Multisystemic inflammatory syndrome in children and the BNT162b2 vaccine: a nationwide cohort study.

Multisystemic inflammatory syndrome in children (MIS-C) is a rare, severe, post-infectious hyperinflammatory condition that occurs after COVID-19 infection. In this study, we aimed to demonstrate the risk reduction of MIS-C and severe MIS-C after Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccination. This nationwide cohort study included 526,685 PCR-confirmed COVID-19 cases (age < 19 years), of whom 14,118 were fully vaccinated prior to COVID-19 infection. MIS-C cases were collected from all hospitals in Israel from April 2020 through November 2021. The MIS-C rates were calculated among two COVID-19 populations: positive PCR confirmed cases and estimated COVID-19 cases (PCR confirmed and presumed). Vaccination status was determined from Ministry of Health (MoH) records. The MIS-C risk difference (RD) and 95% confidence intervals (95%CI) between vaccinated and unvaccinated patients are presented. Overall, 233 MIS-C cases under the age of 19 years were diagnosed and hospitalized in Israel during the study period. Among the estimated COVID-19 cases, MIS-C RD realistically ranged between 2.1 [95%CI 0.7-3.4] and 1.0 [95%CI 0.4-1.7] per 10,000 COVID-19 cases. For severe MIS-C, RD realistically ranged between 1.6 [95%CI 1.3-1.9] and 0.8 [95%CI 0.7-1.0], per 10,000 COVID-19 cases. Sensitivity analysis was performed on a wide range of presumed COVID-19 rates, demonstrating significant RD for each of these rates. CONCLUSION: This research demonstrates that vaccinating children and adolescents against COVID-19 has reduced the risk of MIS-C during the study period. WHAT IS KNOWN: • Most of the published literature regarding vaccine effectiveness is based on case-control studies, which are limited due to small sample sizes and the inability to fully estimate the risk of MIS-C among vaccinated and unvaccinated children and adolescents. • The known underestimation of COVID-19 diagnosis among children and adolescents is challenging, as they often have few to no symptoms. WHAT IS NEW: • Significant risk difference was found in favor of the vaccinated group, even after including extreme assumptions regarding the underdiagnosed COVID-19 rate. • During this nationwide study period, it was found that vaccinating children and adolescents reduced the risk of MIS-C and its complications.

Objective Behavioral Measures in Children before, during, and after the COVID-19 Lockdown in Israel.

Studies using questionnaires report that COVID-19 restrictions resulted in children spending significantly less time outdoors. This study used objective measures to assess the impact of pandemic-related restrictions on children's behavior. A total of 19 healthy 8-12-year-old boys were observed before and during social restriction periods. Of these, 11 boys were reassessed after restrictions were lifted. For each session, Actiwatches were dispensed for measures of time outdoors, activity, and sleep. Changes overall and by school status were assessed using signed-rank test and Wilcoxon rank sum tests. During restrictions, children spent significantly less time outdoors (p = 0.001), were less active (p = 0.001), and spent less time engaged in moderate-to-vigorous physical activity (p = 0.004). Sleep duration was not significantly different between sessions (p > 0.99), but bedtime and wake time shifted to a later time during restrictions (p < 0.05 for both). Time outdoors and activity returned close to pre-pandemic levels after restrictions were lifted (p > 0.05 for both). Children's behaviors significantly changed during the COVID-19 pandemic. The reduction in outdoor light exposure is of importance due to the role of light in the etiology of myopia and vitamin D production. The reduction in physical activity may have negative health effects in terms of obesity and depression, although further research is required to ascertain the long-term effects.

[CORONA VIRUS, BREASTFEEDING AND GUIDELINES - A WORLDWIDE REVIEW].

INTRODUCTION: The COVID-19 pandemic has forced countries worldwide to face major issues and challenges. Among those challenges is breastfeeding from the first hours after birth until late infancy, in hospitals and communities. There is a consensus throughout the world and among leading international professional medical associations that breastfeeding is of significant importance for short- and long-term health outcomes in mothers and infants, as well as for its public health impact and reduction of national health expenditures. Moreover, breastfeeding or human milk feeding have been shown to reduce morbidity, specifically respiratory infections, among infants and children. This is not the first time health systems are dealing with coronavirus outbreaks, although currently, in the COVID-19 pandemic, there is still much that is unknown. Dealing with the unknown can lead to guidelines that may not fully take into consideration relevant risk benefit ratios for individuals and groups. In this review, we aim to summarize the guidelines of different leading professional groups around the world dealing with the COVID-19 pandemic. Evidence-based medicine rests on relevant scientific evidence, patients' values and preferences and clinical judgment. We wish to propose guidelines based on available evidence concerning breastfeeding, the current pandemic and weighing in potential risks and benefits while highlighting the need for ongoing breastfeeding research.

Evidence-based preschool-age vision screening: health policy considerations.

BACKGROUND: There are many causes of visual impairment, and even blindness, which are treatable or at least preventable. Two such conditions are strabismus (crossed-eye, squint) and refractive error (visual image not focused on the most sensitive part of the retina). If these are not detected and corrected at an early age, they can lead to an irreversible impairment known as amblyopia (lazy eye). Pediatric vision screening and subsequent treatment for amblyopia and amblyogenic risk factors are thus key to preventing vision loss. Furthermore, vision screening can detect moderate to high hyperopia, which has been found to be associated with poor school readiness. Evidence-based recommendations call for screening children at 3-5 years of age; they are old enough to cooperate, but still within the window of effective intervention. However, these recommendations have yet to be universally implemented as the standard of care. METHODS: This paper integrates a review of the literature and the international experience of preschool vision screening with the findings from a preliminary feasibility study of expanded screening in Israel to formulate a discussion of the current health policy challenge in Israel and the options for addressing it. The advantages and disadvantages of various venues for vision screening are discussed. FINDINGS: Screening by optometrists in Mother and Child Health Centers, as implemented in a recent pilot project in the Jerusalem District, would allow the most comprehensive testing. Photo-screening in preschools would reach the most children, but at the cost of missing hyperopia (farsightedness). Either approach would probably constitute improvements over the current situation. The relative strengths of the two approaches depends in part on the ability to purchase automatic screening equipment (and the efficacy of that equipment) vs. the ongoing cost of paying trained personnel. CONCLUSIONS: Further research should be conducted in Israel to determine the prevalence of refractive errors, so that best practices can be established for Israel's population and social needs. In the interim, the Ministry of Health should promptly implement the inclusion of preschool visions screening for children in the approved "basket of services" covered by the National Health Insurance Laws, using photo-screening, including collection of the clinical data.

The epidemiology and treatment of conjunctivitis at Urgent Care Centres in Israel.

Purpose: Conjunctivitis is the most common ocular condition diagnosed at emergency departments (ED) in the USA, although it is generally not an emergent condition. Treatment of conjunctivitis at Urgent Care Centres (UCC) could offer lower cost than ED. This study describes the demographics and outcomes of a cohort presenting with conjunctivitis to a nationwide UCC system. Methods: This retrospective study included 17 branches of UCC. Electronic Medical Record data (November 2015-October 2016) of patients diagnosed with conjunctivitis or ocular disorder were retrieved. Data included gender, age, diagnosis, treatment, discharge status and temperature. Patients without conjunctivitis, presenting to UCC during this period served as the control. Results were compared to all ED patients in Israel (from a public report). Descriptive statistics, Chi-square and Z-proportion test were used. Results: Altogether, 602,074 patients presented to UCC, of which 5,045 (0.84%, 95% CI 0.74-0.94%) were diagnosed with conjunctivitis. Conjunctivitis was more prevalent among young males (0-14, p<0.001) and older females. The conjunctivitis cohort at UCC was significantly younger than the ED cohort (p<0.01). UCC treated and released home 96.7% (95% CI 96.2-97.2%) of cases. This is significantly higher than the treatment rate for the entire UCC cohort (93.2%, CI 93.2-93.3%, p<0.05). Treatment in most cases (82.0%, 95% CI 80.9-83.0%) involved the prescription of ocular antibiotic. Conclusion: Similar to previous studies at ED, conjunctivitis patients are primarily young males. Most patients were treated with antibiotics at UCC and released home. This suggests that UCC may be a good venue for treatment of conjunctivitis.

[New guidelines to decrease x-ray use may increase unnecessary antibiotic use].

BACKGROUND: The newly reLeased guidelines of infectious disease societies suggest abstaining from performing routine chest radiographs in the diagnosis of community acquired pneumonia in clinically stable children, based upon studies where the measured outcome is time to resolution of the disease not antibiotic use. However, the impact of possible over-treatment with antibiotics that might result from this clinical approach is not discussed. OBJECTIVES: The goal of this study was to quantify how many children with clinicaL signs suggestive of pneumonia would have been given unnecessary antibiotic treatment had the chest radiograph not been performed. METHODS: In a system of urgent care centers, we reviewed the medical records of patients > 2 months and <10 years with the chief complaint of fever, cough or dyspnea who had a chest X-ray performed upon their evaluation. Demographic and cLinical data were obtained with the final reports of X-rays interpreted by senior radiologists. An X-ray was considered positive if an infiltrate or pneumonia was noted in the report. RESULTS: There were 3343 children over a one year period who met the inclusion criteria. A total of 877 had findings suggestive of pneumonia on the basis of physical examination. Of these, 433 (48.6%) had normal chest radiographs. Among those with negative X-rays, 305 (68.8%) had rates or crepitus on auscultation. CONCLUSIONS: Reliance on physical examination alone in the diagnosis of community-acquired pneumonia (CAP) in children may over-diagnose cases of pneumonia in a clinically significant manner. Further consideration of this possibility is needed before widely disseminating guidelines that advocate antibiotic treatment based on clinical diagnosis alone.

Diagnosis of childhood pneumonia: clinical assessment without radiological confirmation may lead to overtreatment.

OBJECTIVES: Consensus guidelines discourage the use of routine radiologic confirmation of clinically diagnosed pneumonia in children. The goal of the present study was to assess the degree of antibiotic overtreatment resulting from this approach. DESIGN: This was a prospective data collection. SETTING: This was performed in 5 urgent care clinics in Jerusalem, Israel. PARTICIPANTS: This study was composed of previously healthy children between 2 months and 18 years of age who presented with a chief complaint of fever, cough, or dyspnea between August 1, 2007, and March 15, 2008, by for whom chest x-rays were obtained because of clinical suspicion of pneumonia. OUTCOME MEASURES: Outcome measure was percentage of children with clinical findings associated with pneumonia (hypoxia, tachypnea, rales, dyspnea) who did not have radiological findings of pneumonia. RESULTS: With the exception of wheezing, 55% to 65% of children with specific signs and symptoms did not have radiologic pneumonia. A similar range of children with a combination of the signs did not have radiologic pneumonia. For wheezing, alone or in combination, the percentages were higher. On multivariate analysis, only fever was found to be predictive of pneumonia. Wheezing was found to be negatively predictive. CONCLUSIONS: Treatment of childhood pneumonia on the basis of clinical parameters alone with no chest x-ray confirmation may lead to a large portion of children receiving unnecessary antibiotic therapy. In an era when the emphasis is to decrease antibiotic resistance, radiological confirmation of pneumonia should be obtained when possible.