The Link - February 2025

Acute gastrointestinal bleeds (GIB) in the pediatric population can be a nebulous presenting symptom with a wide differential diagnosis ranging from self-resolving mucosal bleeding to life-threatening hemorrhages. Studies have found that the incidence of emergency department (ED) visits for pediatric GIB is increasing.¹ Therefore, it is important that providers have knowledge around triage and management of this complaint.

Antibiotics always seem to get certain reputations. Misconceptions continue to be perpetuated among the medical community, and it can be hard to know what is a myth and what is accurate. Let’s start the new year debunking some common myths in pediatric antibiotic stewardship!

Myth: Penicillin does not work on anything anymore!

A friend of mine was recently evaluated for streptococcal pharyngitis (not in KC!) and was prescribed cefdinir. When she asked why not penicillin, she was told, “Penicillin doesn’t work on anything anymore.” Although there is some truth to increasing penicillin resistance among many bacteria (Staphylococcus aureus is a good example where penicillin is almost never the answer anymore), some bacteria continue to be fully susceptible to penicillin: Streptococcus pyogenes (or Group A Streptococcus), and Streptococcus agalactiae (Group B Streptococcus) are two good examples. The Centers for Disease Control and Prevention tracks resistance for invasive cases and reports zero resistance to these two bacteria (https://www.cdc.gov/abcs/bact-facts/data-dashboard.html).

In fact, penicillin and amoxicillin are often superior to other broader antibiotics, not only because they are associated with fewer side effects, less cost or fewer alterations of the microbiome, but also, because of superior efficacy. For example, as we discussed in a previous article, amoxicillin is better absorbed and less protein bound compared to cefdinir, and thus can achieve concentrations for the time needed to kill common bacteria better than cefdinir can for most infections.

Addressing serious illness and conveying such news is a vital skill for pediatricians. However, many settings may present barriers to delivering it well, resulting in poor communication, misunderstanding and even a lack of trust between the clinician, patient and parents.

Pediatric health care clinicians may find this task challenging for several reasons.

Youth suicide is a critical public health crisis, with pediatricians uniquely positioned to play a pivotal role in prevention. As primary care providers for children and adolescents, pediatricians often serve as the first point of contact for young patients who may lack access to mental health specialists. They are at the forefront of identifying and addressing suicide risks.

The Scope of the Problem

Suicide among young people is a complex issue. According to the Centers for Disease Control and Prevention (CDC), individuals aged 10–24 account for 15% of suicides in the United States. Mental health disorders, particularly depression and anxiety, are significant contributors, often exacerbated by life stressors such as family conflicts, loss, or major transitions. Social challenges, like bullying and struggles with identity, further intensify feelings of isolation and hopelessness. In 2021, for instance, 9% of high school students reported attempting suicide within the previous year. Rates were disproportionately higher among girls (12.4% vs. 5.3% for boys) and non-Hispanic American Indian or Alaska Native youth (20.1%). Alarmingly, LGBTQ+ youth face an even greater risk, with 26.3% of high school students identifying as lesbian, gay, or bisexual reporting suicide attempts—five times higher than their heterosexual peers (5.2%)

Column Author and Editor: Chris Day, MD | Medical Director, Immune Compromised Service & Special Immunology Clinic, Infectious Diseases; Medical Director, International Travel Clinic, Infectious Diseases; Medical Director, Travel Medicine Program

In January 2025, the Centers for Disease Control and Prevention (CDC) issued a report on reported cases of tularemia in the United States from 2011 through 2022, noting an apparent increase in the incidence of infection of 56% from the years 2001 through 2010. Of the 2,462 cases, 50% came from four states: Kansas, Missouri, Arkansas and Oklahoma.

The reason for the increase in reported incidence is unclear. An increase in human cases, or in improved detection, or both, may be responsible. Sixty percent of the cases reported met the surveillance definition of a probable case, compared to only 35% of the cases from 2001 through 2010, with the remainder in both time periods reported as confirmed cases (see Figure 1). The change in the proportions of probable cases may be linked to changes in laboratory testing methods. Previously, most laboratories, including commercial laboratories, used agglutination assays that allowed for comparison of acute and convalescent titers, where a four-fold rise in titers would allow for diagnosis of a confirmed case. Some commercial laboratories are now using newer enzyme-linked immunosorbent assays (ELISAs) that do not allow for easy comparison between titers such that only the definition for a probable case can be met.

Column Author and Editor: Sean Reynolds, MBBCH | Associate Program Director, Pediatric Dermatology Fellowship

A 3-week-old infant presents to the dermatology clinic for evaluation of a rash. The rash developed around one week of life. Mother reported that the rash looked like “rings” and started on the scalp and face before spreading to the chest and abdomen.

The patient was born at 37 weeks. Labor was induced at that time due to maternal hypertension. The patient was diagnosed prenatally with abdominal heterotaxy, levocardia and small ventricular septal defects. Mother reported she was told the rash was due to allergic contact dermatitis to electrode adhesive from an electrocardiogram (ECG) that was performed during admission. The patient continued to develop new lesions after discharge prompting referral to dermatology by the patient’s pediatrician. 

Vaccine hesitancy (VH) in pediatrics is complicated and requires a comprehensive approach to address it effectively. Hesitancy is a spectrum spanning from worries about one particular vaccine to refusal of all vaccines. A Centers for Disease Control (CDC) National Immunization Survey in 2019 found that 20% of parents in the United States self-reported that they were “hesitant about childhood shots.” Caregivers that refuse vaccines or express hesitancy cite safety as the top concern. Other factors involved include misinformation or lack of information, perceived low risk of disease, distrust in medical and government institutions, religious beliefs, influence of social media, and desire for autonomy. Providers of childhood vaccines should have an understanding of vaccine development and licensure, safety and safety monitoring to discuss concerns with caregivers and adequately answer their questions. There are several resources that provide more detailed information about vaccine schedules, contraindications and precautions, ingredients, and side effects: the CDC’s Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book and Morbidity and Mortality Weekly Report. A helpful online resource is the Vaccine Education Center at The Children’s Hospital of Philadelphia, which can be found at https://www.chop.edu/vaccine-education-center.

Could a new vaccine for malaria be in the future? A multi-stage, dose-escalated, double-blind, randomized placebo-controlled trial in the Netherlands suggests an alternative vaccination strategy with the potential to improve protection against infection. 

Battling through winter weather in the Midwest makes it difficult to think about anything other than the cold, but spring often brings opportunities to visit warmer climates around the world. Many popular destinations this time of year also come with travel risks, such as exposure to tropical diseases not often seen in the United States. Among these, malaria is often the most pressing concern when traveling to warmer regions close to the equator. While most cases occur in sub-Saharan Africa, it is also prevalent in Central and South America, portions of Oceania, and Southeast Asia (Figure 1). Traditionally, prevention methods for contracting malaria have included drugs such as potent chemoprophylaxis agents or the antibiotic doxycycline that come with tricky dosing schedules and rough side-effect profiles. Researchers in the Netherlands claim that current licensed and available malaria subunit vaccines such as Mosquirix provide only limited, temporary protection against malaria. These vaccines’ mechanisms of action are based on the major sporozoite surface antigen, circumsporozoite protein (CSP), with only 50%-80% protection that lasts approximately one year. A recent study published in the New England Journal of Medicine provides an outlook for a potential vaccine with a reportedly favorable safety profile based on whole, genetically attenuated plasmodium parasites.