The Link - April 2025

Imagine a child’s mind consumed by persistent worries: Will there be a storm today? Are my parents safe? Will my friends still like me? For many children, these aren’t fleeting concerns but daily struggles that disrupt focus, relationships and wellbeing. Up to 20% of youth experience clinically significant anxiety disorders, which often intertwine with academic challenges, social difficulties and somatic complaints like headaches or stomachaches. While transient fears are developmentally normal, impairing symptoms — such as refusal to attend school, relentless reassurance-seeking or physical distress during routine activities — signal the need for intervention. Pediatricians and mental health professionals must distinguish adaptive anxiety from pathological patterns, recognizing red flags like tantrums in younger children or avoidance behaviors in teens. 

The President’s Emergency Plan for AIDS Relief (PEPFAR) was started under the George W. Bush administration during the ongoing HIV crisis. The crisis was particularly acute in parts of Africa. At PEPFAR’s founding in 2003, HIV had caused life expectancies to decline in many countries in sub-Saharan Africa. For example, life expectancy in Botswana had declined from 62 to 51 years and in Lesotho from 59 to 44.¹ Half of children infected with HIV were dying before their second birthday.² PEPFAR’s initial goal was to “turn the tide in combating the global HIV/AIDS pandemic”: assisting African and Caribbean countries by treating 2 million people infected with HIV, preventing 7 million new infections, and providing care for an additional 10 million people including both the HIV-infected and children orphaned by HIV. At the time, “fighting the HIV/AIDS pandemic” was “a priority of U.S. foreign policy” and PEPFAR tripled the financial commitment from the United States to combat HIV outside the United States (prior funding commitments included contributions to the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria).

From its earliest days, the field of bioethics has been keenly interested in the intersection of disability and pediatrics. But how bioethics has understood and evaluated decision-making at this intersection has changed significantly over the past 60 years. Exploring the historical shifts in conceptual and ethical frameworks is instructive for improving clinical care for patients living with disability today.

It is often in times of crisis that the pendulum will swing. While recent 2025 measles outbreaks have led to increased media coverage of vaccine hesitancy or vaccine refusal movements, other sources have indicated that providers may witness an uptick in “vaccine enthusiasm.” As of April 4, the Centers for Disease Control and Prevention (CDC) reported 607 confirmed cases of measles in over 20 states, with most cases identified in Texas where the initial outbreak began. However, some physicians claim that parents are now expressing increased interest in having their children vaccinated with the measles, mumps and rubella (MMR) vaccine amid concerns for their child’s safety as cases continue to rise.^1,2 In some cases, requests have even been made to vaccinate early (prior to the recommended 12-15 month window), particularly if families have upcoming travel planned.  

Animal bites, whether from a playful pet or a wild encounter, are a common occurrence for which patients seek medical care. They can range from minor abrasions to serious medical emergencies. An estimated 5 million human or animal bite wounds occur annually in the United States¹ and account for a significant number of emergency department visits each year.

Treatment considerations include:

• Prophylactic antibiotics – are they indicated? And if so, which antibiotic, at what dose, and for how long?
• Is rabies prophylaxis indicated?
• Does tetanus vaccine need to be administered?

Not all bites are equal, and treatment recommendations vary depending on the type of animal, mechanism of injury, and location and severity of the bite.

A 9-year-old boy with a history of cerebral palsy and seizures presents for evaluation of changes in his big toenails. His mother reports that his big toenails have looked different since early childhood but that the thickening and discoloration have worsened over the past couple of years. They deny any recent rash. He has had several ingrown toenails but has never developed paronychia. On examination, he has thickening and a yellow-brown discoloration of the bilateral great toenails. The remainder of his toenails and his fingernails appear normal. There is no periungual erythema or scale. A dermatophyte culture was performed on a clipping of the toenail and was negative.

Which of the following is the most likely diagnosis?

1. Onychomycosis
2. Congenital malalignment of the great toenails
3. Nail psoriasis
4. Onychomadesis