Celeste Krewson

Children are more likely to experience symptoms and hospitalizations from influenza than adults during the current influenza season, according to a report from the Centers for Disease Control and Prevention.

Data was collected on influenza cases in Tennessee, which saw an early influenza season beginning in September 2022. In November 2022, high rates of hospitalizations were reported in pediatric patients. Following this rise in cases, data was evaluated from surveillance networks, patient surveys, and whole genome sequencing of influenza virus specimens.

Early influenza activity was examined in 14 of 95 Tennessee counties, using data from the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) and FluSurv-NET surveillance systems.

Information on emergency department visits for influenza-like illness(ILI-ED) was obtained through ESSENCE, while information on hospitalizations associated with influenza was obtained through FluSurv-NET. Data from October 2, 2022, to January 12, 2023, was analyzed.

While all age groups experienced influenza activity earlier than usual, hospitalizations among children aged under 5 years reached 12.6 per 100,000 individuals. These rates are similar to those seen during the peak of high-severity influenza seasons.

When examining patients tested for influenza at outpatient clinics, children were twice as likely to test positive than adults. Children were also twice as likely than adults to become ill through household contacts.

Overall, hospitalization rates from influenza reached high levels earlier than observed in recent influenza seasons. These rates were most common among pediatric patients, with 31% of ILI-ED visits in the week ending on November 26, 2022, being from this age group. Weekly pediatric hospitalizations approached the 98th percentile, which is considered very high intensity.

To reduce the risk of influenza infection, authors of the report advised individuals aged 6 months or older receive influenza vaccination, avoid contact with infected individuals, and take antivirals if recommended and prescribed.

This article originally appeared in Contemporary Pediatrics.

1. Thomas CM, White EB, Kojima N, Fill MA, Hanna S, Jones TF, et al. Early and increased influenza activity among children — Tennessee, 2022–23 influenza season. 

. 2023;72:49–54. doi:10.15585/mmwr.mm7203a1

Articles

In a report from the Centers for Disease Control and Prevention, it was shown that symptoms and hospitalizations associated with influenza this season are higher among children than adults.

Children See Higher Rates of Early Influenza Than Adults

Vitamin C supplementation for pregnant smokers significantly improves airway function and decreases wheeze in children aged 5 years, according to a recent study.

Prenatal exposure to smoke from maternal smoking has been associated with an increased risk of impaired lung development, leading to decreased airway function and increased risk of wheeze and asthma. Over 10% ofindividuals in the United States smoke during pregnancy, causing over 400,000 infants to be exposed to in utero smoke.

Lower airway function in childhood often leads to similarly poor function in adulthood, increasing the risk of respiratory morbidity and chronic obstructive pulmonary disease. Randomized control trials have shown improved airways in children when mothers took vitamin C supplementation during pregnancy, but results in these trials were mixed.

To determine if improved airway function can be achieved early in life and maintained through preschool age, researchers conducted a follow-up investigation to their Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function trial cohort, examining the forced expiratory flow (FEF) of patients aged 5 years.

Participants in the trial included pregnant women aged 15 years and older who had a confirmed single gestation aged 13 to 22 weeks. These individuals also spoke English, had smoked at least 1 in the past week, and were receiving care at clinics near the recruitment sites.

There were 2 groups which participants were randomized into: 1 where they received vitamin C supplementation and 1 where they received a placebo. Data was gathered on participants’ smoking histories and medical adherence, and participants were given brief counseling on smoking cessation.

In the follow-up, FEF measurements for offspring aged 5 years was collected.FEF between 25% and 75% expired volume (FEF25-75), FEF at 50% expired volume (FEF50), and FEF at 75% expired volume (FEF75) were all recorded. Parents and caregivers were also surveyed on the prevalence of wheeze in their children between the child’s fourth and sixth birthdays.

There were 213 children evaluated, with mean ages of 3.1 years in the vitamin C group and 3.2 years in the placebo group. Successful FEF measurements at age 5 were recorded in 90.1% of these children.

Significantly improved FEF25-75 measurements were found in children born to pregnant smokers in the vitamin C supplementation group compared to the placebo group, with a mean difference of 17.2%. Mean FEF50 and FEF75 measurements also improved significantly for children born to women in the vitamin C supplementation group.

The occurrence of wheeze was also significantly lower in children born to pregnant smokers treated with vitamin-C supplementation compared to placebo. Overall, vitamin-C supplementation administered during pregnancy was associated with improved airway function in children born to pregnant smokers.

This article originally appeared on Contemporary Pediatrics.

1. McEvoy CT, Shorey-Kendrick LE, et al. Effect of vitamin C supplementation for pregnant smokers on offspring airway function and wheeze at age 5 years: follow-up of a randomized clinical trial. 

. 2023;177(1):16–24. doi:10.1001/jamapediatrics.2022.4401

A follow-up of a trial cohort showed that children aged 5 years born to pregnant smokers had improved airway function when vitamin C supplementation was administered during pregnancy compared to placebo.

Vitamin C Supplements for Pregnant Patients Can Improve Airway Function in Children

An increasing trend in prescriptions of antipsychotics among pediatric patients, along with the indications associated with these prescriptions, was recently analyzed in a study

Although most antipsychotics are not approved for use in pediatric patients, concerns have arisen over an increase in antipsychotic prescriptions for children and adolescents. Antipsychotics can interact with children’s physical and psychological development, potentially having lasting consequences such as increased cardiometabolic risk.

The 3 antipsychotics approved by the National Institute for Health and Care Excellence for use in pediatric patients arearipiprazole (Abilify; Bristol Myers Squibb), clozapine (Clozaril; Novartis AG), and risperidone (Risperdal; Janssen Pharmaceuticals, Inc).

Aripiprazole was approved for schizophrenia in 2011 and bipolar disorder in 2013, clozapine for adolescent treatment-resistant schizophrenia in 2013, and risperidone for severely aggressive behavior in children aged more than 5 years in 2013.

Studies analyzing the prescriptions of antipsychotics to youths from January 1, 1992, to December 31, 2012, showed a rising rate of antipsychotic prescriptions. There is also little data on the doses and indications of antipsychotic prescriptions in pediatric patients.

Investigators conducted a cohort study to evaluate the trends of antipsychotic prescriptions for children and adolescents in England from January 1, 2000, to December 31, 2019. Data was gathered from the Clinical Practice Research Datalink (CPRD), containing electronic records from participating primary care practices in England.

Participants were aged 3 to 18 years and had CPRD records available during the study period. Antipsychotic use in participants was defined as the prescription of 1 or more typical or atypical antipsychotic listed in the British National Formulary.

The association between CPRD prescriptions and indications was determined through an algorithm developed by investigators. Records from within 6 months before and after the first prescription were used to determine possible indications. These indications were independently categorized by 2 psychiatrists, who then discussed a ranking priority for prescriptions.

Indications were ranked by priority in the following order: non-affective psychosis, affective psychosis, autism spectrum disorder (ASD), conduct disorders, obsessive-compulsive disorders, tic disorders, eating disorders, anxiety disorders including post-traumatic stress disorder, depression, attention-deficit/hyperactivity disorder (ADHD), nausea, other mental illnesses, and other indications.

Other variables identified included participant sex, age, general practice region, and Index of Multiple Deprivation. Participants were categorized into age groups and could transition to new age groups during the follow-up period.

There were 7,217,098 children evaluated in the study. Among this population, 243,529 antipsychotic prescriptions across 26 antipsychotics were recorded for individuals aged 3 to 18 years. Of these, 225,710 were atypical and 17,819 were typical. Risperidone, aripiprazole, quetiapine (Seroquel; AstraZeneca), and olanzapine (Zyprexa; LillyMedical) were the most commonly prescribed antipsychotics.

An increase in the prevalence of prescriptions was observed, from a rate of 0.057% in 2000 to 0.105% in 2019. The highest rate of prescriptions was 0.119% in 2017. Older groups often saw a higherannual prevalence of antipsychotic prescriptions, with adolescents aged 12 to 14 years seeing the greatest relative increase.

ASD was recorded as the most likely indication for antipsychotic prescriptions, followed by non-affective psychosis, anxiety disorders, ADHD, depression, and conduct disorders. The most common prescriptions for most indications were risperidone, except for quetiapine to treat depression and olanzapine to treat eating disorders.

Investigators concluded that authorities in England should observe trends on antipsychotic use in young people, and that future guidelines should reassess the safety and efficacy of these prescriptions.

1. Radojčić MR, Pierce M, Hope H, et al. Trends in antipsychotic prescribing to children and adolescents in England: cohort study using 2000–19 primary care data. 

A recent study found a rise in the prevalence of antipsychotic prescriptions among pediatric patients and noted which antipsychotics were most commonly used for specific indications.

Antipsychotic Prescriptions on the Rise Among Pediatric Patients

Medications for attention-deficit/hyperactivity disorder (ADHD) are not associated with a significantly increased risk of cardiovascular diseases (CVDs), but a mild risk increase cannot be ruled out, according to a recent study.

ADHD is one of the most common neurodevelopmental disorders, with symptoms starting in childhood and often persisting into adulthood. Stimulants and nonstimulants are used for pharmacological treatment of ADHD, and the proportion of children and adults taking ADHD medications has risen in multiple countries.

Evidence has supported the efficacy of ADHD medications, but concerns have arisen over their cardiovascular safety. The dopaminergic and noradrenergic effects of ADHD medications could potentially increase heart rate and blood pressure, with some randomized clinical trials indicating short term increases in pulse or heart rate after taking methylphenidate.

Research on severe cardiovascular outcomes from ADHD medications has produced mixed results, prompting a need for updated data on the association between ADHD medications and cardiovascular events.

Investigators conducted a study to determine the association between ADHD medications and risk of cardiovascular events. A systematic search took place through PubMed, Embase, PsycINFO, and Web of Science, continuing until May 1, 2022. Observational studies on the association between ADHD medications and CVDs were collected.

Data collected on studies included year of publication, first author, sample size, data source, age and sex distribution, study design, study country, year of original data collection, follow-up time, ADHD medication type, measure of medication use, relative risk, definition of CVD, and covariate adjustment.

There were 19 studies published between 2007 and 2021 included, consisting of 3,931,532 participants across 6 countries or regions. Children, adolescents, and adults were included in the study, and about 61% of participants were male. The average follow-up time was between 0.25 and 9.5 years.

When calculating relative risks (RR), it was found that ADHD medications did not lead to a significant risk of CVDs in any of the analyzed age groups. These results were consistent across multiple studies. Subgroup analyses also did not find any significant associations between ADHD medications and CVDs.

While no significant risk was associated with ADHD medications, the pooled RR did not exclude a mild risk increase for outcomes such as cardiac arrest and tachyarrhythmias. Though this risk is relatively low, it could change in high-risk patients or those with preexisting CVD. Investigators recommended that patients follow guidelines established by their clinicians.

1. Zhang L, Yao H, Li L, Du Rietz E, Andell P, Garcia-Argibay M, et al. Risk of cardiovascular diseases associated with medications used in attention-deficit/hyperactivity disorder: asystematic review and meta-analysis. 

 2022;5(11):e2243597. doi:10.1001/jamanetworkopen.2022.43597

A recent study found that the risk of cardiovascular diseases was not significantly greater in patients taking medications for attention-deficit/hyperactivity disorder (ADHD), but investigators were not able to rule out a mild risk increase.

Cardiovascular Disease Risk Not Significantly Increased ADHD Medications

Patients with a history of multisystem inflammatory syndrome in children (MIS-C) are not at an increased risk of experiencing serious adverse events after COVID-19 vaccination, according to a recent study.

MIS-C presents in the weeks following COVID-19 infection in rare occurrences. While data has shown COVID-19 vaccines reduce the risk of COVID-19 infections and complications, there is little evidence on the safety of the vaccine following MIS-C.

The Centers for Disease Control and Prevention recommends waiting at least 90 days after MIS-C diagnosis before receiving a COVID-19 vaccination. However, it is unknown if the risk of a similar immune response after vaccination is present.

As some patients and families may feel concerned at the lack of information on vaccine safety following MIS-C, investigators conducted a cross-sectional study to determine the presence of adverse reactions from the COVID-19 vaccine in individuals with a history of MIS-C.

Participants were individuals enrolled in the Long-Term Outcomes After the Multisystem Inflammatory Syndrome in Children study with a history of MIS-C. Patients were eligible for vaccination if they were aged at least 5 years and it had been at least 90 days since MIS-C diagnosis. These patients were contacted and asked to complete a questionnaire.

There were 895 patients eligible for vaccination during data collection, 385 of which were contacted. Of these, 48.1% received at least 1 vaccination dose. The median age of participants was 12.2 years, with 47% being aged 5 to 11 years, 50.3% being aged 12 to 17 years, and 2.7% being aged 18 to 20 years.

The initial vaccination dose was administered at a median 9 months after MIS-C, with 16.8% of patients receiving 1 dose, 76.9% receiving 2 doses, and 6.5% receiving 3 doses. The most common vaccine given was the BNT162b2 vaccine.

Mild adverse reactions were seen in 48.6% of patients, with arm soreness and fatigue being the most common. Medications were used to treat adverse reactions in 17.3% of patients, while 2.2% sought medical evaluation. None of the patients needed testing or hospitalization.

Medical care was given for conjunctival injection, chill, fever, abominable pain, arm soreness, arm redness or swelling, and fatigue. Only 2 of the 4 patients who sought medical evaluation were given medications, with 1 given acetaminophen and 1 given ibuprofen.

Only 1 girl aged 5 to 11 years experienced chest pain, which presented 1 day after the second dose and lasted for a single day. She did not attempt to receive medication or medical care.

Palpitations were seen in 2 patients in the male groups aged 12 to 17 years and 18 to 20 years. Palpitations appeared 1 day after the first or second dose and did not last more than 48 hours. Neither patient sought medical evaluation.

No serious adverse events were reported, leading investigators to conclude COVID-19 vaccination administered at least 90 days after MIS-C diagnosis has a similar safety profile to that in the general population.

Elias MD, Truong DT, Oster ME, Trachtenberg FL, Mu X, Jone P, et al. Examination of adverse reactions after COVID-19 vaccination among patients with a history of multisystem inflammatory syndrome in children. 

 2023;6(1):e2248987. doi:10.1001/jamanetworkopen.2022.48987

Patients with a history of multisystem inflammatory syndrome in children (MIS-C) completed a questionnaire about adverse reactions following COVID-19 vaccination, and no serious adverse events were recorded.

COVID-19 Vaccine Safe for Children Who Had Previous MIS-C Diagnosis

The US Food and Drug Administration (FDA) has accepted a Biologics License Application for nirsevimab (Beyfortus; AstraZeneca and Sanofi) as a protection against respiratory syncytial virus (RSV) in newborns.

The submission followed phase 3 MELODY, phase 2/3 MEDLEY, and phase 2b trials which showcased safety and efficacy of nirsevimab. Consistent protection was provided to about 80% of patients in the MELODY and phase 2b trials, and the safety profile of nirsevimab was consistent with placebo and palivizumab.

Nirsevimab is a long-acting antibody provided through a single-dose in the United States, made to help protect newborns from RSV through their first RSV season. The antibody can also provide protection for infants aged up to 24 months through their second RSV season.

The antibody found in nirsevimab works to prevent lower respiratory tract infection caused by RSV. Protection is timely, direct, and rapid, as the immune system does not need to activate for monoclonal antibodies to function.

Sanofi and AstraZeneca began jointly working on nirsevimab in March 2017. If approved, it will be the first protective option available to newborns. Newborns born healthy or with specific health conditions, along with those born at term or preterm, will be eligible for the vaccine.

Throughout the 2022 to 2023 season, there has been a spike of RSV cases in otherwise healthy infants. According to the Centers for Disease Control and Prevention, RSV can lead to severe respiratory illness, making it the number 1 cause of hospitalizations among infants aged under 1 year in the United States.

About 75% of newborn RSV hospitalizations occur in infants born at term with no underlying conditions. The current burden RSV has placed on families is greater than normal, and the American Academy of Pediatrics has asked the White House to declare an emergency so the nation response to the disease may receive support.

The Prescription Drug User Fee Act date is projected by the FDA to be in the third quarter of 2023.

1. FDA accepts nirsevimab application as first protective option against RSV disease for all infants. Press Release. Sanofi - Aventis Groupe. January 5, 2022. Accessed January 5, 2022. 

https://www.globenewswire.com/news-release/2023/01/05/2583365/0/en/Press-Release-FDA-accepts-nirsevimab-application-as-first-protective-option-against-RSV-disease-for-all-infants.html

The US Food Administration has agreed to review an application for nirsevimab (Beyfortus; AstraZeneca and Sanofi) to protect infants against RSV.