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The article describes key lessons from the Covid-19 pandemic in K-12 education which pertain to circumstances in which vaccination and therapeutic agents were not available for children. These include the necessity for school closure, masking as a successful mitigation strategy to prevent within-school transmission, and the unnecessary delay of the development of vaccines in children.

NEONATAL CANDIDIASIS IS associated with high mortality and increased risk of neurodevelopmental impairment among survivors. (1-3) Investigators have identified multiple risk factors for individual infants to develop candidiasis (1,4-6) and [...], OBJECTIVES. Previous studies have shown that incidence of invasive candidiasis varies substantially among centers, and previous use of broad-spectrum antibiotics is a risk factor for candidiasis in extremely low birth-weight infants. Differences in center practices, such as antibiotic strategies and the effects of these strategies on center incidence of candidiasis, are not reflected in assessments of an individual's risk of candidiasis. We evaluated the relationship between empirical antibiotic practices for extremely low birth-weight infants and center incidence of candidiasis. METHODS. We studied a cohort of extremely low birth-weight infants who survived ≥ 72 hours and were admitted to 1 of 12 tertiary centers between 1998 and 2001. Multivariable logistic regression was used to validate previous broad-spectrum antibiotics use as a risk factor for subsequent candidiasis in individual infants. We calculated correlation coefficients to assess the relationship between center incidence of candidiasis with antibiotic practice patterns. RESULTS. There were 3702 infants from 12 centers included, and 284 (7.7%) developed invasive candidiasis. Broad-spectrum antibiotics use was associated with candidiasis for individual infants. Center candidiasis incidence ranged from 2.4% to 20.4%. Center incidence of candidiasis was correlated with average broad-spectrum antibiotics use per infant and average use of broad-spectrum antibiotics with negative cultures per infant. CONCLUSIONS. Center incidences of invasive candidiasis differ substantially, and antibiotic practice differences are possible contributors to center variation in candidiasis risk. Key Words antibiotic use, bloodstream infection, candida, candidemia, LBW, extremely low birth weight Abbreviations ELBW--extremely low birth weight BSA-- broad-spectrum antibiotic NEC--necrotizing enterocolitis CC--correlation coefficient

BACKGROUND. Meningitis is a substantial cause of morbidity and mortality in neonates. Clinicians frequently use the presence of positive blood cultures to determine whether neonates should undergo lumbar puncture. Abnormal cerebrospinal fluid (CSF) parameters are often used to predict neonatal meningitis and determine length and type of antibiotic therapy in neonates with a positive blood culture and negative CSF culture. METHODS. We evaluated the first lumbar puncture of 9111 neonates at [greater than or equal to] 34 weeks' estimated gestational age from 150 NICUs, managed by the Pediatrix Medical Group, Inc. CSF culture results were compared with results of blood cultures and CSF parameters (white blood cells [WBCs], glucose, and protein) to establish the concordance of these values in culture-proven meningitis. CSF cultures positive for coagulase-negative staphylococci and other probable contaminants, as well as fungal and viral pathogens, were excluded from analyses. RESULTS. Meningitis was confirmed by culture in 95 (1.0%) neonates. Of the 95 patients with meningitis, 92 had a documented blood culture. Only 57 (62%) of 92 patients had a concomitant-positive blood culture; 35 (38%) of 92 had a negative blood culture. In neonates with both positive blood and CSF cultures, the organisms isolated were discordant in 2 (3.5%) of 57 cases. In each case, the CSF pathogen required different antimicrobial therapy than the blood pathogen. For culture-proven meningitis, CSF WBC counts of >0 cells per [mm.sup.3] had sensitivity at 97% and specificity at 11%. CSF WBC counts of >21 cells per [mm.sup.3] had sensitivity at 79% and specificity at 81%. Culture-proven meningitis was not diagnosed accurately by CSF glucose or by protein. CONCLUSIONS. Neonatal meningitis frequently occurs in the absence of bacteremia and in the presence of normal CSF parameters. No single CSF value can reliably exclude the presence of meningitis in neonates. The CSF culture is critical to establishing the diagnosis of neonatal meningitis. Key Words CSF pleocytosis, neonatal sepsis, spinal tap Abbreviations CSF--cerebrospinal fluid LP--lumbar puncture WBC--white blood cell EGA--estimated gestational age CBC--complete blood cell count IQR--interquartile range RBC--red blood cell, NEONATAL MENINGITIS IS a devastating infection that is often difficult to diagnose. (1-5) Signs of meningitis are often subtle in the neonate; thus, the diagnosis of meningitis must be made […]

NEONATAL CANDIDIASIS IS often fatal among premature infants. (1-4) Most reports of neonatal candidiasis are single-center investigations. (2,5-9) Because of the gravity of the condition, newer diagnostic and treatment strategies [...], BACKGROUND. Neonatal candidiasis is associated with substantial morbidity and mortality rates. Neurodevelopmental follow-up data for a large multicenter cohort have not been reported. METHODS. Data were collected prospectively for neonates born at RESULTS. The cohort consisted of 4579 infants; 320 of 4579 (7%) developed candidiasis; 307 of 320 had Candida isolated from blood, 27 of 320 had Candida isolated from cerebrospinal fluid, and 13 (48%) of 27 of those with meningitis had negative blood cultures. In multivariate analysis of risk factors on day of life 3, birth weight, cephalosporins, gender, and lack of enteral feeding were associated with development of candidiasis. After diagnosis, most neonates had multiple positive cultures despite antifungal therapy, and 10% of neonates had candidemia for ≥ 14 days. Death or neurodevelopmental impairment (NDI) was observed for 73% of extremely low birth weight infants who developed candidiasis. Death and NDI rates were greater for infants who had delayed removal or replacement of central catheters (>1 day after initiation of antifungal therapy), compared with infants whose catheters were removed or replaced promptly. CONCLUSIONS. Blood cultures were negative for approximately one half of the infants with Candida meningitis. Persistent candidiasis was common. Delayed catheter removal was associated with increased death and NDI rates. www.pediatrics.org/cgi/doi/10.1542/ peds.2004-2292 doi:10.1542/peds.2004-2292 The authors had full access to all of the data. The listed authors contributed to generation of the hypotheses (all authors), data collection (B.J.S., A.A.F., W.O., S.D., and R.G.), data analysis (D.K.B., S.A.M., and K.P.), data interpretation (all authors), and writing of the report (all authors). The members of the National institute of Child Health and Human Development Neonatal Research Network contributed to the collection data. Key Words candidiasis, meningitis, sensitivity, specificity, culture, premature infant Abbreviations CSF--cerebrospinal fluid CI--confidence interval DOL--day of life EGA--estimated gestational age ELBW--extremely low birth weight IVH--intraventricular hemorrhage NDI--neurodevelopmental impairment MDI--Mental Developmental Index OR--odds ratio PDA--patent ductus arteriosus PDI--Psychomotor Developmental Index

Allergic rhinitis is a common condition, and its prevalence seems to be increasing. (1-4) The prevalence of school-aged children with allergic rhinitis in Hong Kong is 35% to 44%. (5,6) [...], Objective. To compare active acupuncture with sham acupuncture for the treatment of persistent allergic rhinitis among children. Methods. Subjects with persistent allergic rhinitis were recruited from the pediatric outpatient clinic. They were randomized to receive either active acupuncture or sham acupuncture. Main outcome measures included daily rhinitis scores, symptom-free days, visual analog scale scores for immediate effects of acupuncture, daily relief medication scores, blood eosinophil counts, serum IgE levels, nasal eosinophil counts, patients' end parents' preferences for treatment modalities, and adverse effects. Results. Eighty-five patients were recruited from the pediatric outpatient clinic at Kwong Wah Hospital, in Hong Kong. Thirteen patients withdrew before randomization; 35 patients (mean age: 11.7 ± 3.2 years) were randomized to receive active acupuncture for 8 weeks, and 37 patients (mean age: 11 ± 3.8 years) were randomized to receive sham acupuncture for 8 weeks. Acupuncture was performed twice per week for both groups. Both the assessing pediatricians and the patients were blinded. There were significantly lower daily rhinitis scores and more symptom-free days for the group receiving active acupuncture, during both the treatment and follow-up periods. The visual analog scale scores for immediate improvement after acupuncture were also significantly better for the active acupuncture group. There was no significant difference in the following outcome measures between the active end sham acupuncture groups: daily relief medication scores, blood eosinophil counts, serum IgE levels, and nasal eosinophil counts, except for the IgE levels before and 2 months after acupuncture in the sham acupuncture group. No severe adverse effects were encountered. Numbness, headache, and dizziness were found in both the active and sham acupuncture groups, with no difference in incidence, end the effects were self-limiting. Conclusions. This study showed that active acupuncture was more effective than sham acupuncture in decreasing the symptom scores for persistent allergic rhinitis and increasing the symptom-free days. No serious adverse effect was identified. A large-scale study is required to confirm the safety of acupuncture for children. Pediatrics 2004;114:1242-1247; acupuncture, allergic rhinitis, rhinitis, children, pediatric, trial, randomized, controlled trial, complementary therapy.

Neonatal candidemia occurs in 4% to 15% of extremely low birth weight infants (birth weight There has not been a large multicenter prospective study to outline the prevalence of end-organ [...], Objective. Neonatal candidemia is an increasing cause of infant morbidity and mortality. We evaluated the current medical literature in an effort to critique the literature and to document the reported prevalences of end-organ damage after neonatal candidemia. Methods. We analyzed all peer-reviewed articles of neonatal candidemia published in the English language; inclusion criteria included a cohort limited to all neonatal intensive care unit admissions or all episodes of candidemia in neonates. Articles that also incorporated older patients, did not define a numerator and a denominator for at least 1 form of end-organ damage, included patients from other reports, or did not include all episodes of candidemia in the source population were excluded from the analysis. Results. Thirty-four articles reported episodes of candidemia and mortality; 21 articles reported prevalence for at least 1 form of end-organ damage. Only 4 (19%) of 21 articles reported prevalence for >4 forms of end-organ damage from the following list: endophthalmitis, meningitis, brain parenchyma invasion, endocarditis, renal abscesses, positive cultures from other normally sterile body fluids, or hepatosplenic abscesses. The median reported prevalence of endophthalmitis was 3% (interquartile range [IQR]: 0%-17%), of meningitis was 15% (IQR: 3%-23%), of brain abscess or ventriculitis was 4% (IQR: 3%-21%), of endocarditis was 5% (IQR: 0%-13%), of positive renal ultrasound was 5% (IQR: 0%-14%), and of positive urine culture was 61% (IQR: 40%-76%). The medical literature concerning end-organ evaluation after episodes of neonatal candidemia is heterogeneous and consists largely of single-center retrospective studies. Year that the data were collected and prevalence of neonates infected with Candida albicans were associated with observed heterogeneity. Conclusions. Given the heterogeneity of the medical literature, precise estimates of the frequencies of end-organ damage are not possible and a prospective multicenter trial is warranted, but the data from the published literature suggest that the prevalence of neonates with end-organ damage not only is greater than 0 but also is high enough that until such a prospective trial is completed, end-organ studies should be considered before the conclusion of antifungal therapy. Pediatrics 2003;112: 634-640; invasive candidiasis, deep tissue.

The incidence of candidemia is rising steadily, and Candida species are a leading cause of infectious mortality in the neonatal intensive care trait (NICU). (1) Incidence of candidemia in extremely [...], Objective. Neonatal candidemia is often fatal. Empirical antifungal therapy is associated with improved survival in neonates and patients with fever and neutropenia. Although guidelines for empirical therapy exist for patients with fever and neutropenia, these do not exist for neonates. Methods. A multicenter, retrospective, cohort study was conducted of neonatal intensive care unit patients (N = 6172) who had a blood culture (N = 21 233) after day of life 3 and whose birth weight was ≤ 1250 g. We performed multivariable conditional logistic regression of risk factors for candidemia. From the regression modeling coefficients, we developed a candidemia score. Results. In multivariable modeling, thrombocytopenia (odds ratio [OR]: 3.56; 95% confidence interval [CI]: 2.68-4.74) and cephalosporin or carbapenem use in the 7 days before obtaining the blood culture (OR: 1.77; 95% CI: 1.33-2.29) were risk factors for subsequent candidemia. Children who were 25 to 27 weeks' estimated gestational age (OR: 2.02; 95% CI: 1.52-3.05) and children who were born at Conclusions. We developed a clinical predictive model for neonatal candidemia with high sensitivity and moderate specificity for candidemia. On the basis of our model, when a physician obtains a blood culture, the physician should consider providing antifungal therapy to neonates who are

Objective. Pediatric resident physicians' clinical diagnostic accuracy of otitis media is unknown. We attempted to correlate the clinical examination of pediatric house staff with pediatric otolaryngologists and tympanometry. Methods. Pediatric residents evaluated patients who were scheduled in the pediatric acute care clinic and completed a provider examination form detailing their otoscopic findings, interpretation, and treatment plan. Patients were then immediately reevaluated by a pediatric otolaryngologist using an identical form. Tympanometry was also performed by a pediatric audiologist. We used [kappa] statistics to calculate correlation of clinical findings and interpretation. Results. A total of 103 patients consented for the study; 70 patients were examined by 27 different pediatric residents with 43 patients (86 ears) examined by all 3 providers. Correlation of clinical findings between all pediatric residents and the pediatric otolaryngologists was a [kappa] statistic of 0.30 (fair agreement). The individual diagnostic finding with the greatest correlation was tympanic membrane erythema ([kappa] statistic: 0.40 [fair agreement]), and the worst correlate was tympanic membrane position ([kappa] statistic: 0.16 [slight agreement]). Resident interpretation and tympanometry yielded a [kappa] statistic of 0.20 (slight agreement), and the otolaryngologist interpretation and tympanometry yielded a [kappa] statistic of 0.32 (fair agreement). Conclusions. Otitis media is the most common disease seen by practicing general pediatricians, but there is a paucity of formalized resident education. We demonstrated only a slight to moderate correlation between the clinical diagnostic examinations of pediatric residents and pediatric otolaryngologists and tympanometry. Pediatrics 2002;109: 993-998; otitis media, pediatric resident, education. ABBREVIATIONS. AOM, acute otitis media; OME, otitis media with effusion; MEE, middle ear effusion; ACC, acute care clinic; PGY, postgraduate year; TM, tympanic membrane., Acute otitis media (AOM) is the most commonly diagnosed disease in childhood and a primary factor in increased antibiotic resistance. (1) Variations in diagnostic criteria (2) and antibiotic therapy (3) [...]

OBJECTIVES: We evaluated the safety and efficacy of a test-to-stay program for unvaccinated students and staff who experienced an unmasked, in-school exposure to someone with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Serial testing instead of quarantine was offered to asymptomatic contacts. We measured secondary and tertiary transmission rates within participating schools and in-school days preserved for participants. METHODS: Participating staff or students from universally masked districts in North Carolina underwent rapid antigen testing at set intervals up to 7 days after known exposure. Collected data included location or setting of exposure, participant symptoms, and school absences up to 14 days after enrollment. Outcomes included tertiary transmission, secondary transmission, and school days saved among test-to-stay participants. A prespecified interim safety analysis occurred after 1 month of enrollment. RESULTS: We enrolled 367 participants and completed 14-day follow-up on all participants for this analysis. Nearly all (215 of 238, 90%) exposure encounters involved an unmasked index case and an unmasked close contact, with most (353 of 366, 96%) occurring indoors, during lunch (137 of 357, 39%) or athletics (45 of 357, 13%). Secondary attack rate was 1.7% (95% confidence interval: 0.6%-4.7%) based on 883 SARS-CoV-2 serial rapid antigen tests with results from 357 participants; no tertiary cases were identified, and 1628 (92%) school days were saved through test-to-stay program implementation out of 1764 days potentially missed. CONCLUSION: After unmasked in-school exposure to SARS-CoV-2, even in a mostly unvaccinated population, a test-to-stay strategy is a safe alternative to quarantine. [ABSTRACT FROM AUTHOR]

The article presents the authors' response to the paper on factors with potential contribution to secondary infections in school districts. Topics discussed include the alternative presentation of data that do not affect the regression results, and the absence of evidence on the lead of close contact to differential case-classification adjudication. Also noted is the study's non-observance of higher primary infections in universally masked districts.

Opportunistic infections are an increasingly common problem in neonatal intensive care units (NICUs). Premature neonates often have compromised skin integrity, gastrointestinal tract disease, chronic malnutrition, central venous catheters, long-term endotracheal [...], Objectives. To determine the epidemiology of candidemia in our neonatal intensive care unit; to compare risk factors, clinical presentation, and outcomes for neonates infected with Candida albicans, Candida parapsilosis, and coagulase-negative staphylococcus (CONS); and to suggest a rational approach to empiric antifungal therapy of neonates at risk for nosocomial infection. Design. Retrospective chart review of all neonatal intensive care unit patients with systemic candidiasis or CoNS infection between January 1, 1995 and July 31, 1998 at Duke University Medical Center. Results. Fifty-one patients were reviewed. Nine of 19 patients infected with C parapsilosis and 5 of 15 patients infected with C albicans died of fungemia. Seventeen neonates had [is greater than] 2 positive cultures for CoNS obtained within 96 hours and 1 died. There was no statistically significant difference in birth weight, gestational age, or age at diagnosis between patient groups; however, candidemic patients had a sevenfold higher mortality rate. Before diagnosis, candidemic patients had greater exposure to systemic steroids, antibiotics, and catecholamine infusions. Of the 51 patients, 32 received third-generation cephalosporins in the 2 weeks before diagnosis and 19 did not. Twenty-nine of the 32 who were treated with third-generation cephalosporins subsequently developed candidemia, while candidemia occurred in only 5 of 19 patients who were not treated with cephalosporins. At the time of diagnosis, candidemic patients were more likely to have required mechanical ventilation and were less likely to be tolerating enteral feeding. Multivariate clustered logistic regression analysis revealed that candidemic patients had more exposure to third-generation cephalosporins. Once the clinician was notified of a positive blood culture for Candida, patients infected with C parapsilosis retained their central catheters longer than patients infected with C albicans. Conclusions. In this retrospective review, we were able to identify aspects of the clinical presentation and medication history that may be helpful in differentiating between candidemia and CoNS bacteremia. Those key features may be used by clinicians to initiate empiric amphotericin B therapy in premature neonates at risk for nosocomial infections. Prolonged use of third-generation cephalosporins was strongly associated with candidemia. There was no statistically significant difference in the morbidity and mortality between patients infected with C parapsilosis and those infected with C albicans. Observed delays in removal of the central venous catheter may have contributed to finding a mortality rate from C parapsilosis that was higher than was previously reported. Pediatrics 2000;106:712-718; Candida, parapsilosis, albicans, Staphylococcus epidermidis, neonate, sepsis, platelets, amphotericin, central line, cephalosporin. ABBREVIATIONS. NICU, neonatal intensive care unit; CONS, coagulase-negative staphylococcus; TPN, total parenteral nutrition; CSF, cerebrospinal fluid; OR, odds ratio.