kept biosimilars from entering the market. The companies behind the brand-name drugs have used legal actions to extend the life of their patents and incentives that make offering the brand biologic more attractive than offering a biosimilar on a formulary, listing which drugs are covered on an insurance plan.

“It distorts the market and makes it so that patients can’t get access,” said Jinoos Yazdany, MD, MPH, a professor of medicine and chief of the rheumatology division at Zuckerberg San Francisco General Hospital.

The FDA has approved 31 biosimilar medications since 2015, but only about 60% have made it to market, according to an analysis by NORC, a research organization at the University of Chicago.

Remicade’s manufacturer, Johnson & Johnson, and Pfizer, which makes the Remicade biosimilar Inflectra, have been embroiled in a long-running lawsuit over Pfizer’s claims that Johnson & Johnson tried to choke off competition through exclusionary contracts with insurers and other anticompetitive actions. In July, the companies settled the case on undisclosed terms.

In a statement, Pfizer said it would continue to sell Inflectra in the United States but noted ongoing challenges: “Pfizer has begun to see progress in the overall biosimilars marketplace in the U.S. However, changes in policy at a government level and acceptance of biosimilars among key stakeholders are critical to deliver more meaningful uptake so patients and the health care system at large can benefit from the cost savings these medicines may deliver.”

Johnson & Johnson said it is committed to making Remicade available to patients who choose it, which “compels us to compete responsibly on both price and value.”

Biologic medicines, which are generally grown from living organisms such as animal cells or bacteria, are more complex and expensive to manufacture than drugs made from chemicals. In recent years, biologic drugs have become a mainstay of treatment for autoimmune conditions like Crohn’s disease and rheumatoid arthritis, as well as certain cancers and diabetes, among other conditions.

Other drugmakers can’t exactly reproduce these biologic drugs by following chemical recipes as they do for generic versions of conventional drugs.

Instead, biosimilar versions of biologic drugs are generally made from the same types of materials as the original biologics and must be “highly similar” to them to be approved by the FDA. They must have no clinically meaningful differences from the biologic drug, and be just as safe, pure and potent. More than a decade after Congress created an approval pathway for biosimilars, they are widely accepted as safe and effective alternatives to brand biologics.

Medical experts hope that as biosimilars become more widely used they will increasingly provide a brake on drug spending.

From 2015 to 2019, drug spending overall grew 6.1%, while spending on biologics grew more than twice as much – 14.6% – according to a report by IQVIA, a health care analytics company. In 2019, biologics accounted for 43% of drug spending in the United States

Biosimilars provide a roughly 30% discount over brand biologics in the United States but have the potential to reduce spending by more than $100 billion in the next 5 years, the IQVIA analysis found.

In a survey of 602 physicians who prescribe biologic medications, more than three-quarters said they believed biosimilars are just as safe and effective as their biologic counterparts, according to NORC.

But they were less comfortable with switching patients from a brand biologic to a biosimilar. While about half said they were very likely to prescribe a biosimilar to a patient just starting biologic therapy, only 31% said they were very likely to prescribe a biosimilar to a patient already doing well on a brand biologic.

It can be challenging to find a treatment regimen that works for patients with complicated chronic conditions, and physicians and patients often don’t want to rock the boat once that is achieved.

In Ms. Moxley’s case, for example, before her condition stabilized on Remicade, she tried a conventional pill called Lialda, the biologic drug Humira and a lower dose of Remicade.

Some doctors and patients raise concerns that switching between these drugs might cause patients to develop antibodies that cause the drugs to lose effectiveness. They want to see more research about the effects of such switches.

“We haven’t seen enough studies about patients going from the biologic to the biosimilar and bouncing back and forth,” said Marcus Snow, MD, chair of the American College of Rheumatology’s Committee on Rheumatologic Care. “We don’t want our patients to be guinea pigs.”

Manufacturers of biologic and biosimilar drugs have participated in advertising, exhibit or sponsorship opportunities with the American College of Rheumatology, according to ACR spokesperson Jocelyn Givens.

But studies show a one-time switch from Remicade to a biosimilar like Inflectra does not cause side effects or the development of antibodies, said Ross Maltz, MD, a pediatric gastroenterologist at Nationwide Children’s Hospital in Columbus, Ohio, and former member of the Crohn’s & Colitis Foundation’s National Scientific Advisory Committee. Studies may be conducted by researchers with extensive ties to the industry and funded by drugmakers.

Situations like Ms. Moxley’s are unusual, said Kristine Grow, senior vice president of communications at AHIP, an insurer trade group.

“For patients who have been taking a brand-name biologic for some time, health insurance providers do not typically encourage them to switch to a biosimilar because of a formulary change, and most plans exclude these patients from any changes in cost sharing due to formulary changes,” she said.

Drugmakers can seek approval from the FDA of their biosimilar as interchangeable with a biologic drug, allowing pharmacists, subject to state law, to switch a physician’s prescription from the brand drug, as they often do with generic drugs.

However, the FDA has approved only one biosimilar (Semglee, a form of insulin) as interchangeable with a biologic (Lantus).

Like Ms. Moxley, many other patients using biologics get copay assistance from drug companies, but the money often isn’t enough to cover the full cost. In her old job as a radio reporter, Ms. Moxley said, she hit the $7,000 maximum annual out-of-pocket spending limit for her plan by May.

In her new job, Ms. Moxley has an individual plan with a $4,000 maximum out-of-pocket limit, which she expects to blow past once again within months.

But she received good news recently: Her new plan will cover Remicade.

“I’m still concerned that I will have developed antibodies since my last dose,” she said. “But it feels like a step in the direction of good health again.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Judy C. Washington, MD, a mentor of many young academic family physicians, particularly underrepresented-in-medicine (URM) physicians, advises her mentees on how to see ahead and plot paths to leadership.

Courtesy Dr. Judy C. Washington

For URM physicians, she also imparts a shared experience of being a minority in the field and helps prepare them for the challenges of facing racism or feeling marginalized or not equitably supported in academic life – and for making change.

While family medicine’s demographics have become more diverse over time, and more so than other specialties, they are not yet representative of the U.S. population. Within academia, male physicians who are Black or African American, or Hispanic or Latino, comprised about 4% and 5% of family medicine faculty, respectively, at the end of 2019, according to data from the Association of American Medical Colleges. For women, these numbers were about 9% and 4%, respectively. (Only those with an MD degree exclusively were included in the report.)

“When you have the privilege to serve in leadership, you have the responsibility to reach back and identify and help others who would not otherwise have the opportunity to be recognized,” Dr. Washington said.

Her mentorship work stems in large part from her long-time involvement and leadership roles in the Society of Teachers of Family Medicine (STFM) – roles she considers a pillar of her professional life. She currently serves as president of the STFM Foundation and is associate chief medical officer of the Atlantic Medical Group, a large multisite physician-led organization. She is also coordinator of women’s health for the Overlook Family Medicine Residency Program, which is affiliated with Atlantic Medical Group.

In Dr. Washington’s role as associate chief medical officer of Atlantic Medical Group in Summit, N.J., she focuses on physician engagement, satisfaction, and diversity. She also assists in areas such as population health. For the Overlook Family Medicine Residency Program also in Summit, she precepts residents in the obstetrics clinic and in the family medicine outpatient clinic.

Diana N. Carvajal, MD, MPH, one of Dr. Washington’s mentees, called her an “inspirational leader” for young academic faculty and said she is a familiar speaker at STFM meetings on topics of workforce diversity, equity, and leadership. She is “passionate” about mentorship, Dr. Carvajal said, and has understood “that URMs and women of color were not always getting [the mentorship they need to be successful].”
 

Guiding future leaders

Ivonne McLean, MD, assistant professor of family and community medicine at Icahn School of Medicine at Mount Sinai, New York, and an attending at a community health center in the Bronx, called Dr. Washington for advice a couple of years ago when she was considering her next career move.

Courtesy Society of Teachers of Family Medicine Foundation

“She took a genuine interest in me. She never said, this is what you should do. But the questions she asked and the examples she gave from her own life were incredibly helpful to me [in deciding to pursue a research fellowship] ... it was a pivotal conversation,” said Dr. McLean, associate director of a reproductive health fellowship and a research fellow in a New York State–funded program.

“From a lived experience angle, she also told me, here are some of the challenges you’ll have as a woman of color, and here are some of the ways you can approach that,” she said.

Dr. Carvajal, also a URM family physician, credits Dr. Washington’s mentorship with the development of a day-long workshop – held before the annual Society of Teachers of Family Medicine (STFM) meeting – on the low and declining rates of Black males in medicine. “We’d planned it as a presentation, and [she heard of it and] helped us expand it,” she said, calling Dr. Washington “warm, welcoming, and encouraging.

“That work and collaboration with her and the others she brought [into the process] have resulted in publications and more presentations and strategy building for diversifying the workforce,” said Dr. Carvajal, assistant professor, director of reproductive health education in family medicine, and codirector of the research section, all in the department of family and community medicine at the University of Maryland, Baltimore.

STFM involvement

Dr. Washington, who says that all or almost all of her mentees are now leaders in their academic institutions and communities, has been instrumental in developing STFM’s mentoring programming and in facilitating the organization’s multifaceted URM Initiative.

She has been active in STFM since the start of her academic career, and in 2009, while serving as assistant program director for the residency program in which she’d trained, she joined two other African American women, Monique Y. Davis-Smith, MD, and Joedrecka Brown-Speights, MD, in cochairing the society’s Group on Minority and Multicultural Health.

It was in this space, that Dr. Washington said she “heard people’s stories of being in major academic institutions and not feeling supported, not being given roadmaps to success, not getting assistance with publishing, or just kind of feeling like an outsider ... of not being pulled in.” Hispanic and African American females, in particular, “were feeling marginalized,” she said.

In 2018, having co-led development of the STFM Quality Mentoring Program for URM faculty, Dr. Washington was asked to join the STFM Foundation and subsequently led the STFM Foundation’s fundraising campaign for a new URM Initiative. She exceeded her goal, increasing support for URM participation in meetings and activities, and then participated in an STFM steering committee to create broader and longer-lasting support for URM faculty, community teachers, and medical students and residents going into academic family medicine.

Increasing the percentage of URM family medicine faculty in leadership positions – and raising awareness of structural barriers to achievement – is one of the current pillars of the URM Initiative.
 

Navigating the ‘minority tax’

As part of her mentoring, Dr. Washington helps URM physicians navigate the minority tax – a term referring to the uncompensated citizenship tasks that are more often assigned to Black and other URM physicians than to White physicians, and that take time away from scholarship, further perpetuating inequities.

Courtesy Society of Teahcers of Family Medicine Foundation

“Some of our young faculty members find themselves thrust into being the diversity and inclusion leaders in their institutions at a level at which they feel little power and little buy-in from [leadership],” she noted.

A commentary written by Dr. Washington and several colleagues on the minority tax as it impacts women – and the need to build a “tax shelter” to make academic medicine a more just environment for URM women – was published earlier this year in the Journal of Women’s Health.

She also answers e-mails and fields phone calls from young URM faculty who are mulling career moves and facing other familiar challenges.

Physicians who are URM, and African American physicians in particular, tend to “get pulled into the [often underserved] communities, into the patient care and community service areas,” Dr. Washington explained. “But unless you convert these projects into scholarship and publications, and unless you serve on a national committee outside of your institution, you’re not going to be promoted.”

Dr. Washington helps junior faculty envision themselves 5-plus years down the road, find what she calls scholarly “passion projects,” and prepare themselves for their next steps.

She helps her mentees navigate other parts of the continuum of unconscious bias and racism as well, from microaggressions from colleagues to overt discrimination from patients.

“I spend countless minutes fielding texts and phone calls from those who need support,” she wrote in a blog post. “They are a constant reminder that I must continue to speak up when I get the opportunity to do so.”
 

A journey through family medicine, and through bias and racism

Dr. Washington’s early days in medicine included graduating from Meharry Medical College in 1983 and the Mountainside Family Practice Residency Program in 1990. Following 6 years of working in a private practice in rural Maryland, she moved to academia, spending 6 years at East Tennessee State University and 4 years at the UMDNJ–New Jersey Medical School in Newark as an assistant professor of family medicine.

As had happened in rural Maryland, bias and racism have too often lurked during her career as a physician.

“I grew up in Alabama so I was pretty much ready to deal with racism in the South,” Dr. Washington said. “What I was not ready for was coming to the Northeast and seeing that you’re marginalized because you’re not invited into the room. Or if you do go into spaces when you’re the only one, you often don’t feel as welcomed as you thought you might be.”

Her ideas and contributions were too often dismissed, she wrote in a 2020 blog entry posted on her LinkedIn page. And during contract negotiations, “I was not aware of all the information that my White colleagues had. They had the advantage of inside information.”

Dr. Washington says that “it took a village” to make her who she is today: teachers in her segregated schools in Alabama, one of her college professors, her best friend in medical school – and STFM, “where the list [of her own mentors] is long.”

Judy C. Washington, MD, a mentor of many young academic family physicians, particularly underrepresented-in-medicine (URM) physicians, advises her mentees on how to see ahead and plot paths to leadership.

Courtesy Dr. Judy C. Washington

For URM physicians, she also imparts a shared experience of being a minority in the field and helps prepare them for the challenges of facing racism or feeling marginalized or not equitably supported in academic life – and for making change.

While family medicine’s demographics have become more diverse over time, and more so than other specialties, they are not yet representative of the U.S. population. Within academia, male physicians who are Black or African American, or Hispanic or Latino, comprised about 4% and 5% of family medicine faculty, respectively, at the end of 2019, according to data from the Association of American Medical Colleges. For women, these numbers were about 9% and 4%, respectively. (Only those with an MD degree exclusively were included in the report.)

“When you have the privilege to serve in leadership, you have the responsibility to reach back and identify and help others who would not otherwise have the opportunity to be recognized,” Dr. Washington said.

Her mentorship work stems in large part from her long-time involvement and leadership roles in the Society of Teachers of Family Medicine (STFM) – roles she considers a pillar of her professional life. She currently serves as president of the STFM Foundation and is associate chief medical officer of the Atlantic Medical Group, a large multisite physician-led organization. She is also coordinator of women’s health for the Overlook Family Medicine Residency Program, which is affiliated with Atlantic Medical Group.

In Dr. Washington’s role as associate chief medical officer of Atlantic Medical Group in Summit, N.J., she focuses on physician engagement, satisfaction, and diversity. She also assists in areas such as population health. For the Overlook Family Medicine Residency Program also in Summit, she precepts residents in the obstetrics clinic and in the family medicine outpatient clinic.

Diana N. Carvajal, MD, MPH, one of Dr. Washington’s mentees, called her an “inspirational leader” for young academic faculty and said she is a familiar speaker at STFM meetings on topics of workforce diversity, equity, and leadership. She is “passionate” about mentorship, Dr. Carvajal said, and has understood “that URMs and women of color were not always getting [the mentorship they need to be successful].”
 

Guiding future leaders

Ivonne McLean, MD, assistant professor of family and community medicine at Icahn School of Medicine at Mount Sinai, New York, and an attending at a community health center in the Bronx, called Dr. Washington for advice a couple of years ago when she was considering her next career move.

Courtesy Society of Teachers of Family Medicine Foundation

“She took a genuine interest in me. She never said, this is what you should do. But the questions she asked and the examples she gave from her own life were incredibly helpful to me [in deciding to pursue a research fellowship] ... it was a pivotal conversation,” said Dr. McLean, associate director of a reproductive health fellowship and a research fellow in a New York State–funded program.

“From a lived experience angle, she also told me, here are some of the challenges you’ll have as a woman of color, and here are some of the ways you can approach that,” she said.

Dr. Carvajal, also a URM family physician, credits Dr. Washington’s mentorship with the development of a day-long workshop – held before the annual Society of Teachers of Family Medicine (STFM) meeting – on the low and declining rates of Black males in medicine. “We’d planned it as a presentation, and [she heard of it and] helped us expand it,” she said, calling Dr. Washington “warm, welcoming, and encouraging.

“That work and collaboration with her and the others she brought [into the process] have resulted in publications and more presentations and strategy building for diversifying the workforce,” said Dr. Carvajal, assistant professor, director of reproductive health education in family medicine, and codirector of the research section, all in the department of family and community medicine at the University of Maryland, Baltimore.

STFM involvement

Dr. Washington, who says that all or almost all of her mentees are now leaders in their academic institutions and communities, has been instrumental in developing STFM’s mentoring programming and in facilitating the organization’s multifaceted URM Initiative.

She has been active in STFM since the start of her academic career, and in 2009, while serving as assistant program director for the residency program in which she’d trained, she joined two other African American women, Monique Y. Davis-Smith, MD, and Joedrecka Brown-Speights, MD, in cochairing the society’s Group on Minority and Multicultural Health.

It was in this space, that Dr. Washington said she “heard people’s stories of being in major academic institutions and not feeling supported, not being given roadmaps to success, not getting assistance with publishing, or just kind of feeling like an outsider ... of not being pulled in.” Hispanic and African American females, in particular, “were feeling marginalized,” she said.

In 2018, having co-led development of the STFM Quality Mentoring Program for URM faculty, Dr. Washington was asked to join the STFM Foundation and subsequently led the STFM Foundation’s fundraising campaign for a new URM Initiative. She exceeded her goal, increasing support for URM participation in meetings and activities, and then participated in an STFM steering committee to create broader and longer-lasting support for URM faculty, community teachers, and medical students and residents going into academic family medicine.

Increasing the percentage of URM family medicine faculty in leadership positions – and raising awareness of structural barriers to achievement – is one of the current pillars of the URM Initiative.
 

Navigating the ‘minority tax’

As part of her mentoring, Dr. Washington helps URM physicians navigate the minority tax – a term referring to the uncompensated citizenship tasks that are more often assigned to Black and other URM physicians than to White physicians, and that take time away from scholarship, further perpetuating inequities.

Courtesy Society of Teahcers of Family Medicine Foundation

“Some of our young faculty members find themselves thrust into being the diversity and inclusion leaders in their institutions at a level at which they feel little power and little buy-in from [leadership],” she noted.

A commentary written by Dr. Washington and several colleagues on the minority tax as it impacts women – and the need to build a “tax shelter” to make academic medicine a more just environment for URM women – was published earlier this year in the Journal of Women’s Health.

She also answers e-mails and fields phone calls from young URM faculty who are mulling career moves and facing other familiar challenges.

Physicians who are URM, and African American physicians in particular, tend to “get pulled into the [often underserved] communities, into the patient care and community service areas,” Dr. Washington explained. “But unless you convert these projects into scholarship and publications, and unless you serve on a national committee outside of your institution, you’re not going to be promoted.”

Dr. Washington helps junior faculty envision themselves 5-plus years down the road, find what she calls scholarly “passion projects,” and prepare themselves for their next steps.

She helps her mentees navigate other parts of the continuum of unconscious bias and racism as well, from microaggressions from colleagues to overt discrimination from patients.

“I spend countless minutes fielding texts and phone calls from those who need support,” she wrote in a blog post. “They are a constant reminder that I must continue to speak up when I get the opportunity to do so.”
 

A journey through family medicine, and through bias and racism

Dr. Washington’s early days in medicine included graduating from Meharry Medical College in 1983 and the Mountainside Family Practice Residency Program in 1990. Following 6 years of working in a private practice in rural Maryland, she moved to academia, spending 6 years at East Tennessee State University and 4 years at the UMDNJ–New Jersey Medical School in Newark as an assistant professor of family medicine.

As had happened in rural Maryland, bias and racism have too often lurked during her career as a physician.

“I grew up in Alabama so I was pretty much ready to deal with racism in the South,” Dr. Washington said. “What I was not ready for was coming to the Northeast and seeing that you’re marginalized because you’re not invited into the room. Or if you do go into spaces when you’re the only one, you often don’t feel as welcomed as you thought you might be.”

Her ideas and contributions were too often dismissed, she wrote in a 2020 blog entry posted on her LinkedIn page. And during contract negotiations, “I was not aware of all the information that my White colleagues had. They had the advantage of inside information.”

Dr. Washington says that “it took a village” to make her who she is today: teachers in her segregated schools in Alabama, one of her college professors, her best friend in medical school – and STFM, “where the list [of her own mentors] is long.”

Judy C. Washington, MD, a mentor of many young academic family physicians, particularly underrepresented-in-medicine (URM) physicians, advises her mentees on how to see ahead and plot paths to leadership.

Courtesy Dr. Judy C. Washington

For URM physicians, she also imparts a shared experience of being a minority in the field and helps prepare them for the challenges of facing racism or feeling marginalized or not equitably supported in academic life – and for making change.

While family medicine’s demographics have become more diverse over time, and more so than other specialties, they are not yet representative of the U.S. population. Within academia, male physicians who are Black or African American, or Hispanic or Latino, comprised about 4% and 5% of family medicine faculty, respectively, at the end of 2019, according to data from the Association of American Medical Colleges. For women, these numbers were about 9% and 4%, respectively. (Only those with an MD degree exclusively were included in the report.)

“When you have the privilege to serve in leadership, you have the responsibility to reach back and identify and help others who would not otherwise have the opportunity to be recognized,” Dr. Washington said.

Her mentorship work stems in large part from her long-time involvement and leadership roles in the Society of Teachers of Family Medicine (STFM) – roles she considers a pillar of her professional life. She currently serves as president of the STFM Foundation and is associate chief medical officer of the Atlantic Medical Group, a large multisite physician-led organization. She is also coordinator of women’s health for the Overlook Family Medicine Residency Program, which is affiliated with Atlantic Medical Group.

In Dr. Washington’s role as associate chief medical officer of Atlantic Medical Group in Summit, N.J., she focuses on physician engagement, satisfaction, and diversity. She also assists in areas such as population health. For the Overlook Family Medicine Residency Program also in Summit, she precepts residents in the obstetrics clinic and in the family medicine outpatient clinic.

Diana N. Carvajal, MD, MPH, one of Dr. Washington’s mentees, called her an “inspirational leader” for young academic faculty and said she is a familiar speaker at STFM meetings on topics of workforce diversity, equity, and leadership. She is “passionate” about mentorship, Dr. Carvajal said, and has understood “that URMs and women of color were not always getting [the mentorship they need to be successful].”
 

Guiding future leaders

Ivonne McLean, MD, assistant professor of family and community medicine at Icahn School of Medicine at Mount Sinai, New York, and an attending at a community health center in the Bronx, called Dr. Washington for advice a couple of years ago when she was considering her next career move.

Courtesy Society of Teachers of Family Medicine Foundation

“She took a genuine interest in me. She never said, this is what you should do. But the questions she asked and the examples she gave from her own life were incredibly helpful to me [in deciding to pursue a research fellowship] ... it was a pivotal conversation,” said Dr. McLean, associate director of a reproductive health fellowship and a research fellow in a New York State–funded program.

“From a lived experience angle, she also told me, here are some of the challenges you’ll have as a woman of color, and here are some of the ways you can approach that,” she said.

Dr. Carvajal, also a URM family physician, credits Dr. Washington’s mentorship with the development of a day-long workshop – held before the annual Society of Teachers of Family Medicine (STFM) meeting – on the low and declining rates of Black males in medicine. “We’d planned it as a presentation, and [she heard of it and] helped us expand it,” she said, calling Dr. Washington “warm, welcoming, and encouraging.

“That work and collaboration with her and the others she brought [into the process] have resulted in publications and more presentations and strategy building for diversifying the workforce,” said Dr. Carvajal, assistant professor, director of reproductive health education in family medicine, and codirector of the research section, all in the department of family and community medicine at the University of Maryland, Baltimore.

STFM involvement

Dr. Washington, who says that all or almost all of her mentees are now leaders in their academic institutions and communities, has been instrumental in developing STFM’s mentoring programming and in facilitating the organization’s multifaceted URM Initiative.

She has been active in STFM since the start of her academic career, and in 2009, while serving as assistant program director for the residency program in which she’d trained, she joined two other African American women, Monique Y. Davis-Smith, MD, and Joedrecka Brown-Speights, MD, in cochairing the society’s Group on Minority and Multicultural Health.

It was in this space, that Dr. Washington said she “heard people’s stories of being in major academic institutions and not feeling supported, not being given roadmaps to success, not getting assistance with publishing, or just kind of feeling like an outsider ... of not being pulled in.” Hispanic and African American females, in particular, “were feeling marginalized,” she said.

In 2018, having co-led development of the STFM Quality Mentoring Program for URM faculty, Dr. Washington was asked to join the STFM Foundation and subsequently led the STFM Foundation’s fundraising campaign for a new URM Initiative. She exceeded her goal, increasing support for URM participation in meetings and activities, and then participated in an STFM steering committee to create broader and longer-lasting support for URM faculty, community teachers, and medical students and residents going into academic family medicine.

Increasing the percentage of URM family medicine faculty in leadership positions – and raising awareness of structural barriers to achievement – is one of the current pillars of the URM Initiative.
 

Navigating the ‘minority tax’

As part of her mentoring, Dr. Washington helps URM physicians navigate the minority tax – a term referring to the uncompensated citizenship tasks that are more often assigned to Black and other URM physicians than to White physicians, and that take time away from scholarship, further perpetuating inequities.

Courtesy Society of Teahcers of Family Medicine Foundation

“Some of our young faculty members find themselves thrust into being the diversity and inclusion leaders in their institutions at a level at which they feel little power and little buy-in from [leadership],” she noted.

A commentary written by Dr. Washington and several colleagues on the minority tax as it impacts women – and the need to build a “tax shelter” to make academic medicine a more just environment for URM women – was published earlier this year in the Journal of Women’s Health.

She also answers e-mails and fields phone calls from young URM faculty who are mulling career moves and facing other familiar challenges.

Physicians who are URM, and African American physicians in particular, tend to “get pulled into the [often underserved] communities, into the patient care and community service areas,” Dr. Washington explained. “But unless you convert these projects into scholarship and publications, and unless you serve on a national committee outside of your institution, you’re not going to be promoted.”

Dr. Washington helps junior faculty envision themselves 5-plus years down the road, find what she calls scholarly “passion projects,” and prepare themselves for their next steps.

She helps her mentees navigate other parts of the continuum of unconscious bias and racism as well, from microaggressions from colleagues to overt discrimination from patients.

“I spend countless minutes fielding texts and phone calls from those who need support,” she wrote in a blog post. “They are a constant reminder that I must continue to speak up when I get the opportunity to do so.”
 

A journey through family medicine, and through bias and racism

Dr. Washington’s early days in medicine included graduating from Meharry Medical College in 1983 and the Mountainside Family Practice Residency Program in 1990. Following 6 years of working in a private practice in rural Maryland, she moved to academia, spending 6 years at East Tennessee State University and 4 years at the UMDNJ–New Jersey Medical School in Newark as an assistant professor of family medicine.

As had happened in rural Maryland, bias and racism have too often lurked during her career as a physician.

“I grew up in Alabama so I was pretty much ready to deal with racism in the South,” Dr. Washington said. “What I was not ready for was coming to the Northeast and seeing that you’re marginalized because you’re not invited into the room. Or if you do go into spaces when you’re the only one, you often don’t feel as welcomed as you thought you might be.”

Her ideas and contributions were too often dismissed, she wrote in a 2020 blog entry posted on her LinkedIn page. And during contract negotiations, “I was not aware of all the information that my White colleagues had. They had the advantage of inside information.”

Dr. Washington says that “it took a village” to make her who she is today: teachers in her segregated schools in Alabama, one of her college professors, her best friend in medical school – and STFM, “where the list [of her own mentors] is long.”

PHM 2021 session

Let’s Go Virtual! Developing, Implementing, and Evaluating Telehealth Models of Care for Pediatric Hospital Medicine

Presenters

Brooke Geyer, DO; Christina Olson, MD; and Amy Willis, MD, FAAP

Session summary

Dr. Geyer, Dr. Olson, and Dr. Willis of the University of Colorado presented and facilitated a workshop discussing the role of telehealth in pediatric hospital medicine. Participants were given a brief introduction to the basics of telehealth practices before breaking up into small groups to explore the process of developing, implementing, and evaluating a telehealth model in a pediatric hospital. For each of these topics, the presenters led the breakout groups through a discussion of Colorado’s successful telehealth models, including virtual nocturnists, health system resource optimization, and virtual transitions of care, as well as addressed the participants’ questions unique to their telehealth experiences. The session emphasized the emerging role of telehealth in pediatric hospital medicine and that “telehealth is here to stay, and we have an opportunity to redesign health care forever.”

Key takeaways

• Telehealth is more than just synchronous virtual patient care, it encompasses asynchronous care, remote patient monitoring, education, policy, and more.
• Telehealth standards of care are the same as in-person care.
• Development and implementation of a telehealth model in pediatric hospital medicine is feasible with appropriate planning and conversations with key stakeholders.
• Evaluation and refinement of telehealth models is an iterative process that will take time, much like Plan-Do-Study-Act cycles in quality improvement work.

Dr. Scott is a second-year pediatric hospital medicine fellow at New York–Presbyterian Columbia/Cornell. Her academic interests are in curriculum development and evaluation in medical education with a focus on telemedicine.

PHM 2021 session

Let’s Go Virtual! Developing, Implementing, and Evaluating Telehealth Models of Care for Pediatric Hospital Medicine

Presenters

Brooke Geyer, DO; Christina Olson, MD; and Amy Willis, MD, FAAP

Session summary

Dr. Geyer, Dr. Olson, and Dr. Willis of the University of Colorado presented and facilitated a workshop discussing the role of telehealth in pediatric hospital medicine. Participants were given a brief introduction to the basics of telehealth practices before breaking up into small groups to explore the process of developing, implementing, and evaluating a telehealth model in a pediatric hospital. For each of these topics, the presenters led the breakout groups through a discussion of Colorado’s successful telehealth models, including virtual nocturnists, health system resource optimization, and virtual transitions of care, as well as addressed the participants’ questions unique to their telehealth experiences. The session emphasized the emerging role of telehealth in pediatric hospital medicine and that “telehealth is here to stay, and we have an opportunity to redesign health care forever.”

Key takeaways

• Telehealth is more than just synchronous virtual patient care, it encompasses asynchronous care, remote patient monitoring, education, policy, and more.
• Telehealth standards of care are the same as in-person care.
• Development and implementation of a telehealth model in pediatric hospital medicine is feasible with appropriate planning and conversations with key stakeholders.
• Evaluation and refinement of telehealth models is an iterative process that will take time, much like Plan-Do-Study-Act cycles in quality improvement work.

Dr. Scott is a second-year pediatric hospital medicine fellow at New York–Presbyterian Columbia/Cornell. Her academic interests are in curriculum development and evaluation in medical education with a focus on telemedicine.

PHM 2021 session

Let’s Go Virtual! Developing, Implementing, and Evaluating Telehealth Models of Care for Pediatric Hospital Medicine

Presenters

Brooke Geyer, DO; Christina Olson, MD; and Amy Willis, MD, FAAP

Session summary

Dr. Geyer, Dr. Olson, and Dr. Willis of the University of Colorado presented and facilitated a workshop discussing the role of telehealth in pediatric hospital medicine. Participants were given a brief introduction to the basics of telehealth practices before breaking up into small groups to explore the process of developing, implementing, and evaluating a telehealth model in a pediatric hospital. For each of these topics, the presenters led the breakout groups through a discussion of Colorado’s successful telehealth models, including virtual nocturnists, health system resource optimization, and virtual transitions of care, as well as addressed the participants’ questions unique to their telehealth experiences. The session emphasized the emerging role of telehealth in pediatric hospital medicine and that “telehealth is here to stay, and we have an opportunity to redesign health care forever.”

Key takeaways

• Telehealth is more than just synchronous virtual patient care, it encompasses asynchronous care, remote patient monitoring, education, policy, and more.
• Telehealth standards of care are the same as in-person care.
• Development and implementation of a telehealth model in pediatric hospital medicine is feasible with appropriate planning and conversations with key stakeholders.
• Evaluation and refinement of telehealth models is an iterative process that will take time, much like Plan-Do-Study-Act cycles in quality improvement work.

Dr. Scott is a second-year pediatric hospital medicine fellow at New York–Presbyterian Columbia/Cornell. Her academic interests are in curriculum development and evaluation in medical education with a focus on telemedicine.

Weekly COVID-19 cases in children dropped again, but the count remained above 200,000 for the fifth consecutive week, according to the American Academy of Pediatrics and the Children’s Hospital Association.

Over that 5-week span since the end of August, in fact, the United States has added over 1.13 million new cases, or just under 20% of all cases (5.7 million) in children during the entire pandemic, based on the data in the AAP/CHA joint weekly report on COVID in children.

In the most recent week, Sept. 17-23, there were almost 207,000 new cases of COVID-19 in children, which represented 26.7% of all cases reported in the 46 states that are currently posting data by age on their COVID dashboards, the AAP and CHA said. (New York has never reported such data by age, and Alabama, Nebraska, and Texas have not updated their websites since July 29, June 24, and Aug. 26, respectively.)

The decline in new vaccinations among children, however, began before the summer surge in new cases hit its peak – 251,781 during the week of Aug. 27 to Sept. 2 – and has continued for 7 straight weeks in children aged 12-17 years, based on data from the Centers for Disease Control and Prevention.

There were about 172,000 COVID vaccine initiations in children aged 12-17 for the week of Sept. 21-27, the lowest number since April, before it was approved for use in 12- to 15-year-olds. That figure is down by almost a third from the previous week and by more than two-thirds since early August, just before the decline in vaccinations began, according to the CDC’s COVID Data Tracker.

The cumulative vaccine situation looks like this: Just over 13 million children under age 18 years have received at least one dose as of Sept. 27, and almost 10.6 million are fully vaccinated. By age group, 53.9% of 12- to 15-year-olds and 61.6% of 16- to 17-year-olds have received at least one dose, with corresponding figures of 43.3% and 51.3% for full vaccination, the CDC said.

COVID-related hospital admissions also continue to fall after peaking at 0.51 children aged 0-17 per 100,000 population on Sept. 4. The admission rate was down to 0.45 per 100,000 as of Sept. 17, and the latest 7-day average (Sept. 19-25) was 258 admissions, compared with a peak of 371 for the week of Aug. 29 to Sept. 4, the CDC reported.

“Although we have seen slight improvements in COVID-19 volumes in the past week, we are at the beginning of an anticipated increase in” multi-inflammatory syndrome in children, Margaret Rush, MD, president of Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tenn., said at a recent hearing of the House Committee on Energy and Commerce’s Oversight subcommittee. That increase would be expected to produce “a secondary wave of seriously ill children 3-6 weeks after acute infection peaks in the community,” the American Hospital Association said.

Meanwhile, Dr. Rush noted, there are signs that seasonal viruses are coming into play. “With the emergence of the Delta variant, we’ve experienced a steep increase in COVID-19 hospitalizations among children on top of an early surge of [respiratory syncytial virus], a serious respiratory illness we usually see in the winter months,” she said in a prepared statement before her testimony.

[email protected]

Weekly COVID-19 cases in children dropped again, but the count remained above 200,000 for the fifth consecutive week, according to the American Academy of Pediatrics and the Children’s Hospital Association.

Over that 5-week span since the end of August, in fact, the United States has added over 1.13 million new cases, or just under 20% of all cases (5.7 million) in children during the entire pandemic, based on the data in the AAP/CHA joint weekly report on COVID in children.

In the most recent week, Sept. 17-23, there were almost 207,000 new cases of COVID-19 in children, which represented 26.7% of all cases reported in the 46 states that are currently posting data by age on their COVID dashboards, the AAP and CHA said. (New York has never reported such data by age, and Alabama, Nebraska, and Texas have not updated their websites since July 29, June 24, and Aug. 26, respectively.)

The decline in new vaccinations among children, however, began before the summer surge in new cases hit its peak – 251,781 during the week of Aug. 27 to Sept. 2 – and has continued for 7 straight weeks in children aged 12-17 years, based on data from the Centers for Disease Control and Prevention.

There were about 172,000 COVID vaccine initiations in children aged 12-17 for the week of Sept. 21-27, the lowest number since April, before it was approved for use in 12- to 15-year-olds. That figure is down by almost a third from the previous week and by more than two-thirds since early August, just before the decline in vaccinations began, according to the CDC’s COVID Data Tracker.

The cumulative vaccine situation looks like this: Just over 13 million children under age 18 years have received at least one dose as of Sept. 27, and almost 10.6 million are fully vaccinated. By age group, 53.9% of 12- to 15-year-olds and 61.6% of 16- to 17-year-olds have received at least one dose, with corresponding figures of 43.3% and 51.3% for full vaccination, the CDC said.

COVID-related hospital admissions also continue to fall after peaking at 0.51 children aged 0-17 per 100,000 population on Sept. 4. The admission rate was down to 0.45 per 100,000 as of Sept. 17, and the latest 7-day average (Sept. 19-25) was 258 admissions, compared with a peak of 371 for the week of Aug. 29 to Sept. 4, the CDC reported.

“Although we have seen slight improvements in COVID-19 volumes in the past week, we are at the beginning of an anticipated increase in” multi-inflammatory syndrome in children, Margaret Rush, MD, president of Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tenn., said at a recent hearing of the House Committee on Energy and Commerce’s Oversight subcommittee. That increase would be expected to produce “a secondary wave of seriously ill children 3-6 weeks after acute infection peaks in the community,” the American Hospital Association said.

Meanwhile, Dr. Rush noted, there are signs that seasonal viruses are coming into play. “With the emergence of the Delta variant, we’ve experienced a steep increase in COVID-19 hospitalizations among children on top of an early surge of [respiratory syncytial virus], a serious respiratory illness we usually see in the winter months,” she said in a prepared statement before her testimony.

[email protected]

Weekly COVID-19 cases in children dropped again, but the count remained above 200,000 for the fifth consecutive week, according to the American Academy of Pediatrics and the Children’s Hospital Association.

Over that 5-week span since the end of August, in fact, the United States has added over 1.13 million new cases, or just under 20% of all cases (5.7 million) in children during the entire pandemic, based on the data in the AAP/CHA joint weekly report on COVID in children.

In the most recent week, Sept. 17-23, there were almost 207,000 new cases of COVID-19 in children, which represented 26.7% of all cases reported in the 46 states that are currently posting data by age on their COVID dashboards, the AAP and CHA said. (New York has never reported such data by age, and Alabama, Nebraska, and Texas have not updated their websites since July 29, June 24, and Aug. 26, respectively.)

The decline in new vaccinations among children, however, began before the summer surge in new cases hit its peak – 251,781 during the week of Aug. 27 to Sept. 2 – and has continued for 7 straight weeks in children aged 12-17 years, based on data from the Centers for Disease Control and Prevention.

There were about 172,000 COVID vaccine initiations in children aged 12-17 for the week of Sept. 21-27, the lowest number since April, before it was approved for use in 12- to 15-year-olds. That figure is down by almost a third from the previous week and by more than two-thirds since early August, just before the decline in vaccinations began, according to the CDC’s COVID Data Tracker.

The cumulative vaccine situation looks like this: Just over 13 million children under age 18 years have received at least one dose as of Sept. 27, and almost 10.6 million are fully vaccinated. By age group, 53.9% of 12- to 15-year-olds and 61.6% of 16- to 17-year-olds have received at least one dose, with corresponding figures of 43.3% and 51.3% for full vaccination, the CDC said.

COVID-related hospital admissions also continue to fall after peaking at 0.51 children aged 0-17 per 100,000 population on Sept. 4. The admission rate was down to 0.45 per 100,000 as of Sept. 17, and the latest 7-day average (Sept. 19-25) was 258 admissions, compared with a peak of 371 for the week of Aug. 29 to Sept. 4, the CDC reported.

“Although we have seen slight improvements in COVID-19 volumes in the past week, we are at the beginning of an anticipated increase in” multi-inflammatory syndrome in children, Margaret Rush, MD, president of Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tenn., said at a recent hearing of the House Committee on Energy and Commerce’s Oversight subcommittee. That increase would be expected to produce “a secondary wave of seriously ill children 3-6 weeks after acute infection peaks in the community,” the American Hospital Association said.

Meanwhile, Dr. Rush noted, there are signs that seasonal viruses are coming into play. “With the emergence of the Delta variant, we’ve experienced a steep increase in COVID-19 hospitalizations among children on top of an early surge of [respiratory syncytial virus], a serious respiratory illness we usually see in the winter months,” she said in a prepared statement before her testimony.

[email protected]

On a recent Monday morning, a group of preschoolers filed into the gymnasium at Hillside School in the west Chicago suburbs. These 4- and 5-year-olds were the first of more than 200 students to get tested for the coronavirus that day – and every Monday – for the foreseeable future.

At the front of the line, a girl in a unicorn headband and sparkly pink skirt clutched a zip-close bag with her name on it. She pulled out a plastic tube with a small funnel attached. Next, Hillside superintendent Kevin Suchinski led the student to a spot marked off with red tape. Mr. Suchinski coached her how to carefully release – but not “spit” – about a half-teaspoon’s worth of saliva into the tube.

“You wait a second, you build up your saliva,” he told her. “You don’t talk, you think about pizza, hamburgers, French fries, ice cream. And you drop it right in there, OK?”

The results will come back within 24 hours. Any students who test positive are instructed to isolate, and the school nurse and administrative staff carry out contact tracing.

Hillside was among the first in Illinois to start regular testing. Now, almost half of Illinois’ 2 million students in grades K-12 attend schools rolling out similar programs. The initiative is supported by federal funding channeled through the state health department.

Schools in other states – such as Massachusetts, Maryland, New York and Colorado – also offer regular testing; Los Angeles public schools have gone further by making it mandatory.

These measures stand in sharp contrast to the confusion in states where people are still fighting about wearing masks in the classroom and other anti-COVID strategies, places where some schools have experienced outbreaks and even teacher deaths.

Within a few weeks of schools reopening, tens of thousands of students across the United States were sent home to quarantine. It’s a concern because options for K-12 students in quarantine are all over the map – with some schools offering virtual instruction and others providing little or no at-home options.

Mr. Suchinski hopes this investment in testing prevents virus detected at Hillside School from spreading into the wider community – and keeps kids learning.

“What we say to ourselves is: If we don’t do this program, we could be losing instruction because we’ve had to close down the school,” he said.

So far, the parents and guardians of two-thirds of all Hillside students have consented to testing. Mr. Suchinski said the school is working hard to get the remaining families on board by educating them about the importance – and benefit – of regular testing.

Every school that can manage it should consider testing students weekly – even twice a week, if possible, said Becky Smith, PhD. She’s an epidemiologist at the University of Illinois in Urbana-Champaign, which developed the saliva test Hillside and other Illinois schools are using. Smith pointed to several studies – including both peer-reviewed and preliminary research – that suggest rigorous testing and contact tracing are key to keeping the virus at bay in K-12 schools.

“If you’re lucky, you can get away without doing testing, [if] nobody comes to school with a raging infection and takes their mask off at lunchtime and infects everybody sitting at the table with them,” Dr. Smith said. “But relying on luck isn’t what we like to do.”

Julian Hernandez, a Hillside seventh grader, said he feels safer knowing that classmates infected with the virus will be prevented from spreading it to others.

“One of my friends – he got it a couple months ago while we was in school,” Julian recalled. “[He] and his brother had to go back home. ... They were OK. They only had mild symptoms.”

Brandon Muñoz, who’s in the fifth grade, said he’s glad to get tested because he’s too young for the vaccine – and he really doesn’t want to go back to Zoom school.

“Because I wanna really meet more people and friends and just not stay on the computer for too long,” Brandon explained.

Mr. Suchinski said Hillside also improved ventilation throughout the building, installing a new HVAC system and windows with screens in the cafeteria to bring more fresh air in the building.

Regular testing is an added layer of protection, though not the only thing Hillside is relying on: About 90% of Hillside staff are vaccinated, Suchinski said, and students and staffers also wear masks.

Setting up a regular mass-testing program inside a K-12 school takes a good amount of coordination, which Mr. Suchinski can vouch for.

Last school year, Hillside school administrators facilitated the saliva sample collection without outside help. This year, the school tapped funding earmarked for K-12 coronavirus testing to hire COVID testers – who coordinate the collecting, transporting and processing of samples, and reporting results.

A couple of Hillside administrators help oversee the process on Mondays, and also facilitate testing for staff members, plus more frequent testing for a limited group of students: Athletes and children in band and extracurriculars test twice a week because they face greater risks of exposure to the virus from these activities.

Compared with a year ago, COVID testing is now both more affordable and much less invasive, said Mara Aspinall, who studies biomedical testing at Arizona State University. There’s also more help to cover costs.

“The Biden administration has allocated $11 billion to different programs for testing,” Ms. Aspinall said. “There should be no school – public, private or charter – that can’t access that money for testing.”

Creating a mass testing program from scratch is a big lift. But more than half of all states have announced programs to help schools access the money and handle the logistics.

If every school tested every student once a week, the roughly $11 billion earmarked for testing would likely run out in a couple of months. (This assumes $20 to buy and process each test.) Put another way, if a quarter of all U.S. schools tested students weekly, the funds could last the rest of the school year, Ms. Aspinall said.

In its guidance to K-12 schools, updated Aug. 5, the Centers for Disease Control and Prevention does not make a firm recommendation for this surveillance testing.

Instead, the CDC advises schools that choose to offer testing to work with public health officials to determine a suitable approach, given rates of community transmission and other factors.

The agency previously recommended screening at least once a week in all areas experiencing moderate to high levels of community transmission. As of Sept. 21, that included 95% of U.S. counties.

For school leaders looking to explore options, Ms. Aspinall suggests a resource she helped write, which is cited within the CDC guidance to schools: the Rockefeller Foundation’s National Testing Action Plan.

This spring – when Hillside was operating at about half capacity and before the more contagious delta variant took over – the school identified 13 positive cases among students and staffers via its weekly testing program. The overall positivity rate of about half a percent made some wonder if all that testing was necessary.

But Mr. Suchinski said that, by identifying the 13 positive cases, the school perhaps avoided more than a dozen potential outbreaks. Some of the positive cases were among people who weren’t showing symptoms but still could’ve spread the virus.

A couple of weeks into the new school year at Hillside, operating at full capacity, Mr. Suchinski said the excitement is palpable. Nowadays he’s balancing feelings of optimism with caution.

“It is great to hear kids laughing. It’s great to see kids on playgrounds,” Mr. Suchinski said.

“At the same time,” he added, “we know that we’re still fighting against the Delta variant and we have to keep our guard up.”

This story is from a partnership that includes Illinois Public Media, Side Effects Public Media, NPR, and KHN (Kaiser Health News). KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

On a recent Monday morning, a group of preschoolers filed into the gymnasium at Hillside School in the west Chicago suburbs. These 4- and 5-year-olds were the first of more than 200 students to get tested for the coronavirus that day – and every Monday – for the foreseeable future.

At the front of the line, a girl in a unicorn headband and sparkly pink skirt clutched a zip-close bag with her name on it. She pulled out a plastic tube with a small funnel attached. Next, Hillside superintendent Kevin Suchinski led the student to a spot marked off with red tape. Mr. Suchinski coached her how to carefully release – but not “spit” – about a half-teaspoon’s worth of saliva into the tube.

“You wait a second, you build up your saliva,” he told her. “You don’t talk, you think about pizza, hamburgers, French fries, ice cream. And you drop it right in there, OK?”

The results will come back within 24 hours. Any students who test positive are instructed to isolate, and the school nurse and administrative staff carry out contact tracing.

Hillside was among the first in Illinois to start regular testing. Now, almost half of Illinois’ 2 million students in grades K-12 attend schools rolling out similar programs. The initiative is supported by federal funding channeled through the state health department.

Schools in other states – such as Massachusetts, Maryland, New York and Colorado – also offer regular testing; Los Angeles public schools have gone further by making it mandatory.

These measures stand in sharp contrast to the confusion in states where people are still fighting about wearing masks in the classroom and other anti-COVID strategies, places where some schools have experienced outbreaks and even teacher deaths.

Within a few weeks of schools reopening, tens of thousands of students across the United States were sent home to quarantine. It’s a concern because options for K-12 students in quarantine are all over the map – with some schools offering virtual instruction and others providing little or no at-home options.

Mr. Suchinski hopes this investment in testing prevents virus detected at Hillside School from spreading into the wider community – and keeps kids learning.

“What we say to ourselves is: If we don’t do this program, we could be losing instruction because we’ve had to close down the school,” he said.

So far, the parents and guardians of two-thirds of all Hillside students have consented to testing. Mr. Suchinski said the school is working hard to get the remaining families on board by educating them about the importance – and benefit – of regular testing.

Every school that can manage it should consider testing students weekly – even twice a week, if possible, said Becky Smith, PhD. She’s an epidemiologist at the University of Illinois in Urbana-Champaign, which developed the saliva test Hillside and other Illinois schools are using. Smith pointed to several studies – including both peer-reviewed and preliminary research – that suggest rigorous testing and contact tracing are key to keeping the virus at bay in K-12 schools.

“If you’re lucky, you can get away without doing testing, [if] nobody comes to school with a raging infection and takes their mask off at lunchtime and infects everybody sitting at the table with them,” Dr. Smith said. “But relying on luck isn’t what we like to do.”

Julian Hernandez, a Hillside seventh grader, said he feels safer knowing that classmates infected with the virus will be prevented from spreading it to others.

“One of my friends – he got it a couple months ago while we was in school,” Julian recalled. “[He] and his brother had to go back home. ... They were OK. They only had mild symptoms.”

Brandon Muñoz, who’s in the fifth grade, said he’s glad to get tested because he’s too young for the vaccine – and he really doesn’t want to go back to Zoom school.

“Because I wanna really meet more people and friends and just not stay on the computer for too long,” Brandon explained.

Mr. Suchinski said Hillside also improved ventilation throughout the building, installing a new HVAC system and windows with screens in the cafeteria to bring more fresh air in the building.

Regular testing is an added layer of protection, though not the only thing Hillside is relying on: About 90% of Hillside staff are vaccinated, Suchinski said, and students and staffers also wear masks.

Setting up a regular mass-testing program inside a K-12 school takes a good amount of coordination, which Mr. Suchinski can vouch for.

Last school year, Hillside school administrators facilitated the saliva sample collection without outside help. This year, the school tapped funding earmarked for K-12 coronavirus testing to hire COVID testers – who coordinate the collecting, transporting and processing of samples, and reporting results.

A couple of Hillside administrators help oversee the process on Mondays, and also facilitate testing for staff members, plus more frequent testing for a limited group of students: Athletes and children in band and extracurriculars test twice a week because they face greater risks of exposure to the virus from these activities.

Compared with a year ago, COVID testing is now both more affordable and much less invasive, said Mara Aspinall, who studies biomedical testing at Arizona State University. There’s also more help to cover costs.

“The Biden administration has allocated $11 billion to different programs for testing,” Ms. Aspinall said. “There should be no school – public, private or charter – that can’t access that money for testing.”

Creating a mass testing program from scratch is a big lift. But more than half of all states have announced programs to help schools access the money and handle the logistics.

If every school tested every student once a week, the roughly $11 billion earmarked for testing would likely run out in a couple of months. (This assumes $20 to buy and process each test.) Put another way, if a quarter of all U.S. schools tested students weekly, the funds could last the rest of the school year, Ms. Aspinall said.

In its guidance to K-12 schools, updated Aug. 5, the Centers for Disease Control and Prevention does not make a firm recommendation for this surveillance testing.

Instead, the CDC advises schools that choose to offer testing to work with public health officials to determine a suitable approach, given rates of community transmission and other factors.

The agency previously recommended screening at least once a week in all areas experiencing moderate to high levels of community transmission. As of Sept. 21, that included 95% of U.S. counties.

For school leaders looking to explore options, Ms. Aspinall suggests a resource she helped write, which is cited within the CDC guidance to schools: the Rockefeller Foundation’s National Testing Action Plan.

This spring – when Hillside was operating at about half capacity and before the more contagious delta variant took over – the school identified 13 positive cases among students and staffers via its weekly testing program. The overall positivity rate of about half a percent made some wonder if all that testing was necessary.

But Mr. Suchinski said that, by identifying the 13 positive cases, the school perhaps avoided more than a dozen potential outbreaks. Some of the positive cases were among people who weren’t showing symptoms but still could’ve spread the virus.

A couple of weeks into the new school year at Hillside, operating at full capacity, Mr. Suchinski said the excitement is palpable. Nowadays he’s balancing feelings of optimism with caution.

“It is great to hear kids laughing. It’s great to see kids on playgrounds,” Mr. Suchinski said.

“At the same time,” he added, “we know that we’re still fighting against the Delta variant and we have to keep our guard up.”

This story is from a partnership that includes Illinois Public Media, Side Effects Public Media, NPR, and KHN (Kaiser Health News). KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

On a recent Monday morning, a group of preschoolers filed into the gymnasium at Hillside School in the west Chicago suburbs. These 4- and 5-year-olds were the first of more than 200 students to get tested for the coronavirus that day – and every Monday – for the foreseeable future.

At the front of the line, a girl in a unicorn headband and sparkly pink skirt clutched a zip-close bag with her name on it. She pulled out a plastic tube with a small funnel attached. Next, Hillside superintendent Kevin Suchinski led the student to a spot marked off with red tape. Mr. Suchinski coached her how to carefully release – but not “spit” – about a half-teaspoon’s worth of saliva into the tube.

“You wait a second, you build up your saliva,” he told her. “You don’t talk, you think about pizza, hamburgers, French fries, ice cream. And you drop it right in there, OK?”

The results will come back within 24 hours. Any students who test positive are instructed to isolate, and the school nurse and administrative staff carry out contact tracing.

Hillside was among the first in Illinois to start regular testing. Now, almost half of Illinois’ 2 million students in grades K-12 attend schools rolling out similar programs. The initiative is supported by federal funding channeled through the state health department.

Schools in other states – such as Massachusetts, Maryland, New York and Colorado – also offer regular testing; Los Angeles public schools have gone further by making it mandatory.

These measures stand in sharp contrast to the confusion in states where people are still fighting about wearing masks in the classroom and other anti-COVID strategies, places where some schools have experienced outbreaks and even teacher deaths.

Within a few weeks of schools reopening, tens of thousands of students across the United States were sent home to quarantine. It’s a concern because options for K-12 students in quarantine are all over the map – with some schools offering virtual instruction and others providing little or no at-home options.

Mr. Suchinski hopes this investment in testing prevents virus detected at Hillside School from spreading into the wider community – and keeps kids learning.

“What we say to ourselves is: If we don’t do this program, we could be losing instruction because we’ve had to close down the school,” he said.

So far, the parents and guardians of two-thirds of all Hillside students have consented to testing. Mr. Suchinski said the school is working hard to get the remaining families on board by educating them about the importance – and benefit – of regular testing.

Every school that can manage it should consider testing students weekly – even twice a week, if possible, said Becky Smith, PhD. She’s an epidemiologist at the University of Illinois in Urbana-Champaign, which developed the saliva test Hillside and other Illinois schools are using. Smith pointed to several studies – including both peer-reviewed and preliminary research – that suggest rigorous testing and contact tracing are key to keeping the virus at bay in K-12 schools.

“If you’re lucky, you can get away without doing testing, [if] nobody comes to school with a raging infection and takes their mask off at lunchtime and infects everybody sitting at the table with them,” Dr. Smith said. “But relying on luck isn’t what we like to do.”

Julian Hernandez, a Hillside seventh grader, said he feels safer knowing that classmates infected with the virus will be prevented from spreading it to others.

“One of my friends – he got it a couple months ago while we was in school,” Julian recalled. “[He] and his brother had to go back home. ... They were OK. They only had mild symptoms.”

Brandon Muñoz, who’s in the fifth grade, said he’s glad to get tested because he’s too young for the vaccine – and he really doesn’t want to go back to Zoom school.

“Because I wanna really meet more people and friends and just not stay on the computer for too long,” Brandon explained.

Mr. Suchinski said Hillside also improved ventilation throughout the building, installing a new HVAC system and windows with screens in the cafeteria to bring more fresh air in the building.

Regular testing is an added layer of protection, though not the only thing Hillside is relying on: About 90% of Hillside staff are vaccinated, Suchinski said, and students and staffers also wear masks.

Setting up a regular mass-testing program inside a K-12 school takes a good amount of coordination, which Mr. Suchinski can vouch for.

Last school year, Hillside school administrators facilitated the saliva sample collection without outside help. This year, the school tapped funding earmarked for K-12 coronavirus testing to hire COVID testers – who coordinate the collecting, transporting and processing of samples, and reporting results.

A couple of Hillside administrators help oversee the process on Mondays, and also facilitate testing for staff members, plus more frequent testing for a limited group of students: Athletes and children in band and extracurriculars test twice a week because they face greater risks of exposure to the virus from these activities.

Compared with a year ago, COVID testing is now both more affordable and much less invasive, said Mara Aspinall, who studies biomedical testing at Arizona State University. There’s also more help to cover costs.

“The Biden administration has allocated $11 billion to different programs for testing,” Ms. Aspinall said. “There should be no school – public, private or charter – that can’t access that money for testing.”

Creating a mass testing program from scratch is a big lift. But more than half of all states have announced programs to help schools access the money and handle the logistics.

If every school tested every student once a week, the roughly $11 billion earmarked for testing would likely run out in a couple of months. (This assumes $20 to buy and process each test.) Put another way, if a quarter of all U.S. schools tested students weekly, the funds could last the rest of the school year, Ms. Aspinall said.

In its guidance to K-12 schools, updated Aug. 5, the Centers for Disease Control and Prevention does not make a firm recommendation for this surveillance testing.

Instead, the CDC advises schools that choose to offer testing to work with public health officials to determine a suitable approach, given rates of community transmission and other factors.

The agency previously recommended screening at least once a week in all areas experiencing moderate to high levels of community transmission. As of Sept. 21, that included 95% of U.S. counties.

For school leaders looking to explore options, Ms. Aspinall suggests a resource she helped write, which is cited within the CDC guidance to schools: the Rockefeller Foundation’s National Testing Action Plan.

This spring – when Hillside was operating at about half capacity and before the more contagious delta variant took over – the school identified 13 positive cases among students and staffers via its weekly testing program. The overall positivity rate of about half a percent made some wonder if all that testing was necessary.

But Mr. Suchinski said that, by identifying the 13 positive cases, the school perhaps avoided more than a dozen potential outbreaks. Some of the positive cases were among people who weren’t showing symptoms but still could’ve spread the virus.

A couple of weeks into the new school year at Hillside, operating at full capacity, Mr. Suchinski said the excitement is palpable. Nowadays he’s balancing feelings of optimism with caution.

“It is great to hear kids laughing. It’s great to see kids on playgrounds,” Mr. Suchinski said.

“At the same time,” he added, “we know that we’re still fighting against the Delta variant and we have to keep our guard up.”

This story is from a partnership that includes Illinois Public Media, Side Effects Public Media, NPR, and KHN (Kaiser Health News). KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

PHM 2021 Session

Safe and (Ultra)sound: Why you should use POCUS in your Pediatric Practice

Presenter

Ria Dancel, MD, FAAP, FACP

Session summary

Dr. Ria Dancel and her colleagues from the University of North Carolina at Chapel Hill presented a broad overview of point-of-care ultrasound (POCUS) applications in the field of pediatric hospital medicine. They discussed its advantages and potential uses, ranging from common scenarios to critical care to procedural guidance. Using illustrative scenarios and interactive cases, she discussed the bedside applications to improve care of hospitalized children. The benefits and risks of radiography and POCUS were reviewed.

The session highlighted the use of POCUS in SSTI (skin and soft tissue infection) to help with differentiating cellulitis from abscesses. Use of POCUS for safer incision and drainages and making day-to-day changes in management was discussed. The ease and benefits of performing real-time lung ultrasound in different pathologies (like pneumonia, effusion, COVID-19) was presented. The speakers discussed the use of POCUS in emergency situations like hypotension and different types of shock. The use of ultrasound in common bedside procedures (bladder catheterization, lumbar ultrasound, peripheral IV placement) were also highlighted. Current literature and evidence were reviewed.
 

Key takeaways

• Pediatric POCUS is an extremely valuable bedside tool in pediatric hospital medicine.
• It can be used to guide clinical care for many conditions including SSTI, pneumonia, and shock.
• It can be used for procedural guidance for bladder catheterization, lumbar puncture, and intravenous access.

Dr. Patra is a pediatric hospitalist at West Virginia University Children’s Hospital, Morgantown, and associate professor at West Virginia University School of Medicine. He is interested in medical education, quality improvement and clinical research. He is a member of the Executive Council of the Pediatric Special Interest Group of the Society of Hospital Medicine.

PHM 2021 Session

Safe and (Ultra)sound: Why you should use POCUS in your Pediatric Practice

Presenter

Ria Dancel, MD, FAAP, FACP

Session summary

Dr. Ria Dancel and her colleagues from the University of North Carolina at Chapel Hill presented a broad overview of point-of-care ultrasound (POCUS) applications in the field of pediatric hospital medicine. They discussed its advantages and potential uses, ranging from common scenarios to critical care to procedural guidance. Using illustrative scenarios and interactive cases, she discussed the bedside applications to improve care of hospitalized children. The benefits and risks of radiography and POCUS were reviewed.

The session highlighted the use of POCUS in SSTI (skin and soft tissue infection) to help with differentiating cellulitis from abscesses. Use of POCUS for safer incision and drainages and making day-to-day changes in management was discussed. The ease and benefits of performing real-time lung ultrasound in different pathologies (like pneumonia, effusion, COVID-19) was presented. The speakers discussed the use of POCUS in emergency situations like hypotension and different types of shock. The use of ultrasound in common bedside procedures (bladder catheterization, lumbar ultrasound, peripheral IV placement) were also highlighted. Current literature and evidence were reviewed.
 

Key takeaways

• Pediatric POCUS is an extremely valuable bedside tool in pediatric hospital medicine.
• It can be used to guide clinical care for many conditions including SSTI, pneumonia, and shock.
• It can be used for procedural guidance for bladder catheterization, lumbar puncture, and intravenous access.

Dr. Patra is a pediatric hospitalist at West Virginia University Children’s Hospital, Morgantown, and associate professor at West Virginia University School of Medicine. He is interested in medical education, quality improvement and clinical research. He is a member of the Executive Council of the Pediatric Special Interest Group of the Society of Hospital Medicine.

PHM 2021 Session

Safe and (Ultra)sound: Why you should use POCUS in your Pediatric Practice

Presenter

Ria Dancel, MD, FAAP, FACP

Session summary

Dr. Ria Dancel and her colleagues from the University of North Carolina at Chapel Hill presented a broad overview of point-of-care ultrasound (POCUS) applications in the field of pediatric hospital medicine. They discussed its advantages and potential uses, ranging from common scenarios to critical care to procedural guidance. Using illustrative scenarios and interactive cases, she discussed the bedside applications to improve care of hospitalized children. The benefits and risks of radiography and POCUS were reviewed.

The session highlighted the use of POCUS in SSTI (skin and soft tissue infection) to help with differentiating cellulitis from abscesses. Use of POCUS for safer incision and drainages and making day-to-day changes in management was discussed. The ease and benefits of performing real-time lung ultrasound in different pathologies (like pneumonia, effusion, COVID-19) was presented. The speakers discussed the use of POCUS in emergency situations like hypotension and different types of shock. The use of ultrasound in common bedside procedures (bladder catheterization, lumbar ultrasound, peripheral IV placement) were also highlighted. Current literature and evidence were reviewed.
 

Key takeaways

• Pediatric POCUS is an extremely valuable bedside tool in pediatric hospital medicine.
• It can be used to guide clinical care for many conditions including SSTI, pneumonia, and shock.
• It can be used for procedural guidance for bladder catheterization, lumbar puncture, and intravenous access.

Dr. Patra is a pediatric hospitalist at West Virginia University Children’s Hospital, Morgantown, and associate professor at West Virginia University School of Medicine. He is interested in medical education, quality improvement and clinical research. He is a member of the Executive Council of the Pediatric Special Interest Group of the Society of Hospital Medicine.

Good nutrition has long been linked to better behavior and academic performance in schoolchildren, as longstanding breakfast and lunch programs in U.S. schools attest. Now British researchers report that nutrition, a modifiable risk factor that can adversely impact mental health, should be part of public health strategies to boost children’s psychological wellness.

In a cross-sectional study published online Sept. 27 in BMJ Nutrition, Prevention & Health, a team from the University of East Anglia in Norwich, England, found a nutritious breakfast and lunch were linked to emotional well-being in schoolchildren of both primary and secondary school age. They also found that some school kids ate neither breakfast nor lunch.

In particular, eating more fruits and vegetables was significantly associated with better mental health in secondary schoolchildren, while a nutritious breakfast and lunch were linked to emotional well-being in students across the age spectrum, according to senior lecturer Richard P. Hayhoe, PhD, of East Anglia University and Anglia Ruskin University in Norwich and colleagues.

They found that primary school pupils who ate only a snack for breakfast had mental well-being scores 5.50 units lower than those eating a substantial breakfast, while having no lunch was tied to scores more than 6 units lower.

“The importance of good-quality nutrition for childhood growth and development is well established,” the authors wrote. “As a potentially modifiable factor, both at an individual and societal level, nutrition may therefore represent an important public health target for strategies to address childhood mental well-being.”

Their current analysis examined data on 7,570 secondary and 1,253 primary school children from 50 schools participating in the Norfolk Children and Young People Health and Well-being Survey 2017.

Multivariable linear regression measured the association between nutritional factors and mental well-being assessed by the Warwick-Edinburgh Mental Well-being Scale for secondary school pupils or by the Stirling Children’s Well-being Scale for primary school pupils. All analyses were adjusted for covariates including demographic, health variables, living/home situations, and adverse experiences.

“The 2017 survey provided a means for Norfolk children and young people to share their feelings on topics such as healthy lifestyles and nutrition, relationships, school experiences, bullying, and their mental well-being,” Dr. Hayhoe said in an interview. “Initial analysis of the data suggested an association between nutrition and well-being and so we decided to investigate this further.”

Dr. Hayhoe added that, as in the United States, youngsters in England get a high proportion of their daily calories from ultraprocessed convenience foods of lesser nutritional value.

“But what we didn’t know was whether the dietary habits of children in our survey had any association with their mental well-being,” he said. “Our current findings suggest that increasing fruit and vegetable consumption and ensuring all schoolchildren eat a nutritional breakfast and lunch may be of benefit to their mental well-being.”

His group cautions, however, that this is an observational study that cannot establish direct causation.

“This study provides the first insights into how fruit and vegetable intake affects children’s mental health, and contributes to the emerging evidence around ‘food and mood,’ ” said Sumantra Ray, MD, executive director of the NNEdPro Global Centre for Nutrition and Health in Cambridge, England.

“The findings are timely, not only because of the impact the pandemic has had on mental well-being, food security, and diet quality, especially in school children, but also in light of the recently published National Food Strategy for England, which highlighted gaps in school meal provision,” added Dr. Ray, who was not involved in the study.
 

Study results

In total, 10,853 schoolchildren completed the survey: 9% of Norfolk primary school children aged 9-11 and 22% of secondary school students, with approximately 6% of these in the 17- and 18-year-old age bracket. Comprehensive dietary questions explored fruit and vegetable intake, as well as type of breakfast and lunch eaten, alcohol intake, eligibility for free school meals, and satisfaction with weight.

The survey also gathered information on parameters ranging from having one’s own bedroom and bed and exposure to violence or discord in the home.

“Some of these were found to be associated with lower mental well-being scores, but we did not specifically investigate the interaction between these factors and the nutritional factors,” Dr. Hayhoe said. However, the difference in mental well-being between children who ate the most fruit and vegetables and those who ate the least was on a similar scale to those reporting daily, or almost daily, arguing or violence at home, he said.

Average mental health was assessed using validated age-appropriate measures. The mean mental health score of participants was 46.6 out of 70 for secondary school students and 46 out of 60 for primary school pupils.

Among the survey findings were:

• Just 25% of secondary school participants and 28.5% of primary school pupils reported eating the recommended five portions of fruits and vegetables a day, with 10% and 9%, respectively, eating none.
• 21% of secondary and 12% of primary school pupils consumed only a non–energy drink or nothing for breakfast, while 11.5% of secondary schoolchildren ate no lunch. In one high school class of 30, for example, four had nothing to eat or drink before starting classes in the morning, and three had nothing to eat or drink before starting classes in the afternoon.
• Higher combined fruit and vegetable intake was significantly associated in dose-related fashion with higher mental health scores: 3.73 (95% confidence interval, 2.94- 4.53) units higher in those consuming five or more fruits and vegetables (P < .001), compared with none.
• Breakfast or lunch type also correlated with significant differences in well-being scores. Compared with children consuming a conventional breakfast (porridge, toast, cereal, yogurt, fruit, or a cooked meal), those eating no breakfast had mean well-being scores that were 2.73 (95% CI, 2.11-3.35) units lower (P < .001). Those consuming only an energy drink scored even worse: 3.14 (95% CI, 1.20- 5.09) units lower (P = .002).
• Skipping lunch resulted in a 2.95-unit drop in well-being score (95% CI, 2.22-3.68, P < .001), compared with consuming a packed lunch.

In terms of the amounts of fruits and vegetables consumed, one or two daily portions were associated with a score 1.42 units higher, while three or four portions correlated with a score 2.34 units higher. Those eating five or more portions scored 3.73 units higher.

• For primary school pupils, eating only a snack for breakfast was associated with a score 5.50 units lower, and consuming only a non–energy drink was tied to a score 2.67 units lower than eating a conventional breakfast. Not eating any breakfast was associated with a score 3.62 units lower.
• Eating school food versus a packed lunch was associated with a score 1.27 units lower, although this wasn’t statistically significant. Having no lunch was associated with a score 6.08 units lower, although only a few children fell into this group.

“As a potentially modifiable factor, both at an individual and societal level, nutrition may therefore represent an important public health target for strategies to address childhood mental well-being,” the authors wrote, calling for further investigation of the association between nutrition and mental well-being.

This study was commissioned by Norfolk County Council Public Health and the Norfolk Safeguarding Children Board. The University of East Anglia and Social Care Partners provided funding to support Dr. Hayhoe’s work on this project.

Some coauthors are employed by the Norfolk County Council that commissioned the survey.
 

Good nutrition has long been linked to better behavior and academic performance in schoolchildren, as longstanding breakfast and lunch programs in U.S. schools attest. Now British researchers report that nutrition, a modifiable risk factor that can adversely impact mental health, should be part of public health strategies to boost children’s psychological wellness.

In a cross-sectional study published online Sept. 27 in BMJ Nutrition, Prevention & Health, a team from the University of East Anglia in Norwich, England, found a nutritious breakfast and lunch were linked to emotional well-being in schoolchildren of both primary and secondary school age. They also found that some school kids ate neither breakfast nor lunch.

In particular, eating more fruits and vegetables was significantly associated with better mental health in secondary schoolchildren, while a nutritious breakfast and lunch were linked to emotional well-being in students across the age spectrum, according to senior lecturer Richard P. Hayhoe, PhD, of East Anglia University and Anglia Ruskin University in Norwich and colleagues.

They found that primary school pupils who ate only a snack for breakfast had mental well-being scores 5.50 units lower than those eating a substantial breakfast, while having no lunch was tied to scores more than 6 units lower.

“The importance of good-quality nutrition for childhood growth and development is well established,” the authors wrote. “As a potentially modifiable factor, both at an individual and societal level, nutrition may therefore represent an important public health target for strategies to address childhood mental well-being.”

Their current analysis examined data on 7,570 secondary and 1,253 primary school children from 50 schools participating in the Norfolk Children and Young People Health and Well-being Survey 2017.

Multivariable linear regression measured the association between nutritional factors and mental well-being assessed by the Warwick-Edinburgh Mental Well-being Scale for secondary school pupils or by the Stirling Children’s Well-being Scale for primary school pupils. All analyses were adjusted for covariates including demographic, health variables, living/home situations, and adverse experiences.

“The 2017 survey provided a means for Norfolk children and young people to share their feelings on topics such as healthy lifestyles and nutrition, relationships, school experiences, bullying, and their mental well-being,” Dr. Hayhoe said in an interview. “Initial analysis of the data suggested an association between nutrition and well-being and so we decided to investigate this further.”

Dr. Hayhoe added that, as in the United States, youngsters in England get a high proportion of their daily calories from ultraprocessed convenience foods of lesser nutritional value.

“But what we didn’t know was whether the dietary habits of children in our survey had any association with their mental well-being,” he said. “Our current findings suggest that increasing fruit and vegetable consumption and ensuring all schoolchildren eat a nutritional breakfast and lunch may be of benefit to their mental well-being.”

His group cautions, however, that this is an observational study that cannot establish direct causation.

“This study provides the first insights into how fruit and vegetable intake affects children’s mental health, and contributes to the emerging evidence around ‘food and mood,’ ” said Sumantra Ray, MD, executive director of the NNEdPro Global Centre for Nutrition and Health in Cambridge, England.

“The findings are timely, not only because of the impact the pandemic has had on mental well-being, food security, and diet quality, especially in school children, but also in light of the recently published National Food Strategy for England, which highlighted gaps in school meal provision,” added Dr. Ray, who was not involved in the study.
 

Study results

In total, 10,853 schoolchildren completed the survey: 9% of Norfolk primary school children aged 9-11 and 22% of secondary school students, with approximately 6% of these in the 17- and 18-year-old age bracket. Comprehensive dietary questions explored fruit and vegetable intake, as well as type of breakfast and lunch eaten, alcohol intake, eligibility for free school meals, and satisfaction with weight.

The survey also gathered information on parameters ranging from having one’s own bedroom and bed and exposure to violence or discord in the home.

“Some of these were found to be associated with lower mental well-being scores, but we did not specifically investigate the interaction between these factors and the nutritional factors,” Dr. Hayhoe said. However, the difference in mental well-being between children who ate the most fruit and vegetables and those who ate the least was on a similar scale to those reporting daily, or almost daily, arguing or violence at home, he said.

Average mental health was assessed using validated age-appropriate measures. The mean mental health score of participants was 46.6 out of 70 for secondary school students and 46 out of 60 for primary school pupils.

Among the survey findings were:

• Just 25% of secondary school participants and 28.5% of primary school pupils reported eating the recommended five portions of fruits and vegetables a day, with 10% and 9%, respectively, eating none.
• 21% of secondary and 12% of primary school pupils consumed only a non–energy drink or nothing for breakfast, while 11.5% of secondary schoolchildren ate no lunch. In one high school class of 30, for example, four had nothing to eat or drink before starting classes in the morning, and three had nothing to eat or drink before starting classes in the afternoon.
• Higher combined fruit and vegetable intake was significantly associated in dose-related fashion with higher mental health scores: 3.73 (95% confidence interval, 2.94- 4.53) units higher in those consuming five or more fruits and vegetables (P < .001), compared with none.
• Breakfast or lunch type also correlated with significant differences in well-being scores. Compared with children consuming a conventional breakfast (porridge, toast, cereal, yogurt, fruit, or a cooked meal), those eating no breakfast had mean well-being scores that were 2.73 (95% CI, 2.11-3.35) units lower (P < .001). Those consuming only an energy drink scored even worse: 3.14 (95% CI, 1.20- 5.09) units lower (P = .002).
• Skipping lunch resulted in a 2.95-unit drop in well-being score (95% CI, 2.22-3.68, P < .001), compared with consuming a packed lunch.

In terms of the amounts of fruits and vegetables consumed, one or two daily portions were associated with a score 1.42 units higher, while three or four portions correlated with a score 2.34 units higher. Those eating five or more portions scored 3.73 units higher.

• For primary school pupils, eating only a snack for breakfast was associated with a score 5.50 units lower, and consuming only a non–energy drink was tied to a score 2.67 units lower than eating a conventional breakfast. Not eating any breakfast was associated with a score 3.62 units lower.
• Eating school food versus a packed lunch was associated with a score 1.27 units lower, although this wasn’t statistically significant. Having no lunch was associated with a score 6.08 units lower, although only a few children fell into this group.

“As a potentially modifiable factor, both at an individual and societal level, nutrition may therefore represent an important public health target for strategies to address childhood mental well-being,” the authors wrote, calling for further investigation of the association between nutrition and mental well-being.

This study was commissioned by Norfolk County Council Public Health and the Norfolk Safeguarding Children Board. The University of East Anglia and Social Care Partners provided funding to support Dr. Hayhoe’s work on this project.

Some coauthors are employed by the Norfolk County Council that commissioned the survey.
 

Good nutrition has long been linked to better behavior and academic performance in schoolchildren, as longstanding breakfast and lunch programs in U.S. schools attest. Now British researchers report that nutrition, a modifiable risk factor that can adversely impact mental health, should be part of public health strategies to boost children’s psychological wellness.

In a cross-sectional study published online Sept. 27 in BMJ Nutrition, Prevention & Health, a team from the University of East Anglia in Norwich, England, found a nutritious breakfast and lunch were linked to emotional well-being in schoolchildren of both primary and secondary school age. They also found that some school kids ate neither breakfast nor lunch.

In particular, eating more fruits and vegetables was significantly associated with better mental health in secondary schoolchildren, while a nutritious breakfast and lunch were linked to emotional well-being in students across the age spectrum, according to senior lecturer Richard P. Hayhoe, PhD, of East Anglia University and Anglia Ruskin University in Norwich and colleagues.

They found that primary school pupils who ate only a snack for breakfast had mental well-being scores 5.50 units lower than those eating a substantial breakfast, while having no lunch was tied to scores more than 6 units lower.

“The importance of good-quality nutrition for childhood growth and development is well established,” the authors wrote. “As a potentially modifiable factor, both at an individual and societal level, nutrition may therefore represent an important public health target for strategies to address childhood mental well-being.”

Their current analysis examined data on 7,570 secondary and 1,253 primary school children from 50 schools participating in the Norfolk Children and Young People Health and Well-being Survey 2017.

Multivariable linear regression measured the association between nutritional factors and mental well-being assessed by the Warwick-Edinburgh Mental Well-being Scale for secondary school pupils or by the Stirling Children’s Well-being Scale for primary school pupils. All analyses were adjusted for covariates including demographic, health variables, living/home situations, and adverse experiences.

“The 2017 survey provided a means for Norfolk children and young people to share their feelings on topics such as healthy lifestyles and nutrition, relationships, school experiences, bullying, and their mental well-being,” Dr. Hayhoe said in an interview. “Initial analysis of the data suggested an association between nutrition and well-being and so we decided to investigate this further.”

Dr. Hayhoe added that, as in the United States, youngsters in England get a high proportion of their daily calories from ultraprocessed convenience foods of lesser nutritional value.

“But what we didn’t know was whether the dietary habits of children in our survey had any association with their mental well-being,” he said. “Our current findings suggest that increasing fruit and vegetable consumption and ensuring all schoolchildren eat a nutritional breakfast and lunch may be of benefit to their mental well-being.”

His group cautions, however, that this is an observational study that cannot establish direct causation.

“This study provides the first insights into how fruit and vegetable intake affects children’s mental health, and contributes to the emerging evidence around ‘food and mood,’ ” said Sumantra Ray, MD, executive director of the NNEdPro Global Centre for Nutrition and Health in Cambridge, England.

“The findings are timely, not only because of the impact the pandemic has had on mental well-being, food security, and diet quality, especially in school children, but also in light of the recently published National Food Strategy for England, which highlighted gaps in school meal provision,” added Dr. Ray, who was not involved in the study.
 

Study results

In total, 10,853 schoolchildren completed the survey: 9% of Norfolk primary school children aged 9-11 and 22% of secondary school students, with approximately 6% of these in the 17- and 18-year-old age bracket. Comprehensive dietary questions explored fruit and vegetable intake, as well as type of breakfast and lunch eaten, alcohol intake, eligibility for free school meals, and satisfaction with weight.

The survey also gathered information on parameters ranging from having one’s own bedroom and bed and exposure to violence or discord in the home.

“Some of these were found to be associated with lower mental well-being scores, but we did not specifically investigate the interaction between these factors and the nutritional factors,” Dr. Hayhoe said. However, the difference in mental well-being between children who ate the most fruit and vegetables and those who ate the least was on a similar scale to those reporting daily, or almost daily, arguing or violence at home, he said.

Average mental health was assessed using validated age-appropriate measures. The mean mental health score of participants was 46.6 out of 70 for secondary school students and 46 out of 60 for primary school pupils.

Among the survey findings were:

• Just 25% of secondary school participants and 28.5% of primary school pupils reported eating the recommended five portions of fruits and vegetables a day, with 10% and 9%, respectively, eating none.
• 21% of secondary and 12% of primary school pupils consumed only a non–energy drink or nothing for breakfast, while 11.5% of secondary schoolchildren ate no lunch. In one high school class of 30, for example, four had nothing to eat or drink before starting classes in the morning, and three had nothing to eat or drink before starting classes in the afternoon.
• Higher combined fruit and vegetable intake was significantly associated in dose-related fashion with higher mental health scores: 3.73 (95% confidence interval, 2.94- 4.53) units higher in those consuming five or more fruits and vegetables (P < .001), compared with none.
• Breakfast or lunch type also correlated with significant differences in well-being scores. Compared with children consuming a conventional breakfast (porridge, toast, cereal, yogurt, fruit, or a cooked meal), those eating no breakfast had mean well-being scores that were 2.73 (95% CI, 2.11-3.35) units lower (P < .001). Those consuming only an energy drink scored even worse: 3.14 (95% CI, 1.20- 5.09) units lower (P = .002).
• Skipping lunch resulted in a 2.95-unit drop in well-being score (95% CI, 2.22-3.68, P < .001), compared with consuming a packed lunch.

In terms of the amounts of fruits and vegetables consumed, one or two daily portions were associated with a score 1.42 units higher, while three or four portions correlated with a score 2.34 units higher. Those eating five or more portions scored 3.73 units higher.

• For primary school pupils, eating only a snack for breakfast was associated with a score 5.50 units lower, and consuming only a non–energy drink was tied to a score 2.67 units lower than eating a conventional breakfast. Not eating any breakfast was associated with a score 3.62 units lower.
• Eating school food versus a packed lunch was associated with a score 1.27 units lower, although this wasn’t statistically significant. Having no lunch was associated with a score 6.08 units lower, although only a few children fell into this group.

“As a potentially modifiable factor, both at an individual and societal level, nutrition may therefore represent an important public health target for strategies to address childhood mental well-being,” the authors wrote, calling for further investigation of the association between nutrition and mental well-being.

This study was commissioned by Norfolk County Council Public Health and the Norfolk Safeguarding Children Board. The University of East Anglia and Social Care Partners provided funding to support Dr. Hayhoe’s work on this project.

Some coauthors are employed by the Norfolk County Council that commissioned the survey.